Birmingham Heartlands Hospital

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• 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 rated safe as requires improvement. While there was a strong focus on safety by staff and leaders, circumstances limited their ability to control all risks. Due to crowding in the department caused by the demand for hospital beds, the service was not able to manage patients' risks safely at all times. The environment was not fit for purpose which had had a significant impact on the safety of the department and limited leaders' ability to make improvements. There were not enough staff to care for the numbers of patients, particularly at times of crowding. At our last assessment we rated this key question inadequate. At this assessment, the rating has changed to requires improvement. This meant people were not always safe and were at risk of avoidable harm.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

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 at all levels spoke openly and honestly about incidents and while there was a sense of the department's responsibility for mistakes they did not criticise or blame others. Incidents were taken seriously, and staff were confident to report mistakes.

Concerns could be raised by every member of staff on the trust's electronic incident management system on which all staff had received training. Staff told us that they usually got individual feedback about concerns that they had raised, and that serious incidents and themes were discussed in handovers. One member of staff said that immediate learning points were provided soon after an incident meaning that the information was fresh and relevant to them.

Incident investigations were based on the national Patient Safety Incident Response Framework and generally took place within the required time. Those investigations that were taking longer were subject to monitoring. When required, duty of candour requirements were met, and we saw examples of correspondence with families that were appropriate. Duty of candour responses were always done within the time required.

Incidents were discussed and publicised at the daily safety huddles, shift handovers, team meetings and clinical governance meetings. The latter took place across the Heartlands and Good Hope sites meaning that learning from incidents was shared. There was a newsletter in which incidents and key learning points were discussed.

While there was a high level of incident reporting, reflecting the risks in the department, staff told us some risks, such as those associated with crowding, waiting and the environment were underreported.

There was a bi-monthly mortality and morbidity meeting involving the consultants, specialist and some resident doctors. They discussed any deaths that had happened unexpectantly in the department to identify any learning and reduce the risks to patients. After our site visit, we requested and reviewed 3 sets of minutes from 2024 and 2025, and they were of good quality.

The notes recorded incidents that staff had told us about and explained what was being done in response. We noted that human factors were considered both in the discussions and the proposed responses.

While the service worked well with people and healthcare partners to establish and maintain safe systems of care, due to the number of patients attending there were not always safe transitions for people. People often waited too long to go to other parts of the hospital for assessment and treatment and patients with mental health problems were being held in the department for far too long before leaving for more suitable places.

There were systems to triage patients, both those who arrived by ambulance and those who walked in. For these ‘walk in’, or ambulatory patients, they were met at the front door by a nurse who spoke to them and assessed whether the department was the correct place for them to be treated. Patients were then sent to be registered and undergo a more formal assessment process, or, in many cases diverted to other providers such as their GP, an urgent care facility or a pharmacy. We saw this system working effectively and we noted that a seriously injured patient who was waiting to be spoken to was quickly identified by the nurse and hurried through to the majors area of the department to be assessed.

This approach was used to quickly identify those patients who might be seriously unwell as well as to cope with the high number of patients for whom the department was not a suitable place for treatment. The local population had a particularly low rate of registration with general practice. Even those who were registered often preferred to seek their healthcare from the emergency department at Heartlands because of the reputation for good care it had in the local area. Together with high levels of depravation and chronic ill health this resulted in high numbers of patients attending the department with primary care needs.

The time to triage patients was not always in line with the target but had significantly improved. The target was for ambulatory patients to be triaged within 15 minutes but historically the department had significantly underperformed against this metric with times, during 2024 sometimes exceeding 100 minutes. However, with the introduction of new processes, and staffing models that addressed the busiest times there had been a month-on-month improvement. For the last reporting period we saw, in January 2025, the average figure was 17 minutes.

There were detailed records for patients with mental health needs. We looked at the records of patients with known mental health needs and spoke to staff about how they would identify and assess patients about whom they had concerns. Records were detailed and complete and included assessments of capacity. Staff were knowledgeable of the law and spoke confidently about how they would make assessments, including reassessments if a patient’s capacity altered, such as in a case of intoxication.

There were sometimes delays for mental health patients. For patients who presented in mental health distress, staff spoke highly of the prompt and effective service provided by the Liaison Psychiatry Team which almost always saw patients within the 1-hour target agreed between the providers. However, if they were not able to immediately discharge a patient, these patients always breached the NHS 4-hour constitutional waiting time standard while waiting for assessment by on call psychiatrists and home treatment teams. This impacted the patients as they were cared for in an unsuitable environment with risks to themselves. There was sometimes also disruption to the care of other patients due to demand on staff time and resources although they were medically fit, as well as disturbance to the department. This issue was on the departmental risk register and senior management spent a lot of time liaising with other providers and commissioners to encourage the transfer of these patients to more suitable care.

