New Royal Liverpool University

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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

At our last assessment we rated this key question inadequate. At this assessment the rating has changed to good. The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly and people were protected and kept safe. Staff understood and managed risks. The facilities had been adapted to try and met the needs of people, they were clean, well maintained and any risks were reduced or mitigated. There were enough staff with the right skills, qualifications, and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 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 and embed good practice.

We spoke with patients and their relatives during the assessment, and they told us they knew how to raise a complaint or concern. Patients said they would feel comfortable raising an issue with the staff caring for them and knew how to make a formal complaint, should they need to.

Staff had a good understanding of how to use incident reporting systems. Staff were aware of the key themes which had resulted from recent complaints and incidents and felt confident to raise issues and concerns when they arose. Senior members of staff and leaders were involved in reviewing complaints and incidents. Safety huddles provided staff with a forum in which incidents and complaints were discussed. Reviews of incidents had led to improvements according to staff and leaders.

All staff grades we spoke with reported they were encouraged to report incidents via Datix and the feedback that was given was always from a position of learning and not blame. Learning was communicated through emails, printed staff newsletters and on shift handover documents. An example of incident reporting was actions to be taken to prevent patient pressure areas breaking down, ensuring each patient was risk assessed, and appropriate pressure reduction aids used. Other examples of incident learning communicated by staff were in relation to medicine errors and how risks had been reduced or mitigated.

Staff shared a recent major critical incident and reported it had been well managed; they were able to mobilise and clear space for the major incident patients. Staff had clearly identified roles and responsibilities and wore tabards to identify themselves, so the team knew who was. They reported post incident debriefing sessions took place which were positively facilitated and learning identified. As a result, additional training was offered to staff. For example, the learning identified additional specialist clinical skills were required for some patients who attended the site during the incident who would normally be taken to another specialist hospital.

Staff told us how they had been supported to develop their knowledge and skills by taking on projects, leading them to build confidence. They told us that as a team leader they over saw 10 staff clinically, and the ward managers oversaw some human resource processes, which allowed the team leader to remain clinical. Staff enthusiastically reported they “loved working there” and staff told us they actively sought employment at the New Royal site in the accident and emergency department as a result of student placements. Newly qualified staff reported that the preceptorship programme was supportive and detailed.

Safety was a top priority that involved everyone, including staff and people using the service. The service had the relevant policies and procedures in place for incidents and complaints. Risks were not overlooked or ignored. Safety incidents and complaints were investigated as an opportunity to put things right, learn and improve. Managers kept staff updated about safety incidents and complaints, with learning shared through daily safety huddles. Lessons were learned, resulting in changes that improved care for others. Staff were open and transparent and gave patients and families a full explanation if and when things went wrong.

Staff understood the duty of candour. There was an up-to-date duty of candour policy in place. We reviewed data for duty of candour compliance for the emergency department between April and September 2024 and found 100% compliance.

The emergency department received 110 complaints in the 6 months prior to assessment. The top 3 single issue themes were communication, patient care and access to treatment or medication. We reviewed the trust performance of responding to complaints during the same 6-month period and found that 100% of single-issue complaints were closed within timescales. Complex complaints sometimes took longer to respond to, due to correspondence with other parties involved and extended times were agreed with complainants. People were kept up to date with response to complaints progress.

This trust had recently been awarded National Preceptorship Interim Quality Mark for its comprehensive preceptorship programme.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

Most patients reported a joined-up approach to providing care and treatment that involved them and their relatives. Patients told us the initial assessment of their symptoms had been timely, and treatment initiated where needed. Patients using the temporary escalation area told us they were fully informed, understood their treatment plan and who was reviewing their care and received a letter from the trust apologising and explaining the situation. Additional information was available for patients to explain why they were being treated in the temporary escalation area rather than in a bay or cubicle.

Patients experiencing poor mental health were treated by a team of specially staff who were employed by another trust. Some staff felt collaborative working between the mental health team and the emergency department could be improved but did not give any specific areas for improvement. The ambulance trust staff met regularly with the service in which safe systems of care were discussed and learning from feedback and incidents explored.

