Royal Shrewsbury Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

At our last inspection we rated this key question requires improvement. The service was in breach of legal regulation in relation to safe care and treatment. At this inspection the rating has stayed the same. The previous breaches of regulation in safe have not been met.

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. However, staff understood how to protect patients from abuse and the service worked well with other agencies to do so.

We have not awarded this service a score for Safe.

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

The service mostly had a positive culture of safety based on openness and honesty. They acted on most concerns about safety and investigated and reported on safety events. This enabled some lessons to be learnt to identify and embed good practice. However, staff felt patient safety incidents that arose from crowding and low staffing levels were not always listened to or acted upon.

All staff knew what incidents to report and how to report them. They reported incidents in line with trust policy. For example, staff in the PED told us they always incident reported when a child left the department before being seen, had a wait of over 2 hours in the department, there was an aggressive parent, when they were short staffed, or when there was a medicines error. Staff said they could request feedback on the incidents they reported, and themes of incidents were shared at the monthly staff meeting. Feedback from incidents were also shared in the matron’s monthly bulletin. The February bulletin contained information about a stage 3 pressure ulcer that developed while a patient was in the ED. The article was used to remind staff to ensure tissue viability was regularly assessed and documented to reduce the likelihood of future incidents.

There was evidence that changes had been made as a result of feedback. For example, the system to gain entry to the PED was changed after an unauthorised member of the public was found in the department.

Some staff told us their patient safety concerns, including occasions where there were insufficient staff to meet patients’ needs, were raised but not acted upon. Other staff described feeling that their concerns were minimised or actively ignored. In addition to completing incident reports, some staff had formally escalated concerns to senior leaders in writing.

Reception and administrative staff reported that learning from incidents was not consistently shared with them, even when they had been directly involved. For example, staff described incidents where patients became aggressive, including smashing reception windows and making threats. These staff told us they did not receive support following such incidents, were not involved in debriefs, and were not informed of any subsequent learning or actions taken. This indicates a disconnect in how incidents are managed across staff groups, with some staff excluded from learning, support, and improvement processes.

However, leaders told us serious incidents were recognised as opportunities to put things right, learn and improve. Nursing and medical staff described taking part in consultant-led “hot” debriefs immediately after incidents, focusing on what went well, where improvements could be made, and providing emotional support where needed. Where appropriate, a follow-up “cold” debrief was held days or weeks later to revisit the incident, reflect on learning, and check on staff wellbeing.

Overall, while there were elements of structured incident management and learning in place, these were not applied consistently across all staff groups. There was a process to record and learn from harm caused to patients from delays in treatment. Harm reviews were completed each week for the 5 patients with the longest 12-hour breaches and for all ambulance patients with an offload delay of over 8 hours. The harm reviews were shared with the quality team at the integrated care board (ICB).

The service did not consistently work well with people to establish and maintain safe systems of care. They did not always manage or monitor people’s safety.

At our last inspection there was no clinical oversight of patients in the ED waiting room. At this inspection there was inconsistent clinical oversight of patients in the ED waiting room. Hospital leaders told us a streaming nurse was based in the waiting area between 7.30am and 7.30pm, 7 days a week, “except during periods of exceptional workforce challenges”. However, this did not align with what we saw on inspection or what staff told us.

The plan for a streaming nurse to be based in the waiting room would have meant there was a clear line of sight from a clinician of the patients in the waiting room. However, nursing staff told us there were not always enough staff in the department to have a streaming nurse in the waiting area. They said there was a risk to patient safety when the waiting room was not staffed, because they sometimes had high acuity patients waiting there.

When the streaming nurse was in the waiting area they navigated patients to the area of the department most suited to their treatment needs. For example, they navigated patients to the ED, PED, UTC, MIU or ambulatory majors. The lack of navigation in the main reception meant fewer patients could be streamed to the correct part of the department best suited to their medical needs. The consequence of this was a higher volume of patients who required triage in the ED, even if their needs would have been better managed elsewhere in the department.