Children needing enhanced levels of care were transferred for definitive treatment to specialist children’s hospitals. This was always done using a ‘retrieval’ model where the specialist hospital came to fetch the patient. Should a child become so poorly that they needed a machine to breathe for them, support with intubation was provided by staff from the hospital’s paediatric wards and the intensive care unit.

Many patients waited a long time for transfer to other parts of the hospital. Some of these delays were waiting for staff from the specialities to come and see them but they were mainly waiting for beds to be available. The provider had introduced processes such as the ‘push model’, employed navigators and flow coordinators to deal with barriers to flow, and had doctors from specialities dedicated to the department at busy times. But fundamentally the problem was that spaces in the rest of the hospital only became available when another patient left.

The layout of the department meant some care could not be efficiently managed. Some staff told us of delays in assessing and treating patients with a fractured neck of femur. It was clinically recognised for the best outcome that these patients have surgery on the day of, or the day after admission to prevent negative outcomes. Some of the delays were because the layout of the department meant that it was difficult to manage these patients as what they needed was scattered about. We were also told that it was difficult to get the patients seen in the department by doctors from the trauma and orthopaedic team. Patients then stayed in the department longer than they needed to and might have missed getting onto the next planned trauma list.

A high number of patients came back to the department for various reasons. The department had a higher than expected 7-day reattendance rate. The provider identified that as well as patients leaving because they were frustrated by long waits this was affected by frequent attenders, some of whom were visiting the department to access wound care as local GP practices were no longer funded to do this. Where children left the department without being seen, safety-netting was carried out through a review by senior staff. This was meant to happen the next day, but this target was not always met because of pressures on staff.

The service worked with people and healthcare partners to ensure that they lived in safety, were free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately. However not all staff were up to date with refresher training.

The hospital had improved safeguarding processes and introduced better governance.

All staff we spoke to showed a good understanding of safeguarding. They could tell us of the different kinds of abuse and what they would do to report concerns. Most clinical staff could give examples of when they had reported a safeguarding concern. Staff who had a specific role or responsibility for safeguarding were always familiar with the changes that had taken place and could give detailed examples of safeguarding concerns they had been involved in.

While staff were confident and knowledgeable, mandatory training figures for safeguarding demonstrated that not all staff were keeping up with refresher training. Figures for the basic, level 1 safeguarding training done by non-clinical staff, were low at 60% for the department which was well below the trust target of 90%. However, the level 3 training for clinical staff was 89%, for junior doctors 82% and for staff in the children’s area 93%. Further data showed that for nursing staff the level 3 training was 99%.

Staff described how to protect children and young people and adults who were at risk of abuse. They knew how to report safeguarding concerns to other agencies including how to make a safeguarding referral to the local authority. For example,1 nurse told us “I would complete the adult or child safeguarding referral, which goes to the hospital safeguarding team. They add comments and advice for us, and they send a follow-up email about the outcome and whether the case is closed.”

During our inspection we asked about any current safeguarding concerns in the department. It was clear from the examples that we saw that staff, particularly in the children’s area, were alert to “red flags,” tenacious in their conversations and we saw several cases where this was progressing to follow-up by social services.

A staff member from the children’s emergency department provided examples where they had contacted the police when they had concerns about children being taken away by their carer without being treated. They described how the police carried out welfare checks on the children at home and returned them to the hospital for treatment where there were ongoing concerns for the child’s health. Staff we spoke with in the children’s emergency department knew how to identify children at risk from violence and exploitation and worked closely with a youth work charity which supported children and young people presenting in emergency departments. A form was available to hospital staff to screen children at risk of exploitation, which was sent on to the local authority safeguarding hub for children.

Some medical staff needed to work more closely on concerns around safeguarding with the highly experienced nursing staff. A staff member in the children’s emergency department told us nurses used their experience to support medical staff to identify children at risk of abuse. They felt the requirement of junior medical staff to seek advice from the consultant on duty sometimes resulted in delayed decisions about safeguarding concerns. However, in practice nursing staff were trained, experienced and competent to provide this type of guidance and often the best placed staff.

A parent told us hospital staff had referred her child’s fracture to the local authority safeguarding team who were able to quickly establish the child was not at risk of harm.

There was good feedback from referrals to assure staff action had been taken. A staff member working in the emergency department for ambulatory assessment, told us hospital safeguarding leads gave them feedback about the outcome of safeguarding referrals either using email or in person. Learning from ‘missed opportunities’ was shared over safety huddles to prevent this from happening again. For example, a staff member told us “The educational lead for safeguarding attended our handover this morning and informed us about a case we missed 5 days ago for a young person who had an old injury. We understand now why that needed to be reported, even though it was an old wound and there were no concerns about treatment.”

