Epsom General 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

At our last assessment we rated this key question as requires improvement. At this assessment the rating remained the same. This meant people's needs were not always met. The emergency department did not always provide care in a safe environment or ensure effective systems to manage risk. Overcrowding and poor patient flow resulted in prolonged waits, corridor care, and patients being treated in non-clinical areas that lacked privacy, call bells and appropriate staff oversight. Temporary escalation areas were used without clear staff understanding of exclusion criteria, and the documentation we saw did not demonstrate that risks were assessed or mitigated. The physical layout limited visibility of patients, including in waiting and paediatric reception areas which increased the risk of patient deterioration going unnoticed. There were significant delays in assessment and transfer, including for patients requiring surgical or orthopaedic review at another hospital. This contributed to extended waits, compromised dignity and increased the risk to patients. Systems to monitor patient deterioration were not consistently effective. We saw incomplete observations, delayed escalation of high NEWS scores, limited audit oversight, and poor documentation of key nursing care. Medicines management and controlled drug governance were not consistently robust. We saw gaps in temperature monitoring, CD record keeping and FP10 oversight. Mandatory training compliance, particularly safeguarding, life support and safeguarding for medical staff, did not consistently meet trust targets.

The same day emergency care unit (SDEC) facilities were inadequate (limited washing access, inconsistent drinking water provision, and mixed‑sex breaches); medicines management was largely safe but with concerns around fridge temperatures, incomplete hypoglycaemia boxes, and inconsistent documentation in controlled drug registers.

However, there were areas of good practice. Staff understood how to report incidents and demonstrated openness and learning from incidents. Staff described a positive safety culture supported by managers, with duty of candour being applied appropriately. Safeguarding processes were well embedded in practice and staff were confident in identifying and escalating concerns. We saw effective partnership working in place. Infection prevention and control arrangements were strong, with a visibly clean environment, good hand hygiene compliance and appropriate isolation practices in place. There were clear pathways and specialist support for people with mental health needs, particularly for children and young people, and staff were committed to providing compassionate care under sustained pressure. Staffing plans showed flexibility to respond to demand, with additional registered nurse capacity deployed when required, although vacancies, sickness and reliance on escalation reflected ongoing workforce pressures.

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 a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

All staff we spoke with knew what incidents to report and how to report them.

Staff reported all incidents in line with policy. Where possible, staff were debriefed and received support after a serious incident. Staff understood how to recognise and report incidents using the hospital’s electronic reporting system.

Incidents were investigated by the clinical matron or band 7 nurse and the quality team reviewed all investigations once completed. Staff we spoke with could recall specific incidents and described learning outcomes. Staff told us they received feedback on incidents they had reported and that learning was shared through team meetings, huddles and email updates. The clinical lead produced a newsletter which included information about themes and trends from recent incidents.

There was a positive culture of safety and learning within the department. Staff said they felt supported by managers and colleagues when things went wrong and did not feel blamed or treated negatively. They told us lessons were learned from safety incidents.

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

In the last 6 months there were 31 incidents reporting mental health patients had absconded from the department. Of these 22 were relating to a patient known to have mental health care needs. Police were called for all but 2 of the 22 incidents. Where police were not called, it was documented that the patient was found shortly after the incident, or the family was in contact with the hospital and organised to bring the patient back to the hospital.

The service did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

For the 12 month period from December 2024 to November 2025, the department had 54,586adult and 15,842 paediatric attendances. This is a significantly greater number than the unit was designed and built for.

The physical layout of the department did not always allow staff to maintain clear oversight of all patients waiting to be seen. We observed the triage for walk-in patients were completed in a timely manner. However, during busy periods, we saw ambulance crews queuing to handover patients to the hospital.

Due to crowding and the high demand for inpatient beds, safe transitions of care were not always achieved. Patients admitted with both physical and mental health needs were sometimes required to remain in the emergency department for extended periods. Staff told us it was not uncommon for patients with mental health needs to stay in the department for up to 3 days while awaiting an appropriate placement.

During the inspection, we identified significant pressures on patient flow within the emergency department (ED), resulting in prolonged waiting times and delays in care. There were high patient volumes and limited bed availability. Staff told us that 41 patients were waiting for inpatient beds at the time of inspection. We reviewed, 9 patients were referenced as experiencing delays. We observed and were told about patients being cared for in non-clinical areas, including corridors, due to a lack of available space. This included an ambulance arrival patient with a weakened immune system who remained in the corridor for approximately 7 to 8 hours. Staff raised concerns about the increased risk of infection for this patient and told us there were gaps in communication with both the patient and between teams during this period.

