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 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.

We assessed all 8 quality statements. 

At the last assessment we rated this key question as good. 

At this assessment the rating has changed to inadequate.  

This meant people were not safe and were at risk of avoidable harm.

Following the inspection, CQC issued a Section 29A Warning Notice in relation to concerns requiring urgent action to reduce the risk of harm to patients. The Warning Notice focused primarily on immediate operational risks relating to streaming and triage processes, oversight of patients in waiting areas and corridor environments, ambulance handovers, children and young people emergency care, and the care of patients experiencing mental ill health. The trust responded with an improvement action plan addressing these immediate concerns.

The breaches identified were based on evidence gathered during the assessment and considered against the legal standards that services must meet. While some of the same evidence was used, the breaches and the Warning Notice served different purposes. The Warning Notice addressed concerns that required immediate action, whereas the breaches related to areas where the service was not consistently meeting the standards expected for safe and quality care.

At this assessment we found the service was in breach of legal regulations in relation to safe care and treatment, premises and equipment, and staffing.

The service did not do all that was reasonably practicable to assess, monitor and mitigate risks to patients. Systems to support clinical assessment, ongoing monitoring, medicines management and infection prevention and control were not consistently effective. As a result, the service could not always demonstrate that risks were identified, managed and mitigated appropriately, exposing patients to an increased risk of avoidable harm.

The service did not ensure that premises and equipment were suitable, safe and appropriately maintained for the delivery of care. Clinical environments were regularly used not for their intended purpose, including children and young people overflow areas, mental health assessment environments and the Clinical Decision Unit, which affected the service’s ability to provide care in environments suitable for the needs of the people using them. Environmental safety, security and maintenance concerns, including unresolved defects and limitations in specialist facilities, meant that the premises were not fit for purpose. As a result, vulnerable patients, including children and people experiencing mental ill health, were not always cared for in environments that met their needs or protected their safety.

The service did not ensure sufficient numbers of suitably qualified, competent, skilled and experienced staff were consistently deployed to meet patients' needs safely. Staffing levels, skill mix, workforce planning and rostering arrangements did not consistently reflect patient acuity, demand or operational pressures, increasing the risk that people's needs could not always be met safely.

We have not awarded this service a score for Safe.

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

The service had culture of safety, and staff were encouraged to report concerns and safety events. There were investigated and reported. Learning was identified and shared. However, the service could not consistently demonstrate that lessons learnt had been embedded into practice or resulted in sustained improvements. 

The service had processes to collect data from various sources, including incident reporting, performance and outcome data, and feedback from patients and staff. There were policies, procedures and regular meetings to analyse and investigate this data. Findings were used to support learning, identify improvement actions, and implement changes in practice to improve patient safety, care and outcomes. However, the service could not consistently demonstrate the impact of these actions or that improvements had been sustained over time.

Staff were encouraged to raise concerns and report incidents and near misses in line with trust policies. Staff told us they understood how to raise concerns and were able to give examples of when they had done so. However, staff explained that some incidents, such as patients being cared for in corridors, were no longer consistently reported, as reporting was not felt to result in meaningful change. This meant that risks may not always have been fully captured, monitored and acted upon, and may have limited opportunities for learning and service improvement. 

Between March 2025 and February 2026, the service reported 1,023 incidents. Of these, 68% were rated as no harm, 31% as low harm (minimal harm – the patient required extra observation or minor treatment), and 1% as moderate harm (short-term harm – the patient required further treatment or a procedure). There were 2 incidents rated as severe harm (permanent or long-term harm) and 1 death reported.

Incidents were categorised to identify themes and trends. In the 12 months prior to inspection, the main themes were patient absconding, patient self-harm, medication issues, documentation concerns, poor or delayed care and treatment, violence and aggression towards staff, and patient falls. Incidents were reviewed and investigated in line with the trust’s policies and processes, and action was taken where required. The service provided examples of actions taken, such as reviewing observation levels for patients attending with mental health needs, strengthening escalation processes, and delivering targeted staff retraining. However, the service did not provide evidence to demonstrate whether these actions had reduced the number of incidents in these areas. During the inspection, we observed that many of these issues remained present.

The trust implemented NHS England’s Patient Safety Incident Response Framework (PSIRF) in April 2024 and used this approach to respond to patient safety incidents. This framework focuses on learning and improvement rather than solely on investigation and reporting. The Patient Safety Incident Response Policy (2024) outlined the decision-making process for determining how incidents should be investigated, depending on their severity or level of concern. The policy set out how incidents would be reviewed and the most appropriate learning response determined. Learning responses included Patient Safety Incident Investigations (PSIIs) for nationally defined events and local priorities, alongside other approaches such as multidisciplinary reviews and after-action reviews.

Since implementing PSIRF, the service reported that 1 incident, in January 2026, had been identified for a PSII. This investigation was ongoing at the time of inspection, and documentation was not reviewed for completeness. The service also demonstrated a range of other learning responses through its PSIRF arrangements, including multidisciplinary reviews, rapid reviews and oversight through governance groups. However, the service was unable to demonstrate how learning actions were routinely evaluated to determine whether they had resulted in sustained improvement.

Learning and improvement actions arising from incidents was shared with staff through a range of methods, including clinical bulletins, staff meetings, and face-to-face training sessions when required. 

