William Harvey 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 patients were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked patients’ liberty was protected where this was in their best interests and in line with legislation.

At our last assessment we rated this key question requires improvement. At this assessment, the rating remained requires improvement. Although we saw some improvements the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. We assessed all quality statements.

The service had made improvements since our last visit. However, we identified multiple breaches in relation to safe care and treatment. Key issues included significant pressure on the department as the number of patients attending the emergency department consistently outstripped available capacity. This resulted in crowding within the department, extended waiting times and challenges in maintaining patient flow. The sustained level of attendance limited the service’s ability to deliver timely safe care in line with national standards. Not all specialty teams responded promptly to being contacted. Delays in discharges caused a knock-on impact to transfer to wards which meant patients remained in the emergency department for longer than required.

We also found medicines were not always managed well. Staffing across the department had improved over the last 12 months.

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.

We spoke with patients and their relatives during the assessment, and they knew how to raise a complaint or concern. Patients said they would feel comfortable raising an issue with the staff caring for them and knew how to make a formal complaint, should they need to. We saw a positive culture of safety and learning. There was a no blame approach which empowered staff to report any issues without fear of negative consequences.

We saw examples of service users being listened to and their views being considered, for example a patient’s family had requested Martha’s rule whilst we were onsite. This was taken seriously and staff enabled further review promptly. Martha’s rule is a patient safety initiative allowing patients, families, and carers to request an urgent, independent review if they are worried that a patient's condition is worsening and they are not being heard.

Staff raised concerns and reported safety events and near misses in line with trust policy. The service had reported 31 severe, 27 moderate and 3 fatal safety events between December 2025 and January 2026. The most common safety events were pressure ulcers, security and delay or failure in treatment or care.

Staff could access the incident reporting system, knew what safety events to report and told us how they reported them. Leaders provided feedback on learning from safety events via email, meetings and Themes in Patient Safety (TIPS) newsletters. Recent examples included equipment changes and changes to the Duty of Candour template letters. Leaders would also feedback directly to staff about safety events they raised depending on the severity.

There was a culture of safety and learning. Safety events were analysed, investigated thoroughly, and lessons were learned to continually identify and embed good practices. For example, the department had introduced a system where patients identified as a risk of falls were given yellow blankets to identify them easily to staff.

The service had an up-to-date Patient Safety Incident Response Framework (PSIRF) policy which set out the approach to developing and maintaining effective systems and processes for responding to patient safety incidents and of learning. Safety events and learning were discussed at monthly team days. We reviewed recent patient safety investigation reports and saw they involved the patient and their families (if appropriate) and were of a good quality.

Staff understood the need to be open and transparent when things go wrong. They told us they had access to the duty of candour policy which was in date and version controlled. Duty of candour is the legal and professional responsibility for healthcare providers to be open and honest with patients, and their families, when something goes wrong with their care that has caused, or could have caused, harm or distress. This may include, offering an apology, and explaining the incident and its consequences. Staff told us they were supported by leaders to learn from incidents. Compliance with duty of candour was monitored and showed that 100% compliance was maintained on a monthly basis. Staff received support and de-brief following traumatic incidents. Staff said they felt supported and were given time to reflect if needed.

We found the trust leadership team were responsive to the feedback we gave them and acted promptly to improve the care and learn lessons. They provided assurances to the issues we raised and put immediate actions into place to improve the care for patients.

Morbidity and mortality meetings were held during the advanced emergency medicine teaching days and a learning letter produced which we reviewed. These included learning points and acknowledgements of what went well.

When we spoke with leaders they understood the themes and trends of incidents, and what actions they had taken to address these. For example, changes to the escalation beds and availability of a treatment room to address the privacy and dignity of patients in these areas.

The service mostly worked well with people and healthcare partners to establish and maintain safe care. They did not always make sure there was continuity of care, including when people moved between different services due to high demands on the service.

The department worked collaboratively with internal colleagues and external partners to maintain patients’ safety. However, there were delays in ensuring patients were cared for in the correct area once a decision to admit had been made.

