Queen Elizabeth Hospital Birmingham

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At our last assessment, we rated this key question as requires improvement. At this assessment, the rating has remained requires improvement. This meant people were not always safe and protected from avoidable harm. The service did not always detect and control potential risks in the care environment. Staff did not make sure that all equipment, facilities and technology supported the delivery of safe care. Some equipment found in theatres was out of date. Venous thromboembolism risk assessments did not always match what people were currently prescribed. The service did not make sure all medicines and treatments were safe and met people's needs, capacities and preferences. Although there were some nursing staff shortages at times, this was mostly resolved through the use of bank staff, supernumerary staff, and moving staff to other areas.

However, the service assessed and managed the risk of infection well. Staff disposed of clinical waste safely and were no longer in breach of a regulation in this area. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when people moved between different services.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff knew what incidents to report and how to report them. Staff gave examples of incidents they had reported, confirming this. For example, staff told us about an incident which occurred following the use of a skin preparation in main theatres. Following this incident, changes were made relating to the application of skin preparation and site checks prior to draping. Managers had also arranged training from the supply representatives as an opportunity to refresh staff's knowledge.

Managers investigated all incidents thoroughly and implemented changes where needed but learning was not always shared with staff. Managers shared feedback from incidents with staff through ward information boards, safety huddles and by email and learning was used to improve the service. However, we were told learning was not always shared while incidents were being investigated due to a perceived fear of staff being identified and discriminated against. Senior staff told us a lot of work had been done to support and encourage staff to raise concerns following incidents.

Staff reported serious incidents clearly and in line with trust policy. The service reported 2 never events between February 2024 and February 2025. Both were because of a wrong site surgery. During the same reporting period, 16 serious incidents were reported under surgery and theatre specialties, with 12 classified as unexpected or potentially avoidable deaths.

However, staff said learning from a recent never event was not shared across the surgical specialties and staff did not see the value of sharing this information. We were concerned some staff felt isolated from their colleagues in other clinical areas. This led to staff not being aware of never events that had occurred in other surgical specialties. A senior member of staff told us they did not see the relevance of sharing never events with nursing staff in other areas. We raised this with managers who told us the trust's expectation was for immediate actions to be implemented to prevent a recurrence. Dissemination of information relating to incidents was arranged through monthly Band 7 meetings and by way of `cluster updates' emails. Following our assessment, we were told the associate director of nursing held weekly informal meetings with matrons. They discussed any incidents and shared immediate learning between nursing leaders across various specialties within the clinical delivery group. The trust had implemented a forum to connect with all staff at QEHB called `Listen, Learn and Share' and theatres were among the forerunners since our assessment.

Managers investigated incidents thoroughly. The service looked at patient safety incident investigations (PSII) in line with the NHS Patient Safety Incident Response Framework. Since June 2024, there had been 3,536 incidents recorded under surgical specialties. Incident themes included medication errors, staffing/process failures, equipment failures, patient identification issues, and safeguarding communication failures. Investigations identified any contributory factors and highlighted safety actions to be implemented.

Staff understood their responsibilities to meet the duty of candour and to be open and honest with patients when notifiable incidents occurred. Staff gave patients and families a full explanation and apology when things went wrong. On both wards 409 and 620, staff told us incidents were discussed in staff safety huddles and handovers. On ward 409 they had a `ward newsletter' where learning from incidents was shared.

All medical emergencies were subject to a formal review. We were given an example of a round table discussion from a deterioration review. Learning was shared with staff during team huddles/briefings, newsletters, and during team meetings.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when people moved between different services.

Care and support was planned and organised with people, together with partners and communities in ways that ensured continuity. There were good working links between the service and local GPs, the local mental health service, and the local authority. Information was shared about patients care and treatment with GPs to enable them to provide continuity of care. The local mental health service gave staff advice or support with patients who presented with mental health concerns. Staff referred patients for mental health assessments and psychological support when they showed signs of mental ill-health.

Staff ensured patients received the right care and treatment when they were transferred between wards and services. For example, specialty doctors reviewed surgical patients being cared for in medical wards (surgical outliers). At the time of our assessment, there were no surgical patients on medical wards.