When the patient’s condition changed emergency support care and treatment was available at any time of day or night. Patients were initially assessed using the Manchester Triage System. At times of high demand, clinical staff were deployed in the reception area to undertake a rapid triage to ensure that all patients were initially assessed. There were multiple pathways available for patients to be seen and there was a clear focus on getting the patient to the right place, first time every time. Patients could be streamed internally to the Same Day Emergency Care (SDEC) service, frailty teams, renal, surgery, gastroenterology, cardiology and urology services directly. The numbers of patients being signposted to other less urgent treatment options away from the emergency department were, according to leaders, low but increasing.

Between January 2024 and November 2024 89,110 patients attended the emergency department. This was an average of 8,100 patients per month with approximately 2,300 of 28% of the total monthly patients attending by ambulance. The remaining 5,800 patients were self-attending or taken to the emergency department by police or the prison service.

There was a temporary escalation area (corridor care) standard operating procedure (SOP) in place which outlined actions that were to be taken to ensure that the newest and sickest patients attending the emergency department received timely assessment and initiation of treatment and received senior medical review within 60 minutes of arrival. Patients were nursed with a ratio of 1 nurse to 5 patients (1:5) within the temporary escalation area.

The service had 24-hour access to specialist mental health support. The mental health hub, staffed and provided by another trust, was located in the emergency department. An ongoing Royal College of Emergency Medicine (RCEM) Quality Improvement audit project was underway for the care of patients presenting with mental health illness, which had resulted in an improvement in the care provided. A local audit of one hundred patients undertaken in November 2024 by the Emergency Medicine Consultant Mental Health Lead, identified that 76% of eligible patients received a parallel assessment (joint) with medical and mental health teams. The outcome was the emergency department had referred all eligible patients. Mental health patients were monitored closely and their observations undertaken by trained mental health staff from the local mental health trust.

Electronic alerts were used to make staff aware of violent and aggressive patients. There were electronic flags on the system used for safeguarding and other issues of concern. Security staff had the power to initiate a search of patients who were at risk.

Staff completed risk assessments for each patient on arrival and reviewed these regularly. Staff used nationally recognised tools to identify deteriorating adult patients and escalated them appropriately. Paediatric assessments were available to staff, however there was a local children’s emergency department at another trust that most children attended. Staff followed sepsis guidelines to manage people with sepsis. E-NEWS (Electronic National Early Warning Score Compliance) was 86.6% at the time of assessment.

We found that care records were not always up to date nor completed fully. We reviewed 10 care records and found gaps where documentation was incomplete, and actions not documented as taken. Some care records were paper based and others electronic which caused confusion and duplication.

Data showed that drug and alcohol concerns considered and addressed were 47.3% which was a decrease on the previous year’s figures of 57.8%.

Radiographers supported the emergency department with CT and plain films. They were co-located within the department and had a less than 24-hour turnaround time for X-ray reporting. The emergency department also had access to ultrasound and MRI services between 8 am and 8pm.

There was oversight of the waiting area by health care staff called Guardians, and regular observations were conducted by health care and nursing assistants.

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.

Staff had training on how to recognise and report abuse, and they knew how to apply it. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

We heard how the safeguarding lead proactively led risk assessments for patients who may present a risk to staff and other patients. An example was given of a patient who was known to have inappropriately touched staff. Matrons were tasked to conduct a risk assessment and put measures in place to protect staff, such as 2 members of staff in attendance at all times. There was a designated lead on the sexual charter as well as aggression and violence. Staff reported that the trust was proactive in use of the red flag / 3 strikes, and they would bar patients who were aggressive and abusive.

Whilst in the emergency department we observed good safeguarding practice. We observed staff consulting with the safeguarding team regarding patients presenting with potential safeguarding concerns. Where English was not the patient’s first language arrangements were in place to access interpreters. We saw that staff identified potential risks and made appropriate electronic referrals to local authorities; advice was sought from safeguarding professionals within the trust and plans made to support the patients. This followed the requirements of the trust’s safeguarding policies.

Medical staff training figures for safeguarding adults and children level 1 – 3 were 84.21%. Nursing staff training figures for safeguarding adults were 99.29% and for children were 93.62%. The safeguarding training included Mental Capacity Act training. Mandatory training compliance for Equality, Diversity and Human Rights was 75.44% for medical staff and 92.2% for nursing staff. The trust required compliance rate was 90%.

Staff had a clear understanding of the Deprivation of Liberty Safeguards (DoLS) and application of best interest decision making processes.

