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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

At our last assessment we rated this key question inadequate. At this assessment, the rating improved to requires improvement. However, this still meant not all people were safe and protected from avoidable harm at all times, but progress was seen to be in the right direction. There were issues with patients records not being complete, high levels of nursing vacancies, long waiting times meant not all transitions were managed safely, and specifically for those patients with mental health needs alongside physical health concerns. The long delays for patients meant they were being cared for in circumstances that were not always safe, such as corridors and areas not designed for patients to stay for long.

However, when not using temporary escalation spaces, the environment, although challenging across a large footprint, was safe and well maintained. Infection prevention and control was effectively managed most of the time, but staff needed to challenge those who were not adhering to trust policy around uniform or hand washing. There were some failures to recognise issues within the management of medicines.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Although safety was a priority for staff and leaders in the service, risks around poor record keeping and risk assessments were not being addressed. If identified, missing records were not being reported or escalated to enable the problem to be a focus of attention. Although staff told us they had no fear of speaking up or raising concerns, some of these issues around record management had become commonplace and staff said they were rarely reported. Some staff said they reported issues which were of concern to them, but they were not always seeing a response. They also struggled, we were told, to find the valuable time to report things they knew should be escalated.

There was a culture or willingness to prioritise safety and learning in the department, but pressure from crowding, departmental change, and a relatively high staff turnover meant it did not get the attention needed. However, this was recognised by the senior leadership as a priority but needed support. The clinical practice educators (nurses and healthcare assistants) who supported the department had a fairly fixed programme of learning for staff. However, this needed to be re-evaluated in terms of what areas of practise for nursing competencies were now a clinical priority.

Staff were clear about what should be reported and found the system relatively easy to use. When there were serious incidents or urgent concerns, staff said they were usually involved in any investigation and asked for their input. Most of the staff we asked said they did not feel blamed or were treated negatively when things went wrong. Staff said they were supported by the managers and colleagues and treated with understanding. They felt lessons were learned from safety incidents and changes were made to reduce risks. They understood their responsibilities around duty of candour and when this should be applied. They knew this involved an apology to those affected as well as an investigation into certain adverse events.

A serious incident we investigated showed multidisciplinary staff involvement and how learning, change and improvement resulted from the investigation.

Due to crowding and pressure on the capacity of the emergency department, despite expansion and new elements to the service, there were not always safe transitions for people. This was for all patients but specifically for those with mental health needs where long waits in an emergency department were known to be detrimental.

There was a risk of patients’ transition to a ward or another service being problematic in terms of sharing information. Gaps in the patient’s records for risk assessments meant patients were being transferred to wards with incomplete notes or assessments. This was not in accordance with the NHS Code of Practice for record keeping.

Patients who had been admitted to the emergency department with both physical health needs, but also mental health needs were being held in the department for too long. There was a higher number of patients with mental health conditions seen in the department when compared with the national average. The trust saw around 5% of patients with mental health needs, which was around 1.5% more than the national median average, so this area was challenging in terms of patient management and resources. During our assessment, 2 patients had been in the department for several days when they needed to be assessed for mental health care. At other times in March 2025, 2 patients with mental health needs were in the department for over 72 hours. In February this occurred for 6 patients and in January for 5 patients. As recognised by staff, this presented a significant risk to the patient’s safety and effective treatment. This was an ongoing risk in the department as waits for mental health placements (managed by another NHS trust) were scarce in the area and wider region.

Staff were doing their best to care for the patients, but the aspects of patients’ poor mental health were outside of much of the skills and experience of staff. An experienced mental health nurse was in the department for support but was essentially supporting new admissions and those at risk. Staff spoke highly of this arrangement and the reassurance it gave them from having this experienced oversight for patients with mental health needs. Staff from the mental health service came to assess the patient more formally but were not always treating or managing the mental health concerns alongside any physical health concerns. This was not in accordance with the Royal College of Emergency Medicine mental health toolkit, the Royal College of Psychiatry guidance, or the National Confidential Enquiry into Patient Outcome and Death ‘Treat as One’ report. The delays to ongoing pathways for patients with mental health needs was on the department’s risk register and graded as a medium risk due to some mitigating actions and noted improvements in liaison with the mental health trust.

