Conquest 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 people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement. 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 assessed all quality statements in this key question. 

We found that the service was in breach of legal regulations in relation to safe care and treatment and staffing.

The service did not always provide care and treatment in a timely way in line with clinical guidance. The service and leaders did not make sure patients were admitted from the emergency department to a ward bed in a timely manner. The service's processes were not always effective following the consolidation of their cardiology services. 

Paediatric nurse staffing for the paediatric emergency department was not in line with national standards. The mental health assessment room did not meet national standards, resulting in patients often being cared for in non-therapeutic clinical areas. Staff did not always manage medicines safely or in a timely way. 

There was limited pharmacy support within the department contributed to delays in completing medicines reconciliation.

However, the service investigated incidents and learning was shared. Staff were open and honest when things went wrong and told us they had opportunities to learn and gain experience. 

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.

We scored the service a 3. 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 good practice. 

The service had a proactive and positive culture of safety based on openness and honesty. Staff listened to concerns about safety and incidents were investigated and reported. 

The trust was an adopter of NHS England’s Patient Safety Incident Response Framework (PSIRF), which focused on effective learning and compassionate, meaningful engagement with those affected when incidents occurred.

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 aimed to learn from patient safety incidents reported by staff, patients, their families and carers. Leaders analysed incident reports and took urgent actions to manage or remove risks.

Staff at all levels had a good understanding of how to use incident reporting systems and what to report. Staff we spoke with told us they were debriefed and given support after serious incidents or when support was required. 

The service shared learning in several ways across both the service and the wider trust. These included safety alerts messages, safety huddles, handovers and newsletters. 

The service had a duty of candour policy, which set out staff roles and responsibilities regarding openness, honesty and transparency when something went wrong with a patient’s care or treatment. We saw learning responses that confirmed the duty of candour was completed appropriately.

Morbidity and mortality meetings were used to identify learning from deaths and implement actions to improve practice. Leaders told us mortality reviews were discussed at monthly governance meetings and recommendations were implemented when required.

However, our review of incident investigation reports showed the service did not always implement identified actions consistently or effectively enough to drive improvement.

Leaders introduced a rolling monthly audit to monitor compliance with patient observations. They implemented a separate monthly audit to assess compliance with UK Sepsis Trust guidance. This incorporated sepsis recognition and management into a Band 5 study day. Leaders implemented these actions following a poor patient outcome related to ineffective sepsis management.

Despite these actions, leaders did not consistently implement improvement measures. Previous audit data had already identified ongoing poor compliance with sepsis requirements, demonstrating that the service had not effectively embedded learning or achieved sustained improvement.

We scored the service as 1. 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 manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services

The service did not transfer patients to specialty wards in a timely manner, and patients remained in the emergency department for prolonged periods beyond their clinical need. Although leaders had implemented escalation policies and pressure management plans to support patient flow, these measures did not prevent sustained crowding or ensure timely access to appropriate inpatient care.

During our assessment, we saw significant flow delays. At 9:43am on the first day 50 patients were in the department, including 22 patients waiting for inpatient beds elsewhere in the hospital. At 3:23pm on the second day 87 patients were in the department, with 19 patients awaiting ward placement. Leaders told us the longest wait for a patient requiring admission was 25 hours. These delays increased the risk of patient harm, as patients waited extended periods in an environment not designed for ongoing inpatient care and could experience delays in treatment and review. 

We observed examples where delays had the potential to adversely affect patient outcomes. One patient with a severe ankle fracture waited more than 5 hours for manipulation under sedation because there was no space available within the resuscitation area to safely undertake the procedure. This delay increased the risk of swelling, which could have made treatment more difficult and affected the patient's recovery.

The service did not maintain effective oversight of patients waiting for assessment or review. We observed one patient who had arrived by ambulance following a failed discharge. After a short period in a clinical cubicle, staff moved the patient to the waiting room, where they waited more than 7 hours for medical review. In another case, a patient with a suspected abdominal aortic aneurysm (a potentially life-threatening condition), waited more than 6 hours for diagnostic imaging following triage and remained in the waiting room during this time. 