Patients were initially streamed by a GP or nurse who assessed and directed patients, depending on their acuity, to an appropriate clinical pathway or department. Patients could be streamed to the medical, surgical, same day emergency care (SDEC) departments and urgent treatment centre (UTC).Children and young people were directed to the Children's ED. Patients who were directed to the main waiting room were then called to be triaged by trained staff using the ESI (Emergency Severity Index) which is a 5-level triage tool used in urgent and emergency care to prioritise patients.

The use of areas that were not designed for patient care increased the risk to safety. There were 3 temporary escalation areas with a total of 23 spaces.

We reviewed the adult patient flow and escalation policy and procedure which was in date and had been verified. The policy dealt with the fluctuations in demand and capacity so that any associated clinical risk could be managed. However, patients who had been admitted to the emergency department with both physical health needs and mental health needs would at times stay in the department for too long. At the time of assessment, we saw multiple patients who had been in UEC for over 20 hours awaiting review, discharge or admission to a ward. Delays in specialty review and discharge decisions increased patients overall hospital length of stay. This could also lead to patients deconditioning, deterioration in physical and cognitive function and increased risk of falls among other risks.

Not all specialty teams responded promptly to being contacted. Delays in discharges caused a knock-on impact to transfer to wards which meant patients remained in the emergency department for longer than required. Delays in specialist reviews were highlighted in the bed meetings and staff worked together to try and resolve this.

The department had systems to record these delays. We were provided information that showed referrals that matched to a response from the specialty teams of around 31%. Where a response was recorded, the proportion of reviews recorded within 60 minutes was around 23%. We also saw data that showed over a 6 month period, on average, it took 27.6 hours for patients to be admitted to an acute medical ward, 24.6 hours to general medicine and 28.6 hours to be admitted to respiratory medicine. With the exception of ear, nose and throat and paediatrics all specialties reported an average over 6 months of between 10 and 28 hours.

We saw examples of electronic discharge summaries being completed which contained all relevant information about each patient’s stay in the department if they were discharged home. Clinical responsibility for patients within the department was clearly defined. All patients within the department were cared for by the emergency department staff including those awaiting admission under other medical or surgical specialties, although this increased demand on department staff.

The service had multiple initiatives to improve triage and wait times such as a band 7 nurse front of house navigator to stream patients away from the service, the use of rapid assessment and treatment (RAT) teams and direct surgical referral pathways from SDEC. We observed this was running effectively despite the challenges.

Leaders and staff had a good awareness of the risks to patients across their care journeys including mitigations to these risks.

Bed management meetings were held 3 times per day. The purpose of these meetings was to maintain oversight of patient flow across the hospital. Staff worked in multidisciplinary teams supported by discharge coordinators to facilitate patient transfers and discharges.

Patients that arrived by ambulance were overseen by a band 6 nurse with specific training to ensure that patients were seen assessed quickly. We observed efficient handovers and appropriate checks and escalation.

Children were seen in a dedicated Paediatric ED which had a separate waiting and treatment areas designed to be child friendly. Staff reported positive relationships with the Child and Adolescent Mental health Servies (CAMHS) as well as child safeguarding teams. The Paediatric Operational Escalation Protocol provided a structured response to surges in demand, it outlined escalation triggers, roles, communication pathways, staffing adjustments, and the use of alternative care areas as needed.

The service had 24-hour access to mental health liaison and specialist mental health support for adults, children and young people. There was a good working relationship with the local mental health liaison teams.

The trust had an enhanced care observation risk assessment to determine whether extra staff were required to observe patients with mental health needs. The ED had a clear pathway for supporting people with mental health needs, for example, during triage, nurses complete the Mental Health risk assessment. Audits showed identification of patients requiring a MH risk assessment achieved 100% compliance in November and January, with a slight reduction to 95% in December. This indicated good recognition of risk and appropriate initiation of assessment processes.

The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately. However, safeguarding training figures were not in line with trust targets.

The trust had appropriate safeguarding policies that aligned with national guidance. Staff received training specific to their role on how to recognise and report abuse. Staff were additionally aware of specific safeguarding issues that were related to child sexual exploitation (CSE) and coercive control. The service had a domestic violence team to support patients. Staff followed safe procedures for partners and families visiting the wards. The service controlled access to higher risk areas such as resus and majors.