The World Health Organisation (WHO) safety check was used to ensure patient safety prior to commencement of surgery. We observed staff performing safety checks in line with WHO guidance. The surgeon, scrub nurse and circulator (a member of staff responsible for coordinating and supporting the surgical team) conducted a visual check prior to opening a prosthesis during a check we observed. This was in line with standard practice.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people's lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately. Almost all staff were trained in safeguarding practices.

There was a strong understanding of safeguarding and how to take appropriate action. Staff we spoke with understood how to protect patients at risk of, or suffering, significant harm. The service worked well with other agencies to do so, and staff knew how to escalate safeguarding concerns to their manager.

There was a commitment to taking immediate action to keep people safe from abuse and neglect. This included working with partners in a collaborative way.

Staff we spoke with felt confident to act where they had concerns of abuse. The trust had an accessible safeguarding policy and pathway for the service to apply. Staff knew how to make a safeguarding referral and who to contact with concerns. Where staff identified potential safeguarding risks at home, they consulted with the safeguarding team and other multidisciplinary colleagues to ensure patients were protected.

Staff received training specific to their role on how to recognise and report abuse. All staff completed PREVENT training (the PREVENT duty related to the threat from terrorism in the UK and how to support people susceptible to radicalisation) during induction. Non-clinical staff completed a safeguarding level 1 and PREVENT training package. Clinical staff completed PREVENT level 3 training and a combined safeguarding adults and children level 3 training which included the Mental Capacity Act and Deprivation of Liberty Safeguards; 90% of staff had completed this against the trust target of 90%. Data showed over 99% of staff were trained in level 1 and 2 safeguarding for both children and adults in all surgical areas against the trust target of 90%.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people's needs that was safe, supportive and enabled people to do the things that mattered to them.

Patients told us they were informed of risks related to their care and this was being managed in a safe way. During the pre-operative period, information and advice was provided to support people's health, care and support needs. Patients on the enhanced care ward told us rehabilitation was started before surgery and there was a dedicated physiotherapy team who provided information during admission. People were able to ask questions about this if they were concerned and given helpful advice.

Staff understood and described how to identify, assess and reduce risks. There were routine ward handovers and local and daily team briefings. These enabled leaders to proactively review potential and actual risk for patients.

Staff completed risk assessments for each patient on admission and reviewed this regularly. Nursing staff used nationally recognised tools to assess a patient's risk of developing pressure ulcers, malnutrition, falls, as well as risks associated with moving and handling. Patients identified as at risk had specific care plans and were monitored more frequently by staff to reduce the risk of harm. The patient record system highlighted people at risk of falls which enabled the clinical team to efficiently prioritise people's clinical reviews.

However, risk assessments for venous thromboembolism (VTE) were not always updated in line with the trust policy. The electronic recording system mandated that doctors completed the VTE risk assessment within the first 24 hours of patients being admitted. People's records showed the initial VTE risk assessments had been completed. However, the risk assessment was not always updated when reviewed by clinicians as they recorded the review and outcomes on people's clinical notes rather than within the electronic record. This meant that recommendations under the VTE risk assessment did not always match the medication people were currently prescribed.

Staff used a nationally recognised tool to identify deteriorating patients and escalated them appropriately. Patients had a National Early Warning Score (NEWS) documented in their electronic record when they were admitted to the service. The electronic record alerted senior staff when a NEWS had not been completed or when the score increased and was cause for concern.

There was a critical care outreach team (CCOT) who saw patients who had increasing NEWS. The electronic system allowed the team to see the number and location of patients who required their review. The CCOT team provided support to all surgical areas 24 hours a day, 7 days a week. The electronic system alerted the team that a review was required. The team had a set standard to review patients with a NEWS of 7 within 1 hour. Records reviewed showed patients were seen within 1 hour.

The CCOT comprised of 20 to 30 Band 6 and Band 7 nursing staff. As well as reviewing patients on the wards, they delivered the acute illness management (AIM) training to staff. AIM training was mandatory for all qualified staff. It was competency based and required formal sign off. The training focused on NEWS competencies and the modules included safe care of epidurals, chest drain management, fluid management and sepsis.

Staff knew about and dealt with any specific risk issues. Sepsis training was now mandatory since January 2025 for all medical and nursing staff. Data showed sepsis compliance with the new training in theatres was 86%, it was 82% in surgical areas and 66% in ambulatory theatres. There was an action plan to improve compliance. The service had a sepsis steering group and carried out NEWS 2 audits. Audit results we saw were over 90% across various areas.