The position of the reception desk meant the reception team did not have visibility of most of the waiting area. Reception staff told us they preferred it when there was a nurse based in the waiting room. One member of the team explained that when very poorly patients arrived they often had difficulty notifying the triage nurse or other members of the nursing team to escalate their concerns. Triage nurses told us it was not uncommon for patients in the waiting room to knock on the triage room door to inform them that a patient in the waiting room had collapsed.

Although they did not have visual oversight, the emergency physician in charge (EPIC) and nurse in charge (NIC) had access to clinical oversight of all the patients in the department through an electronic oversight dashboard. The dashboard displayed the National Early Warning Score 2 (NEWS2) and Paediatric Early Warning Score (PEWS) scores of patients so the EPIC and NIC could see if patients showed signs of deterioration and required clinical intervention. The dashboard showed the clinical priority of patients inbound on ambulances as well as for patients on the ambulances that were waiting outside the hospital. Patients with the highest clinical priority were brought into the department first, otherwise patients were brought in by time order.

Patients arriving by ambulance were taken into the ARA for triage and assessment. When we asked staff what guidance covered how, when, and where patients on ambulances were triaged and assessed, they said there was no guidance, and it depended on which staff were working that day. When we asked ambulance staff about their views on how patients were prioritised, for example patients experiencing chest pain or presenting with symptoms of sepsis, they told us it very much depended on what staff were working. Some staff from the local ambulance trust said some doctors assessed patients on ambulances soon after their arrival. Other ambulance staff told us they had been outside on an ambulance for up to 4 hours with a patient before a doctor came onto the ambulance to assess them.

Some patients had long waits in the department while they were waiting to be transferred to a ward or discharged back into the community. Managers told us it was not unusual to have acute patients waiting in the department between 40 and 70 hours. Patients who required a bed in a mental health facility could be waiting for 110 hours.

A senior member of the ED staff group told us that due to the number of patients in the department that were waiting for a bed on a ward (admitted patients) the ED was unable to operate as a fully functional emergency department. For example, at 8pm on 3 March there were 93 patients in the ED, 52 of whom were admitted patients. This broke down to 3 of the 4 patients in the resuscitation area, all 20 patients in majors, 8 of the 12 patients in ARA, and 11 of the 19 patients in fit to sit. Twenty-five of the admitted patients had been in the department for over 12 hours. The member of staff told us there would be enough staff and appropriate space in the ED for the 41 non-admitted patients to have received their care and treatment.

Fit to sit and ARA were intended to be used for lower-acuity patients. Because majors and resuscitation were full of admitted patients, staff said high acuity patients appropriate to be seen in majors had to be treated in ARA or the fit to sit area instead. Staff said they thought many of these patients were too unwell to be treated there. For example, we were told there had recently been a patient with a fractured neck of femur in fit to sit. Information provided by the trust showed a similar case from December 2025 when a patient with pathological fractures was sat in a chair for over 24 hours in ED. In addition to these examples we are also aware of an episode of patient care that took place in March 2025, when a patient with a NEWS2 score as high as 10 (1,9,6,4,8,and 10) and a pain score as high as 9 out of 10 (9,7,3,8, and unable to give a score) was looked after in ARA for 7 hours before being moved to the resuscitation room. Patients with a NEWS2 of 5 or above indicates a high risk of deterioration, and they should receive treatment in an area of the ED appropriate for high acuity patients like majors or the resuscitation area. According to The National Institute for Health and Care Excellence (NICE), patients whose NEWS2 score is 7 or above require emergency intervention by a critical care team.

We identified concerns regarding the safety and oversight of the Fit to Sit area. Although the standard operating procedure set a maximum occupancy of 18 patients, we observed 22 patients in the area and staff reported that this limit was frequently exceeded. Staff described the area as a “dumping ground” for patients when other, more appropriate, parts of the department were full. Staff told us they felt unsupported when allocated to work there. Nursing staff consistently reported that many patients cared for in Fit to Sit required bed-based care rather than management in chairs.