This delay meant there was a prolonged period before staff could confirm or exclude a serious diagnosis and initiate any necessary treatment, increasing the risk of deterioration and potentially affecting patient outcomes.

Staff told us a significant factor impacting good flow was decision to admit (DTA) when patients were ready to clinically proceed but had not been reviewed by medical doctors. This could have impacted patients’ length of stay.

Patients requiring specialist input did not always receive timely review or onward transfer. Despite some specialties providing on-call support, workload pressures across the hospital led to delays in specialty assessment. Senior specialty doctors retained responsibility for admission decisions, which delayed the admission process and timely access to definitive care for unwell patients. Once admission decisions had been made, the service did not consistently move patients to the most appropriate care area, resulting in avoidable delays in treatment and care progression. Staff told us bed availability throughout the hospital contributed to this delay. 

The service had access to the Same Day Emergency Care (SDEC) unit, which assesses and treats patients requiring investigations, diagnostics, or treatment on the same day, avoiding the need for an overnight hospital admission. However, SDEC operated only between 8:00am and 8pm. These limited operating hours reduced the emergency department's ability to effectively offload patients during its busiest periods, which were typically in the evenings and overnight.

The trust had consolidated cardiology services at Eastbourne District General Hospital. We found that pathways for accessing specialist cardiology care were not always effective and did not consistently ensure patients received timely assessment and treatment. The service no longer had access to 24-hour cardiology nursing or medical cover. Specialist cardiac nurse practitioner support was available between 7am and 7pm, and cardiology medical cover operated on weekdays between 9am and 5pm. Outside of these hours, staff relied on remote specialist advice and transfer arrangements to another hospital within the trust. This created a risk of delays in specialist review, treatment decisions and access to definitive care for patients with acute cardiac conditions. 

We observed a patient experience a delay in receiving specialist review overnight. When the patient was subsequently assessed by a cardiology doctor the following morning, concerns were raised that the patient should have been transferred to the specialist cardiology service at an earlier stage. This indicated that escalation and transfer processes were not always effective in ensuring patients accessed the right specialist care in a timely manner. The delay meant the patient remained in a non-specialist setting longer than clinically necessary and demonstrated the potential for patients to experience delays in receiving definitive treatment and care.

During the inspection, staff escalated concerns directly to the inspection team about the safety and effectiveness of the cardiology pathway. Staff told us delays in accessing specialist review and transferring patients to appropriate cardiology services increased risks to patient safety and affected the timely delivery of care.

Trust data showed that, between October and December 2025 following the consolidation of cardiology services, 87 patients who presented to the Conquest Hospital required transfer to Eastbourne District General Hospital for specialist cardiology care. It was unclear from the data whether these patients had attended as walk-in patients or had arrived by ambulance. Of these patients, 31% waited more than 24 hours for transfer.

Although the data suggested the service continued to achieve key performance indicators following the consolidation, this was not consistent with the concerns raised by staff or with examples reviewed during the inspection. Staff highlighted incidents where patients experienced delays in accessing specialist cardiology review and transfer to definitive care. This indicated that performance metrics alone did not fully reflect the challenges staff experienced in operating the pathway or the risks posed to individual patients. 

Although the trust had developed an action plan following the cardiology service transformation, the impact of these actions had not yet been fully demonstrated. Some actions remained in progress and did not reach their implementation deadlines at the time of our assessment.

The service had established a 4-bedded step-down unit adjacent to the intensive therapy unit to support unstable cardiac patients and those awaiting transfer. Staff told us the unit was frequently closed because of staffing pressures. The unit was closed on the second day of our assessment. Leaders told us it operated on an ad hoc basis. This could have limited the service’s ability to safely manage patients requiring enhanced cardiac monitoring while awaiting specialist care.

The service did not have a process to oversee or monitor patients waiting in the waiting room. We identified periods where no nurse or clinician-maintained oversight of patients despite long waits following initial triage. This meant the service could not be assured that deteriorating patients would be identified and escalated promptly, placing patients at risk of harm. Patients told us they experienced delays in follow-up treatment after their initial assessment.