The service used complaint data to also drive patient safety. Complaints identified as potential patient safety concerns were investigated by the patient safety team. Those not deemed safety-related were reviewed by the patient experience team or investigated by the local team. Learning and improvement actions from complaints varied depending on the investigation route. Complaints managed by the patient safety or patient experience teams had learning shared in a similar manner to incident-related learning. Locally investigated complaints were typically overseen by service managers who were responsible for sharing relevant learning with their teams where appropriate. 

Staff understood the Duty of Candour (DoC) and stated they were open and transparent, providing patients and families with a full explanation when things went wrong. However, the patient safety group identified that DoC was not consistently recorded on the electronic reporting system. The service had taken steps to address this, such as introducing weekly DoC meetings, and reported that improvements had been seen.

The department held mortality and morbidity meetings to review cases involving complications, harm or unexpected outcomes to identify learning and improve the quality and safety of care. We reviewed meeting minutes which demonstrated discussion of individual patient cases, clinical decision-making and opportunities for learning. Learning points from cases were identified and shared with staff to support reflective practice and improve clinical care.

The service reviewed and shared national patient safety alerts and made changed where needed. 

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.

Patients accessed the Emergency Department (ED) either by self-presenting or via ambulance services. We identified significant concerns in the systems and processes intended to support safe assessment, streaming, escalation and patient flow.

We observed delays in the initial clinical assessment (streaming) process. The streaming nurse was responsible for multiple tasks, including booking patients in, recording initial observations (such as oxygen saturation and pulse), and clinically streaming patients to the correct area of the department or hospital for their on-going care prior to full registration. This resulted in queues forming, with people waiting up to 20 minutes to be assessed during the inspection. Delays at this first point of clinical contact increased the risk that time-critical conditions were not identified promptly.

There was limited clinical oversight of patients waiting to be streamed. The streaming nurse was positioned behind a screen in the reception area, restricting visibility of the waiting queue, and there was no designated clinician monitoring patients for signs of deterioration or high acuity. This created a risk that seriously unwell patients were not recognised or escalated in a timely way.

Pathways for children and young people (CYP) were not consistently followed. Children and young people should have bypassed the streaming process and been directed to the Paediatric Emergency Department. However, we observed children and young people waiting in the main streaming queue. There were no staff actively monitoring the queue to identify and redirect these patients, creating a risk of delayed assessment and raising potential safeguarding concerns.

There was no clearly defined escalation process to respond to delays within the streaming queue. Despite increasing patient numbers and prolonged waiting times, we did not observe any action to increase staffing levels or provide additional clinical support. This lack of responsiveness contributed to sustained delays and increased risks to patient safety during periods of high demand.

Patients streamed to the minor clinical area did not receive a full triage assessment until they were seen by a clinician within that area. This meant there was a gap between initial streaming and a full clinical assessment. Patients streamed to the major clinical area, who required urgent assessment, also experienced delays in receiving full triage. We observed patients waiting significant periods, in some cases approaching or exceeding 1 hour, before triage was completed. These delays increased the risk that clinical deterioration or urgent conditions were not identified promptly.

There was no dedicated clinical oversight of patients waiting in the main waiting area. Information provided by the service showed patients waited for extended periods, in some cases for many hours and, in extreme cases, over 24 hours. During these periods, observations were not routinely repeated, comfort rounds were not undertaken, and patients were not regularly updated on their care. Information provided by the service highlighted examples of patients with serious conditions, including cardiac and surgical needs, waiting prolonged periods without ongoing clinical monitoring. This lack of oversight presented a significant risk to patient safety and experience.

At the time of inspection, the rapid assessment and treatment area (RAT) was not operational. Staff told us this area had been repurposed to manage increased demand within the department. As a result, patients arriving by ambulance followed an alternative pathway, which involved triage and initial management within corridor areas rather than a designated clinical environment.

We observed patients arriving by ambulance waiting in the ambulance corridor, remaining on ambulance trolleys or being cared for in corridor spaces while awaiting handover and initial assessment. Ambulance crews were required to book patients in at reception before providing handover to the triage nurse. Handover processes did not consistently support safe transitions of care, as ED staff were not always present with the patient at the point of handover. Clinical information was mainly communicated verbally, with limited evidence of immediate verification or reassessment by ED staff.

Following handover, patients entered a holding phase in the corridor while waiting to be reviewed by an ED clinician. Patients were generally seen in order of arrival rather than prioritised according to clinical need. Overall, these arrangements did not ensure that risks were consistently identified, communicated and managed, increasing the likelihood of delays in assessment and treatment.

Internal handover processes within the department were not consistently structured or effective. The service used staff handovers to transfer responsibility for patient care between healthcare professionals. A formal morning medical handover took place. However, there was no structured multidisciplinary handover in the afternoon. Instead, there was an allocation of doctors at 3pm followed by a consultant-to-consultant handover at 6pm. This approach created a risk that critical information was not consistently shared across the wider medical team, potentially impacting continuity and safety of care. Nursing staff were not present at doctors’ board rounds, which further reduced multidisciplinary communication and shared situational awareness. Doctors did not use a standardised communication framework, such as those recommended by the Royal College of Emergency Medicine, to support the consistent and effective transfer of information during handovers. Handovers did not routinely include clear actions, outcomes or identified learning points. This increased the risk that deterioration or changing risks were not consistently recognised and acted upon in a timely manner. We did not identify concerns in nursing handover processes, which were structured and supported effective communication. However, these were not consistently integrated with medical handover arrangements. Although handovers were conducted in a confidential environment and free from interruptions, the lack of structure and multidisciplinary involvement limited their overall effectiveness in supporting safe, coordinated patient care.