There were identified safeguarding leads for both adults and children, and they worked closely with other departments which had responsibility for education and the implementation of external recommendations. The safeguarding lead maintained a list for child protection information sharing purposes. This was checked daily to ensure information was followed up and shared in a timely manner with local authority teams to make sure children received social care follow-up.

Staff worked closely with all professionals involved. The hospital’s lead nurse for safeguarding adults told us hospital staff worked closely together with the Local Authority Designated Officer. They used a ‘whole family’ approach for safeguarding concerns and incidents that were classed as “High Potential for Harm.” We were told hospital safeguarding leads were responsible for reviewing every safeguarding referral within 24 hrs, to check action was taken to ensure the person’s immediate safety. There was also review as to whether a patient’s mental capacity to consent had been assessed. All referrals were logged and quality assured. The hospital safeguarding team had recently improved their audit tool to ensure it was person-centred and legal requirements and processes were met.

Risk assessments for vulnerable people were undertaken. The hospital submitted an under 18 years risk assessment compliance report to the trust’s safeguarding board every month. This was part of a set of reports that was previously required to be reported to CQC, but the provider had taken up themselves as an assurance mechanism. In addition, there was a vulnerability activity report which was both at site level and broken down to wards and departments. The highest numbers of safeguarding reports were from the emergency department as was not untypical. We noted there were actions to increase awareness of standards and compliance across the hospital although these were not necessarily applicable to the emergency department.

Staff involved with patient safety were effectively trained. A security guard told us they were trained in de-escalation and physical interventions. They described that 99% of the time verbal de-escalation was successful, and they would gradient-up to “gentle hands on”. They knew when to move to more restrictive physical interventions to either escort the person off the hospital premises, or to stay on the premises with support to receive medical treatment. They said verbal intervention was paramount because people in the hospital were vulnerable, and they would always liaise with the medical teams. The security guard said they were not involved in writing incident reports as incidents were recorded on body cameras. Neither were they involved in hospital incident debriefs.

There were policies around use of medication for restraint and other intervention practices. At our previous inspection we had made a requirement that the trust should introduce a rapid tranquilisation policy, and we saw this had been produced and was being used. In respect of children there was also a “Children, Young People and Adult Chemical Restraint’ Clinical Guideline” and this included a STOMP (Stopping Over-Medication of People with a Learning disability, autism, or both) element. It was used in conjunction with the Children, Young People and Adult Restraint Policy and Procedure.

Because of crowding in the department caused by demand, the size and configuration of the building, and the lack of capacity in the rest of the hospital the service was not able to manage patients safely at all times. Assessments, observations and treatment did not always take place in a timely manner and put patients at risk.

The provider recognised the challenges and risks in the department and these were documented, discussed and changes and mitigation implemented. Leaders and managers worked innovatively to respond to changes in risk caused by changing demand and capacity, but they were not able to reduce the risks to levels they were satisfied with.

There were delays to handover patients from ambulance personnel. Although on the days of our visit there was a particularly low number of patients arriving by ambulance, staff told us, internal reports noted, and we knew from data that ambulances experienced significant delays in handing over patients. There were often queues of ambulances parked outside of the department and sometimes around the hospital site waiting to handover. There was an ambition to handover within 15 minutes, but patients were often on ambulances for several hours before they could be brought into the department. Figures showed an increase in handover times greater than 8 hours through 2024 with a peak in October. Recent data suggested improvement, but because the numbers were affected by several factors, more time was needed before conclusions could be drawn.

Changes had been introduced to make triage processes safer for patients. The department had addressed this through the introduction of a Rapid Ambulance Assessment (RAA) area providing rapid assessment and treatment. This was located adjacent to the ambulance bay and had 4 curtained cubicles and an area for a staff base. There were dedicated staff which included ambulance triage nurses, a doctor who was the senior clinical decision maker, a healthcare assistant to support them and a Hospital Ambulance Liaison Officer (HALO) who was a paramedic working for the local NHS ambulance trust but funded by the emergency department. The ambulance crew’s role was also specified within the standard operating procedure for the RAA.

The process aimed to assess all patients within 15 minutes of arrival by bringing them into the RAA area and a triage nurse assessing them. Patients were assigned a Manchester triage score, if necessary given treatment or pain relief and the nurse would order diagnostic tests. On the basis of this score, and with the capacity of the department in mind, the patient was then streamed to a suitable area within the department or returned to the ambulance. If returned to the ambulance, a suitable observation process would be carried out by the crew that was within their scope of practice.