However, the notes for patients with mental health needs were becoming more comprehensive and staff were able to access most records from patients’ GPs. Background information or ‘red flags’ which would alert staff to important information were being well used in those records we reviewed. In other records we saw a history of safeguarding information for a patient with a long history of attendance and healthcare needs. We saw records to alert staff to the wishes of a patient around resuscitation or ongoing care or intervention. Staff were aware of the patient’s background and alert to their needs as early as triage, or records being updated in more detailed discussions with the patient and their family.

There were safe systems of triage and oversight of patients, but these were not always operating in a timely way. The triage times in the department were not meeting the clinical guidance for triage which was to see all walk-in patients within 15 minutes of arrival. Data showed the average time to triage all patients in February 2025 was 44 minutes. This was at the higher end of the time to triage over the last 6 months, although none of the data in that time met the 15-minute clinical guidance. September 2024 was the lowest at 35 minutes. Some of the problems in maintaining safe and timely triage was from a low number of staff with the right training to provide triage. When certain thresholds around patient numbers were reached or exceeded, a protocol was enacted to increase the number of nurses from 3 to 4 to reduce the risk of the delays, although staff said this did not always happen if staff were not available.

The trust had lower numbers of patients who reattended when compared with the national average. One indicator of patients being given the right care first time was in the number reattending the service within 7 days. For this trust (so across all 3 emergency departments) the trust saw fewer patients reattend within 7 days than both the regional and national average and had achieved this for at least the last 2 years.

To mitigate some of the other possible clinical risk from delays, patients were asked to use a self-check-in electronic service (known as e-triage). This was to give staff in triage warning of any reg flags for patients who had self-presented (walked in or been brought in) to the waiting area. Patients we met said they found it was easy to use. Patients who could not use the system were able to complete a form provided by the reception staff team. Doctors monitored the patient information in e-triage and clinical records after triage to ensure any patients with possible urgent health conditions were given a priority. This included, for example, patients presenting with chest pain or reporting significant pain. Data provided showed time taken to triage patients was around 10 minutes on average which was indicative of a thorough review.

Patients and those who might speak for them were asked for their views about ongoing care and transitions and this was considered when people were transferred or discharged into the care of other health or social care providers. There were policies and standard operating procedures to guide staff in safe systems, pathways and transitions, and ensuring they listened to people, but they were not always able to be met in the best way due to demand, capacity and crowding in the department.

The staff in the emergency department showed a good understanding of safeguarding and how to take appropriate and immediate action when needed.

Staff who undertook triage of a patient or rapid assessment said they would always have safeguarding on their radar in case of any signs of abuse or neglect. In an issue of possible neglect of a patient brought into the service from another care provider, staff acted quickly to notify the safeguarding team and request support, which was rapidly organised. The person who accompanied the patient was listened to and given time to share their own concerns. This patient’s records showed a good level of detail around safeguarding including historical information. The electronic patient record system produced a flag for staff to then be aware there were ongoing or previous safeguarding concerns.

There were mostly effective systems and practices to make sure people were protected from abuse and neglect. The trust had senior clinicians with responsibility for safeguarding of adults and children. They were visible in the department and staff knew how to contact them. However, we noted in records some possible missed opportunities around safeguarding. For example, there were patients who had arrived at the department who were intoxicated with alcohol and/or drugs. In these cases, staff had not always recorded whether they had asked the patient if they had responsibility for others, such as a child.

Reception staff were trained in safeguarding recognition and checked all patients under the age of 18 to determine if there were any concerns flagged. If so, nursing staff would be alerted and generally come through to the waiting area to get more information. Safeguarding contact details were available in the reception and staff knew who to contact if they had immediate concerns and knew nursing staff were already busy. If a patient indicated on a form or the e-triage system they had been subject to an assault, they were asked to speak to reception staff who raised a specific alert for the clinical team.

There was due regard given to possible abuse or neglect for people. Staff told us they would refer something to the safeguarding team even if they were not sure whether it was within the scope of their remit. They had no concerns about speaking up for people and this included those who accompanied a patient who gave rise to concerns about themself or others.

People’s rights were understood, and staff did all they could to keep people safe but recognised this was limited to what was in their power. They knew how their authority did not include detaining a patient who had capacity to make their own decisions, even if they were concerned the decisions were poorly made. However, this would not include patients making decisions which might lead to others coming to harm.