The service had a pathway for the assessment and management of patients with suspected stroke. Patients were expected to receive rapid assessment in the emergency department before transfer to specialist stroke services. The lead stroke consultant told us that performance had improved over the previous 12 months, with more patients being admitted directly to the acute stroke unit rather than via other inpatient areas. Data provided by the service showed the number of patients admitted directly to the acute stroke unit had increased from 43 to 75 over the previous year.  However, staff described challenges within the hyperacute stroke pathway. Patients with suspected stroke did not have direct access to the stroke ward and the pathway relied on emergency department staff recognising a potential stroke and initiating the required actions. These included recording observations, obtaining intravenous access and taking blood samples before specialist review. Staff told us these actions were not always completed before the stroke team arrived, which created the potential for delays in assessment, diagnostic imaging and access to specialist stroke care. Staff also told us the service continued to work towards ensuring patients were admitted directly to the stroke ward. However, capacity pressures and pathway delays meant this was not always achieved. These findings were consistent with external audit results. Under the revised 2025/26 Sentinel Stroke National Audit Programme (SSNAP) methodology, the hospital was rated E for Hyperacute Assessment (D1) and E for Specialist Pathway (D2). SSNAP describes E as the lowest performance category, indicating significant improvement is required in key stages of the acute stroke pathway.

Poor patient flow led to delays in admission and patients remained in the ED for prolonged periods after a decision to admit, often for many hours or days. This contributed to overcrowding and reduced the department’s capacity to safely manage incoming patients. Escalation processes were not effective, as clinical areas were consistently operating at or beyond capacity.

Systems did not reliably capture key time-based performance measures, including time to first clinician assessment. Record reviews identified that times were often not documented contemporaneously and were recorded later than entries made by specialist teams, despite patients being seen initially by ED clinicians prior to referral. This limited the service’s ability to accurately monitor performance and mitigate risk. 

Standard operating procedures intended to support safe care in escalation areas were not consistently followed. For example, exclusion criteria for patients cared for in the ambulance corridor were not adhered to. We observed patients being managed in this setting who did not meet the criteria, including those with cognitive impairment, a high risk of falls, and conditions requiring closer clinical oversight.

Staff told us that delays in documentation and deviations from established processes were occurring due to significant capacity pressures, overcrowding, and challenges in transferring patients to onward care.

Vulnerable patients, including those with mental health needs and children and young people, were not always managed through pathways that met their needs or protected their safety and dignity. These patients experienced prolonged waits and were sometimes cared for in environments that were not suitable for their condition, in some cases for several days or longer. Delays were associated with limited mental health capacity within the wider healthcare system and the need to transfer children to alternative settings for ongoing care.

Overall, systems and pathways to support safe care and escalation, were not consistently effective in practice due to sustained capacity pressures. This resulted in compromised patient care and an increased risk of avoidable harm.

The service worked with people and healthcare partners to understand what being safe meant to them and how to achieve that. Staff generally identified and shared safeguarding concerns appropriately and worked with partner agencies to protect people from abuse, discrimination, avoidable harm and neglect. However, safeguarding arrangements were not consistently effective. Safeguarding training compliance was below expected levels in some staff groups, and children and young people were not always cared for in environments that fully supported their safety.

The trust had adult and children safeguarding policies which were in date and reflected current legislation and guidance. These policies provided staff with guidance on how to identify abuse and the processes to follow if they needed to raise a safeguarding concern. The policies covered other elements of safeguarding such as radicalisation and female genital mutilation. Policies included what immediate actions to take to keep people safe, and the procedure to follow if the person lacks capacity, and an appendix outlining the steps staff should take to raise a safeguarding concern. However, we did not see information about how to raise safeguarding concerns displayed within the emergency department to support consistent awareness and access to safeguarding processes.

Safeguarding was part of the staff induction and mandatory training. We were told by safeguarding leads the service had high levels of safeguarding training compliance, with approximately 90% of staff trained to level 3, and additional training initiatives, for example how to provide support in the best way to people with a learning disability and autistic people, were in progress. However, training data reviewed for the emergency department did not consistently demonstrate this level of compliance. Compliance amongst ED medical staff was 61% for safeguarding adults level 3 training and 63% for safeguarding children level 3 training. Compliance amongst ED nursing staff was higher but remained below 90%, at 79% for both safeguarding adults and safeguarding children level 3 training. This meant the service could not demonstrate that all staff had completed safeguarding training appropriate to their role.

However, staff demonstrated a good understanding of safeguarding processes and demonstrated awareness of a wide range of safeguarding concerns, including domestic abuse, modern slavery, female genital mutilation (FGM) and exploitation, and were able to provide examples of appropriate action taken to protect patients. They had access to appropriate leadership and specialist support. The service had identified safeguarding leadership, with matrons holding responsibility supported by safeguarding link nurses across adult and children and young people (CYP) ED services. Staff described strong working relationships with the trust’s safeguarding team and reported they could access advice and support when required. Safeguarding referrals were routinely shared with the matrons, which supported oversight of concerns such as discharge risks, patients with mental health needs, suspected exploitation, and non-accidental injury in children.