The service did not consistently achieve the 1-hour response standard for patients requiring assessment by the mental health liaison team. Patients experienced prolonged delays before specialist review, which meant mental health needs were not always assessed promptly. This increased the risk of deterioration and delayed treatment, care planning and discharge arrangements. Audit data provided by the trust for December 2025 showed that all 9 patients reviewed waited over an hour for assessment. The shortest wait was 3 hours and the longest 10 hours. This indicated that some patients experienced significant delays before receiving assessment. 

Crowding and the use of temporary escalation spaces compromised the delivery of safe care. Staff told us operational pressures meant patients were regularly cared for in areas not designed for clinical treatment, including temporary escalation and “super surge” areas. Staff reported that existing systems and processes did not always support safe patient flow, and they identified crowding as a significant risk to patient safety.

However, the service had effective initial streaming and triage arrangements. Staff streamed all patients on arrival and directed them to the most appropriate pathway, including the urgent treatment centre, same-day emergency care, surgical assessment services and specialist clinics. We observed triage being completed promptly and effectively, and most patients told us their initial assessment was timely. Ambulance offloads and triage ran smoothly; staff told us that this ran well and they did not have ambulances queuing up outside of the department. Observation on assessment reflected this. Data showed that the service performed well in comparison to other trusts regarding ambulance handovers. 

The service also had a clearly defined pathway for patients presenting with mental health needs. Triage nurses completed mental health risk assessments, which records showed were usually undertaken. staff had access to a 24-hour mental health liaison service supported by positive working relationships with local mental health providers.

Leaders promoted oversight of immediate safety risks through twice-daily nursing safety huddles led by the nurse in charge. Staff used these meetings to review staffing levels, patient flow, waiting times, safeguarding concerns, safety alerts and learning from patient safety incidents. However, these processes were not sufficient to lessen the ongoing risks created by overcrowding, delayed admissions and prolonged waits for specialist care and transfer.

We scored the service as 3. 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.

Patients were protected from abuse. Most staff had training on how to recognise and report abuse, and they knew how to apply it. 

Staff we spoke with were aware of how to raise a safeguarding referral and knew who the safeguarding lead in the department was. The service had a safeguarding team that staff could readily access. Staff were able to tell us when they had recently completed referrals.

Staff we spoke with demonstrated a good understanding of safeguarding responsibilities and were able to identify adults and children who may be at risk of abuse, neglect or significant harm. They described the processes for recognising safeguarding concerns and taking appropriate action to protect people from harm. The service worked well with partner agencies, including the police and local authority safeguarding teams, to ensure safeguarding concerns were appropriately managed and that people received the support and protection they needed.

Staff had access to safeguarding policies which were based on 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.

The service had policies to guide staff on the use of restraints and restrictions to ensure they were used appropriately. Staff understood and monitored the use of restraint and used less restrictive options were used where possible. The security team worked through preventative methods before using restraint and provided training for frontline staff.

Data showed that compliance for Safeguarding Think Family Level 3 training was close to trust target for nursing staff at 86%, while compliance for medical staff was lower than trust target at 78%. The trust target for mandatory training compliance was 90%. 

The paediatric emergency department had key card access to help protect children and young people. However, there was no restriction on leaving the paediatric department. Staff told us this was due to how busy the department can become. This limited oversight of children and young people in the department. This meant that a child or young person could potentially leave the department undetected as there were no restrictions in place to prevent them from doing so. 

Data showed that staff did not routinely complete domestic violence screening within the department. However, this was in line with best practice guidance. The Royal College of Emergency Medicine (2015) advises that there is insufficient evidence to support universal screening for domestic abuse. Instead, clinicians should remain alert to indicators of abuse and ask direct questions where there is clinical suspicion.

We scored the service as 2. 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.

Some patients attending the department experienced long waits and were therefore at risk of deteriorating. During the assessment, we saw patients in the emergency department waiting more than 20 hours for a ward bed. Patients experienced long waits in the department for follow-up assessment and treatment. 

We observed a band 6 nursing staff member in the waiting area during the assessment who was repeating patient observations. This staff member was also responsible for directing patients to the appropriate areas on arrival. Whilst this provided some oversight of patients in the waiting room at the time, there was no formal process in place to ensure this happened consistently. Staff told us this was not usual practice. As a result, there was a risk that patients in the waiting room may not always receive the same level of observation and support.

