University College Hospital & Elizabeth Garrett Anderson Wing

On this page

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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and teamwork. 

There was a positive safety culture where incidents were investigated, and learning was embedded to promote good practice. Staff were open and honest when things went wrong. Staff provided safe care and treatment. Most staff had the required levels of training to safeguard people at risk and knew what actions to take to keep people safe from avoidable harm and abuse. The environment was safe and met people’s needs. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

At our last inspection we rated this key question Requires Improvement. At this assessment, the rating has changed to Good. This meant people were safe and protected from 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 trust 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. All staff we spoke with knew what incidents to report and how to report them. 

Staff said they felt supported by managers and colleagues when things went wrong and did not feel blamed or treated negatively. They told us lessons were learned from safety incidents. We saw examples of good learning from 2 recent incidents in the Emergency Department. Whilst staff were able to describe the 2 recent incidents, there was limited awareness of learning from earlier events.

Leaders told us they used a broad and proactive range of communication methods to share learning, including clinical governance meetings, multidisciplinary handovers, safety huddles, Trust-wide safety bulletins, and structured tools such as “message of the week” on handover documentation. However, communication routes were recognised as variable and not yet standard practice, with reliance on verbally communicating which meant leaders were not always assured that learning was consistently reaching and being understood by all staff.

In the last 6 months (October 2025 to March 2026), the service recorded a total of 651 incidents across the Emergency Department and Urgent Treatment Centre. The Emergency Department accounted for the majority of incidents (634), while the Urgent Treatment Centre reported a smaller number (17).

The data provided by the trust showed that imported pressure injuries was the most frequently reported concern (210 incidents) throughout the period. Incidents related to aggression and abuse also remained significant (124 incidents), with a notable increase during the winter months. Delays in care were the third most common theme (75 incidents) and fluctuated across the reporting period but increased towards the end. The service monitored trends across all categories and used this information to identify priorities for improvement and risk management.

In the last 6 months there were 6 incidents reporting mental health patients had absconded from the department. All 6 incidents were reported to the police.

The trust operated a weekly Incident Review Group (IRG), chaired by senior executives including the medical director, chief nurse and director for quality and safety. The group was well attended by staff with quality and safety responsibilities across divisions and clinical specialties.

The IRG provided an open forum to review incidents, share learning and support teams to determine appropriate responses, including whether to undertake a patient safety incident investigation. The trust used the IRG to promote organisational learning, with themes triangulated through monthly reporting to the patient safety committee and escalated to oversight committees and the Board.

Staff we spoke with could describe what duty of candour was and gave clear examples of how they had provided this in practice. Leaders we spoke with were assured duty of candour was being applied in practice.

The service made sure that people could access the care, support and treatment they needed when they needed it. The service worked with people and healthcare partners to maintain systems of care, and leaders closely monitored demand, with over 11,000 to 12,700 adult attendances and 1,400 to 2,100 paediatric attendances each month. Staff implemented structured systems to support assessment, pathways and transitions, demonstrating a coordinated approach despite these challenges. However, ongoing pressure from activity levels affected the consistency of patient flow and timely care.

Over the previous 12 months, between 69% and 80.9% of patients were seen, treated, admitted or discharged within four hours of attending the emergency department. Performance improved towards the end of the reporting period, with 80.9% of patients spending less than four hours in the department. Leaders used escalation processes and worked with system partners to address delays and improve flow through the hospital. Leaders took a coordinated approach to managing demand and capacity. They used real-time information to identify emerging pressures and worked with internal teams and external partners to maintain patient flow.

Staff used structured triage processes supported by trained staff, which enabled early identification of clinical risk and prioritisation of care. Leaders also adapted pathways in response to demand, including implementing the Extended Emergency Medicine Ambulatory Care (EEMAC) pathway, which supported early senior decision-making and avoided unnecessary admissions. Patients referred to EEMAC received timely reviews and were often managed and discharged on the same day, demonstrating effective practice. However, performance in initial assessment varied, meaning not all patients received a consistently timely response. Although average triage times remained between 10 and 13 minutes, approximately 67% to 79% of patients were assessed within 15 minutes, indicating inconsistency during peak periods.

Overall compliance with NEWS monitoring remained strong at around 90%, and staff achieved high compliance with 4-hourly and 12-hourly observations. The service embedded electronic prompts and provided training to support escalation, and outcomes for deterioration and infection were better than expected compared with similar services. Monitoring of deteriorating patients was not always consistent, with lower compliance for more frequent (1-hourly) observations at approximately 45% to 61%.

