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

The ED did not have a consistently good learning culture. Staff described a culture of accepting the department was continually at or above capacity and patients did not consistently have their nursing needs met. Staff no longer reported these risks as incidents. Staff in the ED also said they did not always get a response when they reported incidents. Risks to patients in the ED were not consistently assessed. The facilities and equipment did not always meet the needs of people. There were not always enough nursing staff with the right skills, qualifications and experience to provide safe care and treatment. Medicines were not well managed. However, managers made sure staff received training and regular appraisals.

The service was in breach of legal regulation in relation to safe care and treatment because risks to patients were not always assessed or assessed within safe timescales, and because of the ways people’s medicines were managed. The service was in breach of legal regulation around staffing because there was not always enough nursing staff to provide safe care, and staff did not always receive the training and support they needed to keep patients and themselves safe.

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 provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff did not always listen to concerns about safety and did not always investigate and report safety events. Lessons were not always learnt to continually identify and embed good practice.

We had a mixed response from staff in the adults ED when we asked about the types of incidents they reported. All staff knew what incidents to report and how to report them, but some staff told us they no longer reported all incidents because they did not receive feedback or the incidents occurred daily. For example, some staff told us they did not report being short staffed, the department being overcrowded, or patient safety incidents like patients given their medicines late.

Medical staff were more likely than nursing staff to feel they worked in a learning rather than blame culture. However, some nurses in the ED told us the culture was focused on learning and said incidents were always reviewed and feedback given. They talked about a learning loop to ensure any learning was taken to make improvements to care.

Managers told us they had a plan to improve incident reporting and develop a learning culture. The plan included creating a monthly department newsletter which would include themes of incidents and learning to increase awareness of what incidents to report and to use learning to improve care.

The matron met with the governance team every week to review incidents.

Staff in the CED described a learning culture and told us they reported all incidents and near misses in line with trust policy. They told us there was a weekly incident review to look at all incidents of moderate harm or above. Information from the review was fed back to CED staff by managers. Staff in the CED gave us an example of an incident that had been used to make changes to improve patient care. The blood pressure reading of a patient had not been recorded so all nursing staff received refresher training on taking and recording blood pressure and explored, as a group, the potential for harm if blood pressure is not accurately recorded. Staff in the CED told us they received a regular newsletter from the education team that included themes from incidents. Posters were displayed in staff areas of themes of recently reported incidents and the learning taken from them.

We saw harm caused to patients as well as the potential for harm was attached to risks on risk registers, along with actions to mitigate risk. For example, all the staff we spoke to were concerned about overcrowding in the department. Overcrowding was classed as a high risk on the departments risk register, this risk was reviewed regularly, and new actions were added to mitigate risk when they were identified.

The service did not consistently maintain safe systems of care, in which safety could be managed or monitored.

The department used multiple electronic systems and paper notes to record and monitor patients care. A new electronic patient record (EPR) was due to be rolled out across the hospital in 2027 which would replace paper notes and reduce the number of electronic systems in use. One electronic system was being used to provide staff with oversight of patients in the department and the other to record patient’s observations and risk of deterioration using the National Early Warning Score (NEWS2), Paediatric Early Warning Score (PEWS) and the Modified Early Obstetric Warning Score (MEOWS). As the oversight tool did not record NEWS and PEWS scores there was no immediate oversight of clinical acuity by the lead emergency physician in charge (EPIC) and the nurse in charge (NIC). Staff needed to go into the second system and look at individual patients to view the level of information required to monitor deterioration. The NIC told us they relied on nurses who had a coordinator role in each area of the ED to identify patients at risk of deterioration or sepsis and feed this information to them.

Patients admitted to the pit stop had their prescribed medicines recorded on a paper clinical assessment service (CAS) card. Once they were transferred to majors their prescribing was recorded on a paper medication administration record, often referred to as a MAR chart. A third system was introduced for prescribing once patients waiting for a bed on a medical ward were clerked by the medical team. The third system was electronic and meant some patients had an electronic record and 2 paper records. We saw staff struggling to work out which prescribing record to use to ensure medicines were given on time. We have written more about this in the medicines optimisation section of the report.

