East Surrey 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 people were protected from abuse and avoidable harm. 

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

At the inspection we found the service was in breach of legal regulation in relation to safe care and treatment, premises and equipment, and staffing. This was because the service did not always mitigate delays in patient assessment and treatment, have safe oversight of corridor care, monitor medication fridges in line with national guidance, have enough staffing to meet planned numbers, maintain training compliance in line with trust targets or ensure the layout and maintenance of premises and equipment met patient needs or mitigate fire safety risks. 

In response to the concerns around delays in patient assessment and treatment and corridor care, the trust submitted an action plan outlining a range of improvement actions. These included enhanced executive and clinical oversight of patient flow and escalation processes, increased monitoring through operational dashboards and strengthened review of critical capacity escalation beds. The action plan also set out measures to strengthen clinical lead oversight of patient safety and operational management within the Acute Medical Unit. These actions were proposed after the inspection and therefore did not influence the findings of the assessment. 

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 did not always have a proactive and positive culture of safety based on openness. They did not always listen to concerns about safety and did not always effectively share learning and outcomes to continually identify and embed good practice.

Staff told us incidents were not routinely recorded when critical capacity beds were used, nor when complaints about their use were received, meaning the impact of the arrangement may not be formally escalated. Staff on one ward reported they were caring for an increased number of complex patients in inappropriate areas, due to the additional space and equipment required. This increased the risk of delayed emergency response for patients and moral distress among staff. 

The service had policies and meetings to collect, investigate and review data, including incidents, complaints and performance data. Records showed incidents were reviewed, with learning identified. However, learning was not routinely disseminated to staff, creating a disconnect between the review of issues and feedback to those raising concerns. This process did not support raising concerns due to the lack of actions taken. Staff feedback reinforced this finding, with some reporting they felt their concerns were not heard, as senior leaders did not consistently respond to issues raised. For example, staff escalated concerns to leaders regarding people being cared for in unsuitable critical capacity escalation bed spaces. While governance meeting minutes demonstrated this was discussed, staff reported the continued use of these bed spaces left them unclear about what meaningful action had been taken in response to their concerns. 

Staff described feeling “shut down” when they raised concerns that staffing resources did not match demand. This indicated that staff did not always experience a culture where challenge and risk escalation were addressed. Consequently, concerns were repeatedly re-raised, leading to growing frustration and a perception that their voices were not being heard.

Staff received training to identify incidents and knew how to report them using the trust’s electronic incident management system in line with trust policy. Staff gave us examples of incidents they had reported. One example included learning from a patient fall where neurological observations had not been undertaken as per policy. Staff shared there was a no-blame culture and the process for completing the observations changed in response to the reported incident. 

Staff received learning from incidents in a variety of ways. Paper-based summaries were displayed in staff rooms, and learning was communicated during team huddles and through staff group text messages. However, systems for providing feedback to staff were not consistently effective. 

Learning from incidents was shared with staff to drive improvement. For example, in 2025 there was an incident that involved a patient falling during the early hours, with no call made to the next of kin (NOK) due to the time. The NOK was later upset to learn of the fall. As a result, ward teams were reminded to follow procedure and notify the NOK after any fall, regardless of the time, unless the patient has stated they do not wish their NOK to be contacted, in which case this should be documented in the patient record.

Patient safety incidents were reported to the relevant governance panels for review and were subsequently discussed with consultants and divisional leadership teams. This process enabled identification of the appropriate level of investigation in line with the Patient Safety Incident Response Framework (PSIRF). Where incidents met escalation criteria, thematic reviews and investigations were undertaken to identify trends, contributory factors, and opportunities for improvement. Learning outcomes and key actions were disseminated through ward huddles and shared governance resources to support organisational learning and continuous improvement.

Wards displayed performance boards which included top themes from learning from incidents, mandatory and statutory training compliance, complaints and patient feedback. These displays were simple to read and accessible for staff, patients and visitors to be aware of. 

