Good Hope Hospital

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 rated safe as requires improvement. 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 service was in breach of the legal regulations relating to safe staffing and risks to patients due to the crowded environment. 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. People were confident about raising concerns. These were taken seriously, and staff told us about changes made following learning from incidents. For example, a patient came in with chest pain and an electrocardiogram (ECG – heart rhythm test) was not performed. Following this, the managers allocated a healthcare assistant (HCA) on each shift to perform ECGs for anyone who came in with chest pain and there was always a cubicle available to complete an urgent ECG. Improving time to ECG was also part of the Quality Improvement Programme.

Staff saw incidents as an opportunity to learn and improve. The trust’s formal reporting system was easy to use. There were a few different avenues where learning was shared with both nursing and medical staff to ensure learning was embedded. Staff received a newsletter called “risky business” where there were incidents and learning examples, mostly submitted by staff. There was a positive culture for reporting incidents.

Lessons were learnt to continually identify and embed good practice. For example, a doctor told us about a case that was presented in a learning meeting regarding managing a collapsed lung. They told us the previous day they had a patient present in a similar way, they remembered the presentation on this and were able to treat the patient correctly. Incidents were discussed in the emergency department clinical governance cross site meeting. We saw serious incidents were discussed in detail and learning was identified and actions were allocated.

The service looked at patient safety incident investigations (PSII) in line with the Patient Safety Incident Response Framework. This included the duty of candour and ensuring good communication with patients and their families. We reviewed 2 communications to families and PSII reports and found them to be comprehensive. We saw safety actions were issued to ensure learning from incidents. However, they had not been updated on the action log to show these had been completed.

There was a bi-monthly mortality and morbidity meeting with the consultants and doctors. They discussed any deaths which had occurred unexpectantly in the emergency department, and these were used to identify learning and reduce the risks to patients. We reviewed meeting minutes from September 2024 to January 2025 and saw actions were documented. However, there was no evidence of discussing previous meeting actions and ensuring they had been completed.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed and monitored. Staff made sure there was continuity of care, including when people moved between different services. There was a collaborative joined up approach to patient care. The service had information systems which allowed them to see patients GP records which meant there was continuity of care. They worked alongside several services such as ambulances, psychiatric liaison team, older persons assessment and liaison team, alcohol liaison team, and clinical specialities. Referrals were made to enhance patients' care and patients were reviewed and assessed by services effectively.

The views of people who used the services were listened to and considered. Managers acted upon feedback from patients to make improvements to their journey where possible. Patients told us they felt listened to by the team who was looking after them. There were long waits in the department, but most patients we spoke to were aware of their plan of care and felt cared for.

Policies and processes about safety were aligned with other key partners to enable shared learning and drive improvement. There were clear referral pathways for the emergency department, and they worked with the ambulance teams to ensure the correct patients were conveyed to their department.

The service worked with people to understand what being safe meant to them and the best way to achieve that. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Data showed 93% of staff were trained to level 3 safeguarding adults and children; this was a significant improvement from our previous inspection where safeguarding training levels were low. However, PREVENT Level 3 training was 60% for medical staff; this was discussed in safeguarding compliance reports monthly and actions. At our previous inspection, we found no staff were trained in autism awareness. At this assessment, over 85% of staff had completed this training.

There was a clear safeguarding policy and pathway which was accessible to staff. All staff we spoke to knew how to make a safeguarding referral and who to inform if they had concerns. Staff had access to the trust's safeguarding lead for advice. The service shared concerns quickly and appropriately. The trust safeguarding team attended the department daily and also delivered teaching where required.

During our previous inspection, we found safeguarding risk assessments were not always completed for 16- to 17-year-olds. The staff had implemented electronic notes which provided prompts for risk assessments to be completed. These were mandated from 27 February 2025 which meant a patient could not be discharged without completion of the risk assessment. A recent audit showed compliance had improved from 17% to 92%. This was audited by the safeguarding team. At our last inspection, we also found opportunities to safeguard patients were missed. We were told that following an audit of referrals and records there had been no missed safeguarding opportunities in the 6 months prior to the assessment.