Updating of training in safeguarding was below the trust’s 90% target with a variable range of compliance from 64% to 100% in different clinical staff groups. The overall compliance for level 3 training, which was mandated for clinical staff in AE, was 83% in March 2025 which needed to be improved.

Training encompassed everyone who worked in the department or visited as part of their role. The 2 domestic staff and a porter we met had the full range of mandatory training including safeguarding and all 3 said they would have no issue with raising concerns if they saw or heard something about a person or from a patient which worried them. They were confident anything which worried them would be addressed.

There was a lack of evidence of comprehensive risk assessments for many patients. This was recognised by senior nurses as needing to be addressed but had not been tackled yet and was now urgent. In our review of clinical records, we saw constant gaps in all the records we looked at. For example, in 30 patients in Majors A and Majors C, there were 110 incomplete or non-started nursing records. There were 18 patients identified as falls risks, but only 7 had a risk assessment record. A 96-year-old patient had been in the department for 18 hours and had no risk assessments. Although a record had been made at 3.24am to request nurses to complete hydration, falls and skin risk assessments, none had been recorded. Another frail patient who had been in the department for more than 6 hours had no skin integrity record or other risk assessments. Three nurses told us they were too busy to maintain records. However, we did not see evidence of poor care or harm coming to patients, so we determined this was mostly poor record keeping rather than poor care.

Nevertheless, in the 2024 NHS Staff Survey, of the 51 staff in the department who had responded, 75% said they had seen errors, near misses or incidents that could have hurt staff and/or patients.

Clinical records of treatment provided was mostly adequate, but there were some areas of concern. In a clinical review of 7 sets of patient notes at random we found instances of:

• delayed pain relief
• delayed referrals to speciality services
• delayed antibiotic administration
• a failure to undertake serial electrocardiograms when indicated in suspected heart attack patient
• a failure to undertake serial troponin levels when indicated in suspected heart attack patient.

Following our feedback to the trust describing our concerns with clinical records, the trust reported the emergency department would be reinstating the safety checklist for patients in Majors and the resuscitation unit to endeavour to improve compliance in this area.

There were high levels of pressure ulcers being acquired by patients in the department from being kept in chairs or trolleys for extended periods of time. This was of concern given the issues we identified with patient records being incomplete. Evidence from the department’s risk register, where this was listed as an area of concern, stated there were an average of 13 each month in the 6 months from September 2024 to February 2025. This was a significant increase from 8 each month in the previous 6 months. The level of risk on the risk register had been reduced from 12 (medium) to 6 (low) even though this situation had worsened and not been resolved.

At our previous inspection we said the department must ensure there were clear processes to identify, assess and record any individual risks including any identified in relation to the bedrails used on patient trolleys and this was clear in trust policies and patient records. This was a breach of Regulation 12. On this assessment, there had been noted improvements in the way staff attended to patients with risks, but this time the recording of the risks was not adequate.

The trust’s policy around bedrails used with trolleys in the emergency department was they were automatically used for all patients to prevent them falling due to the narrow width of the trolleys. Should there be a clinical or other reason to not use bedrails, this would be risk assessed and should be indicated in the patient records. At the time of our assessment on site, there were no patients who had been indicated as not to be using bedrails. All of the patients we asked said they were fine with the bedrails as they meant they did not risk falling out. One relative of an older person who was confused said they were glad they were being used as their relative had a history of falling from bed at home.

There were tools to monitor deteriorating patients and risks were being acted on. The electronic patient record system created a national early warning score (NEWS) tool for each patient at triage. Staff updated the initial key metrics to monitor deteriorating patients or those already presenting with potential risks which triggered a more urgent review. NEWS data was more regularly updated than some of the other metrics, and in those records we looked through, staff had acted on increased scores where this alerted them to possible or emerging risks.

Patient risk was understood and there was a constant focus on patients being held in ambulances due to recognised risks from long waits. The department had created a new rapid assessment area called RAT 999 for patients coming by ambulance to ensure each patient was given an initial assessment. In RAT 999 a decision was taken about the patient’s onward placement, which could be back on the ambulance to wait until there was a place available to bring them into the department.