When patients attended ED as a ‘walk in’ rather than by ambulance, a streaming nurse (also called ‘the interceptor’) directed the patient to the part of the hospital that was most suited to their needs. For example, the CED, ED or the UTC. The patient then waited for triage (also called navigation) where nurses completed an initial assessment. After this, clinicians undertook clinical observations and diagnostic tests, for example blood tests and electrocardiogram (ECGs), that could be requested by the triage nurse (they called this streaming). This system was introduced to ensure patients received some of the tests they needed prior to being seen by a doctor. However, tests were not consistently carried out in timescales that aligned with national guidance. For example, on our first day onsite we saw a patient with chest pain waiting an hour for an ECG. According to the Royal College of Emergency Medicine (RCEM) an ECG is an important test in suspected heart attacks and should be done within 10 minutes of arriving at hospital.

Patients attending the adult ED were not seen within timescale set by NHS England. This meant the patients’ pathway through ED was delayed. Patients in the CED and ED were triaged using a standardised tool that staff had been trained to use. NHS England guidance is that patients should receive a triage within 15 minutes of arrival for urgent or emergency care. Evidence showed the average wait for triage in the ED in 2025/2026 was 22 minutes. Patients in the CED were being seen within 15 minutes. If waits for triage went over 15 minutes in the CED a second triage nurse would be deployed to ensure waits for triage reverted to 15 minutes or less. However, in the adult ED there were 2 triage nurses but waits for triage for patients arriving on foot were typically around 40 minutes but as high as 59 minutes while we were onsite. While we were onsite waits for triage in the pit stop for patients arriving by ambulance were as long as 2 hours. Staff told us there was not an escalation process to follow when waits went above 15 minutes in the pit stop or for adult patients arriving by foot, so additional nurses were not deployed to triage to bring these waits down.

Some patients also had long waits to be reviewed by a doctor which prolonged their pathway through ED. This meant transitions to other wards or services were delayed which negatively impacted on some patients’ outcomes. Long waits in ED are associated with an increase in mortality. An example of a delay to see a doctor while we were on site was a patient arrived by ambulance at 7.48pm on our first day on site did not have a review until 10.35am the following day. When we asked about the delay in this patient being seen we were told there had not been anyone to review them due to the volume of patients waiting to be seen in the department.

Staff worked well with inbound ambulance crews to ensure the sickest patients were fast tracked to the resuscitation area. The ambulance trusts alerted the hospital if they were conveying a patient with a suspected stroke to the hospital so the stroke team could assess the patient on arrival. Trauma patients and patients who were very unstable were typically conveyed to the local designated major trauma centre (MTC). The hospital had a trauma team (without a surgeon) but would typically transfer any trauma patients who arrived in the ED to the MTC.

Patients arriving by ambulance were taken into the pit stop for triage and assessment. If there was a delay due to capacity and the patient could not be brought into the pit stop straight away, they were assessed by a doctor inside the ambulance within 30 minutes of arriving. Once the patient had been on an ambulance for 45 minutes, space was created in the pit stop for the patient to be brought into.

Nursing staff shared key safety messages during handovers. For example, we saw information about a change to the process of making a safeguarding referral being shared with staff. Doctors had a daily handover meeting which the nurse in charge attended to ensure doctors received the same safety messages as nursing staff. After a quick briefing with the EPIC, resident doctors went straight out to the area of the ED they were assigned to for a full handover of the patients under their care. The consultants remained in the meeting to take handover of the patients in the ED with the greatest clinical risk. This was a shortened version of the ED handover process. Previously it had involved all of the medical team having a board round of all patients in the department which was often a lengthy process. The new meeting structure was designed to ensure medical staff were staffing all areas of the department as soon as possible after starting their shift, but still had all the information they needed about the patients. Feedback from nursing and medical staff about the new style medical handover was very positive.

Senior staff attended regular safety huddles throughout the day. The huddles were operational and safety focused and included a discussion of staffing levels, overall capacity including in the UTC, the potential for flow, the number of ambulances waiting to handover patients, inbound ambulances and a discussion about the patients in the department because of their mental health.

Continuity of care for patients awaiting a bed on a medical ward was maintained by the medical care specialty in-reach team who were based in the ED during the daytime. The team was responsible for the medical assessment of these patients and reviewing them if they deteriorated. The ED medical team were responsible for these patients overnight. Prior to the in-reach team being established the ED team had responsibility of this cohort of patients 24 hours a day. ED staff said the in-reach team had taken some of the risk off the department during the teams opening hours.

The department had a clear pathway for patients with mental health conditions and symptoms. Triage nurses completed an assessment of risk as part of the triage process using the Patient Assessment of Risk and Observation Tool (PAROT). Patients identified as needing a mental health assessment were referred to the external mental health liaison team.

