Eastbourne District General Hospital

Updated 25 January 2023

​We inspected the Maternity service as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

We will publish a report of our overall findings when we have completed the national inspection programme.

We carried out a short notice announced focused inspection of the Maternity service, looking only at the safe and well led key questions.

Eastbourne Midwife Unit (EMU) is in Eastbourne Sussex and part of the East Sussex Healthcare NHS Trust. The unit is run by a group of core midwives and maternity support workers (MSW’s) and is supported by the community midwifery teams. The unit operated 24 hours a day for low risk mothers. Services offered were antenatal care, day assessment unit which ran on Mondays, Wednesdays and Fridays, telephone triage assessment line and low risk childbirth, pregnancy vaccination and postnatal clinics.

The unit has two main birthing rooms, one included a birthing pool, two en-suite postnatal rooms for women to be transferred into after they have given birth. There were clinical side rooms and a community midwifery hub. EMU accepted women from the main acute site once they had given birth and were able to be transferred to receive extra support if required.

EMU accepted ‘low risk’ women and pregnant people over 37 weeks for childbirth. Any women that developed complications during labour were transferred to the acute unit at Conquest Hospital.

The midwifery led unit was closed from the 10 December 2021 until the 21 April 2022 due to staffing challenges. This meant there were 107 babies born at the midwifery led unit from October 2021 to September 2022 this was lower than previous years.

Our rating of the Eastbourne Midwife Unit was requires improvement. We rated it as requires improvement because:

This was the first time we inspected the Eastbourne maternity services without gynaecology, and the first visit since it changed to the Eastbourne Midwifery Unit. We rated safe as requires improvement and well-led as good and the Eastbourne Midwife Unit as requires improvement overall.

We also inspected one other Maternity service run by East Sussex Healthcare NHS Trust. Our reports are here:

Conquest Hospital Maternity Unit: https://www.cqc.org.uk/location/RXC01

How we carried out the inspection

This maternity thematic review was a focused inspection; we inspected the domains of safe and well led using the CQC’s established key lines of enquiries (KLOES).

This was our first inspection of the Eastbourne midwife unit. We visited the telephone triage area and the community midwives office. We spoke with 6 staff members to understand what is was like working for the service, including midwives, maternity care assistants and housekeepers.

We interviewed leaders to gain insight into the trusts leadership and governance model of the service.

We reviewed 3 sets of patient care records. We also looked at a wide range of documents including standard operating procedures, meeting minutes, risk assessments and recently reported incidents.

After the inspection we requested further documentary evidence to support our judgements including policies and procedures, staffing rotas and quality improvement initiatives.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Updated 6 June 2018

Our rating of the service was good. We rated it as good because:

• Patients and relatives we spoke with gave positive feedback about the care they received on the unit.
• Staff showed compassion when dealing with patients and protected their privacy and dignity.
• Strong clear leadership seen, staff felt well managed and well led. Staff said matrons and senior nurses were visible and supportive within the department, they felt valued, listened to and respected and felt confident to raise any concerns with their line managers
• The trust recognised the difficulties in matrons completing clinical and administrative work and they have introduced matron’s assistants. Matron’s assistants support matrons with the clerical side of their job such as monitoring training compliance, collecting, and collating data for clinical audits. Matrons and senior staff felt the matron assistant was a valuable resource, which meant had more clinical time to spend on the ward supporting nursing staff.
• Staff knew how to contact the safeguarding team within the hospital and explained clearly how to make a safeguarding referral. We observed safeguarding folders, which identified the safeguarding lead and the referral process.
• Staff felt able to raise concerns, report near misses and report incidents. There was openness at risk meetings and learning from incidents was shared across the team in a variety of ways.
• Comprehensive risk assessments were carried out on patient admission and kept in the patient records. This included assessing the patient against the risk of falls, nutrition status, skin integrity and pain. Alongside the falls assessment an individual needs assessment is completed. This checks a patient’s dementia and delirium, blood pressure, medication review, visual impairments, continence care plan, call bells within reach and mobility and walking aids.
• We saw staff monitor patient’s national early warning signs (NEWS) scores and discuss patients within safety huddle meetings that had consistently high scores.
• We observed clear referral pathways for patients who were displaying or had mental health conditions. Staff knew where to access support and information. Staff knew about the psychiatric liaison team based in accident and emergency department and that the team were available 24 hours every day.
• Managers investigated incidents and shared lessons learned with the whole team and the wider service. We saw incidents and lessons learned documented on team minutes and observed it happening within safety huddles. When things went wrong, staff apologised and gave patients honest information and suitable support.
• Data collection takes place on one day each month and reported within monthly governance meetings. All staff received a quarterly newsletter called ‘you said, we said’ and gives staff information of common risks and examples of learning from incidents.
• Trust audits taking place were adult asthma, dementia, diabetes foot care, end of life care, falls, Parkinson’s disease action, pulmonary rehabilitation, and cardiology and staff were aware of audits taking place. Recent audits took place for JAG (joint advisory group on gastrointestinal endoscopy) accreditation, which they are currently awaiting the outcome.