During the inspection, we found that there was no on-site surgical or orthopaedic review available within the emergency department. Patients who required surgical or orthopaedic input were referred to another hospital for specialist review and then transferred for assessment. Staff told us this pathway resulted in significant delays in acceptance and transfer which contributed to poor patient flow and created additional pressure on capacity at the receiving hospital.

Audit data showed that approximately 2 patients per day were referred to the surgical team for review via this pathway. Delays in transfer were common due to a lack of available space at the receiving hospital.

Leaders told us the current process had been in place since 2006, when the emergency department was seeing around 100 patients per day. At the time of our inspection, attendances had increased to over 250 patients per day. Staff and leaders acknowledged that the absence of a surgical and orthopaedic review service had a negative impact on flow and patient experience.

The service had a same day emergency care unit (SDEC), for which the aim was for the unit to act as a ward for same day emergency care for medical patients. The unit was open 24 hours a day, 7 days per week. The purpose of this unit was to facilitate admission avoidance with the aim to treat and discharge patients on the same day. However, the SDEC was not working in that manner, and patients spent at times in the SDEC more than 72 hours. Therefore, they were not being treated and discharged in the same day. There were 10 beds in the unit, 3 of which were side rooms and 7 beds in an open ward area. There were mixed sex beds in the open ward area which meant that men and women were bedded next to each other for period sometimes in excess of 72 hours. There were also 4 seats for patients who were not inpatients but required daily treatment such as intravenous antibiotics to be administered. At busy times this seated area was extended to 6 seats.

We observed professional handovers taking place in a confidential space for both adult and paediatric ED’s. Handovers took place at 0745 and 1945 every day. The huddles discussed care of the patients considering their physical and psychological health. In the paediatric ED there were additional handovers at 1600 with the paediatric on call consultant and the nurse in charge of the unit. Staff reported there was a handover at 1300 at the weekend with the on-call paediatrician. In the paediatric ED they used the Manchester triage tool. Staff we spoke with followed escalation policies and knew what to do in an emergency. We saw evidence that the sepsis protocol was in place, documented in patient notes and visual reminders displayed in the unit.

We observed paediatric early warning signs (PEWs) tool that was completed on paper and could not be transferred onto the electronic system. This had been identified as an issue with the senior team. Staff we spoke with said it was a financial issue at present until the trust were able to update the current electronic system to facilitate the recording of PEWs.

The department had pathways of care for patients with mental health needs. However, these pathways did not always provide the care that patients needed. When people with mental health needs arrived in the department, streaming nurses guided them to chairs next to the triage room. Triage nurses completed an initial assessment and identified patients with mental health needs. Triage nurses complete an assessment of risk as part of the triage process, however from the records we reviewed there was limited detail. Staff we spoke with could not clearly explain the training they had to complete for this assessment.

Members of the psychiatric liaison team attended a meeting with emergency department matrons to discuss patients at 0830 daily. Staff told us that these meetings were helpful to identify and plan care for patients with mental health needs. Each shift had 2 mental health support workers. If a patient was identified as requiring 1:1 observation, the nurse in charge would allocate the mental health support worker or another member of the team. However, staff we spoke with told us it was sometimes challenging to allocate staff when the department was busy.

Members of the psychiatric liaison team could access the electronic records system. All referrals to the team were received online and via the bleep system.

The trust had developed strong processes for supporting children and young people with mental health needs attending the paediatric emergency department. The trust employed a clinical nurse specialist and 2 paediatric liaison nurses to assess children and young people attending the department. They completed mental health assessments for patients 0900 – 1700, Monday to Friday. Out of hours, the adult psychiatric liaison team completed the assessments. Doctors could access support from an on-call Child and Adolescent Mental Health Service (CAMHS) consultant.

The team had developed guidelines for children and young people presenting in acute mental health crisis requiring care and treatment to support their mental health and emotional well-being. These guidelines provided a clear overview for staff to guide them in supporting children and young people.