Staff raised further concerns about a revised layout introduced on the second day of inspection. They told us patients were positioned further away from the nurses’ station, reducing direct visibility and increasing perceived risks to patient safety. Staff also reported that, when the area was full, patients were directed to wait in the emergency department waiting room.

Staff told us when very poorly patients arrived in the department for triage, or when patients in the waiting area deteriorated, patients were taken straight into the department for urgent treatment. However, they said this was only into fit to sit or resuscitation, as the rest of the department was full of admitted patients. This was also our observation during the inspection.

Despite the large number of patients waiting for a bed on a ward, predominantly a medical bed, there was no designated medical team based in the department to monitor these patients. The number of admitted patients also impacted on the ability to bring patients arriving by ambulance into the department.

The ED consultants oversaw treatment in the PED. They were supported by advanced clinical practitioners (ACPs) as well as on and off-site paediatricians. Staff told us they typically had a quick response when they paged pediatricians.

Patients in the PED and ED were triaged using a standardised tool that staff had been trained to use. NHS England guidance is that patients should receive a triage within 15 minutes of arrival for urgent or emergency care.

Staff in the PED followed a clear escalation process to follow when demand on their department was high and waits for triage went above 15 minutes. This included increasing the number of nurses triaging patients from 1 to 2, escalating to the NIC, and at times of extreme pressure introducing a member of the medical team to support triage.

However, staff in the ED told us if triage waits went over 30 minutes, they would introduce a second triage nurse, but only when there was enough staff in the department to enable this. When we asked about a formal escalation process, not all staff were aware if there was one. The NIC told us there were “escalation cards” for them to follow when triage waits went over 30 minutes. This included using nurses in a coordination role to be relocated to triage. However, the NIC said staffing issues meant they did not always have enough staff in the department to redeploy a nurse to triage.

Staff told us patients attending with chest pain did not consistently have an electrocardiogram (ECG) performed within 10 minutes. According to the Royal College of Emergency Medicine (RCEM), an ECG is an important test in suspected heart attacks and should be done within 10 minutes of arriving at hospital. There was a room that was used for performing ECGs, but staff said there was not always enough staff to perform these tests. They told us patients were typically sent to fit to sit for an ECG. Staff also told us that patients requiring blood tests were sent to fit to sit for these tests.

Staff in PED described an increase in the number of children and young people attending the department in a mental health crisis. The trust had processes for supporting children and young people with mental health needs. Staff made a referral to the external Child and Adolescent Mental Health Service (CAMHs). The CAMHs service operated 24 hours a day, but response times varied outside of working hours which could cause delays to treatment. There was not a designated ligature free mental health room in PED. To reduce potential ligature risks they could use the ‘quiet room’ where they could remove some of the ligature points. If the risk assessment showed a ligature free room was required, the mental health room in the adults ED could be used. Staff told us some children and young people in mental health crisis waited in the PED for more than 24 hours if they required a bed on an adult ward (children over the age of 16) or an external placement. The play therapists supported these patients with activities that could help reduce their anxiety.

When patients were transferred to a ward or to another hospital their electronic medical and nursing notes were printed out and sent with the patient. Internal transfer of patients was completed by members of the portering team supported by a health care assistant (HCA) or nurse.

When patients were discharged back into the community, they were sent an electronic discharge letter which was also sent to their GP. If patients did not want an electronic copy staff would print them a copy.

All of the Band 6 nurses working in PED were trained in plain film imaging (x-ray) which enabled good continuity of care and reduced waiting times for x-rays.

On our second day on site the electronic patient record (EPR) system temporarily went down. We saw communication being given to staff, and a smooth transfer of all record keeping to paper. When the EPR was restored staff quickly reverted back to using electronic systems.