A local mental health trust provided the psychiatric liaison service. The team provided a service for adults over 18 years old, 24 hours a day, 7 days a week. The team, who were based in the hospital, were notified of referrals from the emergency department by bleep or by telephone. A duty worker in the liaison team managed incoming referrals from the ED. The duty worker had access to the EDs electronic oversight tool. This allowed the duty worker to update the patients ED notes with any recent contacts with mental health services. If a patient spent more than 24 hours in the ED the liaison team would review them daily.

The trust had an alcohol team, homelessness team and dementia team who were available to support patients in ED.

The trust had processes for supporting children and young people with mental health needs attending the CED. The external Child and Adolescent Mental Health Service (CAMHS) assessed young people in the paediatric emergency department.

The service 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. The service shared concerns quickly and appropriately. However, not all staff received training in line with national guidance.

Not all staff were trained to the levels of safeguarding as outlined by national best practice documents. Non-clinical staff who had contact with adults and children were trained to level 1. The intercollegiate documents (Safeguarding children and young people: roles and competences for health care staff and Adult Safeguarding: Roles and Competencies for Health Care Staff) state these staff should be trained to level 2. Nursing and medical staff received training in safeguarding adults and safeguarding children to level 3. The doctor with responsibility for completing level 4 safeguarding adults training had not completed this. Doctor’s overall compliance with safeguarding adults level 3 and safeguarding children level 3 training was 86.07% and nursing staff compliance was 89.81% against the trust target of 95%.

All the staff we spoke with knew how to escalate a safeguarding concern. Staff knew who the senior safeguarding leads were and they were able to describe the safeguarding process, give examples of past cases and explain how they escalated concerns.

Staff in the CED had access to safeguarding systems so they knew if a child attending for treatment had a safeguarding or child in need plan. They had processes and tools to use to assess children at risk of exploitation. There were pathways for staff to follow if children presented with specific injuries, for example knife wounds or dog bites.

Staff had a good understanding of how to address situations where patients presented after an alleged sexual assault. Staff had access to sexual assault consultants who worked on call and liaised with the police and local sexual assault referral centre as required.

The trust had an intranet site with quick links for safeguarding. Referrals were sent to the safeguarding team for them to review and action.

The head of safeguarding for the trust was also the lead for mental health.

Staff in the department received training in the Mental Capacity Act. Staff considered patient’s capacity when assessing them. All of the files we reviewed to check capacity had been assessed contained all of the information expected. However, not all staff knew who to contact if a patient who lacked capacity to make decisions about their health care left the department, for example by alerting the police if required. Resident doctors told us they would discuss this with the nursing staff, but they did not know what processes they should follow.

The service did not consistently work with patients to understand and manage risks. Staff did not always provide care and treatment that met patients’ needs.

Patients experienced long waits in the adult ED. This was due to the wider hospital not having enough beds for patients that needed admitting into hospital from ED. Some patients awaiting a discharge from ED to home also had long waits. This meant the department was often crowded and not able to function as a fully operational ED.

Staff in the ED did not consistently assess patient using standardised risk assessment tools. For example, they did not consistently assess the risk of venous thromboembolism (VTE), falls, skin integrity, or clinical frailty. NHS guidance states the Clinical Frailty Score (CFS) should be completed within 30 minutes for all adults over the age of 65 who present in ED. We checked 13 files for patients in majors and found the CFS assessment had not been completed. Each file contained a falls risk assessment but only 2 had been completed, this was despite 4 of the patients attending the ED because they had fallen in the community. We asked staff in the pitstop when these assessments should be completed. We were told they would be completed once the patient was moved to ‘majors’ (the area for seriously unwell or injured patients). Staff in ‘majors’ told us the assessments should have been completed in the pitstop. According to the National Institute for Health and Care Excellence (NICE) it is important to identify those with a higher risk of falls, for the efficient and targeted delivery of falls prevention interventions. All patients in the quad had had a falls risk assessment and skin integrity risk assessment completed. However, we could not see specific actions for the patients who were identified as high risk of falls, but we could see that preventative measures had been taken, for example, patients were wearing anti-slip socks.

VTE risk was not assessed until patients were transferred to a ward. NICE guidance states if patients have not been admitted to a ward within 12 hours of their arrival in the ED they should have their VTE risk assessed.

There was good visual oversight of patients in both the CED and ED waiting areas. The triage nurses, interceptor and streaming nurses were all based in the waiting area. Patients in the waiting area had the same frequency of clinical observations taken as patients elsewhere in the department.