The trust set a target of 91% for all statutory staff training. Figures showed only 77% of staff had completed level 2 safeguarding in children and 83% had completed safeguarding level 2 for adults. Records also showed 77% of nursing staff had received level 3 safeguarding training in children and young people and 80% in level 3 adults training. Medical staff were 100% compliant with level 2 safeguarding for adults and children. However, fell short of the trust target with only 71% compliance across both children and adult safeguarding at level 3.

We were told this was primarily due to operational pressures. Leaders told us non-compliant staff had been identified and booked onto upcoming sessions. Staff training compliance was monitored through the integrated performance report and reviewed during the care group performance review meetings.

Staff gave examples of how to protect patients from harassment and discrimination including those with protected characteristics under the Equality Act 2010. Staff understood the importance of supporting equality and diversity and ensured care and treatment was provided in accordance with the Act. We saw documented examples of staff assessing patients' capacity. Mental Capacity Act training was incorporated into both safeguarding and mental health training modules. Nursing staff compliance for Learning Disability and Autism training (Oliver McGowan training) was 97%. Medical staff compliance was 84% which was slightly below the trust target.

We saw appropriate flags (identifiers) were applied to the electronic patient record to identify patients who were at risk. Safeguarding information was displayed throughout the department.

The evidence showed some shortfalls. 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.

Patients were seen in order of clinical priority. Streaming nurses were responsible for determining and documenting an Emergency Severity Index (ESI) score for every patient and identifying the most appropriate destination area within the UEC department. Patients could be directed to the urgent treatment centre (UTC), and same day emergency care (SDEC) based on clinical need.

There was a lack of flow within the hospital. The risk of poor flow and use of temporary escalation areas in the department had been on the departmental and trust risk register since 2023. There had been several actions and reviews carried out of UEC procedures during this time. However, the risk still remained high on the register. We saw several initiatives were being implemented but there was not sufficient improvement to reduce the risk rating. For example, areas were being used to bed patients overnight this meant a knock on effect to those awaiting admission and prevented patients from being transferred to the most appropriate inpatient or community setting for their clinical and social care needs.

Site meetings we attended on both days of our assessment highlighted patients awaiting a decision to admit in the department for over 12, 24, 36 and 72 hours. For example, on day 1 at 8:30am there were 34 patients waiting more than 12 hours, 11 who were waiting more than 24 hours, 10 that were waiting 48 hours and 6 patients who had breached 72 hours. The following day at 12pm the figures were almost the same with 32 patients waiting more than 12 hours, 14 who were waiting more than 24 hours, 9 that were waiting 48 hours and 6 patients who had breached 72 hours. This showed that the flow was compromised on both days of our inspection.

The national standard is that patients should have their first initial assessment including National Early Warning Score 2 (NEWS2) within 15 minutes of arrival. Data supplied by the trust showed between 1 November 2025 and 31 January 2026 (150 patients) 90% of patients met this standard. However, during our assessment we saw several patients that had not had their first assessment and NEWS2 within 15 minutes.

We observed the triage area and reviewed associated notes of 8 patients on our assessment period that were not triaged within 15 minutes during a two hour period. Of these, the longest patient waited 51 minutes.

The trust used the National Early Warning Score 2 (NEWS2) to continually assess patients at risk of deterioration in the department and enable staff to take appropriate action. In the paediatric department this was the Paediatric Early Warning Score (PEWS). Staff were clear how to escalate patients that needed clinical review.

The NEWS2 determined the degree of illness and was based on the patient’s vital signs. The score helped to identify patients most at risk of deterioration or sepsis. There was a specific form to assess sepsis which reflected national guidance.

There was a risk that unwell patients were not detected whilst they waited in waiting rooms. The trust told us that patients within the waiting room had their observations taken in line with the ED NEWS2 Observation Frequency and Escalation Procedure. Data supplied by the trust showed that on the assessment days showed overall compliance of 93% to the ED NEWS2 Observation Frequency and Escalation Procedure. However, we found observations were not routinely completed on patients in the waiting room. In patient records we reviewed staff completed the observations and scores as required by the protocol and escalated for review if required. However, during our observation during our assessment, we saw patients in the waiting room who did not have their observations done in a timely manner. For example, a patient who have not had basic observations done who had been in the department 1 hour and 35 minutes, and another who had arrived via a 111 call and not had repeat observations completed for 1 hour 52 minutes this went against guidance and could mean deterioration of the patients may not have been recognised.