Handover delays of patients arriving by ambulance were reducing, but still not to safe levels. In published data for February 2024, 22% of ambulances arriving across the trust (so at all 3 sites) took more than an hour to effect handover. By February 2025 this had increased to 36% trust wide. However, at the Queen Elizabeth Hospital, albeit in unverified data, handovers of more than 60 minutes had dropped to around 23%. In November 2024, they had been almost twice that level. At the time of our assessment in March 2025, the local ambulance service reported to us its data on handover delays of more than 60 minutes from 1 April 2024 to 16 March 2025 as 28.7% for the Queen Elizabeth Hospital Birmingham. The average for the West Midlands region was 24.5%. The staff were clear about the patient on the ambulance being their responsibility and not the ambulance crew, although all staff worked together to support patient safety.

The service worked with people to understand and manage risks by thinking holistically. There was a multidisciplinary approach to issues where specialist advice and guidance was required to make sure people’s needs were met. This included supporting people who had needs relating to neurodiversity, such as dementia, a learning disability, or autism. The lead nurse for dementia was often in the department working with staff and patients to make sure people with dementia and their carers were better understood and able to be less anxious. They described to one of the doctors how to use a specific form for relatives or carers to help complete so the staff could better understand the patient’s needs when they had dementia.

Staff gave people guidance around risks and explained how to keep themselves safe. For example, in triage or clinical consultations with patients, staff explained how to manage risks from physical or mental health conditions but respecting the choices people made about their care and treatment. When people left the department to go home, staff gave them information about any risks from their condition or how it needed to be managed. This included from medicines, but also any equipment such as walking aids. They also were clear about patients either contacting their GP or coming back to the department if they were anxious about not being on the mend.

People were given chance to communicate their feelings and what mattered to them. We observed staff allowing people to communicate their specific needs, but also anxiety or distress and did their best to help reduce those. This happened as well with those who accompanied patients who themselves were anxious or worried about their loved one. At a triage session in the minor injuries unit, staff were kind and understanding with a patient but also asked the patient’s partner if they were okay.

The environment was managed safely with equipment and facilities well looked after and meeting people’s needs. There was a fully equipped resuscitation area, although considering this was a type 1 major trauma centre, it only had 6 bays, and all were being used when we were in the department. Staff said they were concerned this was a risk when the service was dealing with major incidents. NHS England data measured comparable emergency departments and the average for majors and resuscitation beds was 43, whereas this department had only 36. The service had a plan to create a further 2 resuscitation spaces using an adjacent room, although had no timescale of when this would happen. Otherwise, there were 4 bays in the area of Majors A directly adjacent to the resuscitation area which were allocated to step-down resuscitation patients. However, this meant patients occupying any of those bays in the event of a resuscitation patient needing one would have to be moved elsewhere. There was also a space which could be used in the acute medical unit.

Equipment used to deliver care and treatment was safe and suitable for the intended purpose. There was strategically sited emergency equipment, such as resuscitation trolleys, emergency suction and oxygen across the department and staff could tell us where the nearest equipment was located. There was a fully equipped resuscitation department with equipment for multiple events including delivering babies, treating cardiac arrest, strokes, and major trauma.

There were a number of rooms and cubicles used to admit patients with mental health conditions which may be treated alongside any physical health conditions. The mental health assessment room conformed to the guidance from the Royal College of Psychiatrists as it was ligature free, had doors which were not lockable and opened both ways to allow safe access. The furniture was safe from being used as a form of weapon. There were also 2 cubicles where up to 6 patients could wait at any one time, and these rooms were risk assessed as safe. As these rooms did not conform to stricter requirements around mental health assessment rooms, members of staff oversaw the patients, usually those staff trained in mental health nursing, who were stationed outside at all times.

Most patients were observed to ensure they were safe. There were numerous areas used for patients who were waiting for the next steps in their treatment or transfer. The main patient waiting area was overseen by reception staff who could see most of the room. Triage nursing staff otherwise had a constant presence in the area when collecting patients to assess. Other areas where patients were waiting were in thoroughfares used constantly by staff and others, so patients were not hidden from view. In the minor injuries areas, patients were visible to staff either at reception or staff offices. There were no incidents reported about patients coming to harm as they were not visible to staff.

Co-located services for patients were adjacent to the main AE areas. This included the X-ray department and other scanning facilities. The Same Day Emergency Care facility, which was run by the hospital’s medical team, was also close by to allow for joined-up working.

