Milton Keynes 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 rated safe as good. We assessed 8 quality statements. There was a positive learning safety culture where events were investigated, and learning was embedded to promote good practice. Staff knew when and how to report incidents. Staff understood how to protect patients from abuse. Staff worked with partners to establish and maintain safe systems of care, in which safety was managed, monitored and assured. Nursing and medical staff received and kept up to date with their mandatory training and managers supported staff to develop through yearly, constructive appraisals of their work. However, the service did not always have safe systems for appropriate and safe handling of medicines. Patients did not always have their time crucial medicines prescribed in a timely manner. The environment and equipment did not always keep people safe. Mental health triage forms were not always completed for all patients who required them on arrival to ED, and some staff were not aware of this process. Medical staffing levels were not always in line with national guidance. However, leaders produced a business case following our on-site visit to increase medical staffing levels.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We reviewed 3 incident investigation reports during our assessments, which demonstrated that as part of the duty of candour process, patients were invited to be involved in the incident investigation process.

Staff knew what incidents to report and how to report them. Staff said they were encouraged and supported to raise concerns. Staff were aware of duty of candour. Leaders said they met to discuss learning from incidents and look at improvements to patient care. They were able to describe themes from incidents and changes to practice as a result. Leaders described a positive learning culture within the emergency department (ED).

Processes were in place to ensure incidents were reported and investigated. The incident investigation reports reviewed during our assessment included a detailed chronology of events, with evidence of learning, and actions identified to address any areas of concern. Leaders monitored data on incidents through monthly emergency department governance reports. Clinical governance and mortality and morbidity meetings were held monthly within the emergency department. We saw evidence that newly implemented mental health policies and guidelines were being shared with staff via the ED newsletter and at clinical governance meetings. Some of the staff we spoke with during our assessment were unaware of these updates. However, leaders said the process of sharing and embedding this information had only recently begun. Staff shared examples of mandatory mental health training they had completed.

Once triaged, patients understood where they were on the hospital pathway and their treatment plan. However, patients did experience long waiting times when being referred onto specialities within the hospital. Patients with mental health concerns were assessed by the mental health liaison team, from another service provider, who were based on the hospital campus. We observed a well-coordinated transfer of a patient from a local secure unit to ED. A comprehensive risk assessment was completed prior to their arrival to ED and seamless communication maintained between the multidisciplinary ED team and partners. The patient's potential for absconding was identified and security staff and continuity of care were ensured for added safety. We also observed thorough and timely handovers between ambulance crews and ED staff during our assessment. Ambulances were able to access the ED immediately at all times and had direct access to Same Day Emergency Care (SDEC) for both medical and surgical patients and the Early Pregnancy Assessment Unit (EPAU).

Staff had developed a checklist for extended stays of children and young people with mental health issues. Staff said they had good relationships with the children’s mental health colleagues, but this resource was tested continuously with the numbers of children and families requiring support. Staff told us of challenges they experienced when caring for patients with mental health concerns. Staff described a lack of a dedicated space and privacy for mental health patients, concerns about resource constraints and regular struggles to find available beds for mental health patients due to full capacity. Some staff told us that patients with mental health concerns who needed admitting to specialised day and inpatient units could experience significant waits for beds to become available. This was a national issue, which was a significant challenge for staff as patients could often be waiting in ED until a bed was found.

We received positive feedback from partners regarding communication and multidisciplinary team working with emergency department staff. For example, ambulance crews described wait times were low, patients were well managed and there were good relationships between staff. They described the department as “one of the much better places I bring my patients to”.

Processes were in place to support staff to work with people and partners to establish and maintain safe systems of care, in which safety was managed, monitored and assured. The trust had key pathways in place for sepsis, stroke, medical emergency, cardiac arrest, trauma and haemorrhage. The ED had guidelines in place to assist staff when patients may require transfer to another service for treatment. However, some of the guidelines we received were overdue for review. There were guidelines available to assist staff with the streaming process, triage, ambulance handovers and acute admissions from the ED. Multidisciplinary team meetings were conducted regularly, which assisted with the transition of patients through the service. A discharge checklist was available electronically and contained all the relevant sections to safeguard discharges from the ED. The trust had a discharge lounge and the ED had access to the discharge planning team and frailty team to assist with the discharge process. Staff in the ED had access to patients’ GP records via the electronic system. Information relating to past medical history and current medications was available to assist staff within ED. The mental health liaison team were located adjacent to ED, which facilitated joint working and an integrated approach to healthcare. This ensured physical and mental health needs were addressed simultaneously. The trust held daily escalation meetings with relevant stakeholders to discuss care and support of mental health patients. The trust was working to review mental health pathways and a process was in place for mental health patients with extended stays in the ED.