Data showed from November 2025 to January 2026 there were 27 falls in the UEC. Of these, 33% were in the waiting room or corridor areas and 67% were in patient cubicles. All incidents were graded either low harm or no harm, and patients had been identified as a risk of falls with measures put in place to reduce the risk of falls.

Patients arriving by ambulance were triaged in the ambulance bay. To mitigate risks of delays, patients who arrived by ambulances were reviewed by a senior nurse with additional training. Patients could undergo a more comprehensive assessment in 1 of the 2 rapid assessment and treatment bays.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. We observed a nurse checking if a patients slurred speech was a new development since arrival to the ambulance assessment area, they supported the patient to respond and escalated appropriately.

Staff enabled patients to give feedback on the service they received. Patients had access to a QR code which took them directly to information on how to raise a concern or give feedback on care.

Pathways created to keep the patients safe and improve flow were not always adhered to. SDEC was not always used as an SDEC and was used as an area to accommodate the volume of patients in the ED.

There was good oversight of patients by the senior team in the department. Each computer in the department had access to the patient management system which displayed an overview of the patients. It showed the length of time each patient had been in the department, or on an ambulance, or were waiting for triage, or treatment.

Leaders assessed the department regularly throughout the day using the NHS England Operational Pressures Escalation Levels (OPEL) framework. It generated different responses depending on the overall score. It had 4 different levels with level 4 being the highest pressure which meant they were unable to deliver comprehensive care. On both days of our assessment the department was OPEL 4 and on the second day of our assessment the trust declared a critical incident. A trust declares a critical incident when exceptional demand or disruption causes them to lose the ability to provide essential, safe services, putting patient care at risk.

The evidence showed significant shortfalls. The service did not control potential risks in the care environment due to crowding in the department. Not all areas within the department were suitable for their purpose.

We saw the environment was visibly clean, but it was crowded, and patients were staying in the department for long periods of time. People were not cared for in an environment that met their needs.

Not all facilities and premises were appropriate for the service being delivered. There were not enough cubicles for the number of patients in the department. This meant patients were cared for in areas which were not designed for longer staying patients. Patients spent long periods of times, often more than 12 hours, in chairs and on trolleys. Despite the best efforts of leaders to ensure patients had hospital beds who needed them, there were not enough hospital beds. We saw patients remained on trolleys longer than 24 hours, some of these patients were very frail.

The waiting rooms within each area had a screen which displayed the waiting times. Patients had access to drinking water. However, on both days of assessment there were not enough chairs available.

There was a total of 3 temporary escalation areas in corridors and near the nurses' station in resus, these 3 areas can take a maximum of 23 patients .There was a standard operating procedure (SOP) for care in the temporary escalation areas for staff to follow. During our assessment we saw patients in the temporary escalation area who did not meet the criteria in the SOP as they were on oxygen. However, leaders put additional safety procedures in place to ensure these patients were managed as safely as possible given the intense challenges the service faced. In addition, patients who did not meet the criteria to be in the temporary escalation areas were escalated at site meetings.

The department remained crowded in all areas and patients remained overnight in chairs and trolleys. For example, we saw on day 2 that there were 3 patients over the age of 80 who were in chairs for several hours awaiting a decision to admit.

We reviewed risk assessments of all escalation areas which identified that the areas were not appropriate and what action had been taken to try and mitigate the risk. The evaluation identified that corridor C was a non-clinical area not designed, equipped, or ventilated for patient care. Its temporary use during periods of exceptional departmental pressure introduced significant fire safety, environmental, infection control, and clinical governance risks.

The area’s design and location limited the effectiveness of control measures. Despite the departments mitigations there was still considerable risks in the corridor environment. This included bed rails having to be put down to allow two trollies to pass each other, the heat and general environment feeling hot and lack of privacy for patients (particularly if they were being held overnight). The department undertook a trolley and bed rails audit in January 2026. It showed out of 10 records reviewed overall compliance was only 50% referring to the individual patient risk assessment completion, correct date and findings. To improve this compliance the department has introduced daily matron walk rounds and included prompts in safety messages through daily huddles.