At our previous inspection we said the department must ensure there were daily safety checks of specialist equipment including equipment on resuscitation trolleys. This was a breach of Regulation 12. Since that inspection, the department had allocated responsibility for the daily safety checks to a band 7 nurse who was the nurse in charge of the department that day. Data showed compliance was all above 90% in regular audits and our assessment found all equipment we checked had been reviewed each day and a record kept to indicate it had been done.

The service did not always make sure there were enough qualified, skilled and experienced staff to safely manage the department. Not all staff received updated training, supervision and development. However, they worked together well to provide care that met people’s individual needs as much as possible.

There were significant numbers of nursing staff vacancies, although beginning to reduce with recruitment. In the 2024 NHS Staff Survey, only 13.7% of the staff who responded (51 staff) said there were enough staff to enable them to do their job properly. The trust average was 34.4%. Only 9.8% of staff said they did not have unrealistic time pressures, and the same percentage said they found the work emotionally exhausting. The trust average for these 2 questions was 27.4%/22.7% respectively. There were large gaps in the band 5 nurse establishment of around 16 posts (around 20%) still vacant after prospective new starters joined. Band 2, 3 and 4 healthcare assistants/trainee nurse associates had posts of around 24 (around 31%) still vacant after prospective new starters joined.

A shortage of established nursing staff led to elements of risk around safe patient care as not all temporary staff filling rota gaps were familiar with the department and how it operated. Rotas showed the skill mix of staff was not always as required and this was confirmed by staff. Staff told us most nursing and healthcare assistant shifts with gaps were filled with bank nurses, but the staffing levels were, for most of them, their highest worry. They said some of the temporary workers were regularly employed in the department, but the workload of the substantive staff was always increased, even if this was unintentional. Staff who were supposed to be not providing direct patient care, known as supernumerary, were often needed to work with patients to cover shortages in nursing numbers. The nursing staff shortage was on the department’s risk register and recognised as impacted by the high turnover of staff and the increasing demand for services and capacity problems leading to crowding.

Actions taken to mitigate the risk included the recent recruitment of 18 band 5 nurses and 3 anticipated internal transfers. The risk level had been initially assessed as high (scored 20) but reduced in February 2025 to 12 despite the actual mitigations being not yet actually achieved, although the situation was improving. The rate of nurse and nurse associate vacancies in March 2025 was 35.4% and 38.4% for healthcare assistants and trainee nurse associates (HCAs/TNAs). This was down from 41.6% and 44.2% in January 2025 and over 50% for HCAs/TNAs in November and December 2024.

The number of doctors recommended by guidance of the Royal College of Emergency Medicine was not being achieved and trust establishment numbers, if filled, did not meet this recommendation either. Locum and agency staff were used to fill rota gaps. There were 17.2 whole-time-equivalent (WTE) consultants in post from an establishment of 19 consultant posts (although NHS England data reported 16.2 WTE consultants). The Royal College of Emergency Medicine guidance for a ‘large’ department seeing from 100,000 to 150,000 patients each year (this department saw around 133,000 patients) stated the department should have between 25 and 36 consultants on the staff team, with potentially more trauma-trained consultants for a major trauma centre. The NHS England data for consultant to patient ratio showed a median average of around 7,900 patients for each consultant each year, whereas this emergency department had a median average of around 8,200 patients for each consultant each year and therefore more than some other emergency departments.

Governance papers provided stated how the department, as a major trauma centre, did not have a consultant (described as a trauma team leader) available at all times and within 5 minutes of a patient’s arrival. This was not on the department’s risk register and there were no actions. The paper also described nurses not being up to date with trauma training (recognised by the clinical education team) and computed tomography (CT)scanning times not being met.

There was good access to training and support for medical staff. A number of resident doctors we spoke with praised the quality of education, guidance and support from their consultant colleagues. There were teaching sessions each week and simulation training usually monthly. This was highly regarded. Doctors also told us how they could speak with their supervising consultant or other colleagues on any subject for advice and guidance. Consultants and resident doctors worked closely with foundation year doctors to ensure they felt confident in their decision making.

There were high but reducing levels of sickness in the department compared with trust target levels (but much the same across the trust). Sickness was running at 5.3% overall in February 2025 data against a trust target of 4% maximum. Of this, 3.5% was long-term sickness. However, this level of overall sickness had reduced from over 7% in December 2024 and January 2025.