The pre-assessment team had pathways for escalating complications such as anaemia, diabetes complications, and situations where patients had not stopped specific medication prior to surgery. Anaesthetists could also cancel procedures where patients were not well enough for surgery. Staff followed guidance for stopping anticoagulant therapy when they carried out pre-assessments. We saw evidence where a patient's operation had been cancelled for safety reasons as they were deemed to be high risk because they had not stopped specific medication.

Staff carried out patient pressure area audits and acted on identified risks or concerns. For example, an audit was carried out on ward 410. These audits identified where pressure ulcers had been acquired by patients and action was taken to resolve the root cause. The incidence of pressure ulcers in ward 410, for example, was low. Staff told us action was taken to mitigate the risk of patients contracting pressure ulcers by checking pressure areas for patients as a routine. Also, the use of pressure relieving mattresses and changing a patient's position in a bed or chair as a matter of routine.

We observed an effective check of patient identification in the anaesthetic room. We also observed the accurate count of instruments and sterile consumables which involved both visual and verbal confirmation with an instrument checklist in accordance with evidence-based guidance.

There was good compliance with safety checks in operating theatres. Staff carried out the World Health Organisation (WHO) surgical safety checklist observational audit in July to September 2024 and overall compliance was 97%. This audit was carried out across 23 theatres and included 26 procedures. Actions taken following the audits included sharing of WHO audit posters across sites, sharing audits through the theatre standards group and increasing the number of audits undertaken.

There was good compliance with advanced resuscitation training. Staff attended training on resuscitation awareness and training compliance was 99% in ambulatory theatres, 99.6% in surgical areas and 98.1% in theatres against a trust target of 90%. Staff told us the educators arranged emergency simulations. They had recently had one where a patient had collapsed in the toilet in cardiac arrest.

A Birmingham cardiac postoperative physiotherapy screening tool was available for physiotherapists to use. Staff carried out a short clinical assessment of rehabilitation needs for patients and this worked effectively.

The service did not always detect and control potential risks in the care environment. Staff did not make sure that all equipment, facilities and technology supported the delivery of safe care.

Staff carried out daily safety checks of specialist equipment. However, some equipment found in theatres was out of date. We found 4 out of date catheters. Three out of the 4 items were out of date in 2023 in theatre 2. We raised this with staff who immediately removed the items. Data shared with us following our assessment showed staff carried out monthly care quality audits across all theatres and checked expiry dates of theatre consumable items.

Equipment used to deliver anaesthetic was not always checked in line with manufacturer's guidance. We reviewed the anaesthetic machine check logbook and saw 7 omissions in January and March 2025 in theatre 2. We observed 4 further omissions in the anaesthetic room 1. Checks of the anaesthetic machine should be performed at the beginning of every operating list. We raised this with an operating department practitioner who told us the book was still in use and the concern would be escalated.

The operating theatres were safe and fit for their intended purpose. The service had suitable facilities within theatres to meet the needs of patients for the type of procedure delivered. There were 23 theatres in the main block with 15 2-bedded recovery bays. The recovery area was safe and had all the right equipment to care for all patients including those who deteriorated or were at risk of deterioration.

There was a safe process for the management of sterile equipment and surgical instruments. This included a safe process for the storage and use of clean equipment and the safe removal and storage of used equipment. There was an enhanced decontamination area with offsite sterile services for the sterilisation of equipment and surgical instruments. Staff monitored stock flow regularly.

Complex patients were cared for in safe premises. Ward THH5 was an NHS renal surgery ward within the onsite private hospital with 36 beds including 16 side rooms. The nurses cared for very complex patients with high morbidity and the environment was safe for caring for these patients.

Records indicated facilities, equipment and technology were well maintained and supported staff to deliver safe and effective care. There was an in-house medical engineering service that arranged annual servicing of equipment and sent service reports to Band 7 nurses in all areas. Maintenance logs were kept, detailing estates' faults which were addressed in a timely way.

Staff understood their responsibility to ensure they segregated and disposed of clinical waste according to the trust's waste management policy. We saw the correct management of containers for sharps and the use of coloured bags to correctly segregate hazardous and non-hazardous waste.

