Queen Elizabeth The Queen Mother Hospital

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• 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 patients were protected from abuse and avoidable harm. We assessed all 8 quality statements. 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 from bullying, harassment, avoidable harm, neglect, abuse and discrimination.

At our last assessment in 2023 we did not rate this key question. At this assessment we rated safe as inadequate. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

In March 2023, we identified 3 breaches of regulation relating to safe care and treatment, dignity and respect and staffing. During this assessment, they remained in breach of these regulations.

We found the service did not consistently keep patients safe from avoidable harm. Key issues included significant pressure on the department as the number of patients attending the emergency department consistently outstripped available capacity Overcrowding, poor patient flow, and ineffective use of escalation processes meant patients were not always assessed, monitored, or treated in a timely way. Triage was not consistently effective.

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.

Patients were cared for prolonged periods in unsuitable environments, including corridors and temporary escalation areas that lacked appropriate facilities and emergency equipment. We saw the service did not always meet patients basic care needs, including nutrition, hydration, pain relief, hygiene, assessment of risks and physical health monitoring, and governance arrangements for ensuring patients with mental ill health were not effective.

However, staff completed initial physical and mental health assessments on arrival. There were mental health pathways and liaison psychiatry arrangements, with timely responses to most referrals, daily reviews of patients, and access to specialist input. Leaders provided evidence of actions taken following the assessment to strengthen oversight, improve risk assessments, and address areas of concern, although these actions were not yet fully embedded at the time of assessment.

We have not awarded this service a score for Safe.

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

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

Staff gave mixed feedback about the incident-reporting culture and whether risks were managed effectively. Staff reported a disconnect between clinical staff and the senior leadership team.

The service had an up-to-date Patient Safety Incident Response Framework (PSIRF) policy and a Patient Safety Incident Response Plan, which set out how the service sought to learn from patient safety incidents. Leaders analysed incident reports and took urgent actions to manage or remove risks. We looked at a presentation given by a specialist doctor to medical and nursing staff following the death of a patient where learning points were discussed. However, we found no examples of engaging and involving patients and families.

Leaders analysed reports and acted to manage or remove risks, although this was not always timely. Leaders reported that, as of November 2025, 40 actions resulting from learning responses remained overdue, and 49 reported incidents had been open for more than 6 weeks, including 8 that could not be closed due to ongoing patient safety incident investigations (PSIIs), after action review (AAR) or safeguarding investigation. These delays meant the service could not demonstrate that risks were being addressed promptly, which reduced assurance that learning and improvements were embedded.

Leaders identified the top 4 reported incident themes were related to pressure ulcers (95% relating to concerns on admission), security, care and treatment issues or delays or failures in care. However, we found no evidence of examples of learning and improvements.

We looked at the Acute Medicine Governance Report November – December 2025 and saw that an incident from October 2025 in the delay/failure category was discussed at the Pre-Incident Review Panel. We noted that no learning was identified as related to disease progression. We also looked at details of a moderate harm incident reported in November 2025 regarding a patient fall and saw that for local learning – there would be safety huddle discussions with staff regarding neurological observations and that medical learning would be fed back to the team via ward manager.

However, staff had a good understanding of how to use incident reporting systems and knew what to report. The service reported one 1,363 incidents between 1 June 2025 and 30 November 2025, with 97% resulting in no harm or low harm.

The service reported 100% compliance with duty of candour in November 2025, indicating that all patients affected by a notifiable safety incident received the required verbal and written communication, supporting open engagement with patients and their families.

Staff told us they felt confident to report incidents and felt confident raising issues and concerns when they arose. Staff were clear what they should report and when. Leaders told us learning from incidents was shared through staff meetings.

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

At our 2023 assessment, we found that the service had a higher rate of patients re-attending the Emergency Department (ED) within 7 days than the national average. This had not improved. The trust continued to have a consistently higher than average re-attendance rate. Data from the 12 months before our inspection showed that 11.7% of patients re-attended the ED within 7 days of a previous attendance, which was worse than the national average.

At this assessment we found unsafe care and treatment due to systemic failures, including delays in essential care, ineffective triage, and no reliable system to identify critically ill patients. Overcrowding led to inappropriate corridor care for high-risk patients, alongside poor monitoring and missed deterioration. Environmental and equipment issues and delays in key interventions further increased risks and compromised patient safety.