There was a dedicated safeguarding lead for children and there were daily, open discussions with the safeguarding team and discussions in handovers and meetings. There was a rolling programme of drop-in sessions and case studies for children and young people for staff to learn from. We looked at a staff file and saw a reflection for when they had missed a safeguarding. In the children's emergency department, they had implemented a "did not wait to be seen" procedure where parents who took their children home without being seen were followed up by the team to ensure there were no missed opportunities. This was on the department risk register as they did not always have the staffing resources to follow up every patient.

There was a monthly safeguarding meeting where case studies, training compliance, risks and missed opportunities were discussed. Learning points from this were shared with the teams. We saw and read 3 patient stories which were also presented at these meetings which highlighted good practice and outcomes for patients who had been referred to safeguarding.

Children identified as being at risk were referred to the trust's safeguarding team and the local authority. There was a system to make staff aware of known concerns about children and families.

Staff were aware of the Mental Capacity Act 2005 and the holding powers that doctors and nurses had. Staff got the advice from their mental health colleagues as required; they were available 24 hours a day, 7 days a week. Staff reported they were very supportive and easy to access.

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. Some observations of risk were not acted upon quickly and patients were being diagnosed with pressure damage to their skin from long waiting times.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people's needs that was safe, but it was not always timely due to crowding within the department. We found staff worked to reduce the impact of crowding by ensuring, where possible, risks were assessed on arrival to the department. All patients had an assessment on arrival from an ambulance and as a walk-in patient. We observed rapid assessment and triage for ambulance patients taking place and actions taken to reduce risks for patients. Observations were taken hourly while the patients were on the ambulances and in the waiting toom. If patients deteriorated, they were brought into the department.

If a patient were on the ambulance for longer than 3 hours, a band 6 nurse would assess them and check for any deterioration. The staff completed harm reviews for all patients who waited on an ambulance for longer than 3 hours after arrival to the department. We looked at the matron's quality assurance report for January 2025 which showed 367 harm reviews had been completed, and no harm was identified. Where patients stayed over 8 hours on ambulance or over 48 hours in the emergency department there was a process for staff to follow to ensure this was escalated to management.

The department had experienced a steady increase in the percentage of handovers taking over 60 minutes since August 2023. In December 2024, 42% took over 60 minutes which was 7% higher than the county average. It had increased since August 2024 where it was around 15%. Staff told us, and we saw, this was due to the lack of flow within the hospital. We saw on 26 February 2024 at 8.30am there were 55 patients who had been reviewed, and a decision had been made that they needed admitted. There were just 9 other patients in the department who were being treated. There were no beds in the hospital for the 55 patients to be moved into. This meant by 11am there were no spaces in the department for patients who were being brought in by ambulance or had self-presented.

The delays within the department increased and patients were waiting for long times to be moved from ambulances or from the waiting areas into the department. We saw while the department was crowded in all areas, safety spot checks took place to ensure deterioration was recognised and acted upon. These spot checks included patients over 6 hours to have all risk assessments done, safeguarding referrals completed, and high-risk patients to have hospital beds. However, despite the best efforts, we saw this did not always happen. There were not enough hospital beds, and too many patients were high risk and staying over 6 hours. We were told their trolleys were pressure relieving and patients could remain safely on them for 24 hours. We saw patients remained on trolleys longer than 24 hours. Data showed 15 patients between November 2024 and January 2025 were diagnosed with grade 2 pressure ulcers and 3 patients were found to have deep tissue injury due to prolonged length of stay. The patients who had a deep tissue injury all had a length of stay of around 23 hours.