Complex case panels were held at divisional level to oversee the management of the incident process, including compliance with the duty of candour requirements. Regular duty of candour meetings were undertaken, to ensure the service was open and gave patients and families a full explanation if things went wrong. Staff reported performance in this area had improved, with discussions appropriately documented and correspondence issued directly by the team involved. We saw evidence of oversight of duty of candour having taken place through divisional leadership group meetings. 

The service did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services. 

The service had an emergency inpatient pathway for staff to follow. The document determined patient suitability for admission to specific units and how long they should be on the units. However, the service recognised the guidance was out of date and being updated. This meant there was an increased risk that patients were being transferred and cared for in unsuitable areas.

The majority of patients were admitted from AMU and the Emergency Department, with final admission decisions made by the registrar. However, patients were not transferred to medical specialities in a timely manner which impacted the flow through the service. Although weekly data from September 2025 to March 2026 showed an average AMU length of stay of 63 hours, which was better than the 72 hour target, the 72 hour standard was not consistently achieved.  Data showed a persistent proportion of people still remained in AMU for longer than 72 hours each week. While there were periods of improvement, there was no clear sustained improvement over the 6 month period. Performance fluctuated weekly, indicating the ongoing operational pressures and challenges in maintaining patient flow through the unit. 

There was insufficient clinical oversight of the capacity and acuity of patients attending the Acute Medical Unit (AMU), as the unit did not have a clinical lead available to ensure full oversight. Staff were unaware of who to go to if there was an AMU-wide concern. Staff told us they would escalate concerns to a consultant; however, they were unsure who they would escalate to if that particular consultant was unavailable. The absence of clearly defined leadership and escalation arrangements increased the risk of delays in decision-making and potential harm to patients.

Across many of the patients admitted to AMU, there was little or no mention of predicted discharge dates and infrequent communication about the status of discharge paperwork preparation. We reviewed patient notes and saw estimated discharge dates were not always recorded. This did not promote an effective flow through the service. This was recognised by other teams who reported the lack of predicted discharges impacted flow in their respective areas. 

During the inspection, the service was operating at OPEL 3 in accordance with the Operational Pressures Escalation Levels (OPEL) framework, indicating severe operational pressures, reduced capacity across the system, and challenges in maintaining patient flow. The trust worked within the OPEL framework and routinely reported operational pressures through established escalation processes, enabling oversight of patient flow issues.

The hospital regularly experienced increased operational pressure, resulting in increased bed occupancy This required the use of critical care escalation beds across the service. This meant that additional patients were sometimes cared for in existing areas designed to accommodate fewer patients. These beds were intended to be a controlled response to capacity and winter pressures, while maintaining patient safety and quality of care. However, staff reported their use had become normalised. Many staff told us they received a significant number of complaints from patients and relatives regarding these beds. To mitigate the impact, staff ensured patients were moved from these spaces into a core bed at the earliest opportunity.  

We requested the specific inclusion/exclusion criteria to determine who could occupy critical capacity escalation bed spaces safely. However, the service did not provide this information. Staff told us there was no criteria for the additional beds and that they had to manage patients as required, regardless of their complexity. 

The routine use of critical capacity escalation beds for patients who may not have been suitable for them presented significant concerns. In the absence of clear criteria, the trust could not be assured that placements were appropriate, consistent and based on a risk assessed framework. This increased the risk that patients’ clinical, environmental, or support needs may not be met. This could also place additional pressure on staff and resources and reduce the availability of escalation beds for suitable patients.

The hospital had a protocol outlining critical capacity escalation bed management however, the service did not fully adhere to this protocol. The protocol stated compliance monitoring arrangements should be in place, through data such as audits. However, we did not see evidence of this. 

The site team worked with the divisional teams to assess tracking of critical capacity escalation bed use. Matrons completed daily reviews of wards, which included the use of critical capacity escalation beds. They highlighted acuity and staffing, escalating concerns to the relevant teams to ensure staff could safely manage people. For example, a bay was crowded due to a critical capacity escalation bed space and other patients requiring support for all-care needs. After escalating this, the bed spaces were rearranged to ensure adequate space and support was provided, lessening the impact from the extra bed. 