However:

• Current mandatory and statutory training for nursing and medical staff did not meet trust targets
• Nursing staff shared concerns with the level of staffing on most medical wards. Senior staff told us most wards have full establishment of staff at the start of a shift. However, staff are taken from the ward they are based in to work in other areas that do not have a full establishment and staff shortages.

Updated 27 February 2020

Our rating of this service improved. We rated it as good because:

• The service provided mandatory training in key skills to all staff and made sure everyone completed it. Staff understood how to protect children, young people and their families from abuse and the service worked well with other agencies to do so. The environment had improved since our previous inspection all areas were visibly clean and equipment was well maintained.
• Staff completed and updated risk assessments for each child and young person and removed or minimised risks. Staff kept detailed records of children and young people’s care and treatment. Records were clear, up-to-date, stored securely and easily available to all staff providing care.
• The service had enough medical staff with the right qualifications, skills, training and experience to keep children, young people and their families safe from avoidable harm and to provide the right care and treatment. The service managed safety incidents well. Staff recognised and reported incidents and near misses.
• Staff provided good care and treatment, gave children and young people enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of children and young people, advised them and their families on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
• The sepsis link nurse developed a ‘think Sepsis’ poster which highlighted monthly audit results and a ‘Stop’ sticker when the pathway was no longer appropriate, to ensure staff used the screening tool and cascaded results to the clinical leads and matron.
• The children’s service was in the process of introducing Excellence in Care audits and the tool included a regular paediatric early warning system (PEWS) audits. Quality checks were carried out to make sure staff were clearly documenting observations on arrival and during children’s stay on the ward.
• The service set out an improvement plan which introduced a safe surgical pre-assessment and blood taking clinics. Pre-assessment clinics were thorough, and parents had time to ask questions and understand their child's conditions and treatment. Phlebotomy clinics had set appointments and focused on calming children down prior to and during blood taking procedures.
• Staff treated children and young people with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to children and young people, families and carers.
• The service took account of children and young people’s individual needs and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
• The children’s outpatient unit provided families with various clinics for children living with health conditions. There were systems that ensured children with long term medical conditions were seen by paediatric consultants with specialist interests, for example diabetes.
• Leaders had the integrity, skills and abilities to run the service. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff. They supported staff to develop their skills and take on more senior roles.
• The service had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. The vision and strategy were focused on sustainability of services and aligned to local plans within the wider health economy. Leaders and staff understood and knew how to apply them and monitor progress.
• Services were being transformed to make sure acute, outpatients, nursing outreach and community paediatric services holistically met the needs of children and young people.
• The service only employed one play specialist to work cross-site. This meant that often children with complex needs did not have access to this important resource.