The service did not always carry out effective triage. Staff did not consistently apply the correct Emergency Severity Index score (ESI), which led to delays in patients receiving timely onward care and treatment. Triage processes were not in line with NHSE’s Initial Assessments for Emergency Departments guidance.

Data provided by the trust showed that ESI scoring was frequently incorrect. On 12 and 13 January 2026, 50% of patients were assigned an incorrect ESI score, and on 7 January 2026 30% of patients were assigned an incorrect ESI score. This meant the service did not consistently prioritise patients according to clinical risk, which increased the risk of delayed assessment, delayed treatment, and harm to patients whose acuity was underestimated. Following our assessment, the trust reviewed and corrected the patients' ESI scores immediately upon notification by the inspectors. In line with the submitted action plan, a comprehensive training programme was implemented.

Patients were cared for in unsuitable areas for extended periods. Where patients were cared for in corridors, there was no access to piped oxygen or call bells. Patients were on trolleys for prolonged periods, with trolleys positioned close together, which increased the risk of pressure damage and infection. Trust data showed pressure area audit compliance had declined, with an average compliance rate of 80% over the last 3 months of 2025, compared with 90% in July 2025.

The mental health lounge was not always staffed or managed in line with the service’s intended staffing model. During our assessment, staffing levels were below the planned establishment and registered mental health nurse cover was not consistently available. Patients experiencing mental health crises faced prolonged waits in the emergency department due to capacity pressures within external mental health services. The environment was not always suitable for the number of patients using the area, and staff told us there was no defined maximum capacity. In addition, the emergency department mental health pathway remained in draft form, increasing the risk of inconsistent care, delayed monitoring and potential avoidable harm. Although staff actively escalated concerns and worked with system partners to support patient flow, leaders had not fully mitigated the risks associated with these delays.

Following our feedback leaders amended the draft pathway to specify a maximum number of patients who could be accommodated in the lounge.

We observed that call bells were not always answered promptly, and we saw that some patients had no means of alerting staff at all. This included a vulnerable patient who had lost their hearing aid and was being cared for in the corridor without reasonable adjustments to support communication.

We found that escalation processes were not used appropriately during periods of critical pressure, and staff were unfamiliar with key standard operating procedures such as those for corridor care, escalation, mental health pathways and end of life care. The examples demonstrated gaps in oversight, risk management, staff training and operational control within the department.

During the inspection, we identified significant risks to patient safety associated with the management of high-risk patients in overcrowded areas, particularly within ambulance corridors and waiting spaces.

In response to the concerns raised during our assessment, the trust undertook harm reviews for 5 patients who experienced delays during the 2 day on-site assessment period. The trust told us the reviews identified process related risks rather than evidence of widespread unsafe clinical practice. The trust concluded that care was appropriate in all cases, but acknowledged that improvements were required in timeliness, escalation and senior oversight to reduce risk, particularly for frail and complex patients.

During our inspection staff told us there was no formalised or documented plan on how to manage patients waiting for extended periods of time awaiting review. There was a lack of ownership, responsibility and oversight of the number of patients within the department.

Bed management meetings did not provide effective oversight of patient flow or support timely escalation of risks within the emergency department. Although pressures and capacity issues were discussed, concerns were not consistently escalated or acted upon, and leaders did not maintain clear oversight of patients being cared for in escalation areas. This limited the service's ability to effectively identify and respond to risks associated with high demand.

We saw no member of clinical staff was allocated to provide oversight of patients in the main waiting room. There was a risk that patients could deteriorate in this area, and this would not be identified by staff. There was no process to assess and effectively monitor those patients. There was a health care assistant allocated to this area who repeated clinical observations. However, they were frequently called away from this area and may not have the right level of training or experience to have oversight of this area. This was escalated by inspectors on the day, and additional staff were allocated to the waiting room. Further details were provided in the action plan submitted on 20 February 2026.

Clinical responsibility for patients within the department was not clearly defined. We noted the emergency department staff retained medical oversight and nursing care for those patients who were waiting for admission. This caused increased demand on the staff and space available for patients.

There were pathways to stream patients directly to speciality areas such as same day emergency care but due to flow issues throughout the hospital these areas were used as bedded areas.

Patients could be streamed to the Minor Injuries Unit. Children and young people were directed to the Children's ED.