Staff disposed of clinical waste safely. During our last inspection in June 2021, we issued the service with a requirement notice, because clinical waste was not always appropriately stored or disposed of in all clinical areas. At that time, we found sharps bins which were overfilled and unemptied. During this assessment, sharp instruments were appropriately stored, and sharps bins were assembled and labelled in all areas we assessed and not overfilled. The service had an effective system to manage waste disposal.

There was equipment for patients who needed extra support with moving and handling. There was bariatric equipment, walking frames and crutches available for patients to use on ward 407 and other areas where it was needed.

Staff carried out 3 monthly environmental and quality audits. Results shared with us following our assessment showed good compliance.

The service did have gaps in some nursing rotas at times but supplemented this as much as possible with bank staff, staff coming off supernumerary shifts and staff moving around to support gaps. Most of the gaps were due to unplanned sickness as vacancy rates for nursing staff were low. Staff worked together well to provide safe care that met people's individual needs. Mandatory training and annual reviews with staff were compliant with trust standards.

Although the service did not always have enough medical and nursing staff to meet patients' needs due to vacancies and sickness, efforts were made continuously to ensure the numbers were made safe. For example, the planned staffing for main recovery in theatres on day 1 of our assessment was 18 but the actual staffing was 14. A request had been put out for additional staff to be sourced through the hospital bank and senior staff helped to make up the numbers. Similarly, on ward 407 planned staffing was 7 staff nurses and there were 5 staff nurses on shift during our assessment. This was due to short notice staff sickness.

In other areas, the number of nurses and healthcare assistants did not always match the planned numbers, but actions were taken to find staff to fill gaps. Data showed actual staffing levels were less than planned staffing levels on most of the days in March 2025. Senior staff told us gaps in nurse levels was occasionally balanced by an increased number of healthcare assistants. Nurses were still there to lead and ensure care was safely delivered. Staff in the day case unit attended twilight shifts on wards to support day and night staff. Following the publication of the rotas, any short notice absence or unfilled shifts due to vacancies, long term sickness and maternity leave were sent to the staff bank as requests to fill.

The ward manager could adjust staffing levels daily according to the needs of patients. On day 1 of our assessment, staff were unable to adhere to a staffing ratio of 1:4 on the neurosurgery ward high dependency unit due to an increase in patient acuity. There was a patient requiring an increased level of care and there were 5 patients who required higher intensity care. We saw the ward manager, who had initially been allocated to carry out administrative tasks, work clinically to reduce the risk of short staffing and other staff were moved from various areas to support the ward staff.

Staffing concerns were discussed throughout the day. Senior staff held site meetings 3 times a day as a process for assessing and escalating nurse staffing concerns. There was a staffing dashboard which provided a site overview of actual staffing against planned staffing in all areas.

The overall staff sickness rate within surgical services was consistently at or below the overall sickness rate for the trust. However, theatre staff reported a lot of sickness including long term sickness which had a negative impact on staffing levels.

The service had low turnover rates for all staff. With the exception of spikes observed in February 2024 and, to a lesser extent, August and September 2024, the number of leavers in the surgery service was consistent with expectations. Turnover for surgery staff was lower than the trust's turnover for all staff.

The theatres were staffed in accordance with the Association for Perioperative Practice guidelines. Each specialty within theatres was managed by a Band 7 nurse or operating department practitioner (ODP). The main theatres were open 24 hours a day 7 days a week and were used for emergency cardiac, neurosurgery, liver and other surgeries. Out of hours, the planned and actual staffing for theatre recovery was 5 nursing staff, 1 healthcare assistant, and 2 porters in accordance with the staff establishment numbers. An advanced life support trained member of staff was always on duty over 24 hours.

Most staff were given annual reviews on time. Appraisals were used as assurance meetings with staff and protected time was given to allow for training. Staff discussed training and development and reviewed training requirements during appraisals. Appraisal rates across the surgical specialty were 89.2% which was almost in line with the trust target of 90%.

Students were well supported. Student nurses and ODPs were allocated a practice supervisor who had up-to-date knowledge and experience relevant to the student they were supervising.

Staff received training appropriate and relevant to their role. Staff were required to complete mandatory training which was comprehensive and met the needs of the patients and staff. Data showed the overall mandatory training compliance was 97.8% in theatres, 93.1% in ambulatory theatres and 95.2% in surgical wards. This exceeded the trust target of 90%. Mandatory training for both medical and nursing staff included but was not limited to infection prevention and control, fire safety, inclusion and diversity, information governance and safeguarding.