Although monitoring was carried out, there was not a broader audit process to provide effective assurance and oversight. Critical capacity escalation bed data did not include key information such as bed appropriateness, length of stay and impact on service flow and patient wellbeing, limiting effective risk oversight. Staff told us site teams did not always listen and put inappropriate patients with high care needs in critical capacity escalation bed spaces. This resulted in staff having to swap patients to ensure care needs were met. 

Leaders received daily reports containing service performance and pressure data to monitor site activity. The reports included critical capacity escalation bed availability data. However, the occupancy and location of these beds were only updated once a day, which may not have provided live and up to date data. Critical capacity escalation bed data reported to the Board also did not specify details such as the locations of the most used critical capacity escalation beds or if patients met criteria to reside in these spaces. This missing information hindered oversight of these spaces and how the service could improve on them. 

Patients were not handed over to the receiving team in a comprehensive manner. For example, a patient with a severe physical disability and multiple complex health issues was handed over with little to no information about their care needs. For others, the information used to describe their health needs focused on the issues they were admitted with, instead of their most recent healthcare findings. 

Specialist teams had clear referral and review processes, enabling support across the site. For example, the Tissue Viability Nurses (TVNs) contributed to reviews, care planning and complex case discussions throughout the hospital. Staff also used clinical support tools such as a respiratory flowchart to support clinical decision making and prioritise patients for admission according to clinical need. 

Staff reported that the Angiography Suite was sometimes used to accommodate patients over the weekend. This clinical area was not suitable for inpatient admissions and was usually opened in the day, Monday to Friday. Staff reported on Monday mornings they frequently arrived to prepare for elective procedures to find the beds occupied, which could disrupt the service. We requested data regarding this matter however, this was not provided. 

The Medical Same Day Emergency Care (SDEC) and Frailty SDEC services operated daily between 8:00am and 8:00pm. The service had a policy to support the expected flow for patients requiring admission. It stated SDEC would not be bedded so patients who needed to be admitted could be moved quickly to a ward, helping patient flow through the hospital. However, the policy was out of date and being updated by the service. When ward beds were unavailable for a patient to move to, some patients remained in these SDEC areas overnight. To mitigate risk, the service identified clinical leads who maintained oversight of these patients outside of operating hours, which supported safe systems of care and patient safety. 

Nurses allocated to Medical SDEC worked collectively to support all patients within the department rather than holding individual responsibility for specific patients. This flexible approach enabled staff to respond to changing demand and support patient flow through the service. However, the arrangement did not always provide clear patient ownership or continuity of care, which limited oversight of individual patient pathways and presented a potential risk to the consistency of care delivery. Patients did not always have timely discharges from the hospital. This was due to internal issues such as discharge paperwork and medicines not being prepared in a timely manner. Staff had to manage patients’ expectations and often had to chase the medical and pharmacy teams to receive relevant discharge materials. Delayed and late transport services also impacted patient discharges, as it delayed the person leaving hospital and disrupted the flow through the service. 

The discharge unit did however, liaise with relevant health and social care services to encourage continuity of safe care post-discharge. This included communicating with care homes, carers, social workers and general practitioner’s (GP). 

The service did not always work well to ensure staff were up to date with relevant training to ensure people were kept supported and safe. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately.

Staff did not always complete safeguarding training, this was not an improvement from the last inspection. Overall safeguarding training compliance for all staff in the medicine division was 77%, against a trust target of 90%. Although Allied Health Professionals safeguarding compliance was 100%, medical staff (including dental) was only 54%. Level 3 training for medical staff was particularly low at 41%. Low safeguarding compliance created a risk that safeguarding concerns could be missed, thereby putting people at risk of harm. The service did not specify if they were trying to improve staff compliance.

Staff were able to recognise safeguarding concerns and understood the appropriate reporting pathways. They were aware of who to raise concerns with and of the relevant policies and guidance to support safeguarding. Staff knew how to make safeguarding referrals and provided examples of these. Staff demonstrated an understanding that safeguarding considerations extended not only to patients but also to their relatives and dependants. For example, staff described completing referrals when they had concerns about the children of patients with conditions such as eating disorders, alcohol dependency or substance misuse. 