The local NHS mental health trust provided psychiatric liaison services to the department. The service was a member of the Royal College of Psychiatrists’ Psychiatric Liaison Accreditation Network and was in the process of applying for accreditation. The service was commissioned to operate in line with the Core 24 model and provided nursing cover 24/7. Leaders told us the team planned to have 3 nurses on each day shift and 2 at night. The team’s offices were located on the same site as the main hospital.

Members of the psychiatric liaison team had access to the trust’s electronic records system. They responded to most emergency referrals within 1 hour and reviewed all patients in the emergency department daily.

The department had a clear pathway for patients with mental health needs. When patients with mental health needs arrived at the department, staff completed an initial clinical assessment.

Staff used the initial assessment to signpost patients to alternatives to the emergency department where appropriate, such as the safe haven, recovery houses, Mental Health Together services or their GP, when patients had no physical health needs and it was safe to do so.

Staff referred patients to be seen by the Liaison Psychiatry Service (LPS) if the patient consented, in line with agreed contact arrangements. Patients were then allocated to a waiting area. LPS staff assessed patient risks such as self-harm, suicide, the risk of leaving the department and made recommendations on the level of observation required.

The trust had processes to support children and young people (CYP) with mental health needs attending the paediatric emergency department. The Child and Adolescent Mental Health Service (CAMHS) undertook assessments of CYP. They were not based on the hospital site but worked to a 4 hour target to complete assessments, and staff told us responses were generally timely. Where children or young patients required enhanced observations, the service provided this and staff requested bank or agency staff when additional support was needed.

The evidence showed some shortfalls. The service did not always work well with patients and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always share concerns quickly and appropriately.

We found that not all staff had completed safeguarding training to the appropriate level for their role for both adults and children. Trust data showed, that training compliance for Safeguarding Level 3 remained below the trust target of 85%, which meant that staff may not have the safeguarding knowledge and competencies to support people safely.

Medical staff compliance in December 2025 remained at 60% for safeguarding and 69.6% for Prevent (preventing radicalisation), both below of the trust’s 85% target. Nursing staff compliance for the same period was 79% for safeguarding and 84.5% for Prevent also below the target.

The trust provided a trajectory for all training below trust expectation of 85% with monthly increase reaching compliance or above between February-March 2026.

However, teams had effective working relationships; we saw leadership from the matron with particular attention to safeguarding for Children and Young People (CYP) into the department. Level 3 Safeguarding training was at 92% with a planned trajectory to be 100% by February 2026. Staff told us that the safeguarding leads for the trust, undertook supervision with staff every Thursday.

We found that staff had identified the need for a safeguarding referral in 1 clinical record, but the records did not confirm whether the referral had been made.

However, staff knew how to identify adults and children at risk of or suffering significant harm and worked with other agencies to protect them. They told us they felt well supported by the safeguarding team and able to discuss safeguarding matters and any concerns they had.

The paediatric emergency department used established safeguarding pathways. Staff assessed all CYP for safeguarding or concerns on arrival, and a clear set of safeguarding guidelines supported decision making. Staff were prompted to access and check the Child Protection - Information Sharing (CP-IS) system when a child or young person was triaged. CP-IS is a secure, national IT system in England that links local authority social care and NHS health records. It securely shares vital safeguarding information so professionals can protect society's most vulnerable children. The service held weekly CYP safeguarding meetings, where staff discussed safeguarding concerns to ensure appropriate follow-up and oversight.

Leaders routinely shared safeguarding feedback through staff meetings, daily huddles, and follow‑up emails so all staff, including those not on shift, received consistent updates and learning.

Staff had access to a safeguarding policy, as well as guidelines and information to support staff to recognise and manage cases of suspected domestic violence and assault. The policies referenced appropriate legislation and best practice guidance. Flags (identifiers) were applied to the electronic record systems to identify patients who were at risk. Safeguarding information was displayed throughout the department.

Staff had good knowledge of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) and best interest decisions. Staff considered patients’ mental capacity when assessing them. Staff recorded assessments of capacity in the records we reviewed.

The evidence showed significant shortfalls. The service did not work well with patients to understand and manage risks. Staff did not provide care to meet patients' needs that was safe, supportive and enabled patients to do the things that mattered to them.