Clinical observations were used to complete the NEWS2 for adult patients in the ED, and PEWS was completed for all children and young people. The MEOWS was used to detect physical deterioration in pregnant and postpartum women. The observations (vital signs) were used to help staff assess a patient's condition, identify potential deterioration, and guide clinical decisions. An electronic system flagged when patient observations were due and when NEWS2 and PEWS scores were due to be reassessed, this was an improvement since our last inspection. We saw patients in the CED had their PEWS reassessed in line with guidance, but staff in the ED were not always able to complete NEWS2 in the correct timeframe due to the number of patients in the department. However, nurses told us when they identified patients who were deteriorating, they were able to quickly escalate this to a doctor.

Triage nurses in the CED started the Sepsis Six bundle if sepsis triggers were identified at triage. The Sepsis Six bundle is a set of six time-critical interventions designed to be started within one hour of recognising sepsis to reduce mortality. Nurses could take blood cultures and other blood tests prior to review by a doctor. The patient would be seen for an urgent review by a doctor to step this process up or down depending on their findings. In the triage ED nurses were required to wait for a doctor to take blood cultures and staff said doctors were not always available straight away to complete this. Nurses in other parts of the ED told us if changes in patient observations indicated suspected sepsis they were able to escalate this to a doctor without delay.

Staff were tasked with performing two hourly comfort rounding for patients. Comfort rounding is an intentional process of regularly checking in with patients to identify and meet their needs. Staff used the mnemonic TRIPP to describe their rounding process: toilet, refreshments, information, pain and pressure (skin integrity). Designated staff in each area of the ED were assigned to completing TRIPPs. As will be discussed elsewhere in this report, rounding was not consistently completed every 2 hours in line with the trust’s policies and procedures.

There were systems to identify critically ill patients when they arrived at the ED. The ambulance service informed the ED when a critically ill patient was being brought in by ambulance so they could be transferred straight to the resuscitation area. Despite the EPIC and NIC not having clear clinical oversight of patients in the department through an oversight dashboard they told us they could act quickly to move patients into the resuscitation area if patients deteriorated and became critically unwell.

The records we reviewed for adults presenting in mental health crisis showed all patients received an assessment of their physical and mental health needs on their arrival at the emergency department. This included details about any risks to themselves or others.

Security staff were present in the department during the day. Security staff did not complete therapeutic observations but would support staff to restrain patients. Security staff members took part in a four-day training course. The training included trauma informed care and positive behaviour support. Staff we spoke to said security staff were responsive and supportive and they gave positive examples of when security team members had used de-escalation skills. Security team members wore body cameras.

All episodes of restraint were incident reported and reviewed daily by the reducing restrictive practice team and security team leads. The reducing restrictive practice team undertook a yearly review of restraints and used this to inform the yearly plan for training. A previous yearly review had led to the development of the four-day training for security staff members.

The service did not have enough suitable equipment to help them to safely care for patients. Leaders and staff did not consistently take steps to make sure equipment, facilities and technology supported the delivery of safe care. However, the service mostly detected and controlled potential risks in the care environment.

There was routine use of corridor care which risked patients’ safety, privacy and dignity and staff’s ability to provide safe care. Corridor care is the term used to describe any non-designated clinical spaces for patient care. In this service the impact of corridor care was the safety, basic care, rights and respect of patients were not consistently upheld. Emergency equipment (oxygen and suction) was not readily available and functional and easily deliverable to patients cared for in these spaces. There was not enough space to get emergency equipment and staff around a patient to safely deliver care. Especially whilst ensuring privacy and dignity for them and those near them. Patients could not be easily moved between areas in an emergency. It was not possible for staff to maintain privacy and dignity for patients in these spaces.

The ED was very overcrowded at the time of our inspection. There were multiple non-designated clinical spaces in use. The non-designated clinical spaces were often a patient on a trolley in front of another patient’s bed or trolley space. For example, in majors A there was a patient on a trolley in front of each patient cubicle and in the pitstop there was a patient on a trolley in front of other patients on trolleys. Apart from 1 of these spaces there were no curtains or other equipment to provide any privacy for people in non-designated clinical spaces. Because patients were placed on trolleys in front of other patients this would have delayed staff reaching patients who required emergency treatment, for example, resuscitation.

In addition to the non-designated clinical spaces there were several designated escalation areas, that also met the criteria to be classed as corridor care, being used at the time of our inspection. There were 2 escalations areas that could be used 24 hours a day. These were ward 101 and ‘the quad’. Both areas could take 7 patients. In addition to these, the fracture clinic was used overnight to take another 7 patients. If the resuscitation area in CEDs was not in use, 1 adult patient could be located there. Apart from the CED resuscitation room these areas were not suitable for high dependency patients as there was no piped oxygen or suction. To mitigate risk, patients located in these escalation areas were typically waiting to be discharged home or waiting for a bed on the medical assessment unit. They had a NEWS2 of less than 5 and were not confused. The hospital stopped using the quad in April 2026.

