Huddersfield Royal Infirmary

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 inspection, we rated this key question requires improvement. At this inspection the rating remains the same. 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.

We identified breaches of regulation. These included regulation 12 (safe care and treatment) relating to essential safety and safeguarding training compliance and medicines management (see specific headers for summary). We found a breach of regulation 18 (staffing) relating to safe and effective staffing. We also found a breach of regulation 17 (good governance) relating to the inconsistent upload of patient information onto the electronic patient record.

The service did not always make sure there were enough suitably qualified, skilled and experienced staff to deliver safe care. Senior leaders had taken action to address staffing vacancies through targeted workforce planning and recruitment initiatives. Sickness continued to impact on daily staffing throughout the service. However, planning and mitigations were in place to address this.

Essential safety training and role specific training did not always meet the trust target of 90%. However, leaders told us they expected compliance to improve following a more targeted approach, including strengthened oversight through the Well Organised Ward (WOW) initiative. Several modules had been reviewed to determine which required face to face delivery and which could be moved to e-learning.

The service did not always make sure that medicines management and treatments were safe or met people’s needs, capacities and preferences. Clerking of medicines was not always complete and medicines reconciliation rates were low.

We noted inconsistencies in record keeping within the electronic patient record. We found multiple examples across different patient records. Staff documented care in varying and inconsistent areas of the system.

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

The service had a clear process for reviewing and escalating incidents. The Patient Safety Incident Response Framework (PSIRF) was fully embedded, supported by an incident management policy that set out a consistent approach to the reporting, investigation, and management of incidents.

Incident investigations were overseen through divisional and trust‑level governance structures. Initial learning responses were reviewed at Divisional Patient Safety Event Panels, with themes and actions escalated to the Divisional Patient Safety Quality Board (PSQB) for assurance. An overarching trust Patient Safety Panel provided assurance and approval of all Patient Safety Incident Investigations (PSIIs).

The Patient Safety Incident Response Plan (PSIRP) set out a system‑based learning approach, including SWARM huddles, PSIIs, After Action Reviews (AARs), MDT case notes reviews and thematic analysis.

Senior leaders told us it had taken time for the organisation to fully understand the PSIRF process, and incidents were initially over-investigated during the transition from previous frameworks.

The service had planned and funded two clinical posts to support incident management and had identified clinicians to lead staff training and improve the quality of investigations. The trust fully transitioned from the Serious Incident Framework (SIF) to the PSIRF in February 2025. Since transition, the medical service (including urgent and emergency care) had recorded three PSIIs, and no Never Events.

All moderate to severe harm cases were discussed at a weekly panel where risk was validated. If downgraded, incidents were passed for local investigation and resolution. Where moderate to severe harm was confirmed, an AAR was completed and themes were reviewed through thematic analysis. Life or limb threatening incidents were escalated to the medical review panel for oversight.

Learning from incidents was shared at the monthly Patient Safety Quality Board. Key points were summarised into a learning slide and circulated to all staff within the medicine service. The most common incident themes were falls, pressure ulcer damage, medication, and discharge.

Incidents were reviewed through established governance processes, including daily safety huddles and service level oversight meetings. Managers ensured that investigations were completed appropriately, with patient involvement where relevant.

There was a culture of learning and high level of support provided to staff. Staff knew what incidents to report and were confident in reporting them. They demonstrated understanding and compliance with the duty of candour, ensuring openness and honesty when incidents occurred. Daily safety briefings included learning from recent incidents, as well as shared learning across sites and the wider trust.

We reviewed four patient safety investigation learning reviews post inspection. These demonstrated clear learning and prompts for ongoing discussion to prevent recurrence.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

We observed staff following clear protocols to manage transfers and discharges. Most staff reported that admission and transfer processes worked well and shared examples of good practice.

Daily safety briefings and board rounds were well structured, ensuring oversight of admissions, transfers, and discharges to support continuity of care and patient flow. We observed handovers that were consistent, comprehensive, and effectively covered all aspects of patients’ needs.

The service had implemented a continuous flow model during periods of high operational pressure to maintain patient safety and flow. Staff described improved communication and teamwork, supported by appropriate policies and quality impact assessments to mitigate risks. The service had a medical frailty Same Day Emergency Care (SDEC), six escalation beds and a discharge lounge with five overnight beds when required.