Ambulatory patients were mostly assessed in a timely manner. After booking in they were seen by a navigator; a band 6 nurse with additional training, who streamed patients to the most appropriate area based on risk. Recording the acuity and priority score of the patients in the waiting room on arrival provided assurance to the nurse and consultant in charge that the sickest patients had been identified and action taken to ensure they were seen first. There were 2 nurses and HCA's allocated to the waiting room. They took patients' observations hourly to ensure risks were picked up when patients were waiting for long periods of time. We saw on 25 February 2025 at 9.10am there were 30 patients waiting with the longest patient waiting 12 hours and 7 minutes. Although they had a long wait, all patients had been triaged, were low risk, were always visible and had regular observations completed.

The triage process followed evidence-based practice and patients were graded in accordance with the seriousness of their presenting complaint. There was a colour-coded scale on the computer programme to give a visual appearance of those patients who would need more urgent review. The time the patients had been in the department was also colour coded to indicate those waiting longer than the national standard waiting time and gave a visual warning to staff about delayed treatment, particularly when both more high-risk trigger colours were indicated.

People were seen in order of clinical priority. We looked at 24 sets of records and found all patients had a completed triage; this included 5 sets of children's records.

Staff used nationally recognised tools to identify deteriorating patients. These were recorded electronically, and scores were automatically totalled. We saw where National Early Warning Score (NEWS2) and paediatric early warning scores (PEWS) were high, these were acted on appropriately and reassessed mostly in line with guidance. We saw staff mostly acting quickly when patients were showing signs of deterioration. However, we found deterioration was not always acted upon promptly. For example, we saw a patient had a NEWS2 of 4 in the waiting room, and this had not been escalated to a doctor for review. The observations were repeated 45 minutes later, and NEWS2 was still a 4 and observations were declining, and this had still not been escalated to a doctor.

Managers had high standards for documentation within patient notes. All notes we reviewed were contemporaneous and contained a good level of detail. There was a band 6 nurse who was a `clinical support nurse' who audited a different set of notes 4 times a day. We saw this completed and they picked up on an error and this was rectified immediately. We also reviewed a sample of the daily spot checks and found them to be comprehensive and notes were well completed.

We found there was a risk staff could miss the signs and treatment for sepsis due to the lack of prompts. The service did not use a sepsis 6 proforma which meant it was not easy to see if a patient had received prompt treatment for sepsis. We saw an action from the December 2024 emergency department clinical governance meeting was to reinforce with the emergency department assessment nurses a screen for sepsis for a patient presenting with a NEWS2 greater than 3. All staff we spoke to had a good awareness of assessment and treatment of sepsis but this was not always easy to see this in the notes.

We raised this with the matron who immediately put the sepsis 6 proforma into clinical practice and we saw this was being used on the second day of our assessment. We were told this was going to be audited monthly and form part of the quality and safety meeting each month. We saw an audit was completed March 2025 with an action plan to improve compliance. Actions included daily spot checks and education for staff. All notes we looked at where patients potentially had sepsis had received antibiotics and fluids promptly. Sepsis training was made compulsory for clinical staff in 2024. Data showed 86% of emergency department staff and 84% of paediatric nurses had completed sepsis training. This was on the paediatric risk register. The paediatric nurses relied on the adult clinical educator to complete their training, but they did not have the specific paediatric skills to provide the required support; we were told this made it harder to improve compliance.

Staff did not always act to reduce the risks for patients. We were not assured pressure area care and tissue viability was managed well within the department. Clinical governance meeting minutes for December 2024 showed 147 pressure ulcers were reported in November 2024. We saw risk assessments were completed well, such as waterlow and falls risks but where patients were at risk, actions were not always taken to reduce the risks. For example, we saw patients who had high waterlow scores, which meant they were at risk of developing pressure damage to their skin, and they were not turned regularly. They were on hospital trolleys for more than 24 hours without being moved onto a bed with an appropriate pressure relieving mattress. The matron highlighted in their December 2024 quality assurance report that there was poor repositioning on patients. We also saw examples of where a pop-up box on the electronic system had reminded staff about risk assessments to be completed and these had been closed and not actioned.

Those patients who were remaining in the department for longer than clinically indicated were not always getting regular reviews. The matron told us they had discussed this in the band 7 meeting, but the HCAs were often allocated to do 1-to-1 care for patients who required further observation or had mental health needs. The trust had recently recruited a further 13 HCAs to ensure more were available to clinical support.