Systems supported safeguarding referrals, including electronic processes and audit activity to review whether concerns were appropriately identified and escalated. Staff described taking a “Think Family” approach to safeguarding and working collaboratively with external partners, including social workers, police and third-sector organisations. There were established processes to respond to child deaths, with ED staff participating in Joint Agency Response processes and contributing to Child Death Overview Panel reviews. The trust reported a high volume of safeguarding referrals, particularly for children, with many originating from the ED. This demonstrated staff were identifying safeguarding concerns and escalating them through established referral processes.

All patients under 18 that presented to the ED were checked on the national database for any safeguarding or other concerns. When concerns were identified, this was noted on the patient record for the clinical staff to see. Information about when children had attended the Children’s ED was shared with health professionals and relevant authorities. 

However, safeguarding information was not displayed or available within the ED for patients and families at the time of inspection. In addition, when demand exceeded the capacity of the children's emergency department, children and young people were cared for in adjacent outpatient areas that were not fully secure. There were insufficient controls to prevent unauthorised people entering the area or children and young people leaving without staff awareness, creating a potential safeguarding risk.We did not see evidence that the risks associated with using this space had been formally assessed or mitigated. Children and young people were also not consistently identified and prioritised in line with established pathways, and we observed some waiting in the main streaming queue rather than being directed to the children's emergency department. The lack of active monitoring of the queue increased the risk of delayed assessment and may have compromised the timely recognition of safeguarding or welfare concerns.

The service did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled  people to do the things that mattered to them.

The service used recognised tools to clinically assess patients and determine the urgency of their condition to support prioritisation of care. There were processes to escalate patients with time-critical conditions, including sepsis, and to refer patients with identified mental health needs for specialist assessment. The service also monitored aspects of triage performance through audit activity. However, subsequent audit findings, record reviews and inspection observations identified delays in assessment, escalation and treatment, indicating that these systems were not consistently effective in practice.

The service expected all patients to be assessed by a triage nurse within 15 minutes of arrival. A review undertaken in October 2025 identified issues with the triage process and resulted in an action plan. However, the service did not provide data to demonstrate whether these actions had led to improvements. During the inspection, we observed prolonged waits for triage, with some patients waiting up to 90 minutes. The Royal College of Emergency Medicine and NHS England guidance recommend patients presenting to an emergency department should commence initial assessment within 15 minutes of arrival, to support the early identification of those with time-critical illness and injury.

Audit data from July 2025 showed the service was not consistently meeting key elements of the sepsis pathway. Only 33% of patients audited had a documented sepsis screen completed and only 25% received antibiotics within 1 hour of arrival. The audit concluded the department was not meeting the target for timely antibiotic administration and identified the need to improve sepsis screening at triage and streaming to support early identification and management of sepsis. Although actions had been identified, the service did not provide evidence that compliance had improved. Our review of records for 3 patients with suspected sepsis supported these findings, as none received intravenous fluids or antibiotics within the 1 hour target.

Triage nurses completed a mental health assessment when mental health needs were identified. However, mental health screening was not completed for all patients at triage and was more commonly undertaken for presentations where concerns had already been recognised, such as self-harm. Patients referred to the psychiatry liaison team were expected to be assessed within 1 hour, but performance data from March 2025 to February 2026 showed this occurred in 74% of cases, below the trust target of 90%. The service attributed this to high referral volumes, handover delays, and staffing shortages within the liaison team.

Patients arriving by ambulance did not receive a rapid assessment, and triage was not used effectively to immediately identify the sickest patients and prioritise care according to clinical urgency. Triage was undertaken by a nurse who was not always physically located next to the patient, and patients were added to an ambulance queue to await clinical review, with limited evidence of prioritisation based on clinical need. This resulted in delays to time-critical care. For example, a patient with a cranial bleed and stroke symptoms waited approximately 5.5hours following a CT scan to be reviewed by a clinician, and a further 2.5 hours to be admitted. They remained in a corridor for over 8 hours without neurological observations being recorded before receiving definite treatment and admission.  Another patient with polytrauma following a road traffic collision was not clinically assessed on arrival and did not have a trauma call activated. Despite significant injuries and pain, they did not receive pain relief for nearly 6 hours and were not reviewed by a clinician until several hours after arrival.

Patient flow, including adults and children and young people (CYP), through the department was not effective due to delays in accessing onward care within the hospital and community. Patients who had been admitted often remained in the waiting area for extended periods due to bed shortages. We observed patients waiting over 24 hours with a lack of clinical monitoring for deterioration and without receiving appropriate care and treatment. One patient, considered too high risk for transfer to the surgical assessment unit, remained in the waiting room for approximately 12 hours prior to admission to a ward.

The service used the National Early Warning Score 2 (NEWS2) and Paediatric Early Warning Score (PEWS) systems to monitor patients for deterioration. However, the service did not provide audit data to demonstrate whether these observations were consistently completed or acted upon. Records reviewed showed that while observations were recorded, appropriate action was not always taken in a timely manner. In addition, patients cared for in non-designated areas, such as corridors and waiting rooms, did not consistently receive appropriate monitoring, and these areas lacked a regular senior clinical presence. Patients with significant clinical risks, including suspected compromised circulation, major trauma, intracranial bleeding and severe pain, remained in these areas for extended periods without appropriate monitoring, pain relief, or escalation. Staff reported that such incidents were no longer consistently reported, as there was a perception that reporting did not lead to meaningful change. These issues resulted in a systemic failure to identify, monitor and respond to patients at risk of deterioration, placing patients at significant risk of harm.