Staff could see their own mandatory training dashboard, access eLearning modules and undertake additional training that was of interest to them. Leaders told us they had a live view of training compliance. All mandatory training was tracked through the quality people and culture meetings. The teams were targeting staff groups where low compliance was reported.

Staff received the support they needed to deliver safe care. This included support to develop and improve services. There was a clinical education team who comprised of 1 band 7, 4 band 6 nurses and a group of healthcare assistants. A training and competency package was available for staff who needed them.

Staff at all levels had opportunities to learn. Senior staff arranged emergency scenario training which covered most neurological emergencies in theatres and other emergency scenarios. This training was mostly done on governance day or if there was any downtime because of cancellations. Anaesthetists carried out training on how to maintain a patient's airway.

New starters were given induction training to support them joining the team. The pre-assessment team had introduced 3 study days for new starters. Staff were required to be signed off as competent for assessing patients. Staff also received 3 months of supervised practice and had a competency book which covered all specialties.

International nurses were supported. The service had recruited internationally trained nurses who worked as healthcare assistants until they had received approval to work as nurses (obtaining their `PIN' number). They initially worked as supernumerary while they completed their competences. These were reviewed at 4 weeks, and they received support from a clinical educator.

The service assessed and managed the risk of infection well. Staff detected and mostly controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

There was an effective approach to assessing and managing the risk of infection, which was in line with current relevant national guidance. The trust had infection control policies and procedures to help control infection risk. These and other related policies covered the actions required by staff to minimise the risk of infection and cross infection in the hospital and the surgery service.

Staff received training in infection prevention and control (IPC). Compliance with IPC level 1 and 2 training was 89.2% for staff across surgical areas. This was slightly below the trust's target of 90%. Staff had access to personal protective equipment (PPE) including aprons, masks, and gloves in a variety of sizes. We observed most staff used PPE in line with the trust's policy. However, we observed 2 staff in theatres remove PPE without washing or decontaminating their hands which posed a risk of cross contamination. There was good compliance with trust uniform policy. All the staff we saw during our assessment were `bare below the elbows and dressed in line with the trust policy.

Staff worked effectively to prevent, identify and treat surgical site infections (SSIs). Leaders reviewed all incidents of SSI, comparing the service's performance against organisational and national benchmarks. They met with key stakeholders to ensure they took appropriate actions when care was not delivered as expected and made improvements. The hospital carried out minimal orthopaedic surgeries as these were undertaken at other hospital sites within the trust. From 2023 to 2024, the hospital carried out 17 hip replacements and there were no SSIs. A total of 276 repairs of neck of femur were carried out, and 4 out of 276 inpatients sustained a SSI.

The service was set to lead on a national surgical national trial called Rossini-Platform trial which aimed to reduce wound infections (SSIs) that occurred after surgery. It received funding from the National Institute for Health and Care Research (NIHR) and had recruited over 26,000 patients to test ways of achieving this. The trial was led by a Queen Elizabeth Hospital Birmingham based clinician and the Birmingham Clinical Trials Unit who helped experts understand how to reduce infections.

Action was taken to prevent infection entering the theatre area. Patients who were planned (elective) for operations had a MRSA negative swab result available prior to the operation taking place. No patients were admitted to the elective surgery wards without a negative MRSA status.

During our last inspection, we served the trust a requirement notice because staff did not always clean equipment after patient contact, and equipment was not always labelled to show when it was last cleaned. During this assessment, we observed equipment was cleaned after patient use and there was consistent use of `I am clean' labels across areas we visited.

People were protected from the risk of infection because premises and equipment were visibly clean and hygienic. Theatres and ward areas were noted to be visibly clean and well-organised.

There was an internal review of infection prevention and control. The hospital's IPC team undertook audits led by the facilities team. Specialties had oversight of these audits and further oversight was provided at the trust's infection prevention and control group. Compliance for hand hygiene audits was at 85.1% across all areas. There was an action plan to improve compliance.

The service did not make sure that all medicines and treatments were safe and met people's needs, capacities and preferences.