Ambulatory (‘walk in’ patients) care in the ED encompassed the main waiting room and the SDEC. The waiting room was large and contained 89 chairs. During our inspection most chairs were occupied at all times. We returned to the ED in the evening of our first day on site and found this room was overcapacity. There were no unused chairs and people were standing up because there was nowhere for them to sit down. Fifty-nine of the people in the room were patients. Staff told us that sometimes there were over 130 patients in the waiting room. During these periods staff asked relatives to leave to create more space for patients.

The ambulance triage area called the pit stop, had been designed as a space for patients to receive a rapid triage and then be assessed by a senior doctor. This was so investigations and treatment could begin promptly and the plan to discharge or admit could be expedited.

There was not always enough equipment to keep people safe. Patients who spend longer on trolleys are more at risk of developing skin damage or pressure injuries. Frail elderly patients were sometimes kept on stretchers for long periods of time. For example, an elderly patient arrived in the department by ambulance on 3 March 2026. They were brought into the hospital on a stretcher. According to the patient and their relative, the patient was on the stretcher trolley for 21 hours before they were transferred onto a bed on 4 March. The hospital had invested in some trolleys with special mattresses that were designed to be comfortable and reduce the likelihood of skin damage or pressure injuries that could be used for up to 48 hours. Staff tried to get the new style trolleys or hospital beds for patients at high risk of pressure injuries but neither of these options were consistently available for patients during high levels of demand on the service. Senior leaders confirmed it was often difficult for staff to get a hospital bed for patients in the department.

The CED was designed to keep children and young people safe whilst in the department. The rear door to the department was secured with swipe-access for entry and a button-release mechanism for exit. However, the main entrance to the CED was unlocked. Improvement works were planned to ensure the main entrance was appropriately secured. Staff had a direct line of sight to people arriving and leaving the department.

Staff had good visibility of patients from the nurse’s stations. Staff used a large observation bay for babies, children and young people that needed to stay in the department for observation, for example, after a head injury. There were 2 waiting areas, a small waiting area for diagnostic imaging and a larger main waiting area which had an attached outdoor play area. The waiting areas, including the outdoor section, were visible to staff from the nurse’s stations. There were plans to build a cover for the play area so it could be used throughout the year regardless of the weather. All of the waiting areas were decorated appropriately. The outside area had child safe toys and equipment and rubber flooring.

The CED and ED resuscitation rooms had all the equipment and space required to resuscitate and stabilise deteriorating patients. The 2 bed CED resuscitation room could be accessed through the adult ED resuscitation room. This enabled a quick response from ED doctors if support was required in CEDs for a trauma patient. Overnight the ED used 1 of the CEDs resuscitation beds as an escalation area if this area was not already in use.

Not all portable electronic equipment had evidence of safety testing in line with manufactures guidance. For example, in the pit stop we looked at 3 blood pressure machines, 2 had stickers to show they had been safety tested within date, 1 was out of date (due to be retested in August 2024). We saw 1 piece of electrical equipment in the CED resuscitation room that had an expired test (due to be retested in August 2025). We found other equipment in the CED that had not had planned maintenance. For example, we saw 4 sets of baby scales that were due for servicing/maintenance in January 2026.

Not all safety hazards were locked away. We saw an unlocked clinic room and an unlocked clean utility room. Both rooms contained items that should not have been accessible to patients. The drug cupboard was unlocked in the clinic room which gave unauthorised people access to drugs that had the potential for abuse or deliberate overdose, and a variety of other medicines. Both rooms also contained products that came under the Control of Substances Hazardous to Health Regulations 2002 (COSHH) and discarded batteries that could be used by people to self-harm. There were also razors in the utility room. The plaster room was unlocked and there was an unlocked cupboard with two pairs of scissors that could be used to self-harm.

Facilities for safely supporting patients who had mental health symptoms as their presenting condition were mostly safe. The department had one room for assessing mental health patients. The room met Psychiatric Liaison Accreditation Network (PLAN) standards. The rooms had two doors, which opened outwards. Both the doors had viewing panels that could be closed. There were strip alarms around the room. The rooms were furnished minimally. The room had a bed. Staff completed a ligature risk assessment of the room. Ligature cutters were kept in the resus trolley.