Record reviews showed a mixed picture in relation to risk assessments. Falls, frailty and pressure care assessments were generally documented in the records reviewed. However, documentation relating to nutrition and hydration was inconsistent. We requested emergency department-specific skin integrity audit data and care round audit information to assess compliance with these processes. Whilst the service provided trust-wide skin integrity improvement initiatives, it did not provide the requested emergency department-specific audit information or care round audit data. Therefore, we were unable to assess whether these processes were consistently completed and monitored within the emergency department.

The service did not always detect and control risks within the care environment. Facilities, equipment and the use of space did not support the delivery of safe care, and patients were frequently cared for in inappropriate environments.

The service did not consistently provide a safe or suitable environment for patients. Sustained pressure within the emergency department, with patient demand consistently exceeding available capacity, together with overcrowding, delays in patient flow and ineffective escalation arrangements, meant people were not always cared for in an environment that was safe, suitable or met their needs. For example, patient numbers increased throughout the day to over 120 patients, exceeding the capacity of clinical areas. As a result, patients were routinely cared for in inappropriate areas such as corridors and waiting rooms. These environments lacked appropriate equipment, monitoring, privacy and dignity, and did not support the safe delivery of care.

The environment for ambulance arrivals was not safe. Patients were often received and registered in corridor areas without timely clinical assessment or consistent senior clinical oversight. Patients conveyed by ambulance were triaged in corridors rather than dedicated assessment spaces, and staff were not always physically present to assess patients promptly. This meant patients with serious or life-threatening conditions did not have immediate access to appropriate facilities, and delays to assessment increased the risk of deterioration.

Resuscitation and Majors areas were frequently at or over capacity and were not used for their intended purpose. For example, the Majors area, designed for 28 patients, was observed to be over capacity, with additional patients accommodated beyond cubicle availability. These areas were often occupied by patients awaiting admission to the wider hospital for prolonged periods, including in excess of 24 hours. This reduced access to appropriate treatment spaces for acutely unwell patients and limited the department’s ability to respond to emergencies safely.

Corridor care had become routine and did not provide a safe or appropriate environment. Patients, including those with significant clinical needs, frailty, mental health needs and high acuity conditions, were cared for in corridors for extended periods, in some cases for over 18 hours. These environments did not support effective observation or line of sight, particularly when patients extended into main hospital corridors. Patients did not have access to basic safety systems, including call bells, meaning they were unable to summon assistance in an emergency. Staff reported that these conditions were not suitable for patient care. While the risks associated with the use of non-clinical areas had been identified by the service, some remained in draft form and had not been formally adopted through the service's risk management processes. Consequently, the service had not ensured all risks associated with corridor care were effectively managed.

Waiting areas and “sit and treat” spaces were used to manage patients with significant and time-critical conditions, including those who had been admitted and were awaiting inpatient beds. For example, patients with serious conditions such as cardiac issues or surgical needs remained in waiting areas for prolonged periods, including up to 24 hours after a decision to admit.  These areas did not have the necessary clinical facilities or dedicated nursing oversight. As a result, patients were not always monitored appropriately, increasing the risk that a deterioration in their condition would not be recognised promptly.

The environment for children and young people was not consistently safe or fit for purpose. During periods of escalation, the department expanded into adjacent outpatient areas that were not secure. We observed fire doors being held open in these areas, which increased the risk of fire and smoke spreading between areas. This presented a potential risk to the safety of patients, visitors, and staff, particularly those who may require assistance to evacuate. Fire doors should remain closed unless operated by an approved automatic release system to ensure effective compartmentation and compliance with fire safety requirements.

There were insufficient controls to prevent unauthorised access or children leaving the area. There was no clear evidence that risks associated with using this space had been formally assessed or mitigated. In addition, the CYP waiting area had environmental limitations, including full glass walls without blinds, which contributed to excessive heat. Children requiring higher levels of care were managed in curtained areas that did not allow clear visibility, limiting staff ability to observe them safely.

Children and young people experienced long waits in the emergency department due to delays in accessing onward care. Some children remained in the department for over 20 hours awaiting admission, and facilities for high-dependency care were limited to curtained spaces. These environments were not designed or equipped for the level of care being delivered and did not support safe management of acutely unwell children.

The environment did not consistently meet the needs of patients with mental health needs. Patients were frequently cared for in inappropriate areas, including sub-wait spaces, small overflow waiting areas used when the department was full, and general department bays, for extended periods. During inspection, patients with mental health needs were observed waiting for prolonged periods, including over 60 hours, in cramped environments that did not support privacy, dignity or therapeutic care. Some designated mental health rooms did not meet recognised safety standards, with ligature risks identified and safety equipment such as alarms not consistently functional. The service was aware of these environmental concerns. However, they remained present at the time of inspection and patients continued to be cared for in environments that did not fully support their safety.