Mandatory training had variable compliance with the trust’s target of 90% with a significant number of clinical staff not up to date with clinical life support training, but with most of the other subjects. This lack of updated life support training required improvement. The overall rate of compliance with all mandatory training for the department was 82.4% (improved from 77.1% in our previous report) and details were provided by individual course. This had slipped from 93% reported in October 2024. Looking at some of the more key elements of mandatory training gave these results for March 2025:

• Infection prevention and control – 94.6%
• PREVENT – 98.9%
• Resuscitation awareness – 98.2%
• Resuscitation clinical life support – 46.9%
• Sepsis (compulsory since the start of 2025) – 83%
• Conflict resolution – 91%

We were also told the training around trauma competencies at level 2 was exceptionally hard to obtain and achieve. Getting staff onto external courses was particularly difficult as the trust did not have an in-house course accredited. This was a specific challenge for the department.

Staff told us the shortage of substantive nursing staff meant they did not always get the opportunity to update their training. However, the trust had introduced an arrangement for staff who were now given 2 days a year of non-clinical time to update all training. One of the staff we met who was rostered for triage work said they had yet to have any triage training and were booked on in a number of months’ time. The clinical education team told us the training for triage was good, but there were problems getting staff signed off as competent.

Not all staff were receiving regular review of their work (appraisal) which also gave them the chance to discuss opportunities for progression, learning and development. Of the 162 staff listed on trust evidence as working in the emergency department (this excluded doctors who were required to undertake appraisal as part of their revalidation) 76.5% had their annual appraisal. This was against the trust target of 90% minimum. This ranged in staff groups from 67% for ‘additional clinical services’ (45 staff) to 100% which was achieved by the administrative staff (10 staff). In the largest group of 135 nurses, 74.8% had their annual appraisal and this required improvement. In the 2024 NHS Staff Survey, just 14.3% of those who responded (51 staff) said their appraisal left them feeling their work was valued by the organisation and just 18.5% said it had helped improve how they did their job.

At our previous inspection we said the trust must ensure all staff follow infection control procedures. This was a breach of Regulation 12. There was more work to do in this area for the department to be fully compliant, but this was moving in the right direction, and we considered the specific elements of the regulatory breach to be met. However, there were other areas requiring attention including breaches of uniform policy as it affected infection prevention and control and a lack of attention to policy requirements around handwashing, cleaning and some elements of current training.

The service mostly assessed and managed the risk of infection. Any patients who were tested as positive or showing signs of infection which could be passed to others were isolated as soon as possible. Some of the areas looking after majors patients had cubicles converted during the COVID-19 pandemic to have sliding doors to enable them to be enclosed against the spread of infection. This was used now where patients met the criteria for isolation. Other areas had access to individual rooms where infectious patients could be admitted. Some of these had signs to indicate the presence or risk of infection, but not all, or they were not being used. In Majors C, a patient had been admitted to a side room, but there was no indication on the door to the room to be aware of a possible infection. It was also closed which meant there was no observation of the patient as there were no windows.

Patients were otherwise screened at triage or rapid assessment for markers of infection such as temperature and resistance to certain medicines. The department was no longer carrying out mandatory tests for COVID-19 (which was not required by national guidance), but staff could test the patient if there were symptoms. Patients who were positive for COVID-19 or other infections were kept informed, and the protocols around where they could be treated in the hospital were invoked.

There were concerns around some staff not complying with uniform policy and other infection prevention and control requirements. Several staff were wearing wrist watches, and other jewellery which made hand-washing less effective and was not in line with uniform policy. We saw limited handwashing or use of hand gels from some staff. Staff also did not always challenge other healthcare professionals in their department who were not following infection prevention and control rules or uniform policy. Some staff carrying out cleaning of beds and equipment after patient use were wearing no personal protective equipment such as gloves or aprons. There was more to do with training in infection prevention and control with 95% compliance at level 1 but only 66% at level 2.

The department was mostly visibly clean, and cleanliness was well maintained. However, we found some visibly dirty equipment in the mental health assessment room. We spoke with 2 of the domestic team who were working hard to maintain a clean and well-maintained department in a busy part of the hospital. The department was open 24 hours a day all through the year and there was the most footfall from people and staff of any part of the hospital. The domestic staff knew their duties well and said they were supported to do a good job. They had all the equipment they needed and had been trained well at induction and this was regularly updated.