Between October 2023 and April 2024, staff made 116 adult and 304 children safeguarding referrals. During our onsite visit we observed safeguarding concerns had been identified and actioned for two patients as required. An Information sharing form had been completed where applicable.

Staff demonstrated an understanding of safeguarding and how to take appropriate action. Staff were able to provide examples of the types of concerns that would prompt both a safeguarding referral and information sharing. Staff demonstrated a commitment to taking immediate action to keep people safe from abuse and neglect. Staff were aware of the safeguarding team and said they would go to them for any advice or support.

The service had systems, processes and practices to protect people from abuse, neglect, harassment and breaches of their dignity and respect. Emergency Department staff worked closely with the safeguarding team to review safeguarding concerns. There was a robust system in place for staff training for adult and paediatric safeguarding and overall compliance rates were at 90%. The safeguarding team had a single point of contact to ensure staff knew how to contact the team for advice and support. The safeguarding team participated in daily paediatric huddles with emergency department staff.

People who frequently attended ED were flagged on the electronic system and where applicable security flags were also in place to ensure patient and staff safety. The mental health liaison team (MHLT) aimed to assess 80% of ED referrals within 1 hour of referral. The annual average percentage of patients seen within this timescale was 94.14%. We observed staff sought consent from patients throughout their treatment.

The service used early warning scoring and an electronic system to maintain oversight of unwell patients. Staff used safety huddles to communicate if patients required any additional care or had a change in need. Staff said within ED staff worked well together. Some staff told us the mental health liaison team (MHLT) would quickly evaluate patient needs, provide crisis management, and prescribe necessary medications. Leaders made sure staff were trained on restraint.

We reviewed evidence which demonstrated that the service engaged with partners to understand and manage risks by thinking holistically. This meant that care met their needs in a way that was safe and supportive and enabled them to do the things that mattered to them. Mental health partners reported a good working relationship with ED staff.

Whilst we were onsite, we observed mental health triage forms were not completed for all patients who required them on arrival to ED, and some staff were not aware of this process. The mental health triage forms were paper based and required uploading onto the electronic system, so were not immediately available when needed. Following our onsite assessment, we received mental health triage forms for two patients. One was incomplete and the other was not completed at the patients point of arrival to ED. Following our onsite assessment the emergency department had implemented mandatory electronic mental health triage forms. There was a working group focusing on this to oversee training, compliance, guidance and audit. We reviewed the electronic records of patients who attended ED for mental health issues. All patients underwent assessments, and necessary alerts were set for each patient. However, one record lacked documentation of consistent visual observations. The trust stated if one to one supervision of patients was required in the ED, there were processes in place for requesting additional staffing and support. We observed staff providing one to one supervision to patients. The service used electronic risk assessments and early warning scores to risk assess patients. Frailty scoring, pain assessments, adult and paediatric early warning scores, falls assessments and skin assessments were generally well documented. There was a monthly audit for patient observations and deterioration which showed that in March 2024, overall compliance was 80%. Staff had access to a mental health liaison team to assist when the mental health of an adult patient required assessment. The team were located onsite and available 24 hours a day. The ED had a mental health champion, and some members of the nursing and security teams had attended multi-agency mental health simulation training.

On inspection we observed patients were triaged in dedicated areas within the emergency department. We were told by staff that mental health patients often experienced long waits to find available beds. The service had a designated mental health room within the adult emergency department and a room within the children’s ED which could be used after a risk assessment. We were told patients awaiting imaging services within the emergency department, had to walk through the main ED that was often busy with patients receiving care. The layout of the department meant that there was a lack of privacy when patients shared personal information at main reception

Staff and leaders described processes were in place to ensure the environment was safe. Leaders acknowledged there were some gaps in the completion of resuscitation trolley checks, there were expired consumables on the difficult airway trolley, and some consumable equipment was not always immediately available in line with best practice. Leaders took action to address these concerns following our on-site visit. In the 2023 staff survey, 46.2% of emergency department staff agreed with the statement ‘I have adequate materials, supplies and equipment to do my work’. This was compared to the organisational average of 68.1%.