Staff also recognised some patients were at risk of self-neglect. They told us they would only discharge these patients’ home once they were assured appropriate support was in place, such as care packages or other safeguarding measures, to ensure a safe discharge.

The Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) were included in mandatory training. Staff we spoke with understood when mental capacity and DoLS assessments were required to support people.

The service had up-to-date policies aligned with national guidance, ensuring staff understood their responsibilities to protect people from abuse and neglect.

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.

Staff completed care plans and assessments to minimise risks to patients. Staff used recognised tools to identify deteriorating patients and escalated concerns to the appropriate clinical leads. We reviewed multiple medical records for patients on the stroke wards. The records demonstrated all patients received a senior consultant review, venous thromboembolism (VTE) assessment, pain assessment and relevant risk assessments, including pressure ulcer and falls assessments where appropriate. These were completed in a timely manner and in line with trust targets. Pain scores and prescription charts were completed, with pain assessments prompting the prescription and administration of analgesia when required. On the stroke wards, we saw reassessments were completed and those due for review were highlighted each day on the nursing tasks dashboard application. This showed an effective process that supported holistic patient care. 

The service had implemented Martha’s Rule (known at the trust as Call for Concern). Martha’s Rule is used to empower people who use services and their families to seek an urgent review if their health deteriorates. However, the effectiveness and impact of Martha’s Rule training had been variable, as staff understanding was inconsistent. Some staff shared they had received information about Martha’s Rule, but no specific training, whilst others shared they had received training. This meant should an urgent review be requested, staff may not have understood their responsibilities or how to respond appropriately. 

We did however observe, Call for Concern posters around the hospital. Trust data from January to October 2025 showed 59 Calls for Concern, with the medicine division receiving the highest number. Of these, 7% related to acute deterioration, while 93% did not. This meant, although the majority of calls were not related to deterioration, people were involved to manage potential risk by escalating their concerns.

The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The design and maintenance of the environment did not always support safe and efficient care and treatment. Staff told us about ongoing difficulties in obtaining timely support from the estates team to update, repair, replace and install estate-related infrastructure. They described the emotional toll and frustration caused by repeatedly reporting concerns without resolution. For example, staff requested the installation of an electrical socket in a storage room to support a blood gases machine two years previously and were still awaiting completion.

During our inspection we found offices on one ward were excessively warm. The inspection took place in March, and staff told us temperatures in the office regularly exceeded 30 degrees Celsius during the summer months. The ward had been supplied with standalone air conditioning units. However, staff reported these were not functioning. Staff told us they had repeatedly escalated concerns about the high temperatures on the ward but had not received an effective solution.

Critical care escalation beds had been placed between bed spaces on many wards. These spaces were impractical for staff to carry out their roles and lacked privacy and dignity for patients. In the event of an emergency, the limited space could prevent timely access, putting people at risk of delayed or untimely care. 

Patients we spoke to also reported feeling “claustrophobic” in the critical capacity bed space. 

The design of the environment did not always mitigate the risk of unauthorised access. Fire exits posed potential security risks on several wards. For example, on one ward there was a fire exit located directly next to a bay, which opened into the ward corridor. This bay accommodated patients living with dementia who may be at increased risk of leaving the ward unsupervised. In addition, a bay on one ward was designated for male patients. However, the fire exit from this bay opened directly into the female bay on the Acute Medical Unit. Staff told us a member of staff would always be present in each bay to supervise patients. However, we observed several occasions where this was not the case. This meant there was a risk to vulnerable patients’ safety, dignity and comfort. 

A member of staff told us fire exit doors were magnetically locked and would only release when a fire alarm was triggered. However, during the inspection we were able to open a number of fire exit doors which were unlocked without activating an alarm.

Fire safety risks were not always mitigated in clinical areas. We saw fire exits and doors were not always kept clear and free of clutter. A bin blocked one set of doors and lockers were located between an exit point, making it narrower. These barriers increased the  risk of people being unable to safely and quickly exit the area in an emergency. On some wards, staff had placed equipment in front of fire exits to prevent patients from leaving the ward. This practice also created further risk in the event of an emergency evacuation. The service had recently shared communications about door wedging and recognised further door devices would be beneficial to keep doors clear.