We visited the frailty SDEC, which had five trolley spaces with privacy curtains and ten chairs for fit to sit patients. Staff told us the unit offered five trolley spaces for patients requiring overnight care prior to admission to an acute medical bed or discharge home.

Staff managed an effective discharge process, using standardised checklists to ensure safe transfers. Resident doctors liaised with community professionals, including GPs, district nurses, and community pharmacies to facilitate safe discharge.

To ensure patients were placed in the most clinically appropriate environment, each medical ward operated inclusion criteria. These criteria supported safe, effective care by directing patients to the ward best suited to their primary medical needs and specialist requirements.

Discharge liaison coordinators worked closely with therapy teams, patient flow teams and the trust’s discharge command centre, which operated 7 days a week. They collaborated with social services and community partners to support timely discharge, rehabilitation, and continuity of care, helping to prevent re-admissions.

However, onward care packages and delays in confirming immediate care needs continued to affect discharge timeliness, delays, particularly for patients with complex needs.

The discharge team held daily planning meetings reviewing the daily patient list across both sites to ensure quick access to support and escalation where required.

The service did not always work well with people 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 reviewed safeguarding training compliance for the medicine division, which showed an overall compliance rate of 88%, below the trust target of 90%.

Safeguarding children (level 3) compliance was 78% with 15 staff overdue for training (nursing and midwifery). Safeguarding adults (level 3) was 69% with 92 staff overdue for training (nursing and midwifery). This was a breach of Regulation 12: safe care and treatment.

The service had an improvement plan in place which had been discussed at the service`s quarter 2 update to the quality committee. Actions to improve included: all non-compliant staff being allocated a training date with clear expectations for attendance. There was also ongoing work with the corporate team to strengthen training requirement and improve staff attendance. Leaders told us they expected to achieve 90% compliance by the end of March 2026.

The trust provided data to reflect staff compliance regarding Oliver McGowan training. Oliver McGowan mandatory training on learning disability and autism was co-delivered by trainers with lived experience of learning disability and autism.

There were 2 tiers to the training. Tier 1 of The Oliver McGowan essential safety training on Learning Disability and Autism is for people who require general awareness of the support autistic people or people with a learning disability may need. 

Tier 2 of The Oliver McGowan essential safety training on Learning Disability and Autism is for people providing care and support for autistic people or people with a learning disability.  

The service’s Oliver McGowan Part 1 compliance evidenced a compliance rate of 91.51%. Part 2 delivery was underway; the overall compliance was 11% (January 2026).

The trust had 29 funded tier 2 sessions (capacity 928) plus an additional continuing professional development (CPD) funded session providing 192 places, giving a total potential of 1,120 completions. Senior staff, including matrons, senior nurses and ward managers were prioritised for early attendance. This meant there was a risk that frontline staff may take longer to complete the training, which could result in sub-optimal care for people with learning disabilities or autism.

The trust provided data sets to evidence training compliance which reflected data based on division and clinical role. There were some mitigations in place, which included lunchtime learning sessions as well as an increased focus in support from more senior staff. The service had a clear improvement plan on safeguarding compliance in terms of achieving the 90% target for the remaining 2 elements that currently reflected an amber rating. Leaders told us full compliance would be achieved by the end of February 2026.

The service reported 98% compliance rate for dementia awareness training.

We found inconsistencies surrounding the timeliness of effective assessment of patients with limited mental capacity and learning disability (LD) and autism. Of the five records reviewed, only two VIP passports could be located by staff at the request of inspectors. Hospital passports are essential to enabling reasonable adjustments, reducing distress during admission and providing clinicians with clear, person‑centred safety and care information.

Following our inspection findings senior leaders completed a full review which showed VIP passports and discussions with families were present, although this was not consistently visible at the time of the inspection. We reviewed the same patient records when we returned to inspect the Calderdale site in February 2026. However, we found that information was uploaded in different sections of the electronic record, highlighting a training and education gap across the service. This was a breach of Regulation 17: good governance

Senior leaders told us a flag is raised to highlight when a patient has a VIP passport I place, and this is followed up by the Learning Disabilities team when a patient is admitted or under the care of community teams. Responsibility for ensuring they remain accurate and up to date is shared between the clinical team and the patient, their carers or significant others as document owners, to support safe and person-centred care.

