Bradford Royal Infirmary

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that people and communities had the best possible outcomes because their needs were assessed. We checked that people’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring people were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

At our last assessment we rated this key question Good. At this assessment the rating is Requires Improvement.

This meant people’s outcomes were not always consistently good, and people’s feedback confirmed this. The service was in breach of person-centred care and good governance.

We have not awarded this service a score for Effective.

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

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

We asked staff to explain how risk assessments and care planning were delivered in a person‑centered way. They told us that risks were identified at triage and could include safeguarding, cognitive impairment, pressure damage and falls. However, when we spoke with staff, observed the department and reviewed records, this was not always reflected in practice. Therefore, we were not confident that individual needs including communication needs were appropriately assessed and fully understood.

As part of our assessment, we reviewed 10 sets of patient records, including paediatric records. Our review showed that assessments were not always completed. Of the 10 patients, only 5 had a documented pain score, and these scores were not reviewed regularly. For 5 patients, it was unclear from the records whether pain relief had been administered because there was no documentation. We also checked whether patients had been asked about allergies. One patient record contained no information about allergy status. We also reviewed the records for evidence of pressure area assessments. These assessments were not always completed, and 4 of the records contained no information to show whether an assessment had been carried out or whether one was not required. People’s needs were not assessed using a range of assessment tools to make sure their needs were understood or reflected. This was a breach of person centered care.

Patients told us they felt some of the information they gave to staff was not considered. For example, patients told staff about time‑critical medicines, but this was not reflected in their care records, nor did they receive their medication on time. Health assessments did not consider the holistic needs of the patient and focused only on the presenting health complaint, not taking into consideration other health conditions people had that could impact on their overall health and well being as well as their presenting complaint. This meant people did not always receive care or treatment that had the best outcomes for them.

When we asked staff whether falls risk assessments were carried out, we received mixed responses. Most staff told us falls assessments were only completed once a patient had been admitted to a ward. In the records we reviewed, only one patient was identified as at risk of falls, and there were no documented actions. Assessments were not always up to date and staff did not always know what people’s current needs were. An internal review carried out by the trust after our inspection showed staff were relying on family members to keep patients safe in bed. We found no documented evidence of bed rail risk assessments. While bed rails can prevent someone from rolling out of bed, they can cause serious harm if a patient is mobile, confused or attempts to climb over them. This posed a risk to patients in the department. This was a breach of safe care and treatment.

We tracked the care of patients attending the department in mental health crisis and found no documented plans of care in place for them. Some patients waited in the department for long periods (over 24 hours), but there was no information about how their personal care needs, nutrition or hydration would be supported, or how they could safely access daylight or fresh air. There was no evidence that their care and support needs were routinely reviewed. This situation was the same for people who attended with physical health conditions. This was a breach of person centred care.

We saw that staff identified and recorded some cultural needs, such as language and dietary requirements, and aimed to meet these needs. Families could stay with their loved ones, and relatives and carers told us they were involved in discussions and asked for information to help staff understand how best to provide care and support. Staff also provided support to family and carers, particularly during distressing times and we saw families being supported and comforted when patients deteriorated or passed away.

We scored the service as 3. The evidence showed a good standard. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Staff used the trust’s systems to follow the latest guidance and evidence‑based practice. Staff told us they used information shared in safety briefings and newsletters to implement new guidance or changes to existing procedures. We spoke with staff from a range of roles and grades, and all said they could access trust guidelines and standard operating procedures, including flow charts, when needed. Staff also told us their colleagues and senior team members were supportive and willing to share advice and experience.

Staff and leaders were encouraged to learn about new and innovative approaches that could improve care. During our inspection, the department was trialing a Same Day Emergency Care (SDEC) ward to allow patients to be seen and treated quickly, helping to reduce pressure on the main department. The department also held regular safety huddles where changes to practice were discussed.