Cluttered spaces were observed in multiple areas around the service. Audit data for the clinical environment from February 2026, showed low compliance related to environmental standards, such as maintaining a clutter-free environment and ensuring the physical environment remained fit for purpose. These highlighted the need for continued environmental management to ensure the premises supported the provision of a safe and well-maintained environment. However, the data demonstrated high compliance in patient care, staff appearance and stock management. 

Majority of equipment was clean and portable appliance tested (PAT). However, some equipment had expired PAT dates on them, such as a rotator stand mobility aid. This could put people at risk if the equipment did not perform as expected.

The hospital had spacious parking facilities, and all floors were accessible via lifts. Signage throughout the hospital was mostly clear, with different coloured zones used to help patients and visitors navigate the site. Toilets on specific wards were labelled using dementia-friendly signage to support people living with cognitive impairments. However, certain areas had not been updated, for example some signs showed Ambulatory Emergency Care, which had been renamed to Same Day Emergency Care (SDEC) which could cause confusion for people, especially those with a cognitive impairment. 

Mixed-sex accommodation was used within the Discharge Unit and SDEC where required. Staff understood their responsibilities for maintaining patient privacy, dignity and safety. They were able to describe the processes to ensure male and female patients were appropriately separated, particularly if overnight beds were required in SDEC. In the Discharge Unit, male and female patients were nursed on separate sides of the room, divided by a central privacy curtain, with individual bed-space curtains providing additional privacy. Separate male and female toilet facilities were available, alongside a shared shower room. These arrangements helped ensure patients were cared for in a safe and respectful environment.

Staff generally carried out daily safety checks of specialist equipment. This included emergency grab boxes and resuscitation trolleys. Staff on the Angiography Suite had access to a haematoma emergency kit grab box and a bedside emergency response trolley. The trolley contained designated drawers for specialist emergency equipment covering airway, breathing, circulation and sepsis management. 

The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

The service did not always make sure there were enough qualified, skilled and experienced staff. Staff reported this was particularly impacted when patients required 1 to 1 care, which resulted in them being short staffed. The service regularly used bank staff. Staffing boards were clearly displayed on all wards, showing both the planned and actual staffing levels. Many of the boards showed there was at least one healthcare professional less than planned for a shift. One staff member told us they often started the day fully staffed. However, staff were often taken to work on another ward, leaving them short-staffed. Frequent redeployment increased pressure on staff and adversely impacted morale. Staff also reported feeling micromanaged, with limited autonomy over staffing decisions.

Sickness absence data identified anxiety, stress, depression, and other psychiatric illnesses as the third most common cause for absence, after cold and flu related illnesses and gastrointestinal conditions. This indicated ongoing workforce pressures could be impacting staff wellbeing.

However, since our last inspection, vacancy rates had reduced from 12.3% in September 2024 to 8.5% in February 2026 and substantive staffing levels had increased across the medical division. Registered nursing vacancies had reduced, with staff exceeding establishment in some areas. The service continued to employ bank and agency staff, with bank remaining the dominant temporary staffing source. The trust was working to reduce the use of agency staff however, staff reported that there was a risk of staffing gaps and overall staff dissatisfaction.

The service used the NHS Safer Nursing Care Tool, also known as the Safer Staffing Tool, to help decide how many nursing staff were required to provide safe patient care on a ward. The tool was used as per NICE and NHSE guidelines. Audits were undertaken using the tool to support staff and make adjustments as required. The staffing tool, skill mix and staff to patient ratios were considered when making changes to support effective staffing. 

Many staff told us there were opportunities to develop and progress in the service. Training was available and suitable to the patient group using the service. For example, appropriate staff on the respiratory ward received focused training including non-invasive ventilation, opti-flow and end-of-life care. However, staff told us the trust had reduced study hours, leaving time for only mandatory training to be completed. This meant extra training such as dementia and stoma care, was completed in their own time.

Staff did not always receive yearly appraisals in a timely manner. Data provided showed appraisal compliance amongst the divisions medical staff was 78%, which was lower than the trust target for appraisal completion. Without appraisals, performance cannot be effectively evaluated, improvement opportunities cannot be identified and professional development cannot be supported. Staff had received, but were not always up to date with mandatory training. Overall mandatory training compliance for all staff within the service was 82%, which did not meet the trust target of 90%.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. 