All wards had secure entrances and exits; however, we identified blanket restrictive practice, with locked doors at ward exits and no signage explaining the reasons or how to leave. This was a breach of Regulation 12: safe care and treatment. We escalated this to senior leaders on site. We requested assurance from the trust to ensure that care is provided in accordance with legal frameworks protecting people`s liberty.

Although the trust had an in‑date locked doors policy, practice did not align with it. The trust provided assurance that posters would be displayed and that risk‑based decisions would be made by the nurse in charge. On return to site, posters were present; however, there was no clear process to monitor the use of locked doors, and we were not assured that leaders were consistently operating within legal frameworks to protect people’s liberty.

The trust provided immediate assurance stating that the service had a locked doors policy in place. We reviewed the policy which stated ‘the trust expects all staff to ensure patients are aware of their rights to enter and exit secured areas freely, the reasons for the locked door, and the options for access and egress are made clear to both patients and visitors by the use of visible posters on ward doors (Appendix 1)’ The policy was in date with a next review date of May 2026. However, we found practice was not in line with the policy. There were no posters on display highlighting to patients why the doors were locked and how they should exit individual wards.

The trust provided assurance stating ‘the trust operates a locked door approach on inpatient wards for the protection of patients, environments and equipment. When patients in ward areas that are at risk of leaving the ward and are on a Deprivation of Liberty Safeguards (DoLs) the doors are disabled by the green exit button. To allow those who do not have any restrictions to exit we will place a sign on each ward door asking these patients to speak to a nurse so that they can be let out.

The trust gave assurance that posters in the policy would be printed and placed on the doors with an action date of 16th January 2026.There was no risk to the management of fire and evacuation as all doors have an automatic release system in place. When we returned to site on the 4 February 2026 we observed posters on display on locked medicine wards. However, it was evident there was no process to monitor the use of locked doors. We were not assured that leaders are working within the requirements of legal frameworks to protect the freedom of people.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

During 2025 senior leaders commissioned a focused review of the clinical data and accuracy of the data extraction to provide assurance and oversight of clinical documentation within the EPR record in relation to risk assessments, care plans and accurate record keeping.

To strengthen oversight, the trust quality assurance group was established in 2025, chaired by the chief nurse or deputy. Clinical divisions provided monthly reports on key fundamentals of care such as falls assessment compliance along with associated improvement actions.

Divisional improvement plans had led to measurable progress across many of the quality assurance patient assessments.

A weekly cross‑divisional improvement work-stream reviewed patient assessment data and drove targeted improvements. Each topic area included multiple care components; for example, a falls assessment included a risk assessment, care plan, and manual handling considerations.

Regular handover meetings, safety huddles, and daily ward and board rounds provided structured opportunities to escalate concerns, share information, and support collaborative decision making. These meetings were attended by all relevant staff and ensured consistent oversight of patient safety.

Clinical risk assessments included falls, pain scores and national early warning scores (NEWS2) were captured on handheld devices and uploaded to the EPR.

Staff used a handover sheet from the electronic patient record for each patient. The handover between each senior nurse/coordinator on duty used this format. Nursing shift handovers evidenced good communication/corroboration between nursing staff. However, we observed nurse to nurse handover using handwritten handover forms which posed a risk such as incorrect spelling of patient’s names, duplicated names and missing dates of birth.

Daily MDT board rounds ensured patients with the highest needs were prioritised, supporting timely decisions and safe, effective care. We observed examples of staff sharing key information to maintain patient safety, including discussions about falls risk, mobility, care plans, suitability for step-down or discharge, dietary needs, and infection status.

Staff escalated risks appropriately and discussed these with patients to support shared decision making. Consultants reviewed patients across different specialty wards to monitor progress and ensure a coordinated approach to care and treatment.

Staff had an understanding of Martha's Rule, a patient safety initiative implemented in English NHS hospitals from April 2024. The initiative gives patients, families, carers and staff in hospitals who have concerns about a patient's deteriorating condition access to a rapid review from a critical care outreach team. We saw posters on display in some clinical areas explaining the process and patients’ rights. The posters were available on the trust’s intranet in differing languages.

The service were working towards embedding Marthas rule.