We reviewed the mental health referral pathway, which set out how staff should manage both paediatric and adult patients who attended the department with mental health needs. Data showed that between January and December 2024, 1,704 patients attended the ED seeking support for poor mental health. Only 33% of patients were seen by psychiatric liaison services within an hour of referral, and 66% were seen within 4 hours. Results for 2025 up to the time of our inspection were similar at 36%. Mental health support was provided by another trust, and the data showed patients waited for prolonged periods.

Food provision for patients was affected by staff provision which resulted in nutrition and hydration needs not always being met in the department. Staff in other roles were aware of this and would offer food and drink to people. The trust has told us after the inspection this was rectified. People we spoke with in waiting areas told us there was little access to food or drink other than from vending machines, particularly overnight.

We scored the service as 2. The evidence showed some shortfalls. The service worked across teams and services to support people. They did not always make sure people only needed to tell their story once because they did not always share their assessment of needs when people moved between different services.

Although some specialties, such as acute liaison psychiatry and medical care, frequently attended the department, patients who required input from other specialty teams continued to experience delays. Specialty reviews did not take place in a timely way following referral and often exceeded the 60‑minute professional standard. The Royal College of Emergency Medicine (RCEM) inter‑professional standards , which state that referrals must be accepted by specialty teams, were not upheld. Most medical referrals could not move to ward beds because no beds were available. This meant the ED was managing patients who, under the standards, should have been reviewed and managed by specialty teams elsewhere in the hospital. This delayed specialist care. The ED carried the risk for these patients and absorbed patient‑flow pressures for the whole hospital. We were concerned that delays at the front door meant some patients waited too long for care and treatment or received care in an environment that was not appropriate for their needs. This was a breach of safe care and treatment.

The department had access to several specialist teams, including the high‑intensity user team, specialist alcohol support team, homelessness support team, frailty team and the additional support needs team. During our inspection, we saw input from the alcohol support team, occupational therapists and acute liaison psychiatry. Multidisciplinary teams were involved in assessing patients’ needs. We saw examples of effective joint discharge planning, including collaboration between the mental health trust and ED staff to support the transfer of a patient to an inpatient facility.

We observed nursing and medical handovers during our inspection. Staff shared relevant and important information about patients with their colleagues. They understood the importance of handing over detailed information about patients’ needs and wishes, as well as clinical information such as the required frequency of observations and any outstanding tests. Staff could also access patient records to review information, including National Early Warning Score (NEWS) results.

Staff were notably busy throughout the department, but spoke positively about teamwork and support from colleagues. We saw good multidisciplinary working and observed respectful interactions between staff.

We also reviewed how coordinated the care pathway was for children and young people. The paediatric ED had access to youth workers, physiotherapists, the safeguarding team and, until the project ended shortly before our inspection, Barnardos practitioners. Input from these specialist services contributed to a coordinated paediatric pathway.

Staff told us they worked closely with the paediatric ward and shared staff across areas, which helped maintain strong communication and support. However, meeting minutes showed a repeated theme of reluctance from the paediatric ward to escalate and admit children from the paediatric ED. We were concerned that this could affect how quickly children received care and treatment.

We scored the service as 3. The evidence showed a good standard of people being supported to live healthier lives. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

The service displayed relevant information promoting healthy lifestyles and sources of support on welcome boards throughout the department and on electronic screens in the waiting area. This included videos and posters from national, regional, local and hospital campaigns. The information covered a wide range of needs, including both physical and mental health. Topics included cervical screening, smoking cessation, breast cancer screening, weight management, bowel cancer screening, community pharmacy support, mental health services, flu vaccination, stress and mood.

Patient information leaflets were available on the trust’s website through QR codes. However, at the time of our inspection the QR codes were not working. We raised this with the department, who told us they would inform the information technology team so the codes could be checked. When we tested some of the codes later, we found they were active again. Patient information was also available in larger print.

We scored the service as 2. The evidence showed some shortfalls. The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves. We found breaches of good governance.