While systems and processes were evident to support infection prevention and control, these were not always implemented effectively. Audit showed low adherence to the appropriate use of ‘I am clean’ stickers. We saw inconsistent use of these stickers during our visit. This could result in uncertainty regarding decontamination status of equipment, increasing the risk of cross-infection. However multiple wards displayed infection control data, such as MRSA and Clostridioides difficile (C. Difficile), showing transparency of the services practices. Infection prevention and control audits also showed high compliance with hand hygiene across all professional groups. 

Many wards displayed cleanliness ratings. At the time of inspection, Holmwood Ward had received a cleanliness rating of three out of five stars. We asked a senior staff member about the reasons for this rating. However, they were unable to explain which specific areas had fallen below the required standard or describe what actions, such as additional training or re-audit processes were in place to support improvement. 

We were told the ward’s action plan for improvement was displayed beneath the cleanliness rating poster. However, on review this document was a trust-wide statement of commitment to hygiene rather than a ward-specific action plan outlining targeted actions to address the identified shortfalls.

Infection prevention and control arrangements were effective in corridor care spaces. Hand wash basins were available next to reserved main corridor care bed spaces, ensuring access to hand hygiene facilities which reduced the risk of infection transmission.

Across all wards we observed staff following best practice hand hygiene techniques in line with national guidance. Staff were compliant with the ‘bare below the elbows’ policy, and personal protective equipment (PPE) was readily available in all areas, in a range of sizes, in accordance with guidance from the Health and Safety Executive.

Wards had infection signs to prevent people unnecessarily and unpreparedly entering infectious spaces. Patients with infectious diseases were moved to isolated rooms to prevent the spread of infection. 

Leaders had oversight of locations and numbers of people with infectious diseases around the site, for example flu, Norovirus and Covid-19. This information was reviewed daily to manage infection prevention and control. 

The hospital had effective oversight on outbreaks of infectious diseases and were quick to share information with the public to prevent distribution. During the assessment we saw a bay had been closed to prevent an infection spread. 

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Medication fridge monitoring was not in line with national guidance. The trusts temperature monitoring policy and records did not follow national guidance produced by the Royal College of Pharmacy. The trust policy only required documentation of current fridge temperature records instead of; minimum, maximum and current temperatures. Therefore, the fridge temperature records did not provide assurance medicines were stored within the manufacturers’ recommended temperatures.

The trust had an electronic prescribing and administration system for medicines which had inbuilt safeguards. 

The service had policies and processes for the secure storage of medicines including controlled drugs (CDs) and medical gases. Staff showed us dedicated storage for medical gas cylinders. Piped medical air outlets were managed in line with national safety alerts.

The service had policies and procedures for the management of medicines related records and stationery. Where stock, and or patients' own controlled drugs (CD) were stored, relevant records were kept. The CD records were complete and legible.

A report to identify and highlight missed and omitted doses in real time was under development. This would allow missed and omitted doses to be followed up in a more timely manner, including the exploration and resolution of the root causes. There were audit systems to improve medicines management in the service. 

The clinical pharmacy service utilised a pharmaceutical risk assessment tool to prioritise the level of clinical pharmacy oversight patients should receive. This ranged from daily to less frequent reviews. However, the service was unable to provide evidence of the effectiveness of this risk assessment tool across the medical wards.

Staff across the service were clear on their responsibilities for supporting people on discharge. However, many staff told us medicines discharge summaries were not always written in a timely way. When this occurred discharges could be delayed and required alternative methods to get discharge medicines to the patient if they were unable to wait. This resulted in poor flow through the service and patients self-discharging without the required medicine. 

There were regular audits of medicines security, controlled drugs and antimicrobial prescribing. The latest antimicrobial audit showed that performance across the wards varied. Other reviews of clinical practice undertaken included the management of Clostridioides difficile (C. Difficile) infections and patients' reasons for declining Venous thromboembolism (VTE) prophylaxis treatment.