Staff did not consistently complete falls risk assessments for patients. In November 2025, a falls audit showed that 70% of patients had a documented falls risk assessment. This decreased to 50% in December 2025, indicating a decline in compliance with falls risk assessment processes. This meant the service could not be assured that staff consistently identified and managed patients at risk of falling.

Leaders recognised that the emergency department was a high-risk environment for patient falls and had identified concerns through audit activity and divisional reporting. Although action plans and recommendations had been developed in response to identified shortfalls, there was limited evidence of re-auditing to monitor progress or assess the effectiveness of these actions. As a result, leaders could not demonstrate that improvements had been embedded in practice or that risks relating to patient falls had been adequately mitigated.

Patients were seen in order of clinical priority. The department had effective processes and tools for assessing patients when they first presented. Staff used a national triage tool to triage patients. Patients were triaged to the appropriate services. Generally, most patients were quickly and accurately assessed to determine the urgency of their condition and staff prioritised care based on their need. Patients who attended as walk ins were streamed and triaged in the waiting areas. Patients who were bought in by ambulance were streamed by the rapid assessment nurse on entrance to the department. 

The trust used the National Early Warning Score (NEWS 2) to assess patients at risk of deterioration in the department and enable staff to take appropriate action. Staff in the paediatric department used the Paediatric Early Warning Score (PEWS) to assess paediatric patients. 

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.

The service did not undertake standalone NEWS2 audits. Instead, the service reviewed NEWS2 scoring as part of the observations section of the documentation audit, including whether observations were repeated within the required escalation timeframe. This audit showed consistently high compliance over the 3 months reviewed. With scores of 93% in December 2025, 98% in January 2026 and 100% in February 2026. 

The trust recognised that friends and family were often able to identify a patient’s deterioration before staff. As a result, the trust implemented a programme that enabled patients, relatives and carers to make a direct referral to the critical care outreach team if they were concerned about the deterioration of an adult or child inpatient. Posters and written information were available to inform patients and visitors about this programme.

However, staff awareness of the process was not consistent. Not all staff we spoke with were aware of how the programme operated or how referrals could be made.

The service used the Operational Pressures Escalation Levels (OPEL) framework to identify, monitor and respond to operational pressures within the emergency department and across the wider trust. Staff and leaders understood escalation processes and applied OPEL levels in line with the trust's escalation policy. The service had a documented policy that outlined actions, responsibilities and reporting arrangements at each escalation level.

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.

The service did not ensure patients received care in a safe and suitable environment. Leaders did not provide sufficient capacity within the emergency department to meet patient demand. As a result, staff routinely cared for patients in areas that were not designed for prolonged stays or the delivery of ongoing care, increasing risks to patient safety, privacy and dignity.

The department did not have sufficient cubicle capacity to meet demand. During periods of overcrowding, staff cared for patients in temporary escalation areas. Staff submitted incident reports whenever these areas were used, which demonstrated leaders recognised the risks associated with these arrangements.

Leaders used 'super surge' bedded areas within the majors and rapid assessment and treatment areas during periods of high demand. Although leaders had completed risk assessments for these areas, the environment did not consistently support safe care. The beds were located in walkthrough areas and directly in front of nursing stations. Patients accommodated in these areas did not have access to call bells and relied on staff noticing them if they needed assistance. This increased the risk of delays in obtaining help, reporting concerns or escalating deterioration.

During the inspection, we observed a patient struggling to attract staff attention. The patient told us they were unsure what they were waiting for, had reduced mobility and could not walk to the nurses' station to request support. This demonstrated the risks associated with caring for patients in areas without appropriate systems to summon assistance. We escalated this concern to senior staff at the time of the inspection.

Although leaders had completed risk assessments for the super surge areas, these did not clearly explain how they monitored the effectiveness of mitigating actions or identify the level of residual risk. This reduced assurance that leaders effectively managed known environmental risks and increased the risk that patients could experience delays in receiving assistance, observation or escalation of care.