Emergency buzzers were available for staff within the corridor areas and were linked with the main emergency buzzer system within UEC. However, individual patients did not have call bells.

The designated mental health assessment room and adjacent facilities were fully Psychiatric Liaison Accreditation Network (PLAN) compliant. There were 2 assessment rooms and 4 sofas for patients to rest on. However, staff told us that the room was not always sufficient for the number of people requiring this care. Patients were often in the department for extended periods of time due to waiting for a mental health bed placement. The longest patient had been in the area for 4 days at the time of inspection. Although the environment was safe, it was not appropriate for several days stay.

The department had standardised bays in majors, resus, and the RAT areas. Each area had identical equipment and clear labelling, following national guidance. This meant staff were able to find the correct equipment easily.

The main majors area was a bright and calm environment. Each patient had their own cubical with integrated clinical monitoring equipment. The cubicles were glass fronted with sliding glass doors that enable line of sight for nursing staff. There were accessible toilets and shower rooms for patients.

Clinical staff knew where to find the equipment they needed to respond to an emergency and had received appropriate training to enable effective use of it. Planned preventive maintenance and electrical appliance tests were completed and recorded centrally. All electrical equipment we checked had undergone electrical safety checks within the last 12 months. There was strategically sited emergency equipment, such as resuscitation trolleys, emergency suction and oxygen across the department and staff could tell us where the nearest equipment was located.

There was a dedicated paediatric resuscitation area which was fully equipped with paediatric and neonatal equipment and medications. An additional hybrid resuscitation cubicle supported both adult and paediatric advanced airway and complex care.

Resuscitation equipment was easily accessible and there were effective systems to ensure it was checked regularly, fully stocked, and ready for use. We spoke with a range of staff who confirmed that when equipment broke, they had access to replacement equipment promptly.

There was a separate area for children and their families which was safe and secure and there were toys to keep children occupied. The department included 7 majors cubicles with central monitoring. A Child and Adolescent Mental Health Services (CAMHS) assessment room was also available. The department had a future development plan that included a separate entrance and reception area for Children and Young People to enable complete pathway separation from arrival.

The department recently had a new fire alarm system installed and tested. The department's fire safety equipment and emergency systems such as call bells, were tested and maintained appropriately. Fire exits were not blocked; evacuation routes were signposted.

There were effective systems which ensured clinical waste was appropriately segregated and disposed of. During our inspection we observed sharps bins were correctly assembled and labelled in line with national guidelines. We observed that products subject to the Control of Substances Hazardous to Health (COSHH) Regulations were stored correctly. There was also access to a negative pressure isolation room

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

Staff were noticeably busy and worked under pressure when the department had a high number of patients or when people required close supervision. There was a good support and mutual respect among staff working in the department but they were visibly stretched and trying their best to provide good care.

Staffing across the department had improved over the last 12 months. There was a cohort of 10 WTE Emergency Department Consultants, of whom 1 was dual trained in Paediatric Emergency Medicine (PEM). The PEM-trained Consultant currently only worked 3 days per week. There was a business case in place to employ a further PEM consultant in line with recommended whole time equivalent (WTE) ratios.

In the Children’s ED, staff told us that they were not permitted to use agency staff. This meant there were often shifts unfilled. The department often used bank staff to ensure that 2 Children’s nurses were on shift. On the day of our assessment the planned staffing numbers did not meet the actual staffing, there were only 2 trained nurses instead of the planned 4 because of staff sickness. Data provided by the trust showed that overall compliance across November 2025 to January 2026 was 96.2% (177 compliant shifts out of 184 total shifts). Adult nurses with Children and Young People competencies were used on the 7 non-compliant shifts to maintain safety.

Staff were not always up to date with mandatory and statutory training. Current compliance levels for safeguarding, infection prevention and control (IPC), and resuscitation training were below the trust targets. Trust targets were 91% for statutory training and 85% for mandatory training.

We were told all outstanding staff have been identified and booked onto upcoming sessions, with additional training capacity and protected learning time implemented. The department was on track to meet the trust target by the end of June 2026.

