Medics in the emergency department of Altnagelvin Hospital feel tired, burnt out and stressed according to a new inspection report.
The Regulation and Quality Improvement Authority (RQIA) examined conditions at three wards as part of an unannounced visit to the Londonderry facility in July.
Low staffing levels and recruitment difficulties within the ED were highlighted as particular cause for concern.
Olive Macleod, RQIA's chief executive said: "In the ED while leadership was good, staffing levels were concerning, there were delays in recruitment and bank or agency staff could not always be secured.
"Staff told us they were feeling tired, 'burnt out' and stressed as a result of low staffing levels."
Inspectors also found that at busy times the emergency department was not adequately staffed to ensure appropriate care.
The report, published on Tuesday, stated: "We found staff morale was low. Most staff reported that they did not feel supported and valued by executive management and there was a delay in response to raised concerns.
"A stress audit had been carried out but staff had not received any feedback.
"Staffing levels for nursing and healthcare assistants (HCAs) had been agreed and additional nursing posts advertised however staffing levels were low, bank and agency staff could not always be secured to cover shifts.
"The delay in recruitment was impacting on staff who raised concerns over issues including; staffing levels; staff retention; staff induction; having the relevant clinical skills; workload; mandatory training; patient privacy and dignity.
"Staff told us they were feeling tired, 'burnt out' and stressed.
"At busy times nurse staffing levels were concerning, with areas within the department not staffed adequately to ensure appropriate patient care. The recruitment of paediatric nurses for the ED was a reported challenge.
"We were told and observed during the inspection of staff working outside their competencies."
Nursing staff also expressed concerns regarding their ability to care for patients, particularly those presenting with a risk of self-harm, the report noted.
The RQIA inspection team included doctors, nurses, pharmacists and allied health professional peer reviewers plus members of the public.
They spoke to patients, relatives and staff, observed delivery and examined records to determine whether care was safe, effective and compassionate.
They also looked at how each ward was being led and managed.
Ms Macleod said: "At Altnagelvin Hospital's medical and surgical wards inspected we identified good adherence to best practice in the delivery of patient care, with some areas noted for improvement. However, our inspection of the ED identified a range of areas that required improvement.
"In each area inspected we observed caring and committed staff, showing empathy to their patients. While patients told us they were satisfied with the standard of care they received, in some cases relatives highlighted the need for up-to-date information on their family member."
"In the medical ward we observed good clinical leadership from the ward sister. While staff told us that morale was good, we were advised that this was affected by increasing work as a result of staffing shortages.
"Our inspection team observed good compliance with hand hygiene and patient early warning scores were well completed. We also noted good medicines management, with a pharmacist involved from admission to discharge."
"In the surgical ward there was also strong leadership, and morale was good. The ward was operating with a full complement of staff and we were told that staff retention was good.
"However, we were advised that there was no integrated medicines management service on the ward and delays in access to pharmacy services could impact on discharge.
"We also advised the trust that the system for delivery and service of patients' meals requires immediate review and improvement, to ensure patients nutrition and hydration needs are met."
In a statement the Western Health and Social Care Trust said it welcomed the report; accepted the recommendations and had taken steps to address issues raised.
A spokesman said: "Whilst the trust are already aware of many of the issues raised we acknowledge the feedback within the report and are pleased to see the independent leadership recognition of our teams in the ED and at ward level."
The trust said it identified, through an internal review in May, that the ED was coming under increasing pressure and has recruited 14 extra staff.
A spokesman added: " Between November 2015 to September 2016 an additional 6,613 people attended Altnagelvin's ED, an increase of 13% compared with the same period the previous year.
"The ED also saw a 21% increase in GP referrals representing an additional 1,294 persons in the same period compared to the previous year."
Geraldine McKay, director of Acute Hospitals at the Western Trust is in discussion with commissioners with a view to securing more investment.
Ms McKay said: "In May 2016, in light of the increasing demand, the trust implemented measures to ensure patient safety would not be compromised and to prioritise quality of care for our patients and support for staff.
"These measures included recruiting an additional 14 staff to work in Altnagelvin's ED; 12 of whom are already in place. This includes senior medical and nursing appointments."
"Our staff are a credit to the health care system and to the Western Trust and as such we have ensured that all staffing issues are taken seriously.
"We have in place additional support for staff and regularly review closely the demands on staff in this area."