The service did not consistently ensure emergency equipment was appropriately checked and maintained. We found a paediatric grab bag in the resuscitation area that had not been checked since September 2025. A grab bag contained essential emergency equipment and medicines required for the immediate stabilisation and resuscitation of patients. Failure to check this equipment increased the risk that items could be missing, out of date or not functioning when required, potentially delaying treatment during a medical emergency. We escalated this concern to senior staff during the inspection. Senior staff immediately removed the bag from use and replaced it with a checked alternative.

The service also displayed out-of-date resuscitation guidance on a resuscitaire and on the adult emergency resuscitation trolley. This increased the risk that staff could rely on outdated information during a critical emergency, which could result in delays or inappropriate clinical interventions. We escalated this concern during the inspection. Leaders provided assurance that they would remove the outdated guidance. Although current guidance was available elsewhere within the resuscitation area, its inconsistent placement posed a risk to staff following the wrong algorithms for resuscitation.

The service did not provide an environment that met the needs of patients experiencing mental ill health. The mental health assessment room did not meet standards set out by the Psychiatric Liaison Accreditation Network (PLAN). Staff told us they frequently cared for patients experiencing mental ill health in bays within majors or the rapid assessment area. These areas did not provide a therapeutic environment and did not support the privacy, dignity or emotional wellbeing of patients.

The newly developed paediatric emergency department did not include designated mental health spaces. This meant children and young people experiencing a mental health crisis did not have an appropriate environment in which to wait for assessment. The environment did not consistently support their safety, privacy, or emotional wellbeing.

The clinical decision unit (CDU) did not provide a suitable environment for patients. The unit consisted of 4 chairs divided into 2 bays by a single partition, with no curtains or screens to protect patients' privacy and dignity. During the inspection, we observed a medical patient who had spent the night seated in a chair within the CDU. The environment did not meet patients' needs, as it lacked appropriate resting facilities and privacy. This impacted patients' comfort, dignity and ability to rest during their care.

Leaders told us these arrangements were temporary. Leaders could not provide a clear timescale for improvements. Following the inspection, the service shared a business case for remedial works, although no decisions had been made regarding whether or when the work would be completed. This meant leaders could not demonstrate when the risks associated with the environment would be resolved.

Although the paediatric emergency department had improved since the previous inspection, it did not fully meet the needs of children and young people. The department had secure access, toys and child-friendly decoration, which created a more suitable environment for children and families. However, the department did not have dedicated play specialist, which was not in line with Royal College of Paediatrics and Child Health standards. Although, there was a play specialist available elsewhere in the service. The department also did not have a baby-changing facility. Staff told us a changing table had been ordered and, until then parents and carers used a cubicle or bay when required.

The service did not consistently protect privacy and dignity within the paediatric emergency department. Bays were separated only by curtains, which limited confidentiality for children, young people and their families.

The service failed to provide a dedicated therapeutic space for children and young people experiencing mental health needs. Consequently, paediatric patients awaiting mental health assessment or referral were cared for in environments that did not meet their emotional, psychological or safety needs. This increased the risk of distress and further deterioration while waiting for care and treatment and reduced assurance that the service could safely support children and young people experiencing a mental health crisis.

However, staff generally had access to the equipment they needed to deliver care. The service-maintained systems to identify when equipment required servicing, testing and electrical safety checks. Equipment we reviewed was within the required testing dates.

Despite significant operational pressures, staff worked hard to maintain the environment. The department was visibly clean, uncluttered and well maintained. Staff managed clinical waste appropriately and in line with national guidance.

We scored the service as 1. The evidence showed significant shortfalls. The service did not make sure there were enough qualified, skilled and experienced staff to deliver safe care. They did not always 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.

The department had significant workforce shortages. Data showed 14.3 whole-time equivalent (WTE) nursing vacancies within the emergency department, increasing to 29.9 WTE vacancies across departmental clinical services. Although medical staffing was more stable, 1.4 WTE medical vacancies remained. Leaders relied on bank and agency staff to support staffing levels. However, these arrangements did not fully mitigate ongoing workforce pressures or address substantive staffing shortfalls. 