The service had developed an audit schedule for 2024 and 2025 to assess and improve patient care across a range of clinical areas in the ED, including missed fractures, end of life care, cauda equina and coagulation. We reviewed the Local Audit Prioritisation log provided by the trust. Although it listed the audits proposed by the department, the log was incomplete and did not show planned start or completion dates for most entries.

The schedule included audits aligned to Royal College of Emergency Medicine (RCEM) standards. However, the trust did not participate in the mandatory RCEM Mental Health and Self Harm audit in 2024, nor were they collecting data for the same audit in 2025. The department also reported difficulties submitting data for other mandatory RCEM audits, including the National Major Trauma Registry.

We reviewed several clinical audits, including the Sentinel Stroke National Audit Programme (SSNAP), some elements of which relate to ED performance. Although the results showed improvement, performance remained worse than the national picture in all but one category. We also reviewed the invasive procedure checklist audit. Despite improvements over three audit cycles and changes to the records system and staff education, documentation was present in only 64% of cases as required by the Local Safety Standards for Invasive Procedures (LocSSIP). The provider could not demonstrate that patients consistently received stroke interventions in line with guidance or that interventional procedures were completed safely because records remained poor.

The evidence the trust provided contained limited information about actions taken as a result of audit findings. For example, one audit report stated, “data collection shows far better adherence”, but did not include baseline or post‑audit compliance levels. We were not assured the department was using clinical audit effectively to monitor patient outcomes and drive improvement. This was a breach of good governance.

We asked the trust to provide results of any audits completed in the 12 months before our inspection relating to pain management and nutrition and hydration. The trust provided checks completed after our visit, but no audit results from the 12‑month period before our inspection. We were concerned that the department had not carried out any assurance work on timely pain management or access to nutrition and hydration during that year.

The department also shared information about clinical audits that had been completed or were ongoing since 2022. These included audits on paediatric paracetamol overdose, end of life care, care home discharges, leg ulcers and time‑critical medicines. The evidence showed varying progress. We noted that the audit on time‑critical medicines - an area of concern identified during our inspection - showed no progress at the time of writing this report. This was a breach of good governance.

Senior staff told us during the winter period, as part of workforce measures, protected time to carry out or participate in quality improvement work was limited.

We reviewed mortality data for patients who died in the ED. There had been a slight reduction in the average monthly number of deaths since March 2023, apart from a peak in December 2024. The trust investigated this increase and found it aligned with a wider rise across the hospital and an increase in seasonal flu admissions. The information provided showed an improving trajectory and reducing numbers of deaths in the ED.

We scored the service as 2. The evidence showed some shortfalls. The service told people about their rights around consent, however did not always audit this to check it was consistently applied.

We reviewed the trust’s consent policy and found it was in date and due for review in November 2025. The policy was comprehensive and set out the legal requirements, relevant case law, and staff roles and responsibilities. The trust also provided its Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (2009) policy, which was also in date and due for review in March 2029. This policy was similarly detailed, providing staff with clear information about their responsibilities and the actions they should take when they identified concerns about fluctuating mental capacity.

We asked the trust to provide the results of any audits relating to consent, including Do Not Attempt Cardiopulmonary Resuscitation (DNACPR). The trust told us that consent documentation was not currently subject to formal audit in the ED. They explained that implied consent was commonly used for routine care, verbal consent was obtained for urgent interventions, and that staff were trained to document consent “when feasible.” The trust also told us that no formal audits had been undertaken relating to consent or DNACPR, stating this reflected the “unique nature of emergency care and the legal frameworks governing these areas. This was a breach of good governance.

We asked the department to provide compliance data for training in consent, autism awareness, dementia awareness and Mental Capacity Act (MCA) awareness. The trust told us:

• 91% of staff had completed autism awareness training
• 100% of staff had completed MCA Level 1 training
• 98% had completed MCA Level 2 training
• Only 25 staff had completed dementia awareness training
• Only 8 staff had completed consent training

Staff received consent training as part of their induction and other mandatory training modules.