Risks were reviewed by different teams to keep a renewed focus. To provide a holistic review of patients all nursing staff swapped to a different area in the department in the middle of their shift to ensure there were fresh eyes on the patients and they were not in the same area all day.

Patient risks for developing venous thromboembolism (VTE \u2013 blood clots) were assessed but treatment was not always given. We looked at 4 patient records who had been in the department for over 24 hours and they all had a completed VTE risk assessment but only 3 had the appropriate prevention treatment prescribed and 1 of these, it had not been given. Data showed 98.9% of patients in Majors and Resuscitation areas had their VTE completed within 14 hours of admission in line with policy.

Staff were not always aware of mental health risks due to assessments not always being completed in a timely manner. We saw the therapeutic observation assessment, which was a comprehensive \u201chead-to-toe\u201d evaluation of a patient's mental state had not been completed for the 2 patients we reviewed. This meant the level of observation needed by the patient had not been assessed. We raised this with the staff who completed them immediately.

There was good support for adults with a mental health crisis. The service had 24-hour access to the psychiatric liaison team and responsive specialist mental health support to provide advice and guidance for staff to assist with patients with mental health needs. Data showed 156 patients were referred to psychiatric liaison team in January 2025. Of these patients, 97% were seen within the required time for assessment.

There was good support for children with mental health needs. The children's area had access to the child and adolescent mental health service and used risk assessments to assess children presenting with mental health issues. The team had a few frequent attenders. Staff kept all the children's care plans, met with carers and had multidisciplinary team meetings to ensure they gave the right care to these frequent patients.

There were alternative areas and processes for sending patients who did not need urgent and emergency care. However, it was not always easy to return patients who had been streamed to receive minor injury treatment. The minor injuries unit (MIU) was upstairs and was staffed by emergency nurse practitioners. Patients could be sent here by the navigator nurse if deemed appropriate. We were told, at times, the patients sent were inappropriate. For example, a patient with a fractured neck of femur and a patient with burns to their face and chest. Staff in the MIU told us it was difficult to return the patient to Majors when they were in the MIU due to the pressure on the emergency department.

There was good oversight of patients by the senior team in the department. Each computer in the department had access to the patient management system which displayed an overview of the patients. It showed the length of time each patient had been in the department, or on an ambulance, or were waiting for triage, or treatment. Managers saw where the greatest risks were and ensured these areas were staffed appropriately. For example, during our assessment, the matron put out 6 extra bank shifts on the day and night shifts to support with the crowded department and allow for nurses to assess patients on the ambulance and allocated to the corridors. However, these shifts were not always filled.

A patient flow coordinator was based in the department every day and liaised with site managers and doctors to obtain beds on wards for patients as soon as possible. They escalated to the operations manager when there were increasing delays. Risks were discussed at regular bed meetings every day; these were held 4 times throughout the day.

The service did not always control potential risks in the care environment due to crowding in the department. Staff did not always make sure facilities supported the delivery of safe care. However, the technology had improved the safety of the patient care since our previous inspection and the facilities and equipment were well-maintained.

We saw the environment was visibly clean, but it was crowded, and patients were staying in the department for long periods of time. The service used specialist mattresses that fitted on to trolleys. If patients were required to stay on a trolley for a long period of time the risk of pressure ulcers was reduced. However, these were only appropriate for 24 hours and patients stayed up to 48 hours within the department when there was crowding and no available beds. The matron told us there was a tissue viability steering group who were going to look at this to ensure the effectiveness of the mattresses on the trolleys. We spoke to 2 patients who had stayed in chairs overnight and they were happy with the care provided and understood the department was busy.