Patients detained under the Mental Health Act or requiring ongoing mental health support were cared for in environments not safe, including the clinical decision unit, where patients could remain for days or, in some cases, weeks. This reflected a lack of appropriate facilities and did not support safe or therapeutic care.

Overall, clinical areas were not used for their intended purpose, with spaces designed for assessment and treatment being repurposed to accommodate patients awaiting admission. The design, capacity and use of the environment did not support safe patient flow or effective monitoring. Systems to ensure patients were cared for in appropriate settings were ineffective, and the service could not maintain safety standards. As a result, patients, including vulnerable groups such as children and those with mental health needs, were exposed to sustained and significant risks of harm. These concerns were widespread, ongoing and not effectively addressed by the service or the wider organisation.

The service did not consistently ensure there were enough qualified, skilled and experienced staff to meet people’s needs safely. Staffing levels, skill mix and deployment did not always reflect the acuity and volume of patients, and staff did not consistently receive the support, supervision and development required to deliver safe care.

The service did not have sufficient staff with the right skills, experience, leadership and support to deliver safe and effective care. Staffing levels, skill mix and deployment did not reflect the acuity and volume of patients, particularly during periods of sustained demand. Nursing staff were required to work across multiple roles, including triage, ambulance arrivals and the ongoing care of patients waiting in corridor areas, which compromised their ability to maintain effective oversight and respond promptly to patient need.

During the inspection, corridor areas were staffed by small numbers of staff caring for multiple patients at once, with reports of up to 12 patients being managed in these spaces. Staff told us these arrangements did not support safe care or adequate patient oversight. However, staffing levels within designated clinical areas were generally better. In the 4-bedded high dependency area, there was 1 registered nurse and 1 healthcare assistant (HCA) allocated, while the 23-bedded Majors area was generally staffed at a ratio of 1 registered nurse and one HCA to every 5 patients. This demonstrated that concerns related not only to staffing numbers, but also to the deployment of staff across overcrowded and non-designated care environments.

Senior clinical oversight was not consistently effective in managing patient flow and risk. There was limited consistent senior presence in key areas, particularly in the ambulance receiving area, which delayed assessment, prioritisation and clinical decision-making. The department met Royal College of Emergency Medicine (RCEM) guidance for consultant presence, with a tier 4 clinician on the emergency department floor and consultant cover from 8am to midnight 7 days a week, with on-call arrangements overnight. However, this did not consistently translate into timely clinical assessment or effective prioritisation of patients during periods of high demand.

Staffing arrangements were frequently adjusted reactively to manage pressures, rather than being planned to meet patient need. This included staff working across areas outside their usual scope of practice, such as adult-trained nurses overseeing children and young people (CYP) areas, staff redeployed to cover higher-acuity patients, and non-specialist staff supporting patients with complex mental health needs. This reduced the service’s ability to ensure patients were always cared for by staff with the appropriate skills and experience.

Staffing did not meet recognised standards within the Children’s department. The service did not have a clearly defined staffing model or policy and relied on general guidance instead. Consultant provision was insufficient, with no paediatric emergency medicine consultant and limited rota coverage, including gaps outside core hours and weekends. There was no dedicated paediatric registrar presence within the emergency department, and advanced clinical practitioner numbers were insufficient to provide consistent coverage. Although overall staffing numbers had improved, this masked gaps in experience and seniority. There was a high proportion of newly qualified staff, including 8 newly qualified Band 5 nurses, and limited senior CYP nursing leadership, with only 1 Band 7 in post at the time of inspection. Staffing was adjusted reactively to manage pressures, including adult-trained nurses overseeing CYP care. This reduced the level of clinical expertise available to support safe decision-making and oversight. There was limited senior CYP nursing leadership within the department and attempts to strengthen this had not been progressed. The service did not fully meet recognised paediatric standards, including the absence of a play specialist to support children and young people.

Staffing across the emergency department, did not always support the delivery of specialist care. There were gaps in key competencies, particularly during night shifts and periods of escalation. In CYP areas, this included essential skills such as intravenous therapy and blood transfusion. Across the wider department, variability in skills and experience, particularly among bank and agency staff, meant the service could not consistently ensure that staff with the appropriate competencies were available to meet patient needs.

The service relied heavily on bank and agency staff, particularly to support patients with mental health needs. On some occasions, high numbers of agency mental health nurses were required to meet demand. Where shifts could not be filled, non-specialist staff or cohorting of patients was used, including healthcare assistants undertaking observation of patients, which did not always ensure safe or appropriate care. The service also relied on support from non-clinical staff, including security staff, to manage patients presenting with behaviours that challenged. Security staff were appropriately trained to national standards and used structured approaches to de-escalation and restraint. However, their involvement reflected the level of demand and complexity within the department rather than a planned staffing model.

Staff reported increasing numbers of patients presenting with mental health needs and challenging behaviours, including aggression from patients and relatives. This placed additional pressure on staff and required skills and support that were not always consistently available. Safeguarding training was part of staff induction and mandatory training and included training relevant to the Mental Capacity Act and Deprivation of Liberty Safeguards. Emergency department staff also had access to additional mental health training and support provided by the psychiatric liaison team, including Mental Health Act training, risk assessment training, quarterly mental health masterclasses and mental health induction for resident doctors. However, staffing pressures sometimes limited staff access to specialist mental health training opportunities 

Workforce pressures affected staff wellbeing, with staff reporting they were not always able to take breaks, particularly during busy periods and overnight shifts.