The doctor in the senior decision maker role was available to review observations, make clinical assessments, order diagnostic tests and initiate early treatment plans. They also provided the vital role of a senior clinical assessment early in the patient’s journey to identify those who were seriously ill. The HALO liaised with the ambulance crews to ensure patients were immediately registered, coordinated their return to the ambulance, and if appropriate their transfer to other assessment units within the hospital. They also ensured observations made by ambulance crews were entered on the trust’s electronic patient record system.

Patient records for RAA were to a good standard. We looked at a sample of records for patients that were in, or had been transferred from the RAA and they were to a good standard. Observations and assessments were comprehensive and early warning scores were always accurately recorded and repeated.

Staff and leaders were positive about the new system and believed patients were benefitting from its introduction. However, as the system was recently introduced there were no figures or trend data yet available to support this.

There was a risk to unwell patients in crowded waiting areas. Patients arriving at the department by their own means presented at the main entrance. They were registered, triaged and streamed into the majors area or seated in the waiting room for further assessment or treatment. Because of the large numbers of patients arriving, the limited space for seating, assessment and treatment, the department had identified there was a risk of sick patients not being recognised on arrival or if they deteriorated while in the department. This was the highest risk noted both on the risk register and by staff and managers. Aside from the waiting area often having twice as many patients than there was seating capacity there were concerns about the monitoring of patients and harm occurring from long waits, delayed treatment and cross infection.

The department had introduced a process to mitigate some of the risks and address some of the underlying causes including patients presenting at the emergency department when more suitable treatment could be found elsewhere.

Patients making their own way to the department were risk assessed on arrival. All patients attending the department on foot were required to queue outside of the department before being spoken to by a nurse navigator. This initial conversation took place before the patient entered the department to be registered. It served to both identify those patients who needed immediate attention as well as direct those whose treatment could be better provided by another service or in their own home. The system worked with patients being brought into the department or turned away through redirection or advice. In 1 instance during our assessment visit, the nurse noticed a patient joining the queue who appeared to have a serious injury and brought them straight away into the department for assessment.

Due to excessive demand at times, not all patients were seen within the required clinical time for safe triage of 15 minutes. Once registered, patients were seated in the waiting area and called to be triaged. This was meant to be done within 15 minutes, but this was a standard that was not always achieved for every patient. The figures had improved since the introduction of the system, but governance reports still showed an average of 27 minutes for December 2024. The risk was mitigated to some extent by all patients having been seen for an informal assessment at the front door, but this did not fully address the problem.

Not all patients were able to be safely accommodated in the waiting area and some areas used were unsuitable for safe care. Once triaged, patients were assigned a Manchester triage score and streamed to a suitable area in the department or in most cases to the waiting room for further assessment or treatment. Many patients waited a long time in this area and frequently the number of patients exceeded the number of seats available. This presented a risk of patients deteriorating while they were waiting and most staff, when asked, told us that this was the greatest concern they had about the department.

Mitigation was provided by a safety triage every 30 minutes, with observations every 2 hours, but the risk register noted that there was “little assurance that this is taking place.” Other mitigations included the scheduling of a band 7 nurse to have a “helicopter view” of the area to identify and address risks. However, this role in itself could not always be provided when there were staffing challenges.

Aside from deterioration other risks noted by the provider included limited access to food and drink, and a risk of developing pressure ulcers. They also recognised the risk of cross infection through crowding, and violence and aggression because of frustration with the waiting times and the patient environment. Again, there was mitigation, but some approaches were frustrated by the building as more space could not be found for more seating. Sometimes patients were required to share a cubicle space and patients who needed to be kept isolated because of their susceptibility to infection were sometimes put in the plaster room as it was the only space available. Similarly, we were told that patients receiving intravenous antibiotics had been placed in the departmental seminar room as it was the only space available.

Within the majors and resuscitation areas of the department, patients were still at risk because of the root cause of crowding in the department. While there were more staff to attend to their needs, and during our visit we saw patients were responded to quickly, people spent far too much time in the department. It was recognised that stays in the emergency department over 8 hours resulted in increased mortality and morbidity and this was something the department recognised in the risk register.

Some patients had their assessment and treatment, both within and outside of the department delayed with a risk to time-critical treatment. The 4-hour standard of 78% of patients being seen in this time (the reduced post pandemic interim standard) was met only 57% of the time in December 2024, although this was a performance that was improving month on month. Some areas such as Clinic 9 and the children’s area met the target but others, particularly majors and resuscitation, which were constrained by bed availability in the rest of the hospital, performed poorly. This, as noted in the department’s risk register, introduced risks that time critical treatments might be delayed.