The medical same day emergency care (SDEC) team had a push/pull process. This enabled them to move patients from the SDEC into the ED if required. It also meant they could pull patients out of the ED if they thought their treatment needs could be met in the SDEC and they could then be discharged without an overnight stay. The streaming nurse could also stream lower acuity patients to the medical SDEC.

Staff told us they did not have access to the patients’ electronic patient records (EPR) if they lived in Wales. Staff said the lack of access to Welsh EPRs impacted on their ability to discharge patients once they were medically fit.

Staff could put alerts on the patient’s EPR. The alerts were colour coded to make it easier for staff to see if patients had additional needs. For example, dementia, sight impairment or allergies.

The trust’s other acute hospital led on thrombolysing stroke patients. Thrombolysis (or thrombolytic therapy) is an emergency medical treatment that uses medication to dissolve dangerous blood clots and restore healthy blood flow to vital organs.There was a process to ensure patients that presented with a stroke were transferred to the trust’s other acute hospital by land or air ambulance for thrombolysis.

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

Staff received safeguarding adults and safeguarding children training. Compliance with safeguarding training was high (91.2% and 94.3% respectively). Nursing staff received level 3 safeguarding children and level 3 safeguarding adults training. They also received additional safeguarding training to support them identifying people at risk of abuse. For example, training in child and parent abuse and sexual exploitation training facilitated by survivors of sexual exploitation.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. Staff knew how to make a safeguarding referral and did that when appropriate. They worked in partnership with other agencies to keep people safe. For example, staff in the PED completed child exploitation checklists and made referrals to the appropriate local children’s teams when exploitation was suspected. Staff had access to the national safeguarding database so they could see if children and young people were subject to safeguarding. They knew what process to follow when children and young people were subject to safeguarding arrangements.

Staff had access to information on how to assess people who were at high risk of domestic violence, and how to make a referral to the Multi-Agency Risk Assessment Conference (MARAC). The MARAC is a regular local meeting where professionals share information to protect victims of domestic abuse who are at high risk of serious harm or homicide.

Staff knew who the safeguarding leads for adults and children were and how to contact them. The hospital safeguarding team reviewed safeguarding referrals and provided ongoing support to staff. The safeguarding team visited the department each morning and could be contacted by phone at other times.

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.

Handover from ambulance crews did not commonly include a face-to-face patient assessment during the handover. Instances where a face-to-face patient assessment does not take place do not constitute a meaningful triage episode. NHS England guidance states patients should be assessed promptly by locally agreed processes within 15 minutes of arrival.

At our last inspection we raised a concern that some patients had not been issued with a hospital identification (ID) wristband. At this inspection we saw a patient that had been in the department for 16 and a half hours without a wrist band. When we raised this as an issue staff responded straight away and issued a wrist band. Staff checked the other patients to ensure they all had wristbands and found another patient had not been issued a wrist band on their admission. ID wrists bands are to ensure the correct patient has the correct medicines, the right treatments and diagnostic tests. The trust must ensure all patients are issued with an ID wrist band on arrival in the department.

Staff were tasked with performing hourly comfort rounding for patients. Comfort rounding is an intentional process of regularly checking in with patients to identify and meet their needs. Rounding includes assessing patients’ pain, repositioning patients to ensure they are comfortable and to prevent pressure ulcers, and to support patients to use the toilet or bedpan if needed. The EPR system showed that not all patients received regular rounding.

While we were on site patient clinical observations were recorded regularly. Each member of nursing staff had an electronic handheld device that alerted them when a patient’s observations were next due. However, we also saw evidence that showed observations were not always completed on time. We saw staff completed the necessary paperwork when a patient was deteriorating and bleeped the NIC and EPIC to advise them of the patients change in clinical presentation. We saw doctors responding to this information in a timely way.