Workforce planning did not reflect predictable variations in demand, including seasonal increases. This was particularly evident in CYP services, where increased demand was known but staffing enhancements were approved late and were insufficient to meet patient need. Staff were not always able to access training and development opportunities due to staffing pressures, with reports of staff being unable to attend planned training because cover was not available.

Information provided about mandatory training compliance was at division level rather than specific to the emergency department. Within the medical division, medical staff training compliance was approximately 62%, with particularly low compliance in essential areas such as safeguarding, where rates were below 50% in some modules. Nursing compliance across the division was higher at approximately 86%. While not specific to the emergency department, this indicated potential risks in maintaining staff competencies across the wider service. Appraisal data for the emergency department showed variation across staff groups, with administrative staff achieving 100% and medical staff 89%, but nursing appraisal rates significantly lower at 59%, indicating gaps in oversight, supervision and staff development.

Workforce metrics also indicated ongoing pressures, including vacancy rates of approximately 12% for consultants and 20% for specialist doctors, alongside higher turnover within some nursing groups and sickness rates of between 3% and 7%. These factors impacted the service’s ability to maintain a stable and experienced workforce. The service had recognised concerns regarding emergency department nursing establishment levels since October 2024 and had commenced work on a business case to review staffing against the department footprint and Royal College of Emergency Medicine guidance. However, the risks associated with staffing capacity remained evident at the time of inspection in March 2026.

Emergency nurse practitioners were used within the department and were able to assess, diagnose, treat and discharge patients within their scope of practice. 

There was a structured development programme for staff, including role-specific induction, supernumerary periods, competency frameworks and career development pathways. A practice development nurse supported staff education and development across adult and CYP services. However, this role was limited to a single post and was significantly stretched, with much of the focus on supporting new starters, reducing capacity to support ongoing workforce development. The department did not have a practice development nurse dedicated to CYP emergency care. The existing role was primarily focused on adult nursing development, which meant there was limited capacity to support CYP specific training and competency development within the emergency department.

Volunteers were used to support non-clinical tasks such as restocking and providing comfort to patients and relatives. While volunteers were appropriately recruited and trained and provided a vital service, their use could not mitigate the impact of staffing pressures. 

Despite the staffing challenges, staff described strong teamwork and support within immediate teams. However, this local resilience did not mitigate the wider staffing and workforce challenges.

Overall, staffing levels, skill mix, leadership and workforce planning did not enable the service to respond safely to patient need. Staff were not consistently able to maintain safe standards of care, and patients were placed at risk of harm. These concerns were widespread, ongoing and not effectively addressed by the service or the wider organisation.

The service did not always assess and manage the risk of infection effectively. Whilst systems and processes had been established, the service did not always detect and control the risk of infection spreading. Environmental constraints, patient flow pressures and limited isolation capacity reduced the effectiveness of controls intended to mitigate these risks.

The service had systems to assess, manage and reduce the risk of infection, and there was evidence of ongoing audit and oversight. The department had infection prevention and control (IPC) leadership provided by the Band 7 link nurses, and they worked in collaboration with the trust’s IPC team. The IPC team provided advice and guidance to staff, supported education and training, undertook audits, monitored infection risks and worked with internal and external stakeholders to promote and maintain a safe environment.

Staff received IPC mandatory training.  However, mandatory training compliance data was only available at the medicine division level and was not separated for the emergency department. Compliance rates showed variation across staff groups, with 62% for medical staff, 82% for nursing staff, 84% for allied health professionals, and 94% for administrative staff. Overall mandatory training compliance across the division was 79%. The lack of department-specific data limited the ability to fully assess IPC training compliance within the emergency department. In addition, seasonal influenza vaccination uptake among emergency department staff was 56%. This was broadly in line with the overall trust uptake of 58% for frontline healthcare workers, and above the national NHS trust average of 45% for the 2025-26 influenza vaccination programme. However, almost half of emergency department staff remained unvaccinated, which may reduce the department's ability to minimise the risk of influenza transmission.

There were effective housekeeping arrangements. The department had dedicated housekeeping staff who were responsible for cleaning patient and public areas in accordance with daily and weekly checklists. Cleaning records were up to date and demonstrated that areas were cleaned regularly and deep cleaned when required. Cleaning equipment was stored securely in locked cupboards, which reduced the risk of unauthorised access to hazardous materials. During the inspection, we observed housekeeping staff on the unit, and the clinical environment was observed to be generally visibly clean, tidy and free from clutter. Furnishings, including chairs and flooring, were generally wipeable and designed to support effective cleaning.

Staff demonstrated good IPC practice in several areas. We observed appropriate use of personal protective equipment (PPE), adherence to “bare below the elbow” guidance, and availability of hand hygiene facilities including alcohol gel and soap dispensers. There was a designated waiting area for patients at a higher risk of infection in the main waiting room, which reduced the risk of cross-infection. There were also positive multidisciplinary working relationships, which supported escalation and communication of IPC concerns.