We reviewed Martha’s rule referrals audit for data April 2025 - December 2025 which evidenced:

• 40 referrals and breakdown of the referrer
• 19 accepted patient and outcomes
• 25 not accepted referrals and outcome

We reviewed the services risk register, each specialty had its own set of risks, with mitigation actions, which were discussed at monthly meetings.

Medicine inpatient areas within the trust used the electronic hub system to record patient observations and escalation, 24/7. Observations recorded populated directly into the Electronic Patient Record (EPR) and NEWS scores were automatically calculated by the Nerve centre system.

Daytime tasks could be handed over to the out of hours team electronically reducing the risk of tasks being missed during handover.

The acute response team (ART) received alerts for raised NEWS2 scores of 5,6 and 7+ which qualified ward staff could escalate or deactivate based on clinical need.

We scored the service as 1. The evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

We observed multiple environmental and equipment related risks across medical wards. On all medical wards, doors to sluice rooms were unlocked, and corrosive liquids classified as Control of Substances Hazardous to Health (COSHH) regulated substances were accessible. We also observed an unlocked door leading to a patient toilet/shower room in the frailty Same day Emergency Care (SDEC) which had toilet cleaner and descaler stored within patient reach. This posed a risk to some patients suffering with confusion, dementia and delirium.

We observed linen store cupboards left opened which posed a potential fire and ligature risk. The trust responded to concerns regarding linen storage. They clarified they were satisfied that current provision meets the NHSE standards in relation to linen storage and infection control (IPC). Leaders acknowledged that linen could pose a ligature risk for some patients. The intended approach was to manage the environmental risk to individual patients who had been assessed as at risk of self-harm. This was covered as part of ligature risk training with current compliance at 97%. Ligature kits are stocked on each resuscitation trolley.

Patients had access to staff kitchens which had hot water dispensers. This posed a risk of potential scald incidents due to the acuity of patients on medical care wards and units.

We observed resuscitation trollies on wards 8 (acute care ward), medical escalation area (birth centre) and ward 3 (Frailty) which contained equipment that was not in line with the daily checklist. For example, neonatal masks, trollies were overstocked, daily check records were not completed consistently, and resuscitation drugs were not stored safely or tagged (ward 8). On the medical escalation ward, two resuscitation trollies were present. One was stored in the additional six bedded space and one close to the nurse’s station on ward 14. The trolley stored close to the escalation bed space had no security tag, the top was cluttered and visibly dusty, daily check lists were completed sporadically. The weekly full trolley check was last completed on 27th November 2025. The ward sister informed the team that the trolley was not in use. This posed a risk as there were no signs on display to evidence this. The resuscitation trolley was removed immediately post escalation.

We escalated these concerns with ward matrons and senior leaders at the time of the inspection. The trust provided an immediate response outlining corrective actions taken. However, we were not assured that the service had effective oversight of daily resuscitation equipment checks. Ward staff were unclear if the resuscitation team completed monthly/bi-monthly audits.

COSHH items and other hazardous substances identified as being inappropriately stored were secured immediately. To ensure sustained compliance with safety standards, a formal daily storage check had been added to the nurse-in-charge ‘must-do’ checklist. This was further reinforced through the addition of COSHH checks to the FLO audit which is a quality assurance audit embedded across the organisation.

All kitchen areas were reviewed immediately by senior staff following feedback.

The trust reviewed incidents from the last six months and found no reported incidents surrounding scalds or burns. The service established a task and finish group to review the position in relation to locked kitchens taking a risk-based approach in each setting.

We observed an unlocked linen store cupboard on the birth centre which was being used as a six bedded medical escalation ward. The cupboard contained maternity items including boxes of batteries. We also observed a storeroom next to the nurse’s station with the door wedged open containing venflon’s (small flexible intravenous cannula) and needles accessible to patients and visitors.

In a side room used as a medical escalation bed blankets were being used as draft excluders on windows. Staff told us the windows required replacement due to the aged estate. This posed a risk to patients due to potential ligature and infection control risk. The issue was recorded on the services risk register which highlighted risks to the quality of care provided to patients due to poor environmental conditions across acute wards. Windows caused draughts in cold weather and failed to open in warmer weather.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. Essential skills training and safeguarding training figures did not always meet trust target; however, there were plans in place to address this. They did not always work together well to provide safe care that met people’s individual needs.

On acute medical wards 8 and 9, planned staffing levels for registered nurses and healthcare assistants were not consistently met.