Safeguarding systems, processes and practices meant that people’s human rights were upheld, and they were protected from discrimination. People were supported to understand their rights, including their human rights, rights under the Mental Capacity Act 2005 and their rights under the Equality Act 2010.

The Oliver McGowan Mandatory Training on Learning Disability and Autism Part 1 compliance figures for medical staff were below the 90% target at 61.4%. Nursing staff met the mandatory training target at 90.78%.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff assessed and managed risks to patients and themselves well and followed best practice in anticipating, de-escalating and managing challenging behaviour. Staff used restraint and seclusion only after attempts at de-escalation had failed. The ward staff participated in the provider’s restrictive interventions reduction programme.

Staff understood and managed risks so that care met patients’ needs in a way that was safe and supportive. All patients attending the department symptoms were initially assessed to determine where they would best be placed to receive treatment. There was a dedicated nurse who triaged all patients brought into the department by ambulance. Patients were triaged in a timely way and moved to an appropriate area of the department dependent on needs. Ambulance crews did not leave a patient until they were handed over to the emergency department team. Patients who required regular medication to be given at a specific time were flagged to staff as well as those requiring regular sets of observations.

All patients had an initial assessment within 15 minutes of arrival at the department (average 7 minutes over the last 12 months), and this was monitored and progress available to staff and managers throughout the day and night. If the initial assessment was not achieved, particularly, due to the number of patients presenting in the department, a rapid assessment process was deployed. This involved additional staff resourced from other areas within the department being drafted in to support initial assessments.

Screening tools and processes to identify deteriorating patients were used throughout the department. There was an escalation policy for patients with potential sepsis who required immediate review. Patients with suspected / confirmed sepsis received prompt assessment when escalated. The electronic patient record system automatically initiated the sepsis pathway if a patient’s observations scored high on the national early warning score 2 (NEWS2). Clinicians in the department had oversight on this system of all patients on the sepsis pathway and which also was flagged as an icon within each patient record and department oversight board.

There was a referral pathway with exclusion and inclusion criteria for patients to be referred to the Clinical Decisions Unit (CDU) and Same Day Emergency Care (SDEC). We reviewed the pathway for patients to be referred from SDEC into the acute medical unit. The criteria for those patients requiring higher level care and admission to the AMU (Acute Medical Unit) were clear for staff to follow. Consultants within SDEC also provided a telephone advice line for primary care and community staff for individual care and advice and also to agree direct admission to SDEC. There had been 12 direct admissions via an ambulance to SDEC in the previous 12 months.

Staff had identified that SDEC was not located in an ideal position to support the management of acutely unwell patients as an escalation area or for direct admissions. Plans were in place to review this in the future.

There was an effective structured handover process between staff changes which was regularly monitored and assessed for compliance. Audits were undertaken throughout the department to monitor compliance with policies and procedures.

Patients were assessed for risks resulting from falls, pressure area breakdown, absconding, and safeguarding.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Patients felt the waiting area was busy and lacked space to accommodate the amount of people attending the emergency department at times. In the temporary escalation area, patients acknowledged the environment they were located in was not designed to meet their needs. For example, due to the noise, the amount of people walking by and access to bathrooms.

Leaders were aware the estate was not designed to accommodate the amount of people currently attending the department and acknowledged that parts of the environment used as temporary escalation areas for patients had not been designed for clinical use. However, risk assessments of those areas and any actions identified were taken to make sure the environment was safe. We reviewed equipment logs which were regularly updated and maintained in relation to equipment and the environment. Staff informed us that equipment needed to provide care and treatment was readily available and any faulty equipment was replaced promptly.

The environment had been designed for use as an emergency department. However, due to the number of patients attending the department space was now limited. Work was in progress to enhance signage and facilities for those patients with sensory needs.

During the assessment the emergency department was being used at more than full capacity. Fifteen patients had been assigned to temporary escalation areas within a corridor in the emergency department. Patients had access to call bells and if oxygen was required it was administered via an oxygen cylinder. One nurse was allocated to 5 patients within the temporary escalation space and some facilities were available to support patients with their hygiene and toilet needs, however if they were in use alternatives were not easily accessed.

Patients who were allocated to temporary escalation areas were assessed to ensure it was appropriate that they received care and treatment there. Patients mostly were lying on trolleys that had pressure relieving mattresses and regular checks were undertaken of any risks identified. Patients had access to warm food and drinks and could request more if they required it.