However, there were a number of environmental and operational challenges that increased infection risk. Isolation capacity was limited within the emergency department, with more significant challenges identified in the children and young people’s (CYP) emergency care area, where there was reduced availability of appropriate cubicles for isolation compared to the adult ED. A shortage of CYP cubicles meant that patients requiring isolation were not always accommodated promptly. As a result, some patients remained in CYP ED for prolonged periods, in some cases up to 40–48 hours, awaiting swab results or appropriate cubicle availability. There were cohorting arrangements for some conditions, such as respiratory illnesses, but these were not always sufficient to mitigate risk. Policies requiring patients to have a clear swab prior to admission to the CYP ward further contributed to delays. This was compounded by the rapid testing facility not being available overnight (between 10pm and 7am), which resulted in children remaining in ED environments overnight and increased the risk of transmission.

Environmental issues also impacted IPC standards. We observed that 2 outpatient consulting rooms used by the CYP emergency department did not have appropriate handwashing facilities, and 1 room was visibly unclean at the time of inspection. Although cleaning was undertaken promptly once this was raised, there had been no prior risk assessment despite the rooms being used for clinical activity. In addition, differing cleaning schedules between the CYP ED and outpatient areas resulted in inconsistencies in environmental hygiene standards.

Infrastructure concerns were identified that posed ongoing IPC risks. Isolation rooms within the adult ED were not compliant with required standards. One isolation room had a broken door and was not negative pressure ventilated. This had been reported on multiple occasions but had not been resolved. Flooring within the ED was damaged and temporarily repaired with tape, which was not compliant with IPC requirements and presented challenges for effective cleaning, although most other surfaces and furnishings were wipeable. Staff reported that delays in estates responses affected their ability to maintain safe environments.

Compliance with some IPC measures was inconsistent. Although signage stated that all visitors should wear face masks in clinical areas, this was not consistently observed in practice. We noted the absence of handwashing reminder posters in some areas. 

The service demonstrated established IPC systems and generally good staff practice, and staff were committed to maintaining infection prevention and control standards. However, environmental constraints, limited isolation capacity, and gaps in assurance and consistency meant risks were not always effectively mitigated.

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

The service had policies and processes for the secure storage of medicines including controlled drugs (CDs). Whilst medicines were stored securely, staff were not always able to access medicines in a timely way. For example, the streaming nurse at reception could only access the medicines stored in a triage room when the room was not in use by the triage team. Whilst within children and young people’s emergency department (CYP ED) all injectable medicines were stored in the CYP resuscitation room and only accessible when the room was not in use. Then, in emergency department (ED) Majors not all staff were able to access their patient's electronic records whilst preparing medicines for administration, and there was insufficient space to prepare medicines safety. Therefore, we were not assured that staff were always able to access and prepare medicines for administration in a safe and timely manner.

Antidotes and other emergency medicines were securely stored within the resuscitation area of ED. Posters on the antidote cupboard advised staff where further stocks of antidotes and other emergency medicines were stored across the hospital site.

Medical gases were not consistently managed safely. We identified weakness in the planned preventative maintenance (PPM) of medical gas regulators as those we saw were both overdue PPM. This increased the risk that medical gas regulators may not function effectively when required. However, staff showed us the dedicated storage for medical gas cylinders and that 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 CDs were stored relevant records were kept. The CD records we reviewed were complete and legible. However, the records for FP10 prescriptions were not in line with the service's procedures. When we brought this to the service’s attention appropriate actions were taken. The trust’s temperature monitoring policy and records were not in line with national guidance produced by the Royal College of Pharmacy, as only current temperatures were recorded rather than minimum, maximum and current that would provide assurance of the fridge temperature since the thermometer was last reset. As a result, temperature records did not demonstrate that medicines were consistently stored within the required temperature range in line with manufacturers' guidance.

The initial screening of patients (streaming) was undertaken by nurses. During streaming medicine for pain relief and other symptoms were prescribed by doctors or administered by nurses via homely remedies procedures or patient group directions (PGDs). The dispensing of prescriptions for patients who had attended ED had been outsourced to an onsite community pharmacy. The community pharmacy was open for extended hours 7 days a week, this supported the service with the safe and timely supply of medicines for people discharged from the ED.

The ED lacked pharmacy support in line with national guidance produced by the Royal College of Emergency Medicines (RCEM). Analysis of recent service data for patients who had stayed on the clinical decision unit for more that 24hrs indicated that pharmacy staff had taken a medication history for 78% of these patients within the first 48hrs of their stay. However, only 47% had their medicine reconciled by pharmacy staff. Therefore, limited risk based pharmacy support was available to undertake medicines reconciliation (the process of identifying an accurate list of a patient’s current medicine) for patients awaiting admission to the wards, support the identification of patients in ED taking time critical medicines or had complex medicines regimes. Nor to support the timely transfer of information to the patients GP and community pharmacy.

We reviewed recent trust data for omitted doses and time critical medicines. Omitted doses are prescribed doses of medicines that are omitted for various reasons. Time critical medicines are those where the patient could become unwell if the medicines are omitted or administered late. The time critical medicines data indicated that whilst most prescribed time critical medicines were administered close to the prescribed time, a few were not administered in a timely manner. This meant that people could be at risk of poorer medicines related outcomes.

The service was participating in the RCEM Time Critical Medication Quality Improvement Programme (QIP). This multi-year QIP to improve the identification, prescribing and administration of time critical medicines collecting data for people living with Parkinson’s who take oral levodopa medication and for patients living with Diabetes Mellitus receiving subcutaneous insulin, as indicators of how patients requiring time critical medicines are managed and supported.