We identified some gaps in the completion of daily checks on 2 resuscitation trolleys during our on-site visit. However, overall resuscitation trolley check compliance was above 97% for April 2024. Following our on-site visit, leaders implemented an action plan and measures to improve monitoring and compliance. The consumables checked during our assessment were mostly within the expiry date, however, we found 2 expired airway devices on the difficult airway trolley. Following our on-site visit, leaders addressed this issue and updated the checklists and processes for checking this equipment. The ED mostly had enough suitable equipment to help them to safely care for patients. However, we identified some examples where consumable equipment was not available in line with best practice guidelines. For example, paediatric central venous catheters were not immediately available in the ED. The Resuscitation Council UK 2021 guidelines state these should be immediately available. Following our on-site visit leaders took action to address this by adding this equipment to the children’s emergency department (CED) and paediatric ward. Swipe card access and CCTV were in use throughout the ED. This ensured the department remained secure and observable. Waiting areas were mostly visible from the reception areas and screens displayed real time information on waiting times. Reception desks in the adult and children's ED had Perspex screens and hearing loops in place. Security staff were present in ED 24/7. The children’s ED was suitable for children and young people, CCTV was in place and patients were observable from the nurse's station. The ED was visibly clean, tidy and well presented.

There was a designated room within the ED that was used for mental health assessments, which met national standards. A process was in place to risk assess other areas for use by patients with mental health concerns if the designated room was unavailable. Leaders monitored the completion of safety checks of equipment through a monthly audit. Following our on-site visit, leaders increased the frequency of their monitoring to weekly for resuscitation equipment checks. A digital daily resuscitation trolley check system was also introduced to improve compliance. In addition, a new checklist and process was devised to improve compliance of difficult airway equipment checks. There was an environmental risk assessment for the ED relating to violent and aggressive patients. The department’s risk register showed leaders had identified a risk around ligature points within the ED environment. In response, leaders had carried out repeated ligature audits and introduced a ligature risk awareness policy. The ED had an asset register and a medical equipment service contract in place. This ensured equipment was regularly serviced and maintained.

We spoke to 7 patients, and all had positive experiences and said they felt safe within the emergency department. We saw patients who did not speak English as a first language being streamed effectively using translation services. Clear and real time information on waiting times helped manage expectations.

Staff described they enjoyed their roles and felt they were engaged and kept updated by senior members of the team. Staff felt well supported, encouraged to develop, and did not raise any concerns. Leaders described there was a mechanism in place to send extra staff to areas of higher workload and acuity. Leaders acknowledged more consultants, including a paediatric emergency medicine (PEM) consultant were required. Leaders described that a PEM consultant had been in post prior to our assessment but they had recently left the department. Leaders stated consultants within the ED had relevant training to enable them to manage both paediatric and adult patients. Leaders described a business case was planned to increase medical staffing within the ED. Leaders provided a copy of the business case following our on-site visit. The business case was produced in August 2024. The 2023 staff survey showed only 26.4% of emergency department staff agreed with the statement ‘There are enough staff at this organisation for me to do my job properly’. This was below the organisational average of 35.9%.

Safe nursing staff ratios and skill mix were observed throughout the ED and staffing levels were displayed. Staffing levels were discussed at various meetings held throughout the day. We observed staff working in multidisciplinary teams during our on-site visit. We observed junior staff receiving teaching and supervision. Security staff were trained in restraint and provided support to staff where patients required additional or one to one care. Some staff were not aware of guidance or best practice in relation to what information could be shared with the police and in what circumstances. We observed a confidentiality breach whereby a member of staff shared patient information with a police officer, without assessing if this was necessary.

Medical staffing levels were not always in line with national guidelines. The department did not have a dedicated paediatric emergency medicine (PEM) consultant, in line with RCPCH’s Facing the Future: Standards for children in emergency care settings (2018) guidance. Consultant staffing levels were not sufficient to allocate a consultant to each of the functions in the ED at the same time, in line with Royal College of Emergency Medicine guidance. Leaders provided a copy of a business case for medical staffing levels following our on-site visit. There were robust plans in place for the recruitment and retention of nursing staff. The vacancy rate for nursing staff was 11.38% at the time of our assessment. The service had low rates of agency nurses and medical staff. The department had a full-time practice development nurse in post to oversee training and development for staff. There was a process in place to ensure triage nurses received the required knowledge, experience, assessment and support to fulfil the role. Nursing and medical staff received and kept up to date with their mandatory training. Managers monitored mandatory training and alerted staff when they needed to update their training. Managers supported staff to develop through yearly, constructive appraisals of their work. Nurse staffing for the Children’s ED (CED) was in line with national guidance and planned staffing levels had been met on 96.1% of shifts in the 3 months prior to our assessment. Arrangements were in place to cover any shortfalls through staff from the paediatric ward.