There was a toilet adjacent to the room for use by patients in a mental health crisis. It was not ligature free but was a ligature managed room (less ligature points than a regular toilet) and had been risk assessed for use by this cohort of patients. There were no showers in the majors area for patients. If patients needed to use a shower they had to use the one in the UTC. This was not fitted with anti-ligature fittings. Staff would complete a risk assessment for patients presenting in mental health crisis before they were permitted to use this shower.

In the CED there was a designated quiet room for supporting young people with mental health needs. Only one young person could be accommodated in this room at any time. The room was furnished minimally. The room had a bed and a safety pod. Staff told us they would place other young people with mental health needs in cubicles nearer to the nurses’ station to allow for observation. Staff were aware that the cubicles contained potential ligature risks and they would minimise these risks when required by removing as many potential ligature points as possible and ensuring the young person had constant supervision.

The adult ED did not always have enough qualified, skilled and experienced staff, to provide safe care that met patients’ individual needs. Mandatory training compliance and compliance with appraisals was below expected standards. There were enough qualified, skilled and experienced staff in the CED to provide safe care that met patients’ individual needs.

Staff were aware of the clinicians who were in charge of the department (NIC and EPIC).

Medical and nursing staff told us that the size of the ED had increased which meant a greater number of patients could be seen in the department, but there had not been an increase in the number of staff to manage the increase in the number of patients. Some managers told us they thought the model used to staff the ED with doctors was out of date. They said the tool used to staff the department reflected demand on ED prior to the COVID-19 pandemic.

The ED medical staffing numbers was under review at the time of our inspection. The skill mix of resident doctors aligned with RCEM guidance and consultant staffing was above guidance, which enabled the department to have a consultant until 2am every night. However, medical staff told us due to the increased size of the department combined with continuous high levels of demand on the service they struggled to consistently have sufficient staff, and staff with a good skill mix, in all areas of the ED. Although staffing levels met with national guidance, we saw long waits for patients to see a doctor. For example, during our inspection we saw multiple patients who arrived overnight in the main waiting room and waited for approximately 9 hours to have a medical assessment. Evidence provided by the trust showed 72.76% of patients were not seen for initial assessment within 60 minutes and waits of several hours although not typical, were not unusual.

While we were onsite, we saw ED consultants being asked to move from non-clinical to clinical duties and resident doctors being asked to work clinically instead of attending a teaching day because of staff sickness. Resident doctors told us they were not typically pulled away from teaching days.

The nurse staffing rota for the 5 days prior to our inspection showed that registered nurse staffing in the department was sometimes lower than planned for and sometimes over established. However, staff told us the tool that had been used to determine the number of nurses required in the ED did not reflect the number of patients in the department. Staff said this meant there was not enough skilled and experienced nursing staff in the ED for them to meet the needs of patients. This could be evidenced by the fact nurses could not maintain fundamental standards of nursing in the ED as discussed throughout this report. However, the RCEM standards had been used to formulate the basis for a review of the nursing workforce which resulted in an uplift to the departments nursing template. A phased recruitment plan was underway, but senior leaders acknowledged it would be September 2026 before the ED was up to RCEM staffing levels.

Bank and agency staff were used to cover gaps in the nursing rota along with ward staff from other parts of the hospital who may be asked to work in the ED at short notice. Senior leaders said this meant sometimes care was being delivered by staff who were not familiar with urgent care or with their ED. Within the nursing team there were 12 full time vacancies and a sickness rate of 10%. In addition to this, 9 whole time equivalent members of the team were on temporary long-term leave. Coupled with the increased demand in the ED, leaders said bank and agency staff were being used daily along with nurses from elsewhere in the hospital who were being sent to cover gaps in the template.

Treatment in minors was primarily delivered by emergency nurse practitioners (ENPs) between 7am and midnight. ENPs are senior nurses specifically trained to manage patients with minor injuries and illnesses.

Resident doctors told us they received a whole day teaching each month, had designated clinical supervisors and felt supported by the senior staff. They told us senior doctors were visible, accessible and responsive.

Matrons provided cross site cover when their counterpart was away to ensure visible senior leadership for nursing staff.

Although the CED was staffed separately to the ED, consultant cover was provided by the 4 ED consultants who were dual accredited in paediatric emergency medicine. Overnight the CED on call cover was provided by general paediatricians from the women and children directorate. The ED provided support to the CED for trauma patients.