The emergency department was spread out and had grown which meant there were 4 separate areas for majors including a clinical decisions unit (CDU), ambulatory assessment area and MIU was on the first floor, accessed by the lift. CDU had an exclusion criteria to ensure only appropriate patients were in this area as it was not considered safe for high risk patients. The department remained crowded and areas which were for chair assessments had trolleys in and patients remained here overnight. There was limited space and privacy as the bays were designed for chairs and only had curtains around them. Staff recognised this but due to the crowding and lack of flow through the department this was unavoidable.

The waiting area was small and was also used as the main access to the hospital. This meant it was a thoroughfare and often crowded. There was limited privacy for patients who discussed their presenting complaint with the reception staff and navigator. The matron told us they were building a new waiting area which would have 2 private triage rooms. The hospital executive director told us there were plans for a new entrance to the hospital which would mean the emergency department would have its own entrance. There was a separate area for children and their families which was safe and secure and there were toys to keep children occupied.

Staff had access to most of the equipment they needed. Although we were told some nurses bought their own ear examiners as there were not enough in the department. On our previous inspection, we found specialist equipment was not being checked daily; on this assessment, we found it was always checked. The clinical support had daily tasks which included ensuring the specialist equipment had been completed each day.

The department was made safe by specialist estates staff regularly assessing environmental risks.

The mental health assessment room was compliant with quality standards published by the Psychiatric Liaison Accreditation Network for Liaison Psychiatry Services. There was no dedicated mental health cubicle within the department, but mental health patients were admitted to a high visibility cubicle in majors. Staff removed ligature risks and equipment from the rooms, but not all risks were reduced. This was mitigated to an extent by ensuring there was a member of staff with them at all times. However, this was often a healthcare assistant who had not completed any enhanced observation training.

The long length of stay of mental health patients was on the department risk register. We were not told of any plans to create a dedicated mental health assessment room. The mental health room in the children's emergency department was not ligature free, mitigations were in place to reduce the risks for patients. We were told there were plans to repurpose the triage room for mental health patients and ensure it was complaint with quality standards for mental health rooms.

Equipment mostly kept people safe while they were waiting to be seen or receive treatment. The facilities were well maintained, and any equipment used with patients was in good working order and used safely. Staff wore personal protective equipment in line with regulations.

There was space for relatives to have some peace and quiet. There was a relatives' room which was located at the edge of Majors A in a quiet corner which had a viewing room attached. This was in use for families and ensured they had a quiet space to grieve and view their deceased relative should they wish.

Hazardous and clinical waste was responsibly managed.

The service did not always have enough staff to meet patients' needs due to the crowding and capacity of the department. However, staff received effective support, supervision and development. They mostly worked together well to provide safe care that met people's individual needs.

Due to the crowding and lack of available beds in the rest of the hospital, there were more patients in the department and waiting on ambulances than the staffing establishment was designed to safely manage. Six-monthly workforce reviews were undertaken which included acuity and attendance information to ensure emergency department demand was used for up to date workforce planning.

Departmental leaders had requested they were considered for more staff to manage the demand. There had been a recruitment drive in the department following our previous inspection where there had been 45 staff nurse vacancies. They had fully recruited into all band 5 vacancy positions including employing international nurses and had 2 band 2 vacancies. However, this meant the department had a somewhat inexperienced nursing workforce and pressure on the senior staff on duty to support. This was on the department risk register.

Managers had significantly reduced the number of agency nursing staff they used and 6 had converted to the bank. Leaders mostly used bank nursing staff to cover shifts, but often not all shifts were filled. They heavily relied on bank staff to increase numbers while the department was crowded. Agency usage in emergency department between December 2024 and February 2025 was an average of 1% and bank for this time period was 36%. When shifts were unfilled, staff were unable to ensure all areas had adequate staffing, despite vacancies being fully recruited into, due to crowding; this was on the department's risk register.

Children's emergency department staffing was safe and staffed with registered children's nurses including band 7s who worked clinically. There were dedicated paediatric advanced care practitioners (ACPs) who worked in the department.