Staff used recognised tools to improve the detection and response to clinical deterioration in patients as a key element of patient safety and improving patient outcomes. Staff used NEWS2 and PEWS to monitor patients’ risk of deterioration. All the NEWS2 and PEWS we looked at had been completed in line with trust policy.

Staff used tools to assess patients’ risk of developing pressure ulcers. At risk patients were reassessed in line with policy while we were onsite.

The frailty team visited the department each morning to assess and work with patients who may benefit from their support.

An additional triage tool was completed to assess patients presenting in a mental health crisis. The tool included an assessment of their risk to themselves and others.

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.

Corridor care is the term used to describe any non-designated clinical spaces for patient care. Although fit to sit was a designated clinical space for patients to receive care, because there was no piped oxygen or suction, or any way to uphold privacy and dignity it met the criteria to be classed as corridor care. ARA also met the criteria to be described as corridor care because staff were not consistently able to uphold patients’ dignity and privacy. There was limited space to get emergency equipment and staff around a patient to safely deliver care in ARA and the fit to sit area. Staff would have not been able to provide emergency care to patients in these areas, whilst ensuring privacy and dignity for them and those near them was maintained.

The routine use of corridor care risked patients’ safety, privacy and dignity and staff’s ability to provide safe care. In this service the impact was the safety, basic care, rights and respect of patients were not consistently upheld. Emergency equipment (oxygen and suction) was not readily available and functional and easily deliverable to patients cared for in these spaces. Patients could not be easily moved between areas in an emergency. It was not possible for staff to maintain privacy and dignity for patients in these spaces.

The location change of ambulatory majors (which included fit to sit) on the second day of our inspection was part of a transformation process that aimed to improve patient safety. The move meant there was an increase in the number of cubicles for patients to receive care in, and there were fewer fit to sit chairs. However, this change also meant the fit to sit patients were at the opposite end of the room to the nurses station. This reduced visible oversight of patients in this part of ambulatory majors. Leaders told us reduced lines of sight were mitigated through the allocation of a designated nurse for this area. This was a particularly busy part of the ED with high acuity patients, and we did not see a nurse with capacity to have continuous visible oversight of patients.

The ambulance receiving area had been designed as a space for patients to receive a rapid triage and then be assessed by a senior doctor. This was so investigations and treatment could begin promptly and the plan to discharge or admit could be expedited. During our visit we saw instead that ARA had become an extension of majors, where patients remained for over a day while waiting for a bed on a ward.

The service did not always have the equipment they needed to keep patients safe. All patients in ARA were on trolleys because there was not enough room for hospital beds to be used. Patients who spend longer on trolleys are more at risk of developing skin damage or pressure injuries. Frail elderly patients were sometimes kept on stretchers for long periods of time. One patient we spoke to in ARA had been on a trolley for 4 hours on the back of an ambulance and was still on a trolley in ARA 15 hours later. Another patient had been on a trolley for 22 hours. These, and other patients and their relatives told us they thought the time spent on a trolley was too long.

Some patients mentioned being looked after in a corridor, and some staff told us when a patient needed to be admitted to the resuscitation area they had to, “shuffle patients around”. This meant moving them into the corridor while they made space for a new patient, before they could move the other patients back in.

We spoke with a patient and their relative who had arrived at hospital by ambulance. They told us after triage, staff had asked them to sit in fit to sit, but 15 minutes later they were asked to sit in the waiting room. The patient had a potentially life-threatening condition. The patient felt they were placed in an inappropriate environment to manage their condition.

There was an alarm for administration staff to use if a patient collapsed in the ED waiting area. However, staff told us this alarm could not be heard in the triage room where the nearest clinical staff were located. However, the alarm could be heard in all other areas of the department.

Two of the 8 cubicles/bays in the resuscitation room were equipped for children and young people and pregnant women.

There was a room called the swan room for patients requiring end of life care. The room was large and airy and tastefully decorated. It was located at the quietest end of majors, where there were the fewest other cubicles.