Facilities, equipment, and technology were well maintained. Staff conducted daily safety checks of specialist equipment. We reviewed the contents of the resuscitation trolleys, which contained the appropriate equipment for adult and paediatric patients. Equipment used to deliver care and treatment was suitable for the intended purpose, stored securely and used properly. There were arrangements in place for the handling, storage, and disposal of clinical waste, including sharps.

The service monitored the safety of the premises and equipment. We saw fire risk assessments for each area of the emergency department, local evacuation plans, and evidence of equipment servicing testing. The department had an 8 bedded resus area that was fully equipped to manage ventilated patients. The emergency department had a blood gas machine in resus and majors. Facilities were well maintained, modern and cleaned. Maintenance of the department was good.

Audits were completed on a 2 hourly basis by the nurse in charge to ensure that safety within the department was being maintained.

The mental health hub assessment area was staffed by the neighbouring health trust and the facilities provided by New Royal Liverpool University Hospital. Rooms were compliant for people experiencing poor mental health and assessment and action taken to assess for ligature risks. Staff who worked in the hub carried alarms and all patient rooms opened outwards and were not lockable. There were no beds in the rooms for extended stay patients. The chairs were noted to recline, and pillows and blankets were available. Most of the patients in the hub were waiting for admission to the local trust when a bed became available. There were no toilets and bathroom facilities available to patients in the hub. They could access facilities in another area in the emergency department, often accompanied by staff.

There were no Control of Substances Hazardous to Health (COSHH) concerns at the time of the assessment and all suitable risk assessments were completed.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Patients told us they felt there was an appropriate level of staff although they experienced lengthy waiting times. People using the service and their relatives told us staff had all been visible and could be called upon when required.

Staff told us that overall, there were appropriate levels of nurse staffing. Staff felt they received the support from senior members of staff to deliver safe care. They felt they had the opportunity to develop in their roles and had opportunities to gain experience.

Staff told us that they had a new education support team in place, and this had improved access to learning. Staff were given time during working hours to complete mandatory training. Any training completed in their own time was given back in TOIL (time off in lieu). Access to online training courses for some staff was identified during their time on shift. Some training was reportedly not currently available for example, arterial blood gas (ABG) training as the session needed a facilitator and included practical session time. This did not impact on care.

During the inspection we saw from our review of the staffing rotas and our observations that there were staff shortfalls in some areas. This was mainly due to short notice staff absence. Leaders covered staffing gaps with agency workers, and called in additional staff where possible, particularly during periods of high demand.

We observed staff having positive interactions with patients, addressing them by their preferred name in a kind manner despite the capacity demands and patient flow. Staff were available throughout the day to respond to patients and worked effectively together across staff groups. We saw senior staff support junior staff and all staff worked in collaboration with each other.

Records for attendance at core training were kept and monitored through matrons and team leaders to drive improvement. The trust target for training compliance was 90%. Nursing and Midwifery Registered staff training compliance was 91.8%. Medical and Dental staff training compliance was slightly below the trust target at 86.23%. Overall mandatory training compliance for the site, as of November 2024, was 91.94%.

Royal Liverpool Hospital University Hospital emergency department used the SNCT (Safer Nursing Care Tool) acuity and dependency tool twice a year to provide evidence-based decision making on workforce requirements. There were 5 levels of care with associated descriptors to determine the level of care a patient needed, which allowed staff to measure how unwell a patient was and how reliant they were on nursing care to have their normal needs met.

Due to the pressures within the emergency department necessitating the use of the temporary escalation area for patients awaiting a bed, the department had been using additional bank and agency nurses to support the staffing ratios of 1:5 on the corridor. During 2024/25 additional recruitment for further registered nurses and healthcare assistants above establishment had been agreed to enable substantive staff to be recruited to support improved staffing levels over the peak winter period.

The service had enough nursing staff, advanced nurse practitioners and support staff with low vacancy rates for all groups apart from trainee medical grades. There were 8 advanced nurse practitioners in post. Emergency nurse practitioners supported patients presenting at the emergency department with minor injuries.

Medical absence at the time of assessment and for the previous 3 months was low at 0.42% with nursing absence for the same period at 6%. Medical staff leaving or turnover was high at 29.5%. However, this was due to doctor rotation which accounted for 18 staff. Nursing staff turnover was 10.7% which equated to 17 leavers. Reasons provided for nurses leaving included promotion and retirement. We reviewed vacancies within the emergency department and found that the consultant group were over established by 2.75 WTE (whole time equivalent), and registered nurses were over established by 4.19 WTE. Trainee medical grade vacancies were high with vacancies of 9.37 WTE.