Security members of staff did not complete therapeutic observations, but they would support staff if patients needed to be restrained. Security staff received a 2 day training course in restraint. Prior to restraining a patient, the security members of staff asked clinical staff to complete a risk assessment form that detailed the legal framework and rationale for the intervention. Security staff completed body maps following any restraint. Security officers wore body worn cameras and the videos of any incidents was shared with the manager.

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

Staff we spoke with knew how to make a safeguarding alert and did this appropriately. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Staff told us they had no concerns about speaking up for people who might be at risk, including when concerns related to individuals accompanying a patient. They said they felt supported to act in the best interests of patients and to ensure their safety. We saw evidence of safeguarding referrals made by staff at the trust. These were made in line with policy and escalated to the appropriate services.

The trust advised that the target for completion of safeguarding was 85%. However, data supplied by the trust showed that not all staff had undertaken mandatory training in safeguarding. The trust had an overall completion rate of 84%. Staff who were required to undertake adult safeguarding training in level 1 & 2, and for children level 2 this met the target. But for level 3 adult safeguarding this was below trust target at 84%. We saw the biggest shortfall in medical staff completing safeguarding training adults and children for all levels with overall completion rate of 61%. We saw consultants’ overall completion was 73% which did not meet the trust target.

Staff understood their responsibilities in relation to the Deprivation of Liberty Safeguards (DoLS) and told us these were only used when necessary and in the best interests of the person. Safeguarding systems and practices in the department supported the protection of people’s human rights and helped to ensure that no one experienced discrimination.

Staff we spoke with knew who the safeguarding leads were and told us where they would find safeguarding policies. We saw the safeguarding adults and safeguarding children’s policies which were up to date and version controlled.

Staff in the department received training in the Mental Capacity Act. Staff considered patient’s capacity when assessing them. Staff recorded assessments of capacity in the records we reviewed.

We saw patient notes in the paediatric ED which had electronic alerts if required for safeguarding and those on a child protection plan. This alerted staff to escalate patients to the safeguarding team.

The department maintained close contact with the safeguarding team that called daily to check if any patients needed a review. Staff used an online form to share information and make referrals. If children already had social workers (e.g. disability or family support) then information sharing was conducted. We were told a safeguarding meeting took place and there was team oversight to ensure nothing was missed after busy shifts. An email would then be sent to staff to complete outstanding actions.

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

Patient record systems recorded how long patients had been waiting to be seen since arriving, and their clinical priority. The trust aimed to triage all patients within 15 minutes of attending the department. At times of high demand, this was not achieved. Staff told us increases in demand meant they could not always meet this target. We saw patients waiting beyond 15 minutes throughout our inspection. Time to triage (TTT) data between December 2024 and November 2025 showed the average TTT was 49.8% of patients were triaged within 15 minutes.

The trust advised that TTT was discussed and monitored in clinical and operational huddles and site assurance meetings. We were told these would be escalated if they indicated there were concerns.

Patients attending via ambulance were reviewed and triaged in a dedicated Rapid Assessment and Treatment (RAT) area upon arrival. A senior ED doctor or advanced nurse practitioner led decision making in this area. This was to ensure timely senior clinician assessment, early recognition of critically ill patients, and prompt initiation of necessary investigations and treatments. Leaders advised us that all patients arriving via ambulance or walk-in with time-critical presentations should be considered for RAT.

The adult ED had recently moved to an electronic patient record system. Staff found it challenging to navigate the system and to find patient information. We saw patient information was placed in different areas on the electronic system and often information was missing from the patient records.

We reviewed 45 patient records and found they contained omissions of care given and poor documentation. There was minimal documentation of nursing care and poor compliance with falls risk assessments and pressure sore assessments.

We were not assured that there were effective systems in place to manage and escalate risks to minimise avoidable harms. For example, the trust used the National Early Warning Score (NEWS 2) to assess adult patients at risk of deterioration to support staff to take appropriate action. We saw instances where staff did not increase how often they monitored and recorded observations following increased NEWS 2 scores. From the first 2 days of our inspection, we reviewed 35 patient records, and within 14 patient records vital signs had not been acted on appropriately or the records were incomplete. We saw vital signs were not regularly recorded and there were delays in rechecking abnormal or high NEWS scores.

This was not in line with national best practice guidance and local policy, which meant patients who had become increasingly unwell were not reviewed as frequently as they should have been.

We saw that patients who were at risk of falls had been given a yellow band to wear. The matron we spoke with told us that this process had been incorporated into the adults ED to safeguard those at risk of falls. However, there was not a policy of the process to give us assurance that this had been embedded in practice amongst all staff.