The PED did not have a nurse’s station. There was a desk in the triage area. Staff told us doctors, ACPs, and other members of staff seeing patients in the PED expected to use that area to discuss patients or make any phone calls required. Staff in the ED told us when speciality doctors visited their patients, they expected to use the departments computers and phones. They said this sometimes put a lot of pressure on the available resources.

Only 1 of the 2 toilets in the waiting room was in working order.

Facilities for safely supporting patients who had mental health symptoms as their presenting condition were mostly safe. The department had one room for assessing mental health patients. The room met Psychiatric Liaison Accreditation Network (PLAN) standards. Staff completed a ligature risk assessment of the room. Ligature cutters were kept in the resus trolley. We saw the new mental health room and mental health bathroom that were due to be commissioned for use shortly after we left site. The new mental health room met also PLAN standards. The bathroom was ligature managed rather than ligature free, so patients would need to be risk assessed before being able to access it unaccompanied.

The UTC and minors was a small unit that included a plaster room, a treatment room and 4 cubicles.

Access into the PED by members of the public was though a locked door. Access could be requested by a doorbell. This prevented unauthorised visitors from gaining access to this department.

The route to transfer children and young people from the PED to the resuscitation room was through the majors area of the ED. The planned redesign of the estate included introducing a double door from the PED into the resuscitation room for direct access.

The PED had its own plaster room so children and young people did not have to wait with adult patients when they required plastering.

There was a plan to extend the ED and PED. It was anticipated these extension works would be completed in 2028. The plans included adding a cubicle for bariatric patients in majors.

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

Doctors and nursing staff consistently told us they did not think there were enough nursing staff, especially health care assistants (HCAs), in the department to meet the needs of patients. For example, we were told there were regularly only 2 HCAs in majors to help meet the personal care needs of 22 or more patients. Staff told us that while we were on site, nurses from elsewhere in the hospital had been sent to work in the ED to make it appear staffing was less of a problem than usual.

The nursing team was experiencing significant challenges in relation to staffing levels, which had impacted the availability of support, opportunities for professional development, and management capacity. There were 4 full-time clinical practice educators to support the nursing staff to improve their professional practice. However, the clinical practice educators told us due to low staffing numbers they were working clinically and no longer performing their practice educator role. There were also 3 professional nurse advocates who were no longer performing their role as they were required to work clinically for all their paid hours. Professional nurse advocates are trained to deliver restorative clinical supervision to colleagues to improve staff well-being, retention, and patient care. Band 7 nurses told us they were each responsible for line management of around 20 members of the nursing team. This included completing annual appraisals and doing essential paperwork. They told us their management time is typically “pulled” because of staff shortages and the need for them to work clinically, which had led to staff appraisals not being completed.

Managers had calculated the number and grade of nurses and healthcare assistants required. Eighteen nurses were rostered to work each shift in the ED. They were supported by 11 HCAs on the day shift and 9 HCAs at night. Staff said staffing levels did not change to reflect the busiest times in the department. Staff told us there were not always enough staff to cover breaks. However, staff said when they were short staffed the senior nurses did not have the required authorisation to request additional staff from the nursing bank, but they were able to submit a request for agency staff. This was not a quick solution as the request had to be sent to senior leaders for their approval. Staff told us these processes meant shifts were often left unfilled resulting in lower than planned nursing numbers and subsequently an increase in patient safety issues.

On our first day on site, the nightshift had 15 RNs (3 less than planned) and 4 HCAs (5 less than planned). Staff told us this meant they would not be able to provide the level of care they wanted to be able to give to patients, for example, performing skin viability checks on vulnerable patients. They also said they would not be able to take all their allocated break time.