Staff told us that although staffing gaps, patient acuity and requests for 1:1 care were escalated, actions were not always taken to address these concerns. This was a breach of Regulation 18 staffing.

The acute floor comprised 46 beds plus one escalation bed and was at full capacity on all three inspection days and nights

During our first visit the acute floor was full and had 1 patient requiring 1:1 support. There were registered nurse gaps on both early and late shifts.

We observed the ward matron and clinical coordinator providing direct clinical support alongside security staff for a patient with challenging behaviour. They told us this was a frequent requirement due to staffing pressures.

Staff told us they often felt emotionally exhausted, frustrated and burnt out.

On our return visit we again observed registered nurse staffing gaps on Tuesday 3 February 2026 (pm shift) and Wednesday 4 February 2026 (am shift). Although staffing shortfalls had been escalated through bank, agency and internal redeployment processes, gaps remained unfilled. Staff told us the ward matron was available to support; there were no patients requiring 1:1 support.

Following discussions with ward-based staff, we were not assured that staffing gaps or 1:1 requests were always filled. Staffing boards displayed on wards showed only actual staffing figures and did not reflect planned versus actual staffing.

The service provided data which showed fill rates for agency and bank staff split by nursing, medical staff and allied health professionals. Medical staff reflected an agency fill rate of 3.4% against a bank fill rate of 91.20% with an overall fill rate of 94.59%. Nursing staff reflected an agency fill rate of 10.71% against a bank fill rate of 62.36% with an overall fill rate of 73.07%.

Fill rate data from July to December 2025 evidenced a fill rate of over 90% for non clinical and clinical nursing staff and medical staff.

Staff consistently reported that sustained staffing gaps impacted their wellbeing, particularly due to high patient numbers, acuity, and frequent admissions and discharges. Staff described challenges caring for older patients with confusion, delirium and complex medical needs.

Staffing gaps often impacted on staff being able to take breaks unless these were covered by staff from other areas. Staff told us they were regularly re deployed between wards to cover gaps. Most accepted the need to ensure patient safety.

While most understood the need to maintain patient safety, some reported feeling anxious when asked to cover higher‑risk areas and said they did not always feel they had the required skills or experience to work safely on the acute floor.

We escalated safe staffing concerns with senior leaders following inspection.

The trust provided information that confirmed registered nurse gaps persisted for four days after the inspection. Although mitigations and plans were described, rota gaps remained. Further assurance confirmed that bank and agency requests had been made but posts remained unfilled, despite command‑and‑control oversight.

We escalated this with the trust who provided further assurance. Agency and bank staffing requests had been made; however, gaps were not filled. There was evidence of mitigations in place by the command-and-control centre in the evidence provided however; staffing gaps remained.

In line with Developing Workforce Safeguard Standards the trust held twice yearly safer staffing panels overseen by the chief nurse.

The last Safer Nursing Care Tool (SNCT) data collection was June 2025 with findings presented to the safer staffing panel in September 2025. The next SNCT collection was planned for February 2026.

A monthly safer staffing steering group had oversight of key performance metrics in relation to staffing and reports into the quality assurance group.

An overarching corporate risk relating to operational staffing pressures was managed through the safer staffing steering group.

Medical staffing issues were discussed at the services medical huddle held three times weekly and daily during periods of high operational pressure. For resident doctors there was an allocated person who reviews the rosters 6 weeks in advance to mitigate gaps. Leaders told us that operation managers along with the relevant consultant review from 4 weeks in advance to mitigate gaps. Medical gaps were mitigated through bank staffing where possible.

We reviewed 8 patients residing on non-medical wards as medical outliers. Patients were reviewed by medical and therapy staff and records showed individualised plans of care and expected discharge dates documented.

Trust compliance with essential safety training requirement in learning disability and autism was poor. Whilst over 90% of staff had completed eLearning, there were no areas of the service where compliance with the training requirement was above 20%.

This meant there was a risk that staff were not equipped with the necessary skills to meet the specific needs of patients with a learning disability or those who were autistic. Senior leaders told us the trust had committed to the delivery of the preferred model of training for Learning Disability and Autism which is the Oliver McGowan Program. This program consists of 2 parts with a requirement to have delivered both parts over 3 years. Compliance with part 1 on the training was online and over 90% for the whole organisation. Compliance for part 2 which is the face-to-face element currently sits at 18% and is on target to achieve expected compliance in line with the 3-year plan. Colleagues also receive bespoke training sessions in relation to this subject as part of induction and preceptorship programs, through learning disability week and the network of learning disability champions across the organisation.