In December 2025, the urgent care division had 38.9 WTE vacancies and used temporary staffing to support service delivery. This included 21.4 WTE agency staff, 81.2 WTE bank staff and 18.0 WTE locum staff. Emergency care had the highest staffing gaps and relied most heavily on temporary workers, particularly bank nursing staff and locum doctors. The high dependence on temporary staff could also have placed additional pressure on substantive staff to provide supervision and support. 

Staff consistently told us there were not enough staff to meet demand safely. They described sustained operational pressure, high patient numbers and the impact this had on delivering timely care. These concerns aligned with our findings regarding patient flow, overcrowding and delays throughout the department.

The service did not have enough suitably qualified, skilled and experienced staff to keep patients safe and meet their needs consistently. Leaders had not ensured staffing arrangements complied with national standards for children's emergency care, and ongoing workforce shortages increased risks to patient safety.

The service did not provide the required number of paediatric registered nurses on every shift in line with national standards. Leaders told us they were recruiting an additional 2 paediatric nurses; however, this would not be sufficient to meet the minimum staffing requirements or address existing gaps. Leaders mitigated shortages by using adult nurses who had completed paediatric competencies. This did not align with Royal College of Paediatrics and Child Health (RCPCH) standards, which state that every paediatric emergency department should have a minimum of 2 paediatric registered nurses on every shift.

Staffing data showed the service did not meet safe paediatric staffing levels, in line with national guidance. Between 22 December 2025 and 18 January 2026, the service routinely rostered only 1 paediatric registered nurse on day and night shifts. On 15 occasions during this period, no paediatric registered nurse was rostered to work either the day or night shift. This meant the service could not demonstrate compliance with national standards and whilst there were no incidents because of this, there was a risk to patients using the service. 

Staff told us the arrangements in place did not always support safe care. Adult nurses working in the paediatric emergency department told us they did not feel confident caring for children and young people. Although they had completed paediatric competencies, staff said this had not adequately prepared them for the role and they lacked confidence in delivering paediatric care. This increased the risk that children would not always receive care from appropriately skilled staff. We saw evidence that 80% of nursing staff had completed spotting the sick child and neonatal life support training. Nursing staff had 100% compliance with paediatric life support.

The service did not provide data on the overall completion rate of paediatric competencies among nursing staff. The service provided evidence of staff attendance at study days but did not demonstrate the content of the training delivered or overall compliance rates.

Staff did not consistently complete mandatory training relevant to their roles. Data from March 2026 showed compliance with antimicrobial stewardship training was 60% among nurses and blood transfusion training was 73%. Compliance with adult and paediatric resuscitation level 2 training was 73% for nurses and 79% for medical staff, all below the trust target of 90%. These gaps meant leaders could not be assured that staff had the skills and knowledge required to safely recognise and respond to patient deterioration.

The service failed to ensure relevant staff maintained enhanced life support competencies. Data showed Immediate Life Support (ILS) training for a resuscitation practitioner had expired in November 2024 and had not been renewed at the time of our assessment. This represented a significant oversight, as these staff support the management of deteriorating patients and emergency situations.

Leaders did not consistently ensure staff received regular appraisal and professional development support. Appraisal compliance for non-medically trained staff was 75%, with only 60% of administrative and clerical staff having received an appraisal within the previous year. This limited leaders' ability to assure themselves that staff competence, performance and development needs were being appropriately reviewed and managed.

However, managers provided new staff with appropriate induction when they joined the department. Staff told us they completed mandatory training appropriate to their roles and received ongoing training. Nursing staff, associates, healthcare assistants and clinical support workers completed role specific training, including competency assessments.

We scored the service as 3. The evidence showed a good standard. 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.

The service maintained effective infection prevention and control (IPC) systems and processes to protect patients, staff and visitors from the risk of infection. Staff followed the service's IPC policy and the NHS England National Infection Prevention and Control Manual. Staff completed mandatory IPC training, with compliance averaging 93% across staff groups, including nursing, medical, administrative and estates staff.

We observed staff maintaining good standards of hygiene and cleanliness throughout the department. Staff adhered to the uniform policy, were bare below the elbows and washed their hands in line with IPC guidance. Personal protective equipment and handwashing facilities were readily available. Clinical areas were visibly clean and well maintained, cleaning records were up to date, staff followed cleaning schedules and disposed of clinical waste safely.