Arrangements for the safe management, use and oversight of controlled drugs were not being followed at all times. Two controlled drugs (CDs) were found out of date in ward 409 although had not been given to patients when expired. When staff were asked about regular stock management of CDs such as date checks, they were not clear about their roles and responsibilities. CD audits were undertaken by pharmacy every 3 months but failed to identify the issues picked up during this inspection. The last CD audit was 100% for ward 409 and 92% for ward 620. An audit of controlled drugs within theatres revealed 97% compliance. Where compliance was found to be low, feedback would be given to the area, and an action plan would be implemented. However, we found CDs were stored safely and securely with access restricted to authorised staff.

The approach to medicines did not reflect certain current and relevant evidence-based practice and professional guidance. Wards had allocated staff to support with stock management such as ordering and checking expiry dates. However, these staff were unsure when asked as to when they should dispose of stock near expiry date. On both wards 409 and 620 we found out-of-date medicines. These included a laxative which had been open after its expiry date and several medicines with limited shelf-life such as eye drops and used insulin prefilled pens. These were not dated when opened. This posed a risk to people as staff could not ensure the medicines integrity and if they were safe to use. This had been identified in the last 2 medicine audits completed by pharmacy in ward 620. Despite our findings both wards often scored overall above 75%, considered as good compliance.

Medicines for refrigeration were not always stored securely, and records of maximum and minimum temperatures were available but not always acted upon. On ward 409, records noted out of range temperatures in 11 out of 20 days. There were no records of actions taken in accordance with the provider's policy which stated: "Record and report any out-of-range observations to senior nursing personnel as soon as possible; follow the escalation procedure below if a temperature excursion has been identified." (Medicine Code, CD No: 443 - Appendix 4 Fridge/Freezer guidelines). This was not happening and therefore the service was not assured medicines were stored appropriately.

Room temperatures were not always checked where medicines were stored which meant the service could not be assured that medicines were safe to use. In both wards 409 and 620, staff told us when the room felt warm, they called the estates team to turn on ventilation. Room temperatures were not recorded and there was no room thermometer where medicines were stored. According to the trust's heatwave plan, departmental staff should complete a risk assessment to identify areas of risk and how to manage during periods of warmer weather. This was not undertaken so the service could not be assured medicines were being stored safely within recommended temperatures. In ward 409, we saw bottles of 2 litre sodium chloride 0.9% solution for irrigation stored on a window shelf exposed to direct sunlight. There was no assurance they were being kept under 25° Celsius in accordance with the manufacturer's instructions. The pharmacy team was made aware during the assessment. Following our assessment, we were told an established system was available for staff to contact the estates team. Appropriate temperature oversight was available in areas identified as having higher risk for ambient excursions.

Resuscitation medicines and equipment required in an emergency were available and stored in resuscitation trolleys, but these were not secure from potential tampering. Most emergency trolleys were not tamper-evident and were easily accessible to patients. However, the medicines within them were in tamper-evident sealed boxes prepared by pharmacy, kept in the bottom drawer of the trolley. The trolleys were checked daily by staff. The lack of tamper-evident mechanisms was known to senior staff because there was a replacement programme underway. We asked the trust to resolve this at our previous inspection, and we will therefore require the trust to update us on progress to complete this programme of replacement.

Staff completed medicines records accurately and kept them up to date. A patient's allergy status was routinely recorded and the electronic recording system issued pop-up alerts highlighting any allergies which supported safe prescribing. The medicines room had a keypad which was changed every 3 months. Housekeepers checked ward stock and replenished them as required.

Staff told us they had online access to relevant medicine policies, procedures, and guidelines. When asked, they were able to find and show us the hospital's antimicrobial guideline. There were effective processes for reviewing antibiotic prescribing which included documenting a reason for the antibiotic choice, contacting the microbiology team where appropriate and reviews at 48 to 72 hours after initiation of treatment.

There was a clear process for managing and reporting any errors or incidents involving medicines.

A patient told us, "I was in a lot of pain, they gave me morphine. They checked regularly. The NHS is the most fantastic service in the world."

There was support to nursing staff for medicines management. The clinical pharmacy technician was introduced on ward 409 as a role to support nurses with medicines management and to complete drug rounds. This freed up time for nurses to deliver direct patient care.

There were some good processes to enable patients to go home with required medicines. The ambulatory care unit had pre-packed medicines to take home readily available for patients following their surgery.