However:

• The service struggled with staffing numbers and staff did not always have the right qualifications, skills, training and experience to keep children, young people and their families safe from avoidable harm and to provide the right care and treatment. Nurse staffing was on the divisional risk register and staff reported that there were often staff shortages that needed to be filled with bank and agency staff. There had been times when these staff were not specialist trained in paediatric care.
• There were 10 times from 1 January 2019 to the 1 October 2019 where the short stay paediatric assessment unit, was closed at the weekends. Four closures were due to lack of medical and nursing staff at Friston and six of these closures were due to insufficient paediatric nursing staff/skill mix of staff at the Conquest Hospital site to care for two patients with mental health issues needing one to one care whilst on the ward.
• Third party children and adolescent mental health services did not accept assessments after 3pm. This meant any child presenting at risk from complex mental health issues after this time, would be transferred to the short stay paediatric assessment unit or Conquest Hospital site for overnight admission until assessment by a mental healthcare professional could be safely carried out.
• Some policies we viewed on line for example the acute asthma in children, Abdominal pain in children: managing children with gastroenteritis and managing fluids in children needed review as they were up to two years out of date. However, the trust has supplied information to show these policies were in date but these were not displaying when accessed on the inspection.
• The service only employed one play specialist to work cross-site. This meant that often children with complex needs did not have access to this important resource.

Updated 27 March 2015

The intensive care service used procedures to ensure that patients received safe and effective care. Clinical outcomes were monitored and were similar to units of similar size. Practice changed where required improvements were identified. Staff were caring and compassionate, working to maintain privacy and dignity of their patients. However, some improvements were needed in bed management processes to ensure that patients did not remain in the intensive therapy unit (ITU) longer than required and patients requiring critical care were managed in an appropriate setting. Clinical leadership on the unit was strong and supported staff development. However, changes to the clinical unit management team led to a lack of engagement with ITU staff, making it difficult for clinical staff to develop plans for the future.

Updated 27 February 2020

Our rating of this service improved. We rated it as outstanding because:

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, supported them to make decisions about their care, and had access to good information. Key services were available five days a week with out of hours and weekend cover also available when needed.
• Patients and relatives said staff go above and beyond and the care received exceeded their expectations. Staff truly respected and valued patients as individuals. They treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service was tailored to meet needs of individual people and are delivered in a way the ensure flexibility, choice and continuity of care. There was a proactive approach to meeting the needs of those from different cultures or with complex needs. People could access the service when they needed it. The service made it easy for people to give feedback.
• Leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care. Leaders supported staff to develop their skills and motivated them to succeed. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, valued, and were proud of the organisation as a place to work and spoke highly of the culture within the service. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service used innovative ways to engage with patients and the community to plan and manage services and all staff were committed to improving services continually.

• However:

• The service did not keep their risk register updated.
• There were some issues with the structural maintenance of the hospital.
• The service did not have a major incident policy for the mortuary, although they had started work to produce this.

Updated 25 January 2023

Updated 6 June 2018

Our rating of this service improved. We rated it as good because:

• Systems and processes were in place to assess, monitor and manage risks to patients. For example, safety checklists were used and monitored to ensure the safety of patients undergoing a surgical procedure.
• Patient records were available, kept secure and up to date. The trust had made clear improvements to the way health records were managed across the organisation.
• Staff recognised incidents and reported them through the electronic reporting system. Incidents were investigated by senior staff with lessons learnt shared across the trust. Staff were aware of the duty of candour and gave patients honest information and support.
• There were business continuity plans in place for use in the event of a major incident. Learning from the use of the major incident plan included the addition of ophthalmology staff to the list of contacts in the event of a major incident.
• Staff delivered patient care in line with evidence based care and best practice guidance. NICE guidance was used, monitored and audited in a number of clinical specialities, for example, Parkinson’s quality standard (QS164).
• The service ensured that staff had the skills, knowledge and experience to deliver effective care, support and treatment. For example, through the use of practice based competency assessments for a variety of clinical procedures.
• Multidisciplinary working was apparent across a range of specialities within outpatients. Doctors, nurses and allied health professionals worked together to provide integrated care that met the needs of patients.
• People were respected and valued as individuals. Staff throughout outpatient services put patients at the centre of what they did. Staff we spoke with were highly motivated to provide care that was kind and promoted dignity. Patients and relatives told us that they were treated with dignity and compassion. We saw staff interacting in a caring and dignified way with patients with ill mental health and learning disabilities.
• The outpatient department at Eastbourne hospital was undergoing an improvement programme for services provided to patients. This programme addressed issues such as how appointments were booked, queuing systems for specialist doctors, clinic duration and capacity and demand leading to positive results for patient services and patient experience.
• Following our report in January 2017 it was highlighted that the outpatient service must develop play services in line with national best practice guidance. We saw dedicated areas for children in the main outpatient waiting areas.
• We found there was strong and clear leadership capacity and capability. Leaders understood the challenges to quality and sustainability, and were taking action to address them.
• There were clear and effective processes for managing risk and performance. Quality improvement work had begun within speciality clinics and there were plans to develop this across outpatients as a whole.
• There were systems in place to support learning, improvement and innovation. The trust had participated in a national benchmarking programme for outpatient departments and the women’s health service had achieved successful accreditation from the British Society of urogynaecology in 2017. There was a continuous improvement programme in place across administrative services that included health records.