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

Although the provider had systems for appropriate handling of medicines to ensure people were given their medicines as prescribed, there were some issues with storage. Not all critical medicines were safety managed. Staff knew how to contact pharmacy for support and advice. However, given this was a major trauma unit, there was no clinical pharmacy service based within the emergency department to work as part of the multidisciplinary team, which did not follow the Royal College of Emergency Medicine recommendations. This was part of a current business case.

Staff could not demonstrate how relevant information, such as if people were taking critical or high-risk medicines, was communicated to clinicians to ensure these were not missed. This was of particular concern when people were referred to urgent care to be seen by a GP where people could be left waiting up to 3 hours with no oversight by any of the emergency department team. Some of the medicines incidents reviewed showed people missing critical medicines, such as Parkinson's medicines, clozapine and anticoagulants which could have compromised people's medical wellbeing.

The first point of contact for people attending the emergency department was a nurse coordinator. People's medical history including allergies were checked on first contact with the triage nurse. However, medicines reconciliation was only completed once people were in the consultation stage.

Actions required around potential blood clots were taken in records we reviewed. The patient electronic record system mandated that risk assessments for venous thromboembolism were done within the first 24 hours of patients being admitted. On all records seen these were completed promptly and medicines were prescribed appropriately when needed.

Although not mandatory, there was no clinical pharmacy service based within the emergency department. However, it was part of an ongoing business care. Staff told us they knew how to contact pharmacy for advice and support but having a pharmacist within the department would be welcomed to support around medicines issues and staff training. The Royal College of Emergency Medicine recommend the use of dedicated emergency medicine pharmacists and pharmacy services. This was to work as part of the multidisciplinary team to help provide clinical and operational support for the safe and efficient delivery of care to patients in A&E. A pharmacist from the acute medical unit (AMU) attended the emergency department to undertake the medicines reconciliation (the process of gathering a complete list of people's prescribed medicines) for people who had been referred to the medical team. This helped to improve the flow and transfer of patients out of A&E into the AMU, but they were not part of the A&E team.

We reviewed electronic records for patients which showed positive contributions to patient care by pharmacists.

Medicines used for resuscitation were available but were not in tamper-evident trolleys and not always stored in areas where they were overseen at all times. This was a trust-wide issue currently under review. The medicines themselves were in tamper-proof sealed boxes prepared by pharmacy. Although the trolleys were checked daily by staff, they were not tamper-evident, and some were in areas easily accessible to patients. One trolley which was in a short corridor and not overseen so the boxes could be easily removed was relocated by staff at the time of our assessment to their clinical room for more security.

Medicines were stored in clinic rooms or in cupboards within staff rooms. However, we were concerned that safe storage temperatures were not always maintained or risk assessed. Medicines were locked and secure with access only to authorised staff. However, in Majors A the clinic room felt warm, and staff told us when the room felt too hot, they called the estates team to ask them to turn on ventilation. Room temperatures were not recorded or checked where medicines were stored. In the trust's heatwave plan, departmental staff were required to complete a risk assessment to identify areas of risk and how to manage during periods of warmer weather. However, this risk assessment had not been completed.

Not all medicines needing refrigeration were safely stored or checked for expiry. This had not been recognised through audit. These medicines were stored securely with records available of temperatures monitored each day. However, in Minors we found liquids not dated when opened as they should be, and out of date medicines in the fridge, 1 of them frozen on the bottom of the fridge. Staff told us there was no pharmacy support in this area and the nursing staff did the medicines management. However, in the medicines audits completed by pharmacy, Minors often scored over 75%, which was considered good compliance.

There was a lack of accountability for some checks of controlled drugs, and this not picked up at audit. Controlled drugs (CDs) (medicines that require more control due to their potential for abuse) were stored safely and securely in the resuscitation area with access restricted to authorised staff. When staff were asked about regular stock management of CDs, such as date checks, they were not clear about their roles and responsibilities. Two controlled drugs were found out of date, although none of them had been given to patients after they expired. CD audits were undertaken every 3 months by pharmacy. The last CD audit was 76% with minor recording errors noted and no major issues identified.

Staff told us they had online access to relevant medicine policies, procedures and guidelines and this was observed during this visit. A policy for rapid tranquilisation (when an injectable medicine was used to help calm a person who was distressed) was now available (it was not at the time of our previous inspection) and when requested staff were able to show this. There was a sepsis pathway and guideline and all recommended antimicrobials under the guideline were stocked and available for use.