Staff told us there should be 3 RNs and 2 HCAs to look after the patients in the fit to sit area. However, they said there were typically only 2 RNs and 1 HCA assigned to this area, so a ratio of 1 RN to 11 patients. In the afternoon of the second day of our inspection fit to sit was staffed by 1 RN, they were being supported by a nursing associate, a RN that had been drafted in from the intensive care unit and had never worked in ED before, and 2 HCAs. Those staff told us that patients had to keep bringing other patients who were in difficulty to their attention because they were busy with other patients so could not always see what was happening. The shift logs completed by the NIC regularly showed lower than expected numbers of nursing staff than planned for.

Staff told us when they escalated staffing problems to the NIC they received a poor response.

Staff in the PED had adjusted their working pattern to ensure that there were more staff in the department at their busiest time of 4pm to 12 midnight. However, there were not always enough staff in the PED for the number of patients in the department. For example, on Sunday 1 March 2026, 22 patients were in the department at the start of the night shift. This was a ratio of 1 nurse to 11 patients. There was a process for staff to follow when the department was busy but staff told us there was not normally staff that could be pulled from elsewhere at times of high demand. Staff told us they were supported by an on-call advanced clinical practitioner (ACP) at the weekend to help manage the increased number of sports injuries they typically saw during that time. However, staff told us, the ACP on call did not always have a background in urgent and emergency care.

Because the PED was small it did not have any administrative staff. This meant nursing staff had to answer the phone. Staff told us calls that came into the PED were typically to enquire about waiting times so parents could decide which hospital to take their children to. They told us these types of calls were most frequent at the weekend and school holidays and could take up a lot of time during these periods.

Nurses told us they had received a full induction into the service when they started and were supernumerary for a minimum of 4 weeks. One nurse said they did not feel confident in their role after 4 weeks so was given an additional 2 weeks where they were not counted in the staffing numbers. This gave the nurse more time to fully understand the role, complete more core competencies, and increase confidence. Nurses had 12 months to complete their basic competencies when they took on a new role within the department. HCAs told us they attended an academy for 2 weeks prior to starting in their role.

Staff in the ED told us agency staff were typically familiar with the department and had an emergency medicine background. Agency staff received an induction into the department before starting work. Agency staff were not used in the PED. They sometimes used bank nursing staff who were familiar with the department and in providing emergency care to children and young people.

Nursing staff told us they were sometimes pulled from training because there were not enough staff to look after patients. They also said there was not always enough time to complete their mandatory training as part of their working week. They said they could be paid to complete training at home, but this was not always convenient due to their caring responsibilities or other commitments.

Both nurses working in resuscitation on the first day of our inspection told us they had not completed intermediate life support training, advanced life support training, or paediatric life support training. One of the paediatric nurses was a trained paediatric immediate life support (PILS) instructor and had run in-house PILS training to support compliance with this module. Staff did not consistently complete training in resuscitation. Only 56.4% of staff had completed adult basic life support training, and only 59.1% of staff had completed paediatric basic life support.

Only 69.9% of staff had completed training in moving and handling level 2 (patient handling) to ensure they could safely move patients.

Consultant doctors worked across both sites. The number of consultants and resident doctors matched the staffing template. Although the overall number of doctors for the number of patients was insufficient given the complexity from crowding. This was illustrated by the long waits patients had before they were assessed by a doctor.

Resident doctors told us they were well supported by senior doctors, and they were released for teaching and self-development. They received an induction and a period of shadowing, followed by a phased move on to the full rota. New resident doctors were provided with a competency booklet to support their progression to middle grade. Medical staff had simulation training to give them an opportunity to test and develop their clinical skills through a series of life-like simulated patient experiences in a risk-free environment.

Security staff were frequently asked to support with the supervision of patients who had presented in mental health crisis. They received training to carry out this element of their role.

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 department was visibly clean. Cleaning records were up to date and demonstrated that the ED and PED were cleaned regularly.

To create a protective environment against healthcare-acquired infections there was a dedicated cubicle in majors for patients who were immunosuppressed. In the new ambulatory majors there was a designated cubicle for patients with an infectious disease.

Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date. For example, commodes were clean and had “I am clean stickers” to show they were ready to be used.