We were not assured the risk of harm to patients in the ED was mitigated. We found evidence that the service did not always assess or do everything reasonably practicable to mitigate the risk to patients in the department.

On 6 January 2026, we observed 21 patients waiting for admission, some of whom had waited more than 72 hours. We observed a period of 40 minutes during which there was no clinical oversight of patients in the waiting room, creating a risk that deterioration of patients may not have been recognised. These delays meant that, despite actions taken to address overcrowding, patients were coming to harm or at risk of harm. This was escalated by inspectors on the day, and additional staff were allocated to the waiting room. Additional information was provided on 20 February 2026 within the action plan following the visit.

Patients were not always cared for in appropriate areas, and we saw examples, supported by staff accounts, of patients being inappropriately placed in a temporary escalation space, as described below.

On 7 January 2026, we observed 28 patients being cared for in temporary escalation areas and a further 50 patients waiting in the main waiting room, in addition to patients accommodated within speciality and observation areas. As a result of capacity pressures and patient flow challenges, patients experienced delays in the assessment and the start of treatment. This increased the risk of clinical deterioration, unmet care needs, prolonged pain and discomfort, and poorer patient outcomes due to delays in the timely delivery of care and treatment.

Staff did not have sufficient capacity to carry out intentional rounding to monitor skin integrity, pain control and nutritional status, due to the number of patients.

We reviewed the records of 5 patients in the mental health lounge and found inconsistent physical health monitoring. This included gaps in monitoring fluid and food intake, access to prescribed medicines, blood pressure monitoring and completion of required blood tests.

We reviewed records for a patient presenting with mental health needs who experienced repeated episodes of low blood pressure and had a history of poor food and fluid intake. Staff did not consistently monitor or manage the patient's physical health needs alongside their mental health needs, increasing the risk that physical deterioration may not have been identified or responded to promptly.

Staff did not consistently assess, meet or record patients’ basic care needs, including nutrition, hydration, hygiene, comfort and frailty checks., which placed patients at risk of harm. Records showed that a patient made repeated requests for pain relief and basic care needs, including food, while waiting in the department, but these needs were not met.

Following the assessment the trust provided ED care plan audit data covering a 3-week period, focusing on falls, skin integrity and nutrition. The data demonstrated week-on-week improvements in the percentage of patients being assessed. Leaders told us they had introduced weekly monitoring and had taken corrective action in response to our concerns, including addressing inaccurate risk assessments with staff to strengthen oversight and compliance.

Effective leadership oversight of departmental risks was not evident, despite temporary escalation areas being included in safety huddles and site management discussions. Although leaders told us they had access to an electronic system providing oversight of all clinical areas and planned to re-educate staff on its use, this had not been fully embedded at the time of our assessment and therefore remained a risk.

We found that the board rounds were ineffective and lacked clear leadership, accountability and a standardised approach. In response to our assessment, leaders told us they would strengthen the Emergency Physician In Charge (EPIC) and Nurse In Charge (NIC) board round process by further standardisation. This also remained a risk until the revised process was implemented and embedded.

Medical handovers were not always effective, as they lacked structure and focused only on a limited number of patients. Inaccurate Emergency Severity Index (ESI) scoring meant some patients with significant clinical needs were not included in handover discussions, creating a risk that they were not appropriately escalated, reviewed or monitored. Following inspection feedback, leaders introduced a structured handover tool based on Royal College of Emergency Medicine guidance to support more consistent and effective handovers.

The service did not have adequate governance arrangements regarding the safe care and treatment of patients attending with mental ill health. Staff were unable to confirm whether a standard operating procedure (SOP) for the mental health lounge existed. As a result, staff did not have clear or embedded pathways and escalation protocols to ensure patients were cared for safely and risks were identified and managed. Following our assessment, information provided by the trust showed that the SOP had been finalised and implemented.

During the assessment some staff told us that escalation protocols did not make a tangible difference to the challenges of the emergency department, although we recognised the department was under intense pressure.

Poor patient flow across the hospital meant that patients who needed to be admitted from the emergency department could not be admitted within expected time frames. This led to poor patient experience. It also meant that patients arriving in the department could not always be seen and treated in a timely way.

However, staff completed assessments of mental health needs on arrival at the emergency department and the mental health lounge. This included identifying risks to themselves or others. Staff assessed patients on a daily basis if they were required to wait in the mental health lounge for over 1 day.