Patients were held when needed in temporary escalation spaces which increased risk to safe care. When the department was at capacity, there was an operating procedure for the non-cubicle care of majors patients which essentially placed patients on trolleys in non-clinical spaces, for example corridors. There were clear guidelines as to which patients were most suitable, but it was recognised that non-cubicle care introduced risk for any patient. It was known that they have a greater risk of an adverse outcome. Identified risks included lower staffing numbers meaning less staff were available for observation, assessment and treatment. Less space meant there was less room to work in an emergency and basic equipment such as oxygen and suction would not be readily available.

There were high risks from unscheduled care for seriously unwell patients. Within the children’s area there were similar challenges but to a lesser extent. However, because the area was smaller, it meant that a modest rise in patients attending could crowd the department. During our visit 2 poorly children arrived in a short time and while more staff immediately attended, had another very sick child arrived there would have been difficulties. Trust documentation stated there was in increased demand from highly and critically ill patients and that more than 1 patient had been nursed in the same resuscitation space.

Staff used nationally recognised tools to identify deteriorating patients. These were recorded electronically, and scores were automatically totalled. We saw where adult and paediatric early warning scores were high, these were acted on appropriately and reassessed mostly in line with guidance. Staff acted quickly when patients were showing signs of deterioration. All notes we reviewed were contemporaneous, had a good level of detail. Early warning scores had been calculated and where appropriate the patient’s care escalated. At no time during our inspection was there a need to express concern about a patient's condition to the staff.

When asked about safety in the department, most staff, particularly those who worked there, identified the ambulatory area as being the most worrying and this was always the answer from senior staff. This was largely on the basis that the department was frequently crowded with long waiting times and many of the patients who presented there could be very ill or seriously injured but had chosen, or been forced, not to arrive by ambulance.

There was good attention to safety through regular gatherings and handovers. Safety huddles took place during nursing and medical handover and as needed throughout the day. Extra huddles could be initiated by the nurse or doctor in charge as well as the hospital ambulance liaison officer.

Doctors’ handover meetings took place at 8am and 10pm and were attended by all medical staff. Nursing handovers were at 7am and 7pm and involved all staff coming on shift. As well as allocating staff to roles there was a safety huddle where the current risks in the department were discussed. There was a separate handover for band 7 nursing staff afterwards.

In reality, most patients were observed when in the department. Despite the need for patients to be accommodated in areas of the department that had sometimes been repurposed, much thought had been given to how nurses were deployed.

The department recognised the risks associated with delayed ambulance handovers and this was documented on the risk register. Identified risks included delay in time critical treatments for conditions like stroke and heart attacks as well as potential harm caused by dehydration and pressure damage to patients’ skin. The department also recorded the risk to patients in the community caused by emergency ambulances being held up at the hospital.

While the service detected and mitigated risks in the care environment, it did not always have an estate which was fit for purpose, or equipment and facilities to support the safe delivery of care.

The department was no longer safe at all times to manage the patient demand. The department was built in the 1990s for 60,000 patients each year but in 2024 there were more than 150,000 attendances. The department had been expanded, but because of its location some of this expansion had had to be into other parts of the hospital. For example, the Clinic 9 area that assessed and treated patients with minor injuries was located in the main hospital building some distance from the hub of the emergency department. Leaders and managers identified this as posing risk, which they were aware of when the area was commissioned but had limited other options. During our visit we saw patients with injuries making their way to and from this area, and some were clearly in discomfort from having to walk a good distance through the hospital.

There was frequent crowding with patients having nowhere to sit and staff not able to find space to treat and assess them. Although it was not the case during our visit, patients on trolleys frequently had to be accommodated in corridors rather than cubicles. Space constraints, including corridor and doorway sizes meant patients needed to be on trolleys rather than hospital beds because of the need to evacuate in the case of a fire. While risks to these patients was mitigated by monitoring, repositioning and providing drinks, the risk could not be entirely eliminated.

The layout of the department did not support the flow of patients through the department. Although the improvements made to mitigate risks associated with demand were well thought out, the fundamental structure of the department did not allow the siting of clinical areas in a way which promoted safe and effective care.

Some areas were clearly unable to accommodate patients safely and comfortably. While suitable seating, including bariatric chairs was provided in the ambulatory waiting room, the area was frequently too small for the number of patients attending and many stood or in some cases sat or lay on the floor. While vulnerable patients who had been sitting a long while in the ambulatory area were identified and provided with reclining chairs when available, this mitigated rather than eliminated the risk.

Staff frequently told us how the size and configuration of the department, and particularly the ambulatory area frustrated staff’s desire to keep patients safe. Some staff talked of finding it really difficult when they interacted with patients because they were sorry for the lack of space and facilities, particularly in the ambulatory area. Within the children’s area there was previously a separate waiting room for young people, but this had been decommissioned and was awaiting conversion to a clinical area. This reflected the capacity demands and space constraints on the department and how they affected patient care.