The service had safe recruitment practices to make sure all staff were suitably experienced, competent, and able to carry out their role. Staff underwent induction and completed competency-based training. We reviewed the Safe Recruitment and Selection policy, Temporary Staffing policy, Safer Staffing policy and the Local Induction Safety Checklist; all were up to date and appropriate in content.

Leaders described a number of measures to support staff retention in the department. Nurses were able to self-roster which reportedly resulted in higher levels of flexibility and promoted work life balance. A department co-ordinator allocated staff across the department according to patient need. Additional staff had been recruited to support the assessment of patients within 15 minutes of attending the department. There was a triage nurse and an observation guardian in the waiting room at all times checking patients and performing observations such as blood pressure and temperature recordings., During the assessment we observed the waiting room was seen to be exceptionally busy. There were 8 advanced nurse practitioners in post and 24/7 emergency nurse practitioners on site for minor injuries. There were 22 whole-time equivalent emergency medicine consultants including 2 locum consultants. Consultant cover was provided from 6am to 2am with the shift times 6am to 5pm, 3pm to 11pm and 1pm to 2am. On-call consultant cover was available between 2am to 6am. of these hours. One of the daytime consultants was allocated to ‘floating’ (emergency physician in charge) and one was also allocated to following up on investigation reports. Consultants worked 1 in every 5 weekends and were able to self-roster with regular meetings to arrange cover amongst the consultant body. Whilst there were no shared job plans, some consultants undertook specialist work at other hospitals. There were lead consultants for simulation, trauma, education, governance, quality improvement, mortality, research, complaints, and mental health. Two consultants were dual accredited in paediatric medicine.

All consultants job plans consisted of allocated PA’s (work sessions) for direct clinical contact. There was always a consultant or at least ST4 (Speciality Training yr 4) registrar in the emergency department. Between 2am and 8 am, the most senior doctor on site was one registrar, however a second registrar was sometimes obtained by locum (approximately 70% of the time). There was either a consultant or registrar dedicated to responding to unwell patients anywhere in the department during the day, who were flagged by their NEWS score.

There were 10 middle-grade resident doctors, including those not in formal training with a case to increase this number being considered by the hospital management team. There were also FY2 (Foundation Year 2) doctors and other SHOs (Senior House Officers) including clinical fellows and GP trainees who worked in the department. Some resident doctors felt that middle-grade doctors adequately covered the nights. At weekends, reportedly around 50% of the SHO workforce comprised of locum doctors which was usually filled.

A practice development lead oversaw the learning needs of all nursing staff and actively promoted education in the department. This was supported by consultants with educational interests who provided weekly learning opportunities for staff, for example care of the trauma patient. Advanced care practitioners had an established training pathway with regular educational opportunities. New nursing staff undertook a 4-week supernumerary period which they described as being supportive and could be extended dependant on the needs of the individual. All new nursing staff to the department undertook a 12-month preceptorship period. This provided additional guidance and support as newly registered nurses in order to build their confidence and competence.

Staff appraisal compliance was between 87.5% and 100% across the 4 areas of the emergency department for nursing and medical staffing.

Mandatory consultant-led teaching was in place for 3 hours each Wednesday for middle-grade resident doctors which was facilitated by additional registrars and consultants working in the emergency department during that time. The teaching was open to doctors both in and out of a formal training programme and was highly attended. All middle-grade doctors had time allocated to educational and development needs in their rotas. Middle-grade doctors described high levels of senior support at all times. Some resident doctors reported they did not get as much experience of some specialist presentations as other emergency departments were available to patients such as children and people experiencing strokes. Two physician associates were employed in the department, and they described good clinical and educational supervision despite there not being a formal educational program in place for them at the time of the assessment.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Patients, including temporary escalation area patients told us they found the department to be clean and tidy. They told us domestic staff were busy and visible. The trust scored a 4-star rating for cleanliness via the trust internal audit programme at the time of inspection.

Staff were aware of the importance of cleanliness and hygiene and followed trust procedures when they identified concerns relating to infection, prevention, and control (IPC). Staff explained the complexities of managing IPC when there was overcrowding in the department. The department had many single occupancy cubicles and staff could easily isolate any patients who had infectious diseases. Staff said they had ample supplies of personal protective equipment available to them when they needed it.