The trust had a plan for increasing compliance in the coming year, however at the point of our inspection, we could not be assured that staff were trained and therefore able to meet the specific needs of this patient group.

Compliance with some essential safety training remained below the trust target of 90%. For example, fire safety (88%) and data security (88%).

Fire warden training compliance was 88% and had been added to the risk register, with mitigations in place, for example most matrons and senior staff were trained.

Fire safety was an acknowledged low compliance area, often around 75% for the service and partly due to challenges in attending face to face training. Rostering in staff attendance had been completed to support completion.

Medical staff training compliance also remained below the trust target across all areas.

Senior leaders told us that directorate business and performance meetings took place monthly where areas of under compliance were reviewed and actions agreed.

Deanery doctor training completion was recorded on a separate system and delays in data transfer can impact completion figures. One agreed structure for deanery training across West Yorkshire had been proposed, to simplify reporting.

Annual appraisals were mandatory and include review of training completion, with appraisals paused until overdue training was completed.

Basic Adult Life Support Training (BLS) compliance was 87% and Paediatric basic life support was 93%. These required face to face attendance, and additional dates had been added to support completion.

Sepsis acute training for adult’s presentations was available on the ESR (electronic staff record). Sepsis training was mandatory every three years for all doctors, clinicians, registered nurses, nursing associates and advanced health professionals working in clinical areas.

Staff commencing employment were assessed by the lead nurse to determine if they need to be registered for this training.

The sepsis collaborative group monitored compliance through the sepsis portal, with a target of 90%. Overall service compliance for sepsis training was 90%. The lead sepsis nurse also provided training for apprentice health care assistants, mental health student nurses on placement and for newly qualitied nurse and midwife staff at induction. Various communication channels were utilised to strengthen the message relating to the importance of keeping up to date with this essential training.

Leaders told us that Essential Skills Training (EST) and Role‑Specific Training (ReST) formed part of the annual appraisal process and that appraisals could not be signed off without full compliance.

Oversight of EST and ReST sat within the services governance process.

Directorate training compliance was monitored through the monthly Directorate Business and Performance Meeting, where the general Manager, clinical director and matrons reviewed data and actions. Where compliance fell below required levels, mitigation plans were requested and implemented.

There had been significant investment in increasing the number of ward based clinical educators to support both mandatory and role based / speciality-based training.

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

Ward areas were mostly clean, well maintained, and equipped appropriately. Staff cleaned equipment after use, labelled it with ‘I am clean’ stickers, and maintained appropriate storage practices.

Equipment in storage rooms was mostly stored off floor areas to maintain hygiene standards.

Hand hygiene compliance was consistently high. Audit data showed a compliance rate of 98% in December 2025. However, cleaning record audits for the following wards evidenced lower compliance and shortfalls regarding cleanliness assurance. Cleaning audits were completed by an external provider and showed the following results:

• Wards 3 (frailty) 88% (October 2025)
• Ward 6 (general medicine) 82% (October 2025,
• Ward 17 (gastroenterology) 76% (April 2025)
• Ward 20 (care of the elderly) 82% (June 2025).

Non-compliance areas included gaps in daily, weekly and monthly cleaning records, inconsistent adherence to colour coding of cleaning equipment, poor hand hygiene compliance and poor waste segregation and management. The service did not provide actions plans to evidence what actions were taken to address this when they submitted the data return.

Staff adhered to infection prevention principles, including appropriate use of personal protective equipment (PPE) such as aprons and gloves. Staff maintained bare arms below the elbows, washed their hands regularly, and complied with the trust’s uniform policy.

Hand washing facilities and sanitising gel were readily available. We observed posters displayed on wards to instruct staff and visitors on effective hand washing techniques.

Patients were screened for infectious diseases on admission, with symptomatic patients isolated in single rooms or bays. We saw differing examples of patient isolation on the wards inspected. There was adequate signage displayed outside individual patient rooms to demonstrate infection risk. We saw personal protective equipment (PPE) readily available and observed staff adhering to protocol.