The hospital had created extra clinical bays and cubicles within the existing building, but this had required concessions in regard of their size and layout. While mitigating the risk to patients of not being cared for in a cubicle or bay, it introduced other risks such as caring for them in cramped conditions and of cross infection.

There was no suitable area to keep safe those patients who needed to be protected from infection. Immunosuppressed cancer patients who attended the department and were at risk of infection were frequently sat in the plaster room as an isolation measure.

The resuscitation department sometimes was not able to cope with demand for this specialist care. We were told that at times, when the department had no flow there were no available resuscitation spaces. This meant on occasion patients had to be moved from resuscitation and cared for in unsuitable areas without the necessary equipment to make way for sicker patients. We saw this happening during our visit, even though the department was unusually quiet.

The buildings were old and access for maintenance was difficult because the department was so busy. It was difficult to keep areas, including some clinical areas, clean. Staff and patients reported toilets in the waiting room to be frequently blocked, and this was the case at times during our inspection. The department had plans to remove paper towels and replace them with electric hand driers because paper towels they were sometimes used and then flushed rather than put in the bin.

Due to limited space, some areas of the department were crowded and untidy with necessary equipment and furniture taking up space, restricting movement and getting in the way of staff’s work. In contrast other areas, usually those that had been refurbished or repurposed were tidier with a better and safer working environment. However, most areas were visibly clean and domestic staff responded quickly when areas had become dirty.

Not all external areas around the department were safe from obstructions, including vehicles. The children’s area of the department was adjacent to the main department and could be reached through secure doors using a security key or intercom. The entrance for children and their carers was separate from the entrance to the adult emergency department and accessed using an intercom. There was also a separate ambulance entrance for children. Some staff expressed concern that the pedestrian route to the children’s entrance was through an area where the pavement was frequently obstructed by parked trust and contractor’s vehicles. We saw this was the case during our visit and that it was necessary to walk in the roadway.

There was a dedicated mental health room for adults which largely met the requirements of the Royal College of Psychiatrists. However, the furniture, while heavy and difficult to lift, was moveable and it did not have an alarm although staff told us this was mitigated by the room being under CCTV surveillance.

Although it was not mandated, there was no separate mental health room in the children’s area although we were told there was a plan for one should money be available. There was an identified cubicle that could be used to mitigate the risk of self-harm by removing risky items.

There was mostly enough equipment for staff. When asked, most staff said there was enough equipment for the dedicated bays and cubicles and said there was usually enough equipment to accommodate the extra patients when the department was crowded. The exception to this was the majors areas where we were told there was often not enough thermometers and vital signs monitors. We also saw staff waiting for monitors to be returned so that observations could be made in the ambulatory area.

Staff said that the medical engineering department was responsive and usually provided loans while equipment was being repaired. We looked at a sample of medical devices in the department and found none being used beyond their maintenance expiry date.

There was good access to co-located imaging services and other test equipment. The imaging department was immediately adjacent and provided a 24-hour service for plain and computed tomography radiography as well as a mobile unit. There were magnetic resonance imaging machines close by that were open from 8am to 8pm every day.

The department had its own blood gas analyser and access to others nearby for resilience. There was an embedded ‘rapid lab’ facility staffed from the pathology department that could provide immediate tests for COVID-19, flu and other respiratory viruses.

The service did not always have enough staff to meet the patient’s needs because of the number of patients in the department. Staff generally were supported by their leaders and got supervision and development opportunities but the requirement that all staff have appraisals made at our last inspection visit had not been met. However, there was a positive culture in the department and staff supported one another.

There were not always enough doctors employed in the department to care for the number of patients that arrived because of workforce vacancies. A lack of substantive medical senior decision makers was a risk recorded on the departmental risk register. Although numbers required on a shift were usually met through locums, this risked suboptimal timeliness and quality of care as well as a lack of resilience at night because the skill mix could not be assured. The trust aimed to improve recruitment and retention through an educational and development program, some elements of which were novel, but it was recognised this was a national problem, and all providers were competing for the same staff.

Similarly, a lack of substantive nursing staff meant that the department relied on the use of bank staff to maintain minimum nursing levels. If levels were not met or staff spread thinly due to excess demand or crowding, there were risks to patients with vulnerabilities. This included, for example, through falls, as well as the identification of deteriorating patients. These risks were noted in the department's risk register with plans to strengthen recruitment and retention although it was historically noted that workload had resulted in staff leaving. Conversely staff told us that recent changes to the leadership of the department had resulted in staff returning and telling others it was a good place to work. One member of staff told us they had returned because they had been told things were better and another said that they had come to work in the department on the recommendation of a friend. However, other staff said they were stressed and thinking of leaving to work elsewhere.