In March 2026, 9.4% of beds occupied by patients no longer requiring the criteria to reside, which was 4% less than the London average over the preceding year. However, delays in patient flow remained an issue, particularly for patients waiting for admission, with approximately 8% to 21% waiting more than 12 hours after a decision to admit. These delays reflected challenges in accessing inpatient beds and community services and demonstrated that systems did not consistently support timely progression through care pathways. Despite this, the service worked effectively with internal and external partners to deliver coordinated care. Psychiatry liaison teams were co-located and supported timely mental health assessments, and shared electronic records enabled good communication and continuity. The EEMAC pathway also contributed positively, with most patients managed within the pathway and only a small proportion requiring onward referral.

Leaders worked closely with system partners, including the Integrated Care Board (ICB) and neighbouring NHS trusts, to maintain safe and effective pathways for patients. They developed clear system-wide arrangements to manage operational pressures and agreed escalation processes that supported timely decision-making and patient flow across the local health economy. These partnerships helped services respond effectively to changing system needs and ensured patients could access care in a timely way.

Before requesting wider system support, leaders reviewed internal capacity, staffing levels, discharge activity and available escalation measures. They worked with system partners to explore mutual aid options and identify solutions to operational pressures. This proactive approach helped the trust manage demand effectively, reduce risks to patients and promote collective accountability across the system.

Leaders demonstrated strong operational management through daily huddles, clear escalation processes, and visible consultant and management support, enabling timely decision-making and proactive management of patient flow. Although leaders maintained oversight through real-time dashboards and structured operational processes, sustained high demand and crowding limited the effectiveness of these systems. Pressures on capacity required frequent escalation and impacted consistent delivery of safe care.

At the time of the assessment, we were informed a sepsis audit was currently underway. Following the inspection the trust provided us with the completed sepsis audit which demonstrated good compliance with the standards. Staff used national guidance and electronic prompts to support early identification and treatment of sepsis, and outcomes for infection were better than expected. The service also undertook multidisciplinary reviews and contributed to research and service development, demonstrating a commitment to continuous improvement.

Most mental health patients were assessed within expected timeframes, and staff worked with mental health partners to provide care, including through the Transitional Assessment Facility, where co-located teams supported timely clinical input. However pathways for adult patients with mental health needs did not consistently support timely care, with some patients experiencing very long waits, including up to 145 hours on one occasion for one patient. The average length of stay was 7.5 hours. These delays highlighted weaknesses in system-wide pathways, particularly in accessing specialist beds and community support.

Documentation was appropriate and in accordance with the Mental Capacity Act and Mental Health Assessment Act with staff using shared electronic systems to document care and support communication across teams, which promoted continuity and consistency. Staff used shared electronic systems to document care and support communication across teams, which promoted continuity when records were accurate.

The trust worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

There were clear leadership arrangements for safeguarding. The service had a named non-medical safeguarding lead, a paediatric safeguarding lead consultant, and a lead nurse, with additional consultant-level expertise available. Staff knew who the safeguarding leads were and described good access to advice and support when needed.

Safeguarding policies for children and young people, including those relating to child sexual exploitation, were up to date, version controlled and accessible. Staff received safeguarding training relevant to their roles, including Level 3 paediatric safeguarding, which was delivered in-house. The data provided by the trust showed that staff were up to date with their safeguarding mandatory training (overall 91% compliance). Staff were expected to remain up to date, and compliance was supported through regular safeguarding meetings, including weekly discussions and monthly trust-wide safeguarding forums. These arrangements ensured staff had the skills and knowledge to identify and respond to safeguarding concerns.

Staff demonstrated a good understanding of how to identify children at risk of harm. The electronic patient record system (supported risk identification through the use of alerts and flags, including markers for frequent attenders. This allowed staff to recognise patterns and indicators of vulnerability. The department’s electronic tracking systems also provided clear oversight of patient activity and risk, which supported safe and timely decision-making.

Processes were in place to ensure children at higher risk were appropriately reviewed. Children and young people were assessed by paediatric residents, with consultant support readily available on site. Staff told us consultants were visible and responsive, and escalation processes were well understood. This ensured that clinical decisions were supported by appropriate senior oversight.