The service monitored compliance through regular hand hygiene, cleaning and IPC audits. Audit data between January and March 2026 showed 100% compliance with hand hygiene audits, and a routine cleaning audit completed in February 2026 also demonstrated 100% compliance. Staff followed clear guidance on patient isolation and infection control precautions.

However, the emergency department experienced significant crowding during our assessment. Staff cared for some patients in close proximity due to high demand, limiting effective patient separation and cohorting. This increased infection prevention and control risks and made it more challenging to consistently maintain best practice.

Leaders had introduced the Standard Infection Control Precautions (SICP) Monitoring Tool in January 2026 to strengthen oversight and identify areas for improvement. The February 2026 audit identified lower compliance with hand hygiene opportunities at 37% and handwashing technique at 76%. Records showed feedback had been provided to medical staff and matrons following the audit findings. Although the service recognised these areas for improvement, audit documentation did not clearly demonstrate how actions were monitored to ensure sustained improvement.

Despite the challenges associated with crowding, we found staff generally followed infection prevention and control requirements, environments were clean and well maintained, and leaders had systems in place to monitor compliance and identify areas for improvement. 

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

The service did not consistently manage medicines safely or in a timely way. Improvements were needed in medicines storage, documentation and medicines reconciliation. The emergency department did not have designated pharmacy staff in line with Royal College of Emergency Medicine (RCEM) guidance. This is needed to provide risk based clinical pharmacy support, including medicines reconciliation (the process of identifying an accurate list of a person’s current medicines) and the identification of patients taking time-critical medicines. This would also support timely transfers of patient’s information to wards, GPs, and community pharmacies to support discharge arrangements. 

The emergency department did not have routine access to pharmacy support, and pharmacy staff were only available if requested by clinical staff.

In the emergency department waiting area, staff did not always record allergy history during triage and did not consistently check whether people had brought their own medicines or had taken doses prior to arrival. Patients cared for in emergency department majors told us they were self-administering medicines without staff being aware, which increased the risk of omitted or duplicate doses. We reviewed 1 patient who remained in the emergency department for nearly 24 hours, without their regular medicines being prescribed, despite having brought them into hospital. This included high risk medicines to prevent blood clots and manage high blood pressure. We raised this with the senior consultant at the time. There was also evidence of delayed intravenous antibiotic administration for 1 patient. Patients may not have consistently received medicines when they needed them.

We reviewed trust data on omitted doses (prescribed medicines that are not given) and time critical medicines. The data showed that not all time-critical medicines were administered in a suitable time frame, which placed patients at risk of poorer medicines outcomes.

We identified concerns with medicines storage and security. In the Majors area, we found patients’ own medicines in the fridge, including expired insulin and liquid antibiotics dated 2025, as well as stock insulin that was past its in-use date. In the paediatric emergency department treatment area, staff did not store liquids securely in locked cupboards, which created a risk of access by children. 

However, staff used an electronic prescribing and medicines administration system (EPMA) to support accurate prescribing and recording, view people’s records, and documented reasons for delayed doses. Staff told us they checked GP records, with consent, to confirm patients’ medicines histories and allergy status. They also had access to recognised prescribing guidelines and used in-date patient group direction (PGDs), which allows health care professionals to administer specific agreed medicines to patients without a prescription where required. Staff stored FP10 prescription pads securely, with access restricted to authorised staff. 

Temperature data showed no abnormal fridge temperatures over the past 3 months. Cupboard stock was in date, and blood glucose monitoring machines were checked daily, with results uploaded centrally. The service had governance processes and audits to support safe medicines management. The pharmacy department ran regular reports to provide oversight, which highlighted areas for improvements, including the completion of required controlled drugs (CD) stock checks by staff.

The service had clear arrangements for handling people’s own controlled drugs (CD), including appropriate entry into the CD register and secure storage prior to return on discharge. Incident reporting was well embedded, with most harm levels low or no harm. Since the introduction of EPMA, the emergency department antibiotic audit demonstrated significant improvements in documentation, including indications, allergy status and review dates, with compliance close to 100%. Where staff did not follow prescribing guidelines, we saw evidence that this had been identified and addressed through education and training.