Staff in the paediatric emergency department completed care plans and risk assessments alongside triage and assessment.

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

We found that the service had overcrowded escalation areas that compromised safety and infection control, with trolleys placed too closely together and limited ability to maintain cleanliness. Essential safety features were lacking, including emergency call bells and piped oxygen and suction equipment. Patients were managed in environments where access to emergency equipment was restricted, and those requiring oxygen were given portable cylinders positioned unsafely, increasing the risk of pressure damage.

Prior to our assessment, the trust told us it had a risk-based approach for corridor care and the use of non-clinical spaces, supported by standard operating procedures and dynamic risk assessment. At the time of our assessment, patient examples showed the trust was not following this approach in practice.

The service did not consistently meet the care and treatment needs of patients presenting with mental ill health. Patients were held in an unsuitable mental health lounge environment for extended periods, including 1 patient who remained for 6 days while awaiting admission. The lounge had only 1 bed, with other patients sleeping overnight on sofas, which did not support dignity, comfort, or therapeutic care. At the time of assessment, the area was overcrowded, exceeding its safe capacity, with patients accommodated in both the lounge and adjoining assessment rooms. This compromised patient dignity, comfort, and safety, and increased the risk that care needs were not adequately met.

Data provided by the trust showed that between October 2025 and December 2025, a total of 325 patients were cared for in the mental health lounge. Of these, 272 patients stayed for less than 1 day, 38 stayed for between 1 and 3 days, 9 stayed for between 3 and 5 days, and 6 stayed for more than 5 days, demonstrating sustained pressure on an environment not designed for prolonged or high‑volume use.

We saw that the mental health lounge had 2 outward‑opening doors, both fitted with viewing panels that could be closed, and strip alarms positioned around the room.

The paediatric emergency department could not always provide an environment that was suitable for children and young people presenting with mental health needs. The liaison room could accommodate only 1 young patient at a time, which limited the service’s ability to safely manage more than 1 child or young patient requiring support. Where capacity was exceeded, children and young patients were cared for in cubicles near the nursing station, which were not specifically designed for mental health care. Although staff had access to distraction resources and showering facilities, the limited capacity of the dedicated space restricted the service’s ability to consistently provide a safe and appropriate environment.

The service used temporary escalation areas that were not suitable for some patients being cared for in them. These environments included the waiting area, specialty waiting room, rapid assessment and treatment area, ambulance offload area, Corridor B and Corridor A. The use of these environments did not support safe observation or timely intervention for these patients and placed them at increased risk of harm.

We raised concerns with the trust about the use of these environments for patients whose needs were not supported by them. In response, the trust told us it had a standard operating procedure (SOP) for corridor care. Leaders said the protocol had been reviewed and reissued in late 2025 and had been discussed with staff. Despite this, patients remained at risk until the use of these environments was consistently aligned with the defined safety criteria as set out in the SOP.

However, in the adult emergency department, the paediatric resuscitation bay was well equipped, with equipment clearly labelled and accessible. We observed that the paediatric airway equipment was clearly laid out with plan A,B,C,D.

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

There were significant concerns regarding patient safety due to inadequate staffing levels, insufficient clinical oversight, and a lack of assurance regarding staff competence within the Emergency Department (ED).

Staff did not consistently monitor patients in the waiting room during periods of high demand. During our inspection on 6 January 2026, we observed a period when no clinician was overseeing the waiting room because of staffing shortages. Although nursing staff were undertaking streaming at the front entrance, only one healthcare assistant was allocated to the waiting room despite high patient volumes. In addition, patients did not receive ongoing clinical assessment following their initial Emergency Severity Index (ESI) assessment, as no secondary triage process was in place. This increased the risk that deteriorating patients may not have been identified or escalated appropriately.

Consultant cover did not meet Royal College of Emergency Medicine recommendations. Leaders told us consultant cover was provided Monday to Friday between 8am and 10pm, with on-call cover overnight, and at weekends between 8am and 4pm, with on-call cover thereafter. National guidance recommends consultant cover between 8am and midnight, 7 days a week, and then on-call thereafter. This meant patients did not consistently receive timely senior medical review or intervention.