Staff had access to key safeguarding information through NHS alerts, which identified if a child was subject to a Child Protection Plan. While staff did not have direct access to full plans, they appropriately contacted the local authority to obtain relevant information when needed. This supported effective information sharing and risk management

Access to safeguarding advice was available through consultant escalation, including out of hours. While there was no formal 24/7 dedicated safeguarding service, a pathway was in place to enable staff to access advice and escalate concerns. Staff reported that concerns were escalated to the on-call consultant, with follow-up by the safeguarding team where required. These arrangements ensured risks were always managed safely.

The service had appropriate processes to manage children presenting with mental health needs. Young people were assessed from triage and, where appropriate, given the opportunity to speak independently from parents or carers. Patients assessed as high risk were moved to safer clinical areas, such as designated high observation bays. Staff took reasonable steps to reduce environmental risks, including removing ligature risks where possible, although they acknowledged not all risks could be fully eliminated.

Staff carried out risk-based property searches where necessary, which were conducted by 2 members of staff and documented clearly. Records included the child’s identity, clothing, risk of absconding, and details of escalation and communication. This demonstrated a structured approach to risk management

Staff understood their responsibilities in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS). They assessed and recorded capacity appropriately and ensured decisions were made in the best interests of the child. Care was delivered in ways which respected human rights and promoted equality.

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

The service took a balanced and proportionate approach to assessing and managing risk while respecting people’s choices and involvement in their care. Staff carried out risk assessments, such as for falls risks and skin integrity, at triage using clear inclusion criteria to determine whether patients were suitable to be seen in the unit. The service also had systems to identify and monitor frequent attenders. Staff undertook regular reviews to understand the reasons for repeated attendance and, where possible, involved patients in these discussions to support safer and more appropriate care planning.

Staff used recognised national tools to identify patients at risk of deterioration and escalated concerns appropriately. They recorded vital signs, such as blood pressure, heart rate and respirations electronically and calculated early warning scores to support clinical decision-making. The service had clear escalation procedures for deteriorating patients, ensuring timely responses. Initial assessments included a focused clinical history, baseline observations and, where required, diagnostic tests such as blood tests, X-rays or electrocardiograms. Clinicians made decisions about patient suitability for the service at the point of triage, which supported safe onward care pathways.

Staff demonstrated they involved people in managing risks associated with their care. They considered individual preferences, communication needs, language requirements and levels of health understanding when discussing care and treatment options. Staff explained symptoms and management plans in a way patients could understand and involved relatives or carers in decision-making where appropriate. Feedback from patients indicated they felt listened to and involved in decisions about their care. Assessments were holistic and took account of each person’s health, wellbeing and communication needs to support safe care and achieve positive outcomes.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The design, layout and use of facilities generally supported the delivery of safe care. The waiting area was clearly visible from the reception desk, allowing reception and nursing staff to maintain direct oversight of patients and respond promptly to concerns while people waited to be seen.

Patients were cared for in environments that were mostly safe and met their needs. Within the Emergency Department (ED), there were clearly defined and separate areas for ambulance arrivals and for patients who self-presented, which supported patient flow and reduced associated risks. There was also a secure, dedicated paediatric waiting area equipped with appropriate furniture and toys to support children’s comfort and wellbeing. Water dispensers were available in waiting areas to support patient comfort.

Call bells were accessible to patients, and staff responded promptly when activated. During inspection, we observed call bells being answered without delay. The layout and design of the department followed recognised national guidance and supported safe observation.

Facilities were generally suitable to meet the needs of patients and their families. The service had sufficient and appropriate equipment to deliver safe care. Consumables were well organised, stored appropriately in trolleys, and all items we checked during our inspection were within their expiry dates. Emergency trolleys were managed safely, with daily checks completed consistently to ensure equipment was available and fit for use.

The service had visible on-site security arrangements. Two security staff were based within the ED area and were present and accessible throughout our inspection, providing reassurance to staff and patients and supporting the management of potential risks.

Mental health facilities were located within a separate corridor and included a suite of 3 rooms, known as the Transitional Assessment Facility (TAF), for patients awaiting formal mental health assessment or transfer. These areas had been designed with safety considerations, including observation windows and doors that could not be locked. Rooms were spacious, well-lit with natural light and appropriately furnished to promote comfort and dignity. A dedicated mental health nurse was allocated to the area at all times, and a security officer was stationed nearby to provide immediate support where required.