We raised these concerns with the trust. However, when we returned for an unannounced visit. It was clear that staff were still not consistently completing risk assessments. We reviewed a further 10 patient records on day 3 of our inspection. We found that pressure area risk assessments, falls risk assessments, information about if the patient was informed about their care plan, if the patient has had food or drink, whether the sepsis bundle had been commenced and a record of their ECG was not consistently recorded. We saw 9 out of 10 records had one of those missing.

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

Staff in the paediatric ED completed an environmental checklist and risk assessment for all young people. This was developed jointly with, and signed by, parents and patients.

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

There were multiple areas for patients waiting for assessment, treatment, or transfer. The main waiting area was not fully visible from the reception desk, and we saw the majors was often cramped, particularly when temporary escalation spaces were in use to manage overcrowding. These temporary spaces consisted of trolleys and chairs positioned around the main nursing station, which limited movement and privacy. These spaces had no dedicated areas for personal care. There were also no patient call bells. This created a falls and ongoing safety risk to all patients in this area.

The corridor was continuously brightly lit and offered no privacy. Whilst staff were aware and managed some risks of corridor care, the environment in these areas were not appropriate for patient care. The environment also reduced the space for other patients being moved through the areas or being brought in by ambulance. Due to the close proximity of all patients and size of this area, patients’ privacy was compromised and sensitive medical information including reason for attendance could easily be heard by other patients.

Staff told us they had agreed to deliver care to a maximum of 6 corridor ambulance spaces and a maximum of 6 in the reverse corridor. However, this was not always possible due to the demands on the emergency department.

We reviewed the temporary escalation spaces in the emergency department standard operating procedure (SOP). The policy had an exclusion criteria for patients in the corridor areas. All the staff we spoke with did not know about the exclusion criteria. During our inspection, we reviewed 13 patient records of patients in the temporary escalation areas. The records we reviewed did not include any information on why those patients met the criteria to be in the temporary escalation area. Therefore, we could not be assured that the clinical risk to patients due to overcrowding was managed or mitigated. The trust was not maintaining the safety of patients within the temporary escalation areas. Patients we spoke with told us that the corridor bed spaces were cold and did not offer any privacy.

During our inspection we saw a patient being placed in corridor bed space 8. We were informed during the inspection corridor bed space 8 was not to be used. This bed was beyond a set of double doors where staff members had less visual oversight over the patient. This space was also very cold.

Staff told us they felt this area was not big enough to function in the way it did currently. Although staff and leaders were able to see the number of patients waiting in each area, they were limited in taking steps to reduce the numbers waiting due to poor patient flow.

However, the SDEC had insufficient access to washing facilities for patients. There was only one shower located in a side room, which if it was occupied it was unavailable to other patients. Staff told us they provided basins of water for patients to wash themselves when requested. Access to drinking water was not sufficient for patients during their long stays in the SDEC. During our assessment there were 3 jugs of water near the nurse’s station, but we were told by staff that these weren’t usually available because of a lack of dishwashing facilities for cleaning the jugs each day. The SDEC unit was not adhering to mixed sex accommodation guidance. There was very limited access to pressure relieving mattresses in SDEC. Staff from the SDEC told us that they have had to break bad news to patients in the toilet because that is the only private space available to them.

There were separate areas in the department to care for people who required support and treatment for their mental health. This was intended to provide a more private and dignified patient experience. The department had 2 rooms for assessing mental health patients, mental health bays A and B in the majors area. These room met Psychiatric Liaison Accreditation Network (PLAN) standards.

The designated mental health rooms were often not available due to people with mental health needs having long waits to access beds. In these instances, psychiatric liaison members of staff used the relatives’ room or cubicle for assessing people. The rooms had 2 doors, which opened outwards. Both the doors had viewing panels that could be closed. There were strip alarms around the room. The rooms were furnished minimally. The room had boxed beds and heavy furniture. One room had some superficial damage to the strip alarm. Staff completed a ligature risk assessment of the room. Ligature cutters were in the resus trolley and accessible for staff.