Training figures for immediate life support (ILS) for nurse staff was 97.5%. Figures provided showed current paediatric immediate life support (PILS) training was 89%. Nine members of staff were currently non-compliant; they have all secured training dates and will be compliant by the end of May 2026. In the Children’s ED, there was a minimum of 1 registered nurse with PILS competency on each shift. Training figures were 93.5% for PILS and 88% for ILS.

The service used bank and agency nursing staff to cover unfilled shifts. Managers requested bank staff who were familiar with the service and ensured they had a full induction and orientation of the area they were working.

The service had a good skill mix of medical staff on each shift and managers reviewed this regularly. Managers could access locum doctors when they needed additional medical staff. In the month of January bank and locum staff covered hours on every day to ensure adequate cover. Staffing levels for corridor care were 1 registered nurse for every 6 patients receiving corridor care. The lead nurse was identified using an arm band to ensure staff and patients could easily identify them.

The department had a dedicated practice development nurse to provide support and education to clinical staff and to improve their professional practice. Staff were extremely complimentary about having this role in the team and how they had made a positive difference to performance. There was a structured development programme for all staff that included unit and role specific induction programmes and supernumerary periods for new nurses to the team. There was a dedicated consultant nurse who oversaw the education programme within the department.

There are 138 registered adult nurses currently in post. Of these 62 registered nurses met the criteria to undertake triage and streaming training, based on experience, banding, and departmental competency framework requirements. All but one of these have completed competencies and training to ensure they are able to undertake triage and streaming. There was an embedded support system and training programme which had clear objectives and monitoring.

All nursing staff we spoke with told us they received regular review of their work in the form of an appraisal. They said this was an opportunity to speak about development and raise any concerns. They were supported to make quality improvement suggestions and told us they were valued by their managers. Data reviewed showed appraisal compliance rate of 81% ; the trust target is 80%.

However, medical staffing appraisal rates were below targets with 69% of ED medical staff had received an appraisal within the expected period. Appraisal compliance was included in the Integrated Performance Report and reviewed during the monthly care group performance review meeting.

All doctors were required to complete an induction programme. This included orientation to departmental processes, clinical pathways, and escalation procedures alongside mandatory and specific training. Locum doctors received additional governance and assurance processes. Pre-employment checks include verification of General Medical Council registration, Disclosure and Barring Service (DBS) checks, appraisal and revalidation status, references, and mandatory training compliance to ensure suitability for the role.

Leaders we spoke to outlined the importance of staff engagement and development. They encouraged staff to make suggestions for care quality improvements and understood the service pressure staff faced.

The evidence showed some shortfalls. People using the service told us the department was visibly clean, and cleaning staff were active in all areas of UEC. The temporary escalation areas created an infection control risk which had been identified by the trust and risk assessed with mitigations in place. However, our observations of staff conduct during our inspection showed that they managed infection prevention and control well.

Patients cared for in temporary escalation areas could be more at risk of infection. A risk assessment for corridor C and B highlighted that while enhanced cleaning, waste segregation, adherence to personal protective equipment (PPE) protocols, and corridor care criteria were in place, these measures were difficult to maintain safely in the environment. That poor air flow and absence of mechanical ventilation further elevated the risk of infection. The beds in corridors were in very close proximity meaning it was hard to ensure measures to protect patients were effective.

We saw housekeepers in all areas working hard to keep the areas clean. There are clear roles and responsibilities around infection prevention and control (IPC). The infection prevention and control team supported the department.

The department was visibly clean in all areas. Domestic, hazardous and clinical waste bins were emptied regularly, and sharp bins were labelled correctly. Cleaning audits showed compliance was above 97% for the past 3 months. However, the audits did not appear to include the temporary escalation areas.

In the Children’s Emergency Department, the January 2026 audit demonstrated 100% compliance across hand hygiene, bare below elbow and personal protective equipment (PPE) standards.

Staff told us they completed mandatory training on infection prevention and control annually. Average compliance for annual updates was 99% across all staffing groups.