However, there were some environmental risks. There was no separate paediatric mental health room. Although leaders told us there were plans to expand facilities in the future, staff told us they were required to use available rooms and complete risk assessments when caring for paediatric patients with mental health needs. These rooms were not fully ligature free, which posed a potential risk to patient safety. In addition, there were no separate bathroom facilities within the paediatric ED, and those available were not ligature free at the time of inspection. Staff mitigated these risks by undertaking individual risk assessments and maintaining appropriate levels of observation.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service planned and regularly reviewed staffing levels and skill mix to ensure people received safe care and treatment.

Leaders planned and reviewed staffing levels using a structured and evidence-based approach to ensure there were enough staff with the right skills to meet patient needs. They used a triangulated method to set establishment, which included the Safer Nursing Care Tool (SNCT), nurse-sensitive indicators and professional judgement. Staff collected patient acuity and dependency data consistently, including for patients staying longer than 12 hours, which supported an accurate understanding of demand across the Emergency Department (ED), Same Day Emergency Care (SDEC) and Urgent Treatment Centre (UTC).

Safer Nursing Care Tool modelling demonstrated that leaders understood staffing requirements well. The combined recommended establishment was approximately 199 whole-time equivalents (WTE) and the service had an establishment of 185.76 WTE, representing a small shortfall of around 13 WTE. Despite this, the service managed staffing flexibly across ED, SDEC and UTC to maintain safe care delivery.

The service maintained an appropriate medical skill mix across adult and paediatric ED. The workforce included consultants (14 WTE against 15 budgeted), specialty doctors (3 WTE against 2.8), residents and foundation doctors, with a total of 75 WTE in post compared to 78.6 WTE budgeted. This demonstrated that overall staffing remained close to establishment levels, with only a small gap of approximately 4 WTE (around 5%).

Planned versus actual staffing data showed that staffing levels were generally maintained close to planned levels across shifts. Fill rates for registered nurses were typically between 91% and 100% during the day and night, while healthcare assistant (HCA) staffing frequently met or exceeded planned levels, in some cases reaching over 100%. This additional HCA support helped to maintain patient safety and flow during periods of increased demand.

Workforce data showed that staffing remained relatively stable over time. Vacancy rates were low at the start of the reporting period (around 1.6% in April 2025) and increased gradually to approximately 13.9% by March 2026. Leaders actively monitored these vacancies and continued recruitment activity, supported by a steady number of starters. Staff turnover remained moderate, ranging from around 12% to 17%, and workforce stability indicators improved over time, demonstrating strengthening retention.

Sickness rates were consistent and manageable. The rolling 12-month absence rate remained stable at approximately 4.3% to 4.6%, with most absence attributable to short-term sickness. There were no significant increases that impacted the service’s ability to deliver safe care.

The service used bank staff effectively to maintain safe staffing levels and continuity of care. Bank usage was consistent across both nursing and medical staff groups, for example nursing bank use reduced from 30.5 WTE in April 2025 to 14.8 WTE in February 2026, while medical bank use remained steady at around 12–13 WTE. Agency use was minimal across all staff groups, often close to zero, which supported team consistency, familiarity and safer care delivery.

There was an effective approach to assessing and managing the risk of infection, which was in line with national guidance. The department was visibly clean, well maintained and free from clutter. Domestic staff maintained high standards of cleanliness throughout the inspection. Staff confirmed that cleaning schedules were in place, and we saw the domestic teams responded promptly to requests for additional cleaning. This demonstrated effective systems to maintain a clean and hygienic environment.

We observed staff following appropriate hand hygiene procedures, including effective handwashing and use of alcohol-based hand gel at point of care. Personal protective equipment (PPE), including gloves, aprons and hand sanitiser, was readily available and used appropriately across clinical and public areas. Privacy curtains were clean, clearly dated and appropriately maintained. These arrangements reduced the risk of cross infection and supported safe care and treatment.

However, during the first day of inspection, we identified some areas of non-compliance with ‘bare below the elbows’ guidance, including staff wearing wristwatches. We raised this with the trust and saw immediate improvement in compliance. On the second day of our inspection, we observed some staff wearing false or painted nails, which did not align with best practice for infection prevention. These concerns were escalated to the trust. While these issues did not outweigh the overall good practice observed, they showed the need for continued oversight and reinforcement of IPC standards.

Equipment within the department was safe, clean and appropriately maintained. Sharps containers were correctly assembled, not overfilled and safely managed. Clinical waste bins were clean and appropriately used. Daily checks of the resuscitation trolley were consistently completed and recorded, and fire safety equipment, including extinguishers, was in date.

The infection prevention and control policy was in date and version controlled, providing staff with current guidance to support safe practice.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.