People told us they thought the service appeared clean and tidy.

Leaders had oversight of cleaning records and audits to assure the emergency department had robust infection prevention and control measures. Staff described policies and guidelines were in place to assist staff when inserting invasive devices in the ED.

We observed staff cleaning areas within the emergency department. The emergency department was visibly clean and well maintained. We observed staff were bare below elbows and cleaning their hands between caring for patients. Staff were observed using personal protective equipment and aseptic technique for invasive procedures. Waste was segregated into clinical; household and recycling and appropriate signage was in place.

Both the infection prevention and control (IPC) and environment summaries for March 2024 for both Paediatric ED and adult Majors ED showed the daily cleaning logs had not been fully completed for the last seven days (respectively only 83% and 60%). We noted the action plans provided did not make mention of this. Between October 2023 and March 2024 six patients attending/admitted tested positive for Clostridium difficile (C diff).In March 2024 the trust conducted a mock CQC inspection. They reported that "still evident is the busyness of the department with occupancy of trollies, cubicles and treatment areas supporting a greater number of patients in these spaces than is designed." Hand hygiene audits were in place within the ED. A hand hygiene action plan had been developed in April 2024 to raise hand hygiene awareness, identify hand hygiene champions and to ensure hand hygiene training compliance was above 90%. The hand hygiene inspection summaries for CED in March 2024 showed compliance was 97%. Cleaning was carried out 24/7 in the ED. Cleaning was audited weekly in the ED and compliance rates were 98% at the time of our assessment.

Patients received their medicines as prescribed. This was recorded on their electronic prescribing system. However, from records we reviewed, not all patients were prescribed their time critical medications in the ED as per policy. Patients received information about newly prescribed medications. Although 3 out of 4 patients we spoke to on the day of inspection told us they were not offered pain relief, we saw patients being offered pain relief when attending the ED. Recent audit results showed 98% of patients in March when attending the ED were asked if they were in pain, 82% were offered pain relief within 15 minutes.

Staff told us they were supported by ward leaders. Staff told us they received mandatory medicine management training and regularly updated it as well as training on relevant topics such as insulin and sepsis. The service was currently up to date with medicines management training. The emergency department told us they were supported by pharmacy assistants when managing medicine processes for ordering, receiving and managing stock. They told us a pharmacist was available to support the department when required and they were responsive to queries. They were also contactable out of hours. However, the department did not have a dedicated ED pharmacist or pharmacy technician department which was not line with national guidance. The service leaders were aware of this and informed us they were in the process of addressing this.

Medicines were not always stored securely in line with national guidance. We saw in one medicine room; medicines were stored in unsecured bulky trays and in hard-to-reach places. Prescription stationary was not always stored securely or in line with best practice. The stationary was stored in the controlled drugs cupboard which could allow access to the prescriptions from staff who could access the controlled drugs. The service had had two recent incidents where prescription stationary had gone missing and were unaccounted for. Patients' allergy status was clearly highlighted on patient records. Patients also received colour coded wristbands to indicate allergy status to staff. Antimicrobial agents were prescribed within national guidance. Staff had to access prepared emergency drug trays that contained the required medications to support them when responding to an emergency. We reviewed the controlled drugs register and saw ordering, administration and destruction was documented accurately.

Staff could access information easily. The ED used an electronic prescribing system to prescribe and administer medicines which was integrated with other prescribing systems in the hospital. The system could also flag high risk patients who presented to the emergency department. The service had a process for the supply of medicines including using FP10 prescriptions, prepared To Take Out (TTO) medicines and patient group directions (PGDs). PGDs were used by specifically trained staff to supply medicines for routine or minor ailments. However, it was unclear how often these were reviewed as many PGDs had been signed from staff from as early as 2018. There was a process to report incidents and raise controlled drug concerns. The service routinely submitted quarterly reports to their regional Controlled Drugs accountable officer. Incidents were analysed and learning shared through monthly governance reports. The service conducted several audits of medicines management which included controlled drugs and safe and secure management of medicines. Areas of improvement were identified trust wide and results were shared with senior nurses to cascade to frontline staff.