These concerns were reinforced by information received from staff and patients through our call centre, which we continued to monitor. Between 6 and 26 January 2026, we received 6 items of concerning information relating to insufficient staffing to provide basic patient care, infection control risks, nutrition, unsafe discharge practices and patient safety.

We visited the Paediatric ED on 6 January 2026 and noted that there were no patients present at the time. However, the department was appropriately staffed, including a consultant, matron, senior paediatric nurse, 2 student nurses, and administrative personnel.

At our last assessment, we found that mandatory training compliance did not meet the trust target in subjects such as Mental Capacity Act (MCA), life support and dementia training. At this assessment we identified that resuscitation training compliance across staff groups remained below the trust target, which limited assurance that staff had the required skills to respond effectively to medical emergencies. Data for December 2025 showed 76% compliance for adult resuscitation, and 69% for paediatric resuscitation among medical staff, and compliance of 50% for paediatric resuscitation among senior nurses. All figures were below the trust target of 85%. The trust provided a trajectory for all training below trust expectation of 85% with monthly increase reaching compliance or above between February-March 2026.

The service did not have sufficient numbers of staff with the required competence to safely care for patients attending with mental ill health. Staff told us there should be 2 members of staff assigned to the mental health lounge, while the trust’s draft emergency department mental health patient pathway stated the lounge should be staffed by 3 staff. On 6 and 7 January 2026, staff did not meet either of these staffing expectations increasing risks to both patients and staff.

On 6 January 2026, the service allocated 2 health care assistants to the area who had not received specific training in de-escalation techniques or enhanced observation. On 7 January 2026 the service allocated 1 enhanced observation support worker (EOSW) to the mental health lounge to provide enhanced therapeutic observations and care. The service allocated up to 8 patients over 24 hours to the lounge, all of whom required eyesight observations, and 1 patient required 2-to-1 observations, which staff could not safely deliver with the staffing available. This placed staff and patients at risk of harm.

Staff we spoke with were unaware of a standard operating procedure for the mental health lounge. As a result, the service could not provide assurance that a maximum capacity for the lounge had been defined or that clear arrangements when no more patients could be accommodated.

During the assessment on 7 January 2026 a support worker made the decision to not accept an additional patient into the mental health lounge room due to safety and capacity concerns. The patient, who had been conveyed to hospital by police, was required to wait elsewhere within the emergency department, on a chair near an exit. The patient later left the emergency department, requiring police, and security search the hospital grounds. Leaders later confirmed the patient had been located and returned to hospital by the police.

In response to our assessment leaders told us the Associate Director of Nursing for Mental Health had developed a training package for enhanced observation support worker (EOSWs). The package was designed to support EOSWs in providing care to patients with mental health needs. This was under review but would be rapidly implemented through a pilot. Until this training was fully implemented and embedded, this remained a risk.

In addition, leaders told us the trust had taken steps to ensure that there were always 2 enhanced observation support workers allocated to the mental health lounge. Leaders said coloured tabards had been purchased to identify the 2 staff who could not be moved from the area. Leaders told us that, while adult emergency department staffing had previously been presented as a single Red Amber Green rating, staffing for the mental health lounge was now discussed separately and reported separately on the daily staffing situation report.

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

The emergency department was experiencing significant crowding at the time of our assessment, and the hospital was also managing a norovirus outbreak. Patients were being cared for on trolleys positioned in close proximity to one another, which limited space and separation. This increased the risk of infection transmission and compromised the service’s ability to maintain effective infection prevention and control measures.

We observed that the toilets in the waiting area were visibly unclean, with urine present on the floor. Inspectors escalated this concern to staff, who responded promptly and cleaned the area. Staff compliance to bare‑below‑the‑elbows was inconsistent.

Staff had access to appropriate cleaning equipment and personal protective equipment and told us there were no issues obtaining these. We observed that staff followed the 7-step procedure for Commode Cleaning Standard Operating Procedure (SOP).

The trust had a 3-point learning week that commenced in November 2025 for sepsis. We saw that this included streaming ambulances, completing the sepsis tool and the golden hour to give antibiotics. We noted that since April 2024, trust compliance had gone from 40% to 90%.

Information provided by the trust showed that infection prevention and control audit results in the emergency department remained consistently high. Between October and December 2025, compliance with commode cleaning was between 98% and 100%; for the trust hand hygiene compliance was between 99% and 100%.