However:

• Not all nursing staff working in outpatient clinics where children were cared for were trained to child safeguarding level 3.
• Not all complaints were answered within 30 days of their receipt as per trust policy and people were not made aware of the trust’s complaints response deadline.
• Signposting was not dementia friendly and did not accommodate visual deficit needs.

Updated 27 January 2017

We found the surgery services at Eastbourne District General Hospital (EDGH) to be good because:

• The hospital had good medicine management processes in place, which related to the security and storage of medicines on all the wards we visited. In general, medicines in theatres were well managed but we observed the block signing of controlled drugs which was contrary to best practice guidance.

• The trust was compliant with the intercollegiate document, safeguarding children and young people: role and competences for health care staff (March 2014). Staff we spoke to were able to demonstrate an understanding of their responsibilities to safeguarding vulnerable adults.

• The identification, reporting and investigation of incidents had improved significantly since our previous inspection. We saw minutes of meetings where incidents including never events were discussed and learning fed back to staff via ward meetings and newsletters, which were available in hard copy and circulated by email. There were readily observable changes made across the trust in relation to never events that had occurred, with learning widely disseminated. Learning from Morbidity and Mortality meetings needed further development. Records were brief and suggested limited discussion and challenge.

• The recently introduced electronic observation recording system had led to improvements in the management of deteriorating patients. Earlier recognition and identification resulted in more timely review by the critical care outreach team, who had oversight of all NEWS Scores for all patients in the hospital. Where the NEWS score was elevated to a higher level there was automatic review by the medical emergency team.

• The incidence of both pressure damage and falls had shown a sustained improvement over time. Ward and departmental safety thermometer results showed improvements across the service. Medicines management had been added to the safety thermometer as an additional performance measure.

• Where compliance with VTE risk assessment and prevention had been a concern in our previous inspection report, there was now evidence of high rates of compliance with 95% of patients having a properly completed VTE risk assessment in July 2016.

• Infection prevention and control measures had improved since our previous inspection. The ‘Bare below the elbow’ policy was enforced more rigorously through the daily safety huddles. Hand hygiene audits showed sustained high levels of compliance with results maintained above 97% since February 2016.

• The trust rate of surgical site infections (SSIs) was better than the national average.

• Equipment checks were now given a higher priority. Daily checks of essential equipment were taking place with records available to confirm senior oversight of equipment checks occurring.

• Care pathways used in surgery referred to national guidance from the National Institute for Care and Excellence (NICE) guidance and other bodies such as the British Orthopaedic Association guidelines. We observed staff following national best practice guidance in theatres.

• Consent was obtained in accordance with the trust policy and guidance from the professional regulatory bodies. Staff had an understanding of what informed consent entailed. They had received training in the Mental Capacity Act 2005 and knew how this impacted on their work.

• Friends and Family Test results showed a higher than average response rate and the scores were higher than the England average. Over 98% of surgical patients would recommend the hospital.

• The hospital staff tried to ensure that the individual needs and preferences of patients were met. There was a system in place to identify patients who might be a little confused and need careful support in decision making.The coloured butterfly markers allowed staff to differentiate these patients from those with more advanced dementia.The dental team provided exemplary planning of care for patients with learning difficulties who needed dental surgery. Every adaptation was offered to make the appointment as comfortable and relaxed as possible.