There were signs to show staff the correct handwashing procedure in the resuscitation area. There were no handwashing signs anywhere else in the department. However, staff adhered to infection control principles, including for handwashing. We saw staff washing their hands in between patients and using antimicrobial hand gel. The most recent handwashing audit showed 96% compliance for staff following the correct handwashing procedure.

Most but not all staff received training in infection prevention and control. Only 83.4% of medical staff completed infection prevention and control level 2 training. However, 100% of nursing staff had completed infection prevention and control level 1 training.

The weekly infection protection and control (IPC) audit result for the ED on 26 February 2026 showed the ED was only 77.6% compliant. Thirty-four out of 45 key areas had achieved compliance, the reasons for the failures included clutter in the corridors, equipment not labelled as clean, and urinary catheters situated on the floor instead of on a stand.

IPC risk were included on the departments risk register. For example, ARA was flagged as an IPC risk because it did not have any side room to segregate patients who were infectious which put immunocompromised patients at risk. Mitigation of this risk included the change of location for ARA to an area that included side rooms.

Staff followed safe waste and clinical specimen management practices. There was appropriate segregation, storage, labelling, handling and disposal of waste, including sharps waste.

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.

Staff did not always follow systems and processes when prescribing, administering and recording medicines. We reviewed eight medicines charts and found that although allergies were recorded, one patient had been prescribed a medicine they were allergic to. This increased the risk of the patient coming to harm. We escalated this immediately and this was rectified by a doctor.

We reviewed the records of, and spoke to, a patient who was self-administering their medicines using their own blister pack. The dose of a blood pressure medicine had been changed during their admission; however, they continued to take the previous dose because staff had not checked their medicines appropriately. This meant they were not receiving their medicine as prescribed, and they were at risk of being treated ineffectively. We escalated this at the time of inspection.

Patients prescribed preventative treatment for blood clots did not always have their weight documented. This is necessary due to the dose being weight dependent for the correct treatment and to ensure safe administration.

The emergency department had obtained pharmacy support since December 2025. Pharmacy provided a service from Monday to Friday. An on-call pharmacist was available outside these hours for urgent medicines advice.

The pharmacy team had access to the departments EPR which had flags to identify patients deemed at high risk, for example, those with a learning disability or on time critical medicines. This supported them to identify and prioritise patients for medicines reconciliation and clinical pharmacy support. The pharmacy team had developed a list of critical medicines, and staff had a good understanding and awareness of this. These medicines were prioritised when ordering from the pharmacy. However, for other medicines including those for high blood pressure, we were told that the pharmacy team used their discretion to decide whether they needed to be ordered or could be omitted. We were not assured that there were clear processes defining which medicines could safely be missed or when missed doses should be reviewed. However, the trust was in the early stages of work aligned with the Royal College of Emergency Medicine’s ‘Time Critical Medications’ publication, with planned pharmacy involvement.

We observed two patients receiving medication before a patient identification wristband had been applied. Administering medication without first confirming the patient's identity through an approved identification process is not in line with NHS patient safety requirements. Positive patient identification should be completed before any care, treatment, or medication is provided.

Systems were in place to identify and treat sepsis in a timely manner. A designated sepsis bleep was carried by a doctor to cover the department, and staff understood when to escalate deteriorating patients. Trust audits showed that in January 2026, 79% of patients had received antibiotics for sepsis within the recommended 1 hour, which fell just below the 80% target. Action plans were in place to improve recognition and respond to deteriorating patients in a timely way.

Medicines and prescription stationary were generally stored safely across the department. However, in one area we saw medicines cupboards were unlocked and some liquid medicines had no open date labels on. Resuscitation equipment and emergency medicines were checked daily and monthly using an electronic system.

Medicines incidents were reported and discussed in clinical governance meetings. These were investigated and themes identified by the medication safety officer. Information was then cascaded to staff through one-minute briefings.