University College Hospital & Elizabeth Garrett Anderson Wing

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

Staff provided evidence-based care and treatment in line with current legislation, good practice and standards. Staff worked together and with others when assessing people’s needs and shared information to maintain continuity of care. Staff obtained consent before they delivered care, support, or treatment. The service routinely monitored people’s care and treatment and carried out quality improvement projects to improve care.

At our last inspection we rated this key question Good. At this assessment the rating has remained Good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

We have not awarded this service a score for Effective.

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

We did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

The trust planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and national standards.

Staff followed established clinical pathways to ensure patients received appropriate and effective care. Staff told us they knew how to access clinical guidance and pathways when needed and were confident in using these to inform decision-making.

The trust maintained a detailed range of up-to-date policies, procedures and standard operating procedures (SOPs), which were easily accessible through the electronic intranet system. During our inspection we reviewed several documents which reflected current best practice and were aligned with guidance from the National Institute for Health and Care Excellence (NICE). Policies were reviewed regularly to ensure they remained current and supported safe clinical practice.

Staff protected the rights of patients subject to the Mental Health Act. During handover, staff routinely considered patients’ psychological and emotional needs, as well as those of relatives and carers, ensuring a holistic approach to care. Patients were given clear and accessible information to support both their physical and mental health needs.

Staff received regular appraisals, which were used to review performance, identify development needs and align individual objectives with service priorities. Records showed the majority of nursing staff had completed their appraisal (95%) however medial staff had only completed 70% of their appraisals.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff across the Emergency Department (ED) and specialty teams worked together effectively, following clear governance arrangements with defined roles and responsibilities. The ED retained overall responsibility for patients awaiting specialty input and continued to monitor their clinical condition, responding promptly to any deterioration. Specialty teams assessed patients in a timely manner, in line with agreed standards, including review within 30 minutes where required. Once accepted, responsibility for ongoing management transferred appropriately, although ED staff-maintained oversight and supported escalation when necessary.

Staff described clear escalation processes, which they used effectively to resolve concerns or differences in clinical opinion through consultant-to-consultant discussions. They communicated agreed outcomes clearly to the wider multidisciplinary team.

Referral processes were well supported by an integrated electronic patient record system, which helped to have clear documentation, effective communication, and access to up-to-date on-call rotas. Staff understood referral pathways, including inclusion and exclusion criteria, and ensured that once patients were accepted by specialty teams, they were not inappropriately redirected back to the Emergency Department.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

The service used a range of audit, benchmarking and quality improvement processes to monitor outcomes and drive improvements in patient care. Leaders participated in local and national audit programmes to assess performance against recognised standards and used findings to implement targeted improvements. For example, the Royal College of Emergency Medicine (RCEM) acute stroke imaging audit demonstrated strong compliance with neurological assessment documentation. This showed that staff completed detailed clinical assessments for patients presenting with suspected stroke. The audit identified opportunities to improve antiplatelet prescribing and the timeliness of follow-up care, and the service responded by delivering focused staff education, strengthening clinical pathways and planning re-audit to ensure sustained improvement.

The service monitored outcomes for patients with mental health needs and demonstrated good compliance with key standards. Audit findings showed that staff completed risk assessments, documented mental health histories and made timely referrals to specialist services. Leaders used this information to drive further improvements, including enhancing documentation quality, improving the assessment environment and strengthening pathways for follow-up care to ensure continuity and better patient outcomes.

The service undertook additional quality improvement work to improve clinical effectiveness and patient safety. Projects focusing on electrocardiogram (ECG) documentation and senior clinical review identified variation in practice and gaps in consistency. In response, leaders arranged targeted training, introduced improved documentation tools and increased the availability of senior decision-makers. The service used ongoing audit cycles to monitor progress and ensure that improvements were embedded into practice.

Where audits were completed, each area held monthly performance review meetings, where leaders reviewed audit outcomes such as oxygen prescribing, safe medicines storage and hand hygiene compliance. Results were escalated to the medicine Board for oversight and shared learning.

The service also demonstrated a proactive and coordinated approach to improving outcomes for patients who frequently attended the emergency department. A High-Intensity User (HIU) group reviewed patients who attended 3 or more times within a month and monitored the top 20 re-attenders on a regular basis. Staff developed individualised management plans to support consistent and appropriate care and to reduce avoidable attendances. The service worked well with multidisciplinary partners, including mental health services, primary care, community teams and ambulance services, to address underlying needs. Systems such as electronic patient flags and shared care records supported information sharing and continuity of care across services.

The trust informed people about their rights in relation to consent and respected these when delivering person-centred care and treatment. Staff provided care that was supported by clear and appropriate consent processes. They ensured patients understood their rights and upheld these throughout the delivery of individualised care. Within the Emergency department, staff predominantly obtained verbal consent, which was appropriate for the clinical setting and supported timely decision-making.

The trust had policies and procedures which aligned with current legislation, national standards and recognised best practice. These included clear guidance for situations where patients were unable to give consent, such as when they lacked capacity or were unconscious. Staff had access to relevant documentation and used this to support safe and consistent clinical practice.

Staff assessed capacity appropriately and took steps to support patients who lacked capacity or who were experiencing mental ill health. Where patients were unable to make decisions, staff acted in their best interests, which contributed to safe and effective care outcomes.

Staff considered people’s views and wishes when planning care. They used systems and approaches to ensure patients understood the care and treatment being offered, enabling them to make informed choices. Staff provided information in ways patients could understand and allowed sufficient time and support for decision-making where required.