Advanced clinical practitioners (ACPs) and ENPs supported staff to deliver safe care and treatment to patients attending the CED. ACPs are master's-level trained healthcare professionals who work autonomously to assess, diagnose, treat, and manage patients.

To ensure patient safety the shift pattern for nurse staffing in the CED had been altered to so there was more staff available at the busiest times, which were 10am to midnight.

The nurse in charge completed a risk assessment for children and young people to establish if they required enhanced observations. If they did, they were assigned a member of staff from the CED staffing establishment. If there were not enough staff to enable this staff from across the wider paediatric team would be sourced. Otherwise, bank or agency staff would be requested to ensure there were enough staff to meet the needs of patients.

At our last inspection the service was in breach of legal regulations in relation to staffing because staff did not consistently complete mandatory training in line with trust policy. We found the same breach of regulation at this inspection. At the time of our assessment, overall compliance with mandatory training for medical staff, including safeguarding training, was low, with the exception of ‘infection control level 1’, ‘resus automatic external defibrillation’, and ‘resus paediatric basic life support’ which all had a compliance rate of 100%. The compliance target was 95% for most training modules and 85% or 75% for others. Compliance with moving and handling level 1 was 75% and compliance with level 2 was 51.5%.

Overall compliance with doctor’s essential to role training was 69.10%. Mandatory training compliance for nursing staff was typically higher than doctors but still low with overall compliance at just below 90%. Managers told us nurse compliance with mandatory training was low because staff were sometimes pulled off training to cover sickness.

The psychiatric liaison team provided training to the departmental staff. This includes training on the Mental Health Act, Mental Capacity Act, triaging mental health patients and how to prioritise mental health patients. The department offered breakaway and de-escalation training for staff. However, overall compliance with staff training outside of mandatory training to support them to work with people under the Mental Health Act (1983) and Mental Capacity Act (2005) was low at 69.27%.

The clinical learning team had tools to show them which nursing staff in the ED required training and which staff needed competencies signing off. This meant they could schedule training to meet demand.

Compliance with annual appraisals in the CED was 89.13% and 68.40% in the ED. In addition to their appraisal, staff also took part in a 6 month (or more frequent) wellbeing conversation with their managers.

The service did not consistently manage the risk of infection well.

The environment was mostly visibly clean. However, cleaning schedules in the CED were not always up to date. Toys in the CED toy cupboard were not consistently cleaned. The daily cleaning checklist showed the toys were predominately cleaned by the same member of staff, but when that person was not working the toys were not always cleaned.

Patient and staff toilets in the ED were clean, and the cleaning schedules were on view and up to date. We regularly saw members of the housekeeping staff cleaning the areas around patient’s bedsides.

Staff in the CED used ‘I am clean’ stickers to show that equipment was clean and ready for use. We saw a roll of ‘I am clean’ stickers in the ED but we did not see the stickers being used to show when things had been cleaned.

Furnishings were not consistently in a good state of repair. For example, there was an armchair in the CED observation room which was not infection prevention and control (IPC) compliant because it could not be wiped clean. There was a rip on each arm of the chair and five visible rips on the cushion area. However, we saw evidence of regular cleaning in the CED including nursing staff cleaning cubicles in between patients. Nursing staff said they cleaned the cubicles before and after every patient and conducted a deep clean once per shift.

Staff in the ED said there was nowhere to provide barrier nursing (isolation) in the main waiting room to prevent the spread of contagious pathogens from an infected patient to staff, visitors or other patients. Staff were concerned because of the high volume of unwell patients in the waiting area who historically would have been moved to majors, but because of demand on the service needed to stay in the waiting room, often for several hours.

Staff performed regular local IPC audits including for cleaning, handwashing, staff uniform compliance and observation of the environment. When audit results were below expected compliance, action plans were developed to improve this. Handwashing audits showed compliance of 100% from November 2025 to January 2026. However, we saw some staff did not wash their hands or use hand sanitising gel between patients. We saw one nurse that did not wash their hands after taking a patient’s blood sample. We saw staff wearing gloves and not changing these in between working with different patients. The audit of IPC across the department was 67.74% for November 2025, 92.77% for December and 97.92% in January 2026. Cleanliness of beds and mattresses improved from 70.91% in November to 97.12% in January and cleanliness of transfer trolleys improved from 71.82% in November to 79.55% in January. No data was collected for either metric in December.

Staff had access to and used personal protective equipment (PPE). We also saw PPE (face masks) for patients and other visitors to the department. Hand gel was available in all areas for use by staff, patients and other visitors. This was an improvement since our last inspection.