The service monitored performance against mandatory Healthcare Associated Infection (HCAI) surveillance indicators.

From October to December 2025, infection data showed five hospital‑onset hospital‑acquired and five community‑onset hospital‑associated E. coli bacteraemia cases across medicine wards.

The service had an Infection Prevention and Control (IPC) lead. The lead represented the service in the trusts (IPC) strategic group and the infection control committee.

The medical service had IPC champions in each clinical area. The role of the champion is to support teams with enhanced knowledge in all IPC related issues, attending additional updates throughout the year to develop their knowledge and expertise.

IPC issues such as C Difficile infections, MRSA Bacteraemia's were investigated under the PSIRF framework. Themes and trends were analysed twice yearly by the lead nurse for IPC and fed back into the service through the Patient Safety Quality Board (PSQB) to inform quality improvement.

IPC performance data was available through the knowledge portal for oversight and monitoring and are aligned through the quality dashboard with associated audits to support triangulation and understanding of issues.

The IPC team have a service link practitioner that provides a quarterly report into the PSQB. This provided an update of actions against agreed priorities and any appropriate escalations.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Clerking of medicines was not always complete and medicines reconciliation rates were low. This puts patients at risk of not receiving the correct medicines.

We conducted a review of areas used to store medicines which included treatment rooms and medicines trolleys. We also reviewed the storage and records of medicines that are controlled drugs (CDs). We reviewed the electronic records of 8 patients and reviewed audits and policies. We spoke with a clinical site matron, a staff nurse, a ward manager and 2 specialist pharmacists working in the safari team and the Acute Medical Unit (AMU).

Medicines were stored safely, securely and were well organised in most areas, however, we did find 1 medicines trolley on Ward 9 that was unlocked and unattended. We escalated this at the time of inspection, and this was rectified by the nurse in charge. Controlled drugs were stored securely with restricted access; record keeping was accurate and there was a process in place to report any discrepancies found. All medicines checked were within their expiry date.

There was a system in place to replenish medicines when needed and there was a regular service provided by the pharmacy to supply medicines and manage stock. There were designated Pharmacists and Pharmacy Technicians supporting the wards.

Details of patient allergies were documented well in all patient records. Where antibiotics had been prescribed, we saw that indications for these were documented, however the duration of treatment was not always clear.

Patient records seen during the inspection did not always have full medicines histories recorded during initial clerking that resulted in missed doses of critical medicines. We saw that of the 8 patient records we looked at, 3 did not have comprehensive clerking completed. These were addressed when the pharmacy teams conducted the medicines reconciliation process (comparing the list of medicines people were taking prior to admission with what was currently prescribed), however, for some people this occurred greater than 24 hours and critical medicines were missed. This was a breach of Regulation 12: safe care and treatment. Once medicines reconciliation had been completed, the required medicines were prescribed.

Medicines reconciliation was conducted using various sources to ensure the information was correct and up to date. However, medicines reconciliation rates supplied to us by the trust were low with 81% of patients having this completed during their hospital stay and only 44.90% of patients within the first 24 hours (on average over a 7-month period from June 2025 to December 2025). NICE Guidance states that people who are inpatients in an acute setting should have a reconciled list of their medicines within 24 hours of admission. This puts patients at risk of not receiving the correct medicines. There was no prioritisation tool to help identify and prioritise patients requiring a medicines reconciliation; however, the trust was working on developing a software tool for this.

For one patient who required their medication and nutrition via a feeding tube (Percutaneous Endoscopic Gastrostomy or PEG), this method of administration was not documented for all medicines on their medicines chart, and some medicines had been prescribed via the oral route. This put them at risk of receiving their medicines in a way which was not intended or appropriate. The administration records were also unclear and stated, ‘Patient administered, unsupervised.’ These issues were raised during the inspection and escalated by the pharmacy team.

For the patients records reviewed, time critical medicines were not always given at the prescribed times, and some doses were given late. We also saw a patient record showing that paracetamol, which requires a minimum of 4 hours between doses, had been given before the 4-hour interval had passed.

The trust explained that the safari discharge team is a pharmacy led initiative supporting safe and effective discharge. The trust shared that where the team were involved, they had seen a reduction in the number of discharge medicine errors, improved patient satisfaction and improvement in discharge timeliness.