The rooms did not have any windows and was decorated in a clinical style. Staff we spoke with told us that this presented some challenges in nursing patients, especially neuro divergent people. Staff told us they would try and place other mental health patients in cubicles nearer to the nurses’ station. Staff completed a review of risks in these cubicles and where possible, removed items that could be used to self-harm. Staff were aware that the cubicles contained potential ligature risks. In other areas, the environment was not ligature-free. Staff managed risks through individual and environmental risk assessments, continuous observation, and the use of ligature-free rooms when available.

If a patient needed to use a shower, patients could use a shower in the Urgent Treatment Centre (UTC). We saw the shower was not fitted with anti-ligature fittings. Staff told us they would complete a risk assessment before a patient used that shower.

The paediatric ED was a separate department for children and families. There was no area for babies to play and when the unit was busy, the space was not big enough for buggies. We observed the paediatric emergency department become crowded and there was limited capacity to sit down. Staff we spoke with told us the waiting area had been escalated to senior teams and they would like to convert a desk space into a reception area.

The paediatric ED had 2 designated quiet rooms for supporting young people with mental health needs. The rooms had 2 doors, which opened outwards. Both the doors had viewing panels that could be closed. There were strip alarms around the room. These had been refurbished since the previous inspection. The rooms were furnished minimally. The room had boxed beds and heavy furniture.

The paediatric ED was shaped in a way which meant the paediatric ED reception area was not always visible to staff. Therefore, families attending the paediatric ED were not greeted by staff or always provided with regular updates. Parents and relatives, we spoke with told us they were confused when coming into the reception as there were no staff members sitting on the reception desk.

We spoke with staff about the oversight of the reception area and we were told staff used CCTV to observe the waiting area and to buzz families into the unit. We observed the triage nurse communicating to the families and having sight of patients waiting to be seen. However, during busy periods there were times when the area was left without staff having sight of patients in the unit, relying on informally walking through the unit to check on the waiting room. This represents a risk to patients who may deteriorate suddenly or rapidly.

We observed the paediatric resuscitation bed space occupied by an adult in the main ED. However, there was an additional paediatric resuscitation bed space in the paediatric ED area which would be used in an emergency. Staff we spoke to said that there were clear lines of communication if they needed to use the paediatric bed space in the main ED and the bed space could be cleared for a paediatric patient.

Equipment used in the department was safe and appropriately maintained. Oxygen cylinders were secured and in date. Sharps containers were assembled correctly, and clinical waste bins were clean and not overfilled. Daily checks of the resuscitation trolley were completed and recorded. Fire extinguishers were in date.

The trust did not always make sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. However, teams in the ED worked hard to provide safe care that met people’s individual needs.

Overall demand for UEC at the trust had increased. Senior leaders told us staffing was planned in advance to anticipate the levels of staff required. This was to ensure planned staffing was sufficient to maintain staff to patient ratios and considered risks associated with staff shortages. The trust had 127.15 whole time equivalent for registered nurses and healthcare assistants. The emergency department had 11% vacancies, and their staff turnover was 11% over the 12 month period prior to the inspection.

Staff told us they would escalate increased nursing to patient ratios to leaders, who would reallocate staff from other areas in the trust. When staff were redeployed for the first time, staff members completed the trust's local induction checklist in collaboration with the nurse in charge of the shift. This checklist was designed to familiarise staff with the department, ensuring they were aware of essential policies and procedures relevant to their roles.

We reviewed data on staffing for the trust which showed that during December 2024 to November 2025 the staff sickness rate was 5.7%, this was at the higher end of the national average of 5.7%. The most common reason recorded for staff sickness in the UEC was stress and anxiety which was similar to other NHS Trusts in the region.

At the time of inspection, the emergency department had a mixed medical workforce across training and senior grades. There were six foundation year 2 (F2) doctors. Middle-grade cover comprised 9 tier 3 rota lines, which included two GP vocational training scheme (GPVTS) doctors and seven junior clinical fellows (JCFs). In addition, there were 2 international training programme (ITP) GPVTS doctors who each worked two days per week within the urgent treatment centre (UTC). Senior decision making was provided by tier 4 doctors, with a total of 130 programmed activities (PAs), equivalent to 13 whole-time equivalent (WTE) specialty doctors (SpDrs).

Overall mandatory training in Learning Disability and Autism level 1 had 86% compliance. Life support training was below the trust target at 65% completion and basic life support part 1 and 2 were both below the trust target of 72% compliance and 67% compliance.

The psychiatric liaison team provided some training to the departmental staff. This included training on the Mental Health Act (MHA) and Mental Capacity Act (MCA).