• A robust governance system was being introduced. At the time of our inspection visit it was partially rolled out with a clear timeline for continued introduction of key aspects of the framework.The triumvirate management structure for the division gave clear lines of reporting, clear accountabilities and responsibilities and was known to staff. All those we spoke with were clear who their immediate manager was; this was not the case on the last inspection visit in 2015.

• The majority of staff reported positive changes in their workplace culture and spoke of approachable and supportive middle managers. We saw real warmth in the relationships between ward leaders and nurses and from the HoN towards their wider team. One team of staff felt their manager was less approachable and they felt less supported but this appeared to be about an individual middle manager’s approach.

• Black and minority ethnic (BME) reported that they felt supported and accepted as part of the hospital workforce. We saw respectful and confident interaction between BME staff and white British staff on the wards we visited.

  However

• The trust systems for the management of patient records were new and not yet fully embedded.Patient records had been moved off site and were retrieved when needed but staff reported some delays in this. There were times still when patient records were not available for pre-assessment clinics and consultations.

• There was a high vacancy rate of 12% for surgical nursing staff and the service was highly reliant on bank and agency staff for both nursing and medical staffing. Recruitment continued to provide challenges and whilst the trust had taken many steps to address this, the problem of recruiting sufficient permanent staff continued. The nursing staffing levels had improved since our previous inspection visit in September 2014. Theatres staffing met the recommendations of the AfPP and ward level planned nursing staffing versus actual staffing was usually met, albeit with temporary staff.

• The trust’s referral to treatment time (RTT) for admitted pathways for surgical services had been worse than the England overall performance since July 2015.

• There were 735 mixed sex breaches on surgical wards at EDGH during a 12-month period. The reason for these was not documented in most cases.

Updated 6 June 2018

We last inspected in October 2016 and rated urgent and emergency services as requires improvement overall. This reflected a rating of inadequate for safe, requires improvement for effective, responsive and well led and good for caring. Our ratings reflected low levels of consultant cover, variable compliance with hand hygiene, inconsistent pain management, limited paediatric services and delays to triage, assessment and treatment. We told the trust they must ensure consultant cover meets the minimum requirements of 16 hours per day, as established by the Royal College of Emergency Medicine.

Our rating of this service stayed the same. Whilst we noted significant improvements in the service from our findings on previous inspections, there were still areas where further work was needed. We rated it as requires improvement because:

• There remained gaps and inconsistencies in the quality and completion of patient records. This included in the completion of baseline observations and information critical to monitoring patients for deterioration.
• Records for patients with mental health needs required improvement to assure us of patient safety. In some of the records we looked at we found missing referrals, no evidence of consistent risk assessment and evidence of the discharge of a patient at significant risk of self-harm or suicide.
• Most staff did not meet the trust’s 90% target for mandatory training completion and demand pressures on the service meant staff often found it difficult to attend training. Standards for the completion of safeguarding training were variable with all staff meeting the requirement for level 1 training. However, the trust had made demonstrable improvements in mandatory training rates since our last inspection.
• Infection prevention and control standards were variable. Hand hygiene audits in 2017 indicated consistently good practice with 98% compliance. However there was inconsistent recording of infection control assessments in patient documentation and we did not observe consistent practice during our inspection.
• Provision for patients with mental health needs was variable. A mental health liaison team provided urgent reviews within two hours of referral although there were gaps in the service out of hours. Mental health services were provided by another trust.
• Consultant vacancies were listed on the service risk register and the latest available data noted 69% of patients were reviewed by a consultant within 14 hours of admission against Royal College of Emergency Medicine guidance.
• The incident-reporting system indicated consistent oversight from the senior team and a detailed approached to establishing the causes. However records indicated persistent delays in completing investigations and contributing factors included those identified by quality audits, which the senior team had not resolved.
• Options for food and drink had improved for patients in the clinical decisions unit but audits of the use of the malnutrition universal scoring tool (MUST) noted poor compliance with trust standards.
• There was evidence of effective multidisciplinary working with the hospital intervention team the security team and specialties when these were available. However non-availability or delays in responding to referrals to specialties had resulted in negative patient outcomes including for patients who needed a stroke assessment. This was evidenced through a few incident reports, such as when a patient remained in the emergency department for 19 hours when multidisciplinary medical teams failed to identify an appropriate care pathway.
• The trust’s urgent and emergency care Friends and Family Test performance (percentage recommended) was better in comparison to the England average. In the same survey the trust performed in line with the national average for 13 questions relating to how they involved patients in their care and worse than the national average in 11 questions.
• Data for the period December 2016 to December 2017 indicated variable performance in RCEM audits. This included no month in which patients were admitted, transferred or discharged within four hours of arrival. In addition patients consistently spent longer in the emergency department than the national average. However no patients waited more than 12 hours from the decision to admit until being admitted and much work had been done by the site management and executive team to address patient flow throughout the hospital.
• The trust had been sent a letter by the Secretary of State congratulating them on being one of the most improved emergency departments nationally.
• We noted that whilst the rating remained the same, there were noticeable improvements in many aspects of care.
• The trust had introduced an additional daily consultant shift, which meant consultant cover now met the RCEM requirements of at least 16 hours per day. This was a very significant improvement and meant that decisions about the care of complex patients were being made at the right level of seniority.
• The senior team demonstrated a significant focus on improving sepsis screening and treatment. This included greater emphasis on evidence-based practice and training. Data provided by the trust showed improvements in the implementation of the sepsis pathway.
• Facilities in the department included a dedicated area for patients with mental health needs and for children.
• The department performed similarly to or better than national averages in the Emergency Department Survey 2016 and between November 2016 and December 2017 in the time from arrival to initial assessment.
• Appraisals were consistently carried out, fit for purpose and focused on staff achievements and goals. Where individuals needed support this was provided.
• The service had improved the triage process with significantly improved training and clinical competency checks for nurses and HCAs.
• The healthcare assistant team had been awarded as ‘unsung heroes’ for their work in improving the patient experience and in most of our observations staff demonstrated a commitment to kindness, compassion and empathy. The team readily provided emotional support to patients when they were distressed or confused and used appropriate resources to support patients experiencing confusion as a result of dementia.
• Some aspects of service planning were expanding to meet increased patient demand. This included an extension of the Hospital Intervention Team to 12 hours each day and a planned increase of overnight mental health team availability.
• There was a dedicated practice development nurse in post who provided support to all members of the emergency department team. The practice development nurse also supported healthcare assistants to achieve the national care certificate and had helped to develop a new initial training and support programme for newly qualified nurses.
• Training rates for the Mental Capacity Act (2005) exceeded the trust’s target of 90% and staff demonstrated good knowledge of this. However, monthly audits indicated low levels of compliance with trust standards relating to mental capacity assessments.

• The emergency department team and multidisciplinary colleagues had implemented a number of initiatives to improve the experience of patients living with dementia, including more resources and increased staff training
• An established escalation process involved progressively senior staff as waiting times increased and capacity decreased. This enabled staff to use escalation areas and additional spaces for patients whilst they waited for diagnosis and treatment. Along with the introduction of GP streaming this reflected a targeted approach to improving access and flow.

• Senior staff monitored and updated risks on the service risk register frequently and had initiated a number of strategies to reduce risks. This included a workforce development plan, additional consultant shifts and better utilisation of resource plans for access and flow.

• Clinical governance systems were embedded in the operation of the service and reviews of incidents, complaints and risks were frequently carried out. However some governance processes did not demonstrate effectiveness or improvements in patient outcomes. This was demonstrated through consistently poor audit results despite governance interventions.

• Demand for mental health services far outstripped capacity. However the mental health liaison team had introduced monthly multidisciplinary meetings and responsive debriefs with the ED team to review care and effective use of mental health pathways.
• Staff with substantial expertise in safeguarding and child protection provided support to the emergency department (ED) team although the use of safeguarding tools and assessments was variable. The safeguarding team had recently been expanded and was addressing specific areas of the trust where shortfalls in practice were identified. A new training programme was being rolled out.