Staff in the main department frequently mentioned low staffing as a concern and while all staff cooperated with our inspection it was frequently difficult for them to find time to talk to us and we sometimes noted their anxiety as they wanted to return to a patient. This was not because the department was understaffed against the planned establishment but because of the numbers of patients attending. On the days we visited, the department was staffed to the planned establishment and there were low vacancy rates for nursing staff.

We were told by senior and junior nursing staff there was improved management of sickness offering staff the support needed to stay in work. Newly recruited international nurses told us that they had received a good induction and training and that they were supernumerary for 6 months.

While there was high use of bank staff there was a policy that no agency staff were used. The only exception to this was when specialist mental health nurses were needed to support patients in mental health distress.

Staff in the children’s area did not raise any serious concerns about nurse staffing, but we noted the area was often supported by adult nurses. While these nurses usually had experience in the children’s area, they did not always have children’s qualifications.

There was sufficient cover from medical staff for children. The Royal College of Paediatrics and Child Health (RCPCH) define standards for the care of children in emergency departments. It is required that there was a Paediatric Emergency Consultant (PEM) with dedicated session time allocated to paediatrics. Through the departments integrated staffing model with the trust’s Good Hope Hospital there were 4 PEM consultants sharing this responsibility. There was an emergency medicine consultant working in the department from 11am to 7pm 7 days a week with cover across the adult and paediatric areas outside of these times.

To meet the RCPCH requirements for there to be a minimum of 2 registered children’s nurses on each shift the department planned for there to be 4 on each shift so that the requirement was met should there be staff absence. The department employed more play specialists than required by the RCPCH guidance and was further recruiting to the role as it was valued and contributed to the effectiveness and safety of assessment and treatment.

All consultant medical staff, registrars and advanced clinical practitioner nurses were trained in Advanced Paediatric Life Support (APLS) or the equivalent European Paediatric Life Support. This meant the requirement to have an APLS trained member of staff on each shift was easily met.

Staff updating mandatory training was tracked on a computer system and reported to governance meetings. For most off the compulsory training modules the trust target of 90% compliance was met but there were shortfalls in fire training and information governance training. There were significant shortfalls in training in the Prevent duty to address the threat from terrorism and radicalisation, and clinical life support. However, while the latter was concerning, those staff who would be involved in the resuscitation of a collapsed person were well qualified and experienced. However, several members of staff told us mandatory training attendance had improved because of better leadership resulting in time to attend and the following up of missed training.

In response to a CQC requirement that patients with sepsis were assessed and managed in line with national guidance the trust had developed training which became mandatory towards the end of 2024. Hence not all staff had yet completed it but there was a trajectory to do so, and we saw correspondence instructing staff of their responsibilities to complete this training. Staff were positive about this development but some, in the children’s area said that they were concerned that there was no specific sepsis training for children like there was for maternity and neonatal. This issue was on the department’s risk register, and we saw a request for a suitable training package had been made to an external provider.

There was improvement needed with some urgency to ensure staff had an annual performance review. This had increased since our previous inspection but remained not meeting the trust target. A previous CQC requirement was for staff to have a regular appraisal. Staff appraisals for junior medical staff were all completed as part of their education programme. For consultant, specialist and locally employed doctors’ overall completion rates were 82% which was below the trust target of 90% but was a significant improvement on the number at our previous visit which was 58%.

For nursing staff in the main department, the appraisal rate was 63% and for the children’s area 80% which was again below the trust target. This was only a small improvement on the number at our previous visit which was 54%. For other staff groups across the whole department the rate was 61%.

The service assessed and managed the risk of infection. Staff detected infection and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. However, the patient environment made it difficult to keep clean and crowding in the department brought the risk of cross infection as it was difficult to keep patients separate from one another.

There were processes and there was effective governance and oversight to assessing and managing the risk of infection which was in line with current national guidance. Managers carried out infection prevention and control audits including for hand hygiene which showed high levels of compliance. This was generally what we saw, with staff washing their hands between patients. However, we did see occasional lapses in the resuscitation area when staff briefly touched a patient but did not wash their hands before leaving the area.

Cleaning could not always be effective due to damage to the environment in places. Other audits, and our own observations, reflected the difficulties in maintaining cleanliness due to the poor condition of the estate. This was particularly noticeable in the ambulatory, minors and majors areas. Examples included damage to walls, floors, furniture and non-clinical equipment that meant they could not be effectively cleaned.

Similar issues were present in the children's area and same day emergency care, but not to the same extent which reflected the newer and better condition of these parts of the department.

Many of the comments we received from the public and saw in patient experience reports reflected their concerns and spoke of dirty areas in the department, including blocked toilets and spillages of food and drink as well as body fluids.