The premises and equipment were kept visibly clean and hygienic. Cleaning records were up-to-date and demonstrated that all areas were cleaned regularly, and equipment was cleaned after each patient contact. We observed staff following infection prevention and control principles, including the use of personal protective equipment, effective handwashing and being bare below the elbows. Hand hygiene signage was displayed throughout the department.

The department monitored key metrics in relation to infection rates, including MRSA (Methicillin-resistant Staphylococcus aureus), MSSA (Methicillin-susceptible Staphylococcus aureus) and E. coli (Escherichia coli). All patients were screened for infectious diseases when a decision had been made to admit them or if they were displaying symptoms. Results were then made available to staff and any infectious cases were followed up by the sites infection prevention and control team.

The site is above trajectory for all infection KPIs and reportable infections (as of October 2024):

• MSSA bacteraemia–12 cases against an internal year to date (YTD) threshold of no more than 10.5 cases.
• CDI (Clostridium Difficile) - 64 cases against a YTD threshold of no more than 33 cases
• E. coli–55 cases against a YTD threshold of no more than 54 cases
• Klebsiella–32 cases against a YTD threshold of no more than 19.8 cases

Patient-Led Assessments of the Care Environment (PLACE) results at the time of the assessment showed outcomes for cleanliness at 97.32%.

Information available about infections demonstrated an increase in outbreaks in September to November 2024 were reported, including an increase in staff reporting diarrhoea and vomiting symptoms. Actions were taken to mitigate the risk of cross infection to patients including additional equipment and area cleaning between patients, additional focus on the importance of staff handwashing and additional sanitising of staff toilets, patient cubicles and corridor areas.

Hand hygiene audits results at the time of the emergency department assessment were 100%. IPC practice and environment results were 80.6% for September and October and 83.9% for November 2024. Learning was identified following each audit and we saw evidence of action being taken.

Further audits undertaken demonstrated:

• PVC/Cannula insertion audits were showing 93.3% for 2024 Quarter 3 audit. PVC/Cannula ongoing figures had improved in November 2024 to 82.8% from Julys 2024 of 72.8% compliance.
• Urinary Catheter insertion results were 100% for 2024 Quarter 3 audit. Urinary Catheter ongoing care audit results in November 2024 were 66.7%.
• Cleaning audits in the emergency department Majors area results were 97% for September, 98% for October and 90% November 2024.
• IPC Training compliance within the emergency department for mandatory training level 1 was 95%, mandatory training level 2 ANTT competency was 95% against a target of 90%.

There were no IPC concerns on the emergency department risk register at the time of the assessment.

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.

There was a large team of pharmacists who supported predominantly the emergency department between 8am and 8pm on weekdays (and up to 4pm on weekends), they also worked with AMU and SDEC as required. There was non-residential general hospital pharmacist cover outside of these hours. Pharmacists prioritised medicine reconciliation for patients with time-critical medications by use of a flagging system and were normally able to achieve medicine reconciliations within 24 hours of presentation.

The service made sure that medicines and treatments were safe and met people’s needs,

capacities, and preferences. They involved people in planning, including when changes happened. We spoke with 2 pharmacists, 3 pharmacy technicians, and 2 nurses. We reviewed records for 11 people.

Overall, high-risk medicines were identified and recorded upon admission to ensure appropriate monitoring. There was good accessibility to time-critical medicines such as medicines for the treatment of Parkinson’s disease, to ensure that these medicines were given in a timely manner. We saw that these medicines were given on time. People’s medicines allergies and regular medicines were recorded upon arrival to the department and Summary Care Records were used to support this process. However, we saw one instance where an antibiotic was prescribed to a person without their allergy status being documented. We also saw this occur at another site at the Trust. We saw one person was given a single dose of rapid tranquilisation (an injectable medicine to help calm a person who is distressed). Staff followed guidance from the National Institute for Health and Care Excellence (NICE) on monitoring and observation of the person following rapid tranquilisation. Risk assessments for venous thromboembolism (VTE) were completed promptly and medicines were prescribed appropriately. We saw that the prescribing of antibiotics followed trust policy and national guidance. Whilst the prescribing of oxygen had improved at the trust, there were still some instances where oxygen had not been prescribed.