There were enough nursing staff with the right training and qualifications to safely treat children. There was 1 nurse to 4 patients. We were told if they were busy, the matron assisted. They relied on bank staff to cover shifts, and usage was between 20-40% each month. There was an 11am until 7pm paediatric doctor daily but they also covered ambulatory majors as well. One consultant told us at times this could be unsafe. We were told they wanted to get a second consultant onto this shift due to it being very busy. There were ACPs who worked in the children's department to assist the doctors. Staff told us since they had a dedicated paediatric matron the department had more structure, more development and training days and good support for the staff.

Staff mostly kept up to date with mandatory training and any role-specific training or education. Overall mandatory training percentage for department was 93%. However, all staff were required to have clinical life support training and only 69% of adult nursing staff had completed it and 84% of paediatric nurses; medical staff were 100% compliant.

The hospital had started a new `Nursing Quality Assurance Meeting' attended by matrons in February 2025; this focused on ward performance including mandatory training. The purpose of this was to have a focused approach on training performance and to generate collaboration between wards for sharing of teaching resources and solutions for increasing compliance.

Where training was low, staff took actions to improve compliance. For example, specialist education teams had recently opened a weekly session of clinical life support to boost practical assessments across the hospital. The band 7 nurses each had a team of staff whom they were responsible for. They completed appraisals and supported with mandatory training and any progression goals. At our previous inspection, we found appraisals were not done; only 22.6% of staff in the emergency department and 71.4% of paediatric staff had completed appraisals. On this assessment, we found there had been an improvement; 80.3% in emergency department had completed appraisals and 100% in the children's emergency department. The trust target was 90%.

Staff were trained in Manchester Triage training with compliance at 88%. However, sign-off compliance was low at 23%. All staff who worked in triage had completed their training, but not all had been signed off. The clinical educator had recently been added as an assessor and the sign off compliance had since increased.

Staff received effective supervision and annual reviews of their work, and discussions about future learning and development opportunities. We spoke to new starters, including nursing associates, an advanced care practitioner in training and band 5 staff nurses. They all said they were well supported by the managers and the department. One told us they love working here and do not feel like a new starter. We were told when they needed support, the band 6 clinical support or the clinical educator would step in and assist. They had a supernumerary period of a minimum of 8 weeks, and this was extended if staff were not ready to manage a group of patients. There was a new starter programme which included 1 day a week information training.

Staff were noticeably busy and worked under pressure when the department had higher numbers of patients or when people required close supervision. There was a good degree of support and mutual respect among staff working in the department.

The service did not have enough substantive medical staff to keep patients safe and relied on regular locum consultants to reduce the risks and increase the safe staffing levels within the department. The department did not meet the recommendations of the Royal College of Emergency Medicine (RCEM) of 16 hours consultant presence every day. The trust had recruited 5 consultants since our previous inspection, but they required more to meet the RCEM recommendations.

The service always had a consultant on call during evenings and weekends. There was a senior decision maker allocated overnight when consultants were not on shift. When locum doctors were needed, they had training in emergency medicine. Between November 2024 and February 2025, the department used 27 whole time equivalent (WTE) locum trainee medical doctors and 2 WTE consultants. There was a consultant who was the lead for locums to ensure they had support. Sickness levels were low between December 2024 and February 2025. There were advanced care practitioners who assisted the medical staff with reviewing the patients.

Medical staff had weekly teaching. This was also available to connect with online if they were not on shift. One resident doctor told us the learning was especially good between 8am and 5pm as the medical staff supported them doing procedures and felt they were gaining good skills. Doctor appraisals were 81.5% at the time of the assessment; they were supported by the revalidation team and their clinical leads to complete them.

The MIU area was staffed by emergency nurse practitioners with an emergency department doctor, staff nurse and 2 GPs. This was in line with establishment.

There was a band 6 clinical educator who ensured band 5 staff had support with their training and learning opportunities. There was also a recently appointed band 4 clinical educator who ensured the HCA's were supported with skills and training. Staff were supported to progress within the department and there were many examples where staff had started as a band 5 and progressed to band 7 or as a band 2 and progressed to a nursing associate. However, there was no clinical educator for the children's department. The children's team were supported by clinical educators from other areas, but they did not have the specialism in children's emergency medicine. This was on the department risk register. Advanced care practitioners told us there was minimal training and progression at their level.