Staff followed safe waste and clinical specimen management practices. There was mostly appropriate segregation, storage, labelling, handling and disposal of waste. However, sharps waste was not consistently being followed in line with guidance. We saw modified sharps boxes on housekeeping trolleys. The modification meant the contents could be accessed. In one of the boxes we saw a broken pair of scissors as well as other sharps items.

The service did not always make sure that medicines and treatments were safe and met patient’s needs, capabilities and preferences. Patients were not involved in planning.

The RCEM recommends a dedicated emergency department pharmacist and pharmacy technician work within EDs as part of the multidisciplinary team to help provide clinical and operational support for the safe and efficient delivery of care to patients. At the time of our inspection there was no clinical pharmacy service based within the department. However, senior leaders told us they had recently run an initiative called ‘a perfect week’. During this time, they introduced all the things into the department that staff thought would improve patient care. This included a dedicated pharmacy team. Following the success of this initiative senior leaders told us that a business case had been submitted to ensure the department will have pharmacy support in line with national guidance in the future. At the time of our inspection staff across the department had access to a clinical pharmacist for clinical support during the day seven days a week, and there was a clear process for staff to follow to obtain medicines and clinical advice out of hours.

Staff in the ED used multiple electronic systems alongside paper records to document people’s medicines and related care notes. This created duplication and inconsistency, as information for the same person was stored in several places. We saw discrepancies in the way allergies were recorded. This included 2 charts where allergies were not recorded on admission paper charts but later flagged up on electronic systems, 4 charts where allergies were noted but reactions were missing and 1 chart where there were differences between a patient’s admission notes and the prescribing chart. This placed people at risk of receiving medicines they were allergic to.

We identified delays in prescribing and administering medicines. We observed 4 patients who received medicines late including time sensitive medicines that were critical to their care. We spoke to the relatives of 2 patients who had to prompt staff to administer time critical Parkinsons medicines, and in one instance we had to escalate this ourselves. Staff told us there was a system that had been introduced following a quality improvement project, to use yellow wristbands and charting stickers to identify patients on time sensitive medicines, but this was not consistently being implemented.Staff could add a tag to one of the department’s electronic systems for patients prescribed time sensitive medicines, allowing the system to flag these patients. However, resident doctors told us they had to rely on nursing staff to inform them when patients were prescribed time‑critical medicines. Staff also reported that medicines were not always available which often led to delays in administration while waiting for vital medicine to arrive in the department.

VTE risk assessments were not completed for any of the patients we reviewed. This put patients at risk of developing clots during their admissions to hospital and caused delays in the prescribing of appropriately assessed prophylactic medications.

We saw instances of good practice in paediatric emergency care relating to medicines prescribing and administration. Staff provided person-centred care and demonstrated responsive action to sepsis management.

Medicines were not always stored safely. Expired medicines were present in all clinic room cupboards we inspected, and date opened stickers were not routinely applied to liquids in line with trust policy. We also found that prescription pads (FP10s) and associated records were not stored securely or recorded accurately and staff had not escalated concerns about missing FP10s in line with policy when issues were identified. Staff did not complete all controlled drug (CD) records correctly. Managers created action plans following CD audits when issues with CDs were identified. However, findings from the inspection did not provide assurance actions from these plans had been implemented.

Staff did not routinely record medicines fridge temperatures. Policy required room temperatures to be recorded only when a risk was identified, but staff did not have access to the necessary equipment such as thermometers. So they were unable to determine if the room was exceeding the acceptable temperature range. As a result, we could not determine the temperatures of several rooms that appeared to exceed temperature range.

Staff did not always complete daily resus trolley expiry date checks. There was a shortage of in-date anaphylaxis drug boxes which prevented the replacement of the contents of their resus trolley through trust supplies. This issue was known to the pharmacy team responsible for allocation of these boxes, but no communication had been cascaded across the hospital which meant there was no wider awareness of this safety risk.

Staff across the service had received medicines training. However, data showed that some nursing staff in the ED and CED had not completed this required learning. Medicines Safety training compliance was reviewed and found to be below the compliance target of 90%.

The trust had a policy and procedure for staff administering rapid tranquilisation. The policy had been revised as it was recognised the previous policy heavily relied on chemical sedation.

One member of staff told us that oxygen cylinders and oxygen concentrators were frequently left lying around the ED. They said the concentrators were typically not cleaned or left plugged in to charge, so there was a risk of equipment not being available when it was needed. Oxygen concentrators are a medical device that separates nitrogen from the air to increase the amount of pure oxygen patients breathe.