The department had been offering breakaway courses for staff. Mandatory training included an introduction to mental health.

The paediatric team had contributed to paediatric study days, including delivering a session on the Rapid Tranquilisation Policy. The CAMHS team provided a session on MHA sections and their role.

The department had changed its approach to mental health staffing. The trust did not have an enhanced care team. The trust had rostered 2 bank mental health support workers for each shift. Senior nursing members of staff told us they found the consistency offered by these members of staff had improved the support for people with mental health needs.

The trust assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

There was an effective approach to assessing and managing the risk of infection, which was in line with national guidance. The department was visibly clean, and cleanliness was well maintained by domestic staff throughout the day. Staff told us that cleaning schedules were in place and that domestic teams responded promptly when additional cleaning was required.

The trust had effective systems to prevent and control infection. There were hand sanitiser at regular points throughout the department including at entrances and exit points of the department. Disposable curtains were clean, dated and appropriately maintained. Staff had access to PPE, including gloves, aprons, and hand sanitiser at key points throughout clinical and public areas.

We observed good infection prevention and control practices throughout the paediatric ED. Staff were bare below the elbows and followed correct hand hygiene practices.

We saw I am clean stickers were used across the paediatric ED.

There were isolation rooms available for infectious patients and evidence that symptomatic patients were being screened and isolated in accordance with policy. We observed flu positive patients being isolated and the correct PPE being used.

Infection prevention and control information was displayed in public places with up-to-date hand hygiene scores. Following the inspection, we saw the hand hygiene audits from 1 April 2025 to 31 December 2025 which were 100% compliant.

Staff we spoke with were aware of who their infection prevention control (IPC) link nurse was.

We observed correct waste management of clinical waste and sharps.

Staff we spoke to were aware of screening patients and sending samples of symptomatic patients. However, we saw there was limited space for the storage of diagnostic equipment. We raised these concerns with staff who told us this had been raised and was on their risk register.

The systems and processes in place to ensure that medicines , including controlled drugs (CDs), were stored securely, and access was restricted to authorised staff were not consistently followed. There was a lack of oversight of prescription stationery (FP10 pads). However, teams worked together to develop solutions.

There was not always good security oversight of FP10 prescription stationery (prescription pads) as monitoring oversight was not always followed. For example, records showed an FP10 prescription had been signed out and recorded as used, but the FP10 prescription was physically blank and still present within the ward. The pharmacy team does review completed logs, but issues are only identified when pads are returned after they run out, which does not provide timely assurance. This means there’s a risk that prescriptions could be misused or go missing without anyone noticing in a timely manner.

Whilst controlled drug audits were routinely undertaken, we found several issues around compliance to CD policy. Controlled drug registers contained entries that had been crossed out, CD wastage was not always recorded, and daily CD balance checks did not always occur. For example, we found 9 days since September 2025 where checks were missed in one department. Failure to properly maintain a Controlled Drug (CD) register can result in consequences such as misuse, diversion and increasing the risk of medication errors.

During discharge, medication from pre-labelled medication packs (TTO packs) were removed to supply exact amounts for patients. Whilst the impact on patient care was minimal, staff should not remove medication from TTO packs as the quantity on the label and box will not match what was given. In addition, we found a TTO pack of medication labelled for a patient amongst regular stock items on the ward. Therefore, we could not be assured that the patient received this medication on discharge.

We found pill cutters containing powdered medicine residue creating a risk of cross-contamination and poor infection control.

Temperature monitoring did not always occur in line with policy; and in one treatment room, room temperatures were not recorded at all. As a result, we could be assured medication was being stored safely. Failure to monitor temperatures may compromise medicine stability and effectiveness.

Staff described clinical pharmacy input as accessible and helpful, and staff had access to medication policies, including those for medicines requiring therapeutic drug monitoring. We saw adherence to antimicrobial stewardship principles (safe and effective use of antibiotics), such as prompt intravenous-to-oral switches and compliance with local antimicrobial guidelines. Staff knew how to report incidents, and learning was shared. These practices supported safe prescribing and reduced the risk of antimicrobial resistance.

There was a pilot project in the ED where staff added a green wristband to patients who brought their own medicines from home. This acted as a visible reminder to help ensure that patients’ own medicines move with them as they transfer through the hospital. The aim was to reduce delays in giving medicines and prevent medication wastage.