On the days of our visit the children's area of the department was clean and tidy although staff said it was harder to keep it so during busier times. There was a cleaning protocol for the toys and games which was recorded for audit purposes.

Medical devices and other equipment and items were cleaned between patients and were labelled as such. Staff adhered to uniform policy, and we did not need to raise any concerns during our assessment visit.

The trust had safe systems for appropriate and safe handling of medicines to ensure people were given their medicines as prescribed. Medicines storage was locked and secure with access only to authorised staff although there was some storage issues identified. Staff knew how to contact pharmacy for support and advice. However, 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.

Staff knew how to contact pharmacy for advice and support. However, staff spoken with said they would like to have an increased pharmacy presence within the emergency department. The Royal College of Emergency Medicine recommends the use of dedicated emergency department pharmacists and pharmacy services to work as part of the multidisciplinary team. This is to help provide clinical and operational support for the safe and efficient delivery of care to patients in the emergency department. A pharmacist from the Acute Medical Unit (AMU) visited the department and undertook medicine reconciliation (the process of gathering a complete list of people's prescribed medicines) which helped to improve the flow and transfer of patients out of the emergency department into the AMU. However, they were not part of the emergency department team.

We met with one of the pharmacy team and with just a quick look at the electronic records, they demonstrated how much of a difference they could make including with patient flow among other things. We were informed there was a business case for a pharmacy service in the emergency department.

Medicines were locked and secure and were stored safely in line with recommended practice although some issues were identified.

The new purpose-built medicine storage room was a good size and a big improvement for the safe and secure storage of medicines. Medicines storage was locked and secure with access only to authorised staff. Despite the room feeling warm, the temperature was recorded at 23 degrees C which is within the safe medicine storage range. We were told that a room cooling solution was being discussed.

The area in resuscitation for medicine storage and preparation was small and cramped as the workbench was used to store consumables and equipment such as syringes. Although we observed staff managed with the situation, we noted available space underneath was not being utilised. For example, there was plenty of available space underneath the workbench where it had become a general space for boxes and bags. This would help to create some much-needed workspace above and put the consumables underneath. We fed this back to the service at the end of our inspection had received assurance it had been immediately addressed.

Medicines for refrigeration were stored securely with records available of maximum and minimum temperatures to ensure the medicines were stored safely. Staff informed pharmacy if there were any issues so that appropriate action would be taken to ensure the safe storage of medicines. However, we did find a rarely used medicine in a fridge which was just out of date. It was removed, and we were subsequently informed that a process of reviewing all medications had been introduced to ensure replacement before expiry. A new daily checklist was being created to form part of the audit process in the department.

Controlled Drugs (CDs) which are medicines requiring more control due to their potential for abuse, were stored safely and securely with access restricted to authorised staff. Checks were undertaken and recorded by 2 staff in each area twice a day with no issues identified. Full and detailed CD audits were undertaken by pharmacy quarterly. The last CD audit was 74% with minor recording errors noted and no major issues identified.

Resuscitation medicines required in an emergency were available and followed Resuscitation Council (UK) guidance. Emergency medicines were stored in tamper evident sealed boxes prepared by pharmacy and the oxygen cylinders we looked at were within date. Staff undertook daily safety checks on medicines and equipment and available records showed they were safe to use.

Time critical medicines such as medicines for Parkinson's disease were safely stored in 1 location and were immediately available when needed.

Staff told us that pharmacy conducted twice yearly audits on the safe and secure handling of medicines. The last pharmacy audit in February 2025 was highlighted in the `Pharmacy News' on the staff room bulletin board which showed good overall compliance with the safe and secure handling of medicines with no major issues identified.

There were processes to ensure people received their medicines as prescribed. Medicine administration records were documented including recording a reason if a medicine had not been administered.

We reviewed 5 medicine administration records using the Electronic Prescribing and Medicine Administration (EPMA) system. The EPMA system flagged missed doses, so staff were aware when a medicine was due or overdue. However, we were informed that the system was currently unable to capture data on missed medicine doses within the department. But it was possible to track consecutive missed doses which was more important for high-risk medicines to identify any trends and problems. Pharmacy was able to use this information to provide advice and support about the availability and supply of medicines to the department.

Patient's allergies were highlighted, and medicines could be prescribed safely. The allergy status of patients was recorded on all medicine records seen.

A green bag system was used for patients' own medicines to ensure they were stored together and easily identified with patients' belongings. However, it was recognised that this system might not always be used effectively. We were informed this system would be re-looked at and promoted to help the safe storage and transfer of patients own medicines.

There was a process or managing and reporting any errors or incidents involving medicines. Staff were able to talk through the process that would be followed if this occurred. Medicine incidents would be discussed within the team at team huddles.

Staff told us they had online access to relevant medicine policies, procedures and guidelines.