The trust used an Infection Prevention Screening Tool to identify patients at increased risk of infection or infection-related harm on arrival to the emergency department. The tool supported staff to recognise clinically vulnerable patients, including those with severe respiratory conditions such as cystic fibrosis, severe asthma and chronic obstructive pulmonary disease (COPD), so that appropriate infection prevention and control measures could be implemented promptly to reduce the risk of transmission and protect patient safety.

The evidence showed some shortfalls. The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Patients were not involved in planning.

At our last assessment, we found that that the service had insufficient pharmacy support, delays in administration, and poor documentation.

At this assessment we found that the service did not manage medicines safely, with insufficient pharmacy support, delays in administration, and poor documentation. Pharmacy provision did not meet national guidelines, with limited technician availability, no resilience for absence, and no additional support during periods of escalation.

There were unsafe processes for managing high‑risk medicines, including inadequate monitoring and lack of timely access to essential drugs, alongside unclear care plans when medicines were unavailable. Delays were also caused by limited access to patient records and a failure to identify high‑risk medicines at triage, increasing the risk of harm.

The service did not consistently follow safe systems and processes for prescribing and administering medicines. We found ongoing issues with the administration and recording of time-critical medicines.

We spoke with a variety of the pharmacy staff. We reviewed medicines storage areas within the emergency department and the records of 6 patients.

The clinical pharmacy service available to the department was not aligned with national guidance, and there was no dedicated pharmacist presence. At the time of assessment, the service relied on 1 whole time equivalent (WTE) pharmacy technician to support with medicines reconciliation, stock management, advice to staff and patients, and access to national care records for out-of-area patients. This arrangement was not resilient. For example, in November 2025, no pharmacy service was provided to the department.

Leaders told us they were recruiting to a vacant pharmacy technician position to strengthen the support. Given the high acuity of the emergency department, this did not provide assurance that safe and effective reviews were consistently in place to identify patients taking high-risk medicines or to ensure patients waiting for prolonged periods received their medicines. This concern was also highlighted at the previous assessment.

The service did not ensure patients’ treatment was consistently monitored in line with local protocols. For example, staff administered fluids and insulin to manage a patient with diabetic ketoacidosis (DKA), but records did not show that required blood sugar and ketone monitoring had been completed in line with the service’s policy. (DKA is serious complication of diabetes). Staff told us there was inconsistency in how blood results were recorded due to the mixed use of paper and electronic systems. This meant the service could not provide assurance that the ongoing monitoring of patient’s insulin treatment was consistently safe.

The service could not provide assurance that patients with time critical medicines were consistently identified and supported to ensure they received their medicines in a timely way. On the day of assessment, we saw an instance where a patient’s insulin was not flagged as time-critical at triage, which contributed to delays and omissions in treatment and placed the patient at risk of harm.

The service did not consistently assess venous thromboembolism (VTE) risk in line with national guidance. (VTE is a condition that occurs when a blood clot forms in a vein). A recent snapshot audit showed VTE risk assessment compliance was 81.9%, which was below the trust target of 95%.

However, the service told us that nurses used Patient Group Directions (PGDs) to give patients pain relief for patients waiting in the department, and VTE risk assessment outcomes and prescribing were completed in patients notes that we reviewed. Staff recorded patient’s allergy status clearly in records we reviewed.

Staff stored medicines, including controlled drugs securely using electronic storage systems, with access restricted to authorised staff. The service had good oversight of stock used within the department through electronic systems and regular safe and secure medicines audits. We saw that when staff identified issues, they escalated and acted. Staff used an established system to ensure that medicines were made available when requested.

The services had processes for supplying medicines to people on discharge. Staff used pre-labelled To Take Out (TTO) packs with standardised directions. They used FP10 prescriptions (the standard prescription form used in the NHS) to enable medicines to be dispensed in the community. Staff kept prescription stationary secure and maintained a clear audit trail of their use.

Where the service identified gaps in practice, leaders provided learning and training for emergency department staff. This included training on antibiotic prescribing, management of rapid tranquilisation and controlled drug management.

The service had contributed to the Royal College of Emergency Medicines (RCEM) ‘Time Critical Medicines’ quality improvement programme, which aimed to ensure patients received their time-critical medicines according to their usual regimen while in the department. We saw evidence of action plans and some improvements arising from this work, and overall performance was broadly in line with national averages.