All visitors to the department were prompted to clean their hands on entering the department. Staff followed infection prevention and control principles and used PPE correctly. We observed staff washing their hands or sanitising them with antibacterial hand gel. Staff were bare below the elbow. Hand hygiene audits showed 93% compliance from December 2025 to February 2026.

Staff cleaned equipment after contact with patients. Staff used ‘I am clean’ stickers to show equipment was clean and ready for use. We observed that cleaning checks had been completed in all the UEC areas. Clinical curtains in all areas were also clean and had been changed within the past 6 months.

Staff identified patients within the department who were tested as positive or showing signs of infection and they worked closely with the hospital laboratory teams. These patients would be isolated as soon as possible and infection risk noted on their care records. Each cubical in majors could be used for isolation as they were individual rooms with sliding glass doors. Staff had access to additional personal protective equipment such as gloves, aprons and masks. During the assessment we observed clear signage on cubical doors to indicate the patient was under isolation and additional personal protective equipment was needed.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. There were significant shortfalls in the management of medicines.

Medicines were generally kept secure and were only accessible via authorised staff. Whilst there was a clear system for ordering medicines not normally stocked in the pharmacy, we were not assured that staff consistently followed it. For example, we saw a patient’s regular insulin was not ordered for a period of 3 days and so was not given, however, once the inspection team notified the service of the issue the patient’s insulin was given. Not taking insulin for 3 days carries extreme risks, primarily Diabetic Ketoacidosis (DKA), a life-threatening emergency where the body breaks down fat too fast, creating toxic acids called ketones. Following the inspection, the service told us that additional training had been provided to staff, including agency staff and that additional assurances would be sought through enhanced audits.

The service was working towards implementing clinical pharmacy support in line with the Royal College of Emergency Medicines (RCEM) guidelines. The department was supported during the week by dedicated band 7 and 8a pharmacists. They also received ad hoc support from other areas. Pharmacy technicians had previously provided additional support, but these posts were currently vacant at the time of inspection. The service told us these were out for recruitment.

The pharmacy teams had effective systems in identifying people who would most benefit from pharmacy input including people on high-risk medicines. However, staff told us that these systems were not always effective as they relied on triage processes which were not consistently followed.

Pharmacy leaders completed regular audits including performance of missed doses, time critical medicines, antimicrobial stewardship and CD management. The most recent antimicrobial stewardship audit showed that only 56% of antibiotic prescriptions where compliant with trust guidelines against a target of 80%. It was unclear what improvement was work was ongoing to improve this.

Nursing staff spoke highly of the pharmacy support. They told us the pharmacy team were visible in the department and were accessible when they needed advice or support.

Patient’s documents recorded allergy status clearly in records we reviewed.

The services had processes for supplying medicines when leaving the department. The department held To Take Out (TTO) packs. These packs were pre-labelled with standardised directions. They used FP10 prescriptions to supply medicines to be dispensed in the community. Prescription stationary was stored securely. The service monitored their use through regular checks. However, these were not always completed daily which was not it in line with policy.

Nursing staff used Patient Group Directions (PGD) to supply medicines for pain relief. Documentation authorising specific trained staff to administer medicines under a PGD was not always fully completed in line with legislation. We saw PGD documents, provided by the trust post inspection that were in date and developed in line with relevant healthcare professionals. However, not all staff who had signed the PGD were counter signed by an authorising manager. This meant we could not be assured that all staff had been formally authorised by the organisation to operate under the PGD.

There was a self-administration policy in place. People were encouraged to bring in their own medicines and take their own medicines were appropriate. People without capacity or were at risk (of overdose for example) had their medicines stored securely and administered by staff.

The service had contributed to the Royal College of Emergency Medicines (RCEM) ‘Time Critical Medicines’ quality improvement project. This work aims to ensure that people receive their time critical medicines according to their usual regime whilst they are in the department. We saw evidence of action plans and some improvement. Work was still ongoing to improve this performance.

Medicines related incidents were discussed at monthly governance meetings and relevant learning was shared with staff at huddles and team meetings.

Patients notes that we reviewed showed venous thromboembolism (VTE) risk assessment outcomes and prescribing were completed. However, a recent snapshot audit from the trust indicated that not all peoples VTE risk were being assessed in line with national guidance. There were further audits and improvement work planned for 2026.