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

There was an effective approach to assessing and managing the risk of infection, which was in line with current relevant national guidance. Managers audited compliance with infection control practices including hand hygiene, care quality assurance and cleaning. Results for cleaning audits between December 2024 and February 2025 for all areas of the adults' children's emergency department were mostly above 95%. There were no action plans associated to the audits, but we saw IPC audits were discussed in the emergency department clinical governance meeting and actions were taken if results were low. Staff we spoke to were aware of audit results and told us compliance was addressed at handover, and they could see the results within the communications folders and on their closed social media group.

People were protected as much as possible from the risk of infection because premises and equipment were kept clean. All areas within the emergency department were visibly clean and had suitable furnishings which were mostly well maintained. The matron had also asked for further support to assist with cleaning additional equipment. This had been escalated to the operational teams to support.

We were told there were concerns as there were times when multiple patients needed side rooms for infection prevention and control (IPC), and this was not always possible due to demand for space.

Most staff we saw followed IPC principles including the use of personal protective equipment. We saw staff washed or gelled their hands in line with the 5 moments for hand hygiene. There was an IPC team in the hospital, but they did not attend the department frequently. The matron had added IPC onto the clinical support role checklist to ensure they were monitoring it. However, we saw 3 members of staff who were not following uniform policy to be bare below the elbow, and this had not been noticed.

The department had safe systems for appropriate and safe handling of medicines to ensure people were given their medicines as prescribed.

There was no clinical pharmacy service based within the emergency department. However, there were processes for the supply of medicines. Staff knew how to contact pharmacy for advice and support, but staff told us they would like an increased pharmacy presence within the emergency department. Having a pharmacist presence in the department was recommended by the RCEM guidelines. A pharmacist from the Acute Medical Unit (AMU) visited emergency department and undertook medicine reconciliation which helped to improve the flow and transfer of patients out of emergency department into the AMU, but they were not part of the emergency department team. We were informed that there was a business case for a pharmacy service in emergency department.

Medicines were locked and secure and were stored safely in line with recommended practice. All clinic rooms seen were neat and tidy. Controlled drugs 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 control drug audits were undertaken by pharmacy quarterly. The last controlled drug audit was undertaken in November 2024 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 oxygen cylinders seen were within date. Staff undertook daily safety checks on medicines and equipment and available records showed that they were safe to use; this had improved since our previous inspection where checks were not done regularly.

Medicine room storage and refrigerator temperatures were monitored daily. Staff informed pharmacy if there were any issues so that appropriate action would be taken to ensure the safe storage of medicines. Time critical medicines such as medicines for Parkinson's disease, were safely stored in one location and were immediately available when needed.

Staff told us that pharmacy conducted audits (biannually) on the safe and secure handling of medicine. However, due to operational pressures within emergency department the last audit was undertaken in April/May 2024 and was therefore overdue. The audits 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 3 medicine administration records using the electronic prescribing and medicine administration (EPMA) system. It was easy to track a patient's medicine administration timeline which helped to ensure that medicines were being given as prescribed. 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 emergency 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 emergency department. Where a `PRN' (when required) medicine was administered, staff recorded why it was needed. Allergy status of patients was routinely 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.

There was an effective process for 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.

We spoke to a hospital ambulance liaison officer from the local NHS ambulance trust who told us there were patient group directives (PGDs) for pain relief and anti-sickness medication so these could be given without a prescription and review from a doctor.

The children's emergency department used PGDs following initial triage for patients who required prompt analgesia. We were told these were mostly out of date and they were in the process of renewing them; this was on the departmental risk register but the actions were not updated to show how this was progressing.

The National Urgent and Emergency Care Survey 2024 showed that Good Hope Hospital had 2 question scores which were better than expected when compared to all NHS trusts. One was related to receiving support from staff to take medication for any pre-existing medical conditions.