Royal Albert Edward Infirmary

Updated 4 August 2023

Pages 1 and 2 of this report relate to the hospital and the ratings of that location, from page 3 the ratings and information relate to maternity services based at Royal Albert Edward Infirmary.

We inspected the maternity service at The Royal Albert Edward Infirmary 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 announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

Royal Albert Edward Infirmary is a district general hospital located near Wigan town centre. It provides a full range of maternity services including both antenatal and postnatal ward with 28 beds including three single rooms. There are approximately 2000 deliveries each year, with caesarean sections and instrumental delivery rates in line with national average.

The trust has two offsite antenatal clinics; The Thomas Linacre Centre in Wigan and Leigh Infirmary; both clinics provide consultant and midwifery clinics. We did not inspect these clinics as part of this inspection.

Our ratings of the maternity service stayed the same and the ratings for the hospital remained the same. We rated safe as requires improvement and well-led as good and the hospital as good.

How we carried out the inspection

During our inspection of maternity services at Wrightington Wigan and Leigh Teaching Hospitals NHS Foundation Trust we spoke with 27 staff including leaders, obstetricians, midwives, and maternity support workers.

We visited all areas of the unit including the antenatal clinic, maternity triage, labour ward, birth centre, day assessment, antenatal and postnatal ward. We reviewed the environment, maternity policies and 12 maternity records. We also looked at a wide range of documents including standard operating procedures, meeting minutes, risk assessments, recent reported incidents as well as audits and audit actions. Following the inspection, we reviewed data we had requested from the service to inform our judgements.

We ran a poster campaign during our inspection to encourage pregnant women, birthing people who had used the service to give us feedback regarding care. We analysed the results of the eight responses we had back to identify themes and trends. These reflected a mixed response describing a kind and caring workforce but with some people experiencing delays to treatment and support during their stay in the maternity unit.

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 22 June 2016

We found that the Royal Albert and Edward Infirmary was delivering good medical services to patients but some areas of the service, particularly those relating to safety, required improvement.

All staff knew the trust vision and behavioural framework and said they felt supported and that morale was good. All staff were committed to delivering good, compassionate care and were motivated to work at the hospital.

The hospital had implemented a number of schemes to help meet people’s individual needs, such as the forget-me-not sticker for people living with dementia or a cognitive impairment and a red label to indicate that a patient was frail or elderly. This helped alert staff to people’s needs. However, we found on the discharge lounge patients’ privacy and dignity was not always being maintained and this was due to the facilities available not being fully used.

People were supported to raise a concern or a complaint and lessons were learnt and improvements made. Medical services captured views of people who used the services with changes made following feedback. A survey showed that people would recommend the hospital to friends or a relative.

There were governance structures in place which included a risk register. Some actions on the register had no timeframes for completion and it was unclear if these were being managed in an effective way to lower the risk.

There were concerns in relation to nursing staffing on some of the wards during the day and at night, especially on Ince ward and Astley ward. Clinical staff had access to information they required, for example diagnostic tests and risk assessments. However, we found records were left unsecured on the wards we visited and whilst records did include a treatment plan for each patient, there were standards for record keeping that required improvement.

Clinical waste was not always being stored in the designated places and there were concerns over the design of the endoscopy unit leading to the use of the discharge lounge to recover patients. There were also concerns about the decontamination facilities on the unit.

Nursing staff were unclear about the procedures to follow when reaching decisions about using bed rails which are a form of restraint. This was due to the assessment paperwork not including the recording of consent or best interest decisions but staff knew about the key principles of the mental capacity act. Incidents were reported by staff through effective systems and lessons were learnt and improvements made from investigations where findings were fed back to staff. There were systems in place to keep people safe and staff were aware of how to ensure patients’ were safeguarded from abuse. The hospital was clean and staff followed good hygiene practices.

There were a number of patients being cared for in non-speciality beds but there were clear protocols in place to help manage care for these patients. Best practice guidance in relation to care and treatment was usually followed and medical services participated in national and local audits. Action plans were in place if standards were not being met.

Updated 14 September 2017

• There was one never event reported by the trust on Rainbow ward between 1 March 2016 and 31 March 2017.
• Duty of candour was not fully documented in the never event investigation report.
• Compliance rates for safeguarding children level three was 77.8% for paediatric medical staff and 28.6% for registered paediatric nurses on Rainbow ward.
• Records we reviewed showed that four out of five records did not have appropriate actions taken on triggering Paediatric Early Warning Score (PEWS).

However,

• Staff knew how to report incidents and lessons learned were shared with staff
• The ward was visibly clean and staff adhered to current infection prevention and control guidelines.
• Emergency resuscitation equipment and safety testing was in place, and a bedrails assessment was completed on admission.
• Safeguarding policies and procedures were in place across the trust. Staff we spoke with were aware of their roles and responsibilities and knew how to raise matters of concern appropriately.
• The nursing staff ratio on Rainbow ward was a maximum of 1:5 for both general paediatric patients and paediatric surgical patients. Between 1 January and 31 March 2017, this had been achieved on all but four shifts (98.5%).

Updated 26 February 2020

Our rating of this service stayed the same. We rated it it as good 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 collected safety information and used it to improve the service.
• 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, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
• Staff 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 planned care to meet the needs of local people, took account of patients’ 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.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

Updated 22 June 2016

We found that there were good EOL services across all five domains of Safe, Effective, Caring, Responsive and Well Led.

Incident reporting systems were in place and actions were followed up at ward level via handover. There had been no recent serious incidents related to EOL care. Anticipatory EOL care medication was prescribed appropriately and training for the use of syringe drivers was included in mandatory training for which the SPC team were 100% compliant. EOL services were adequately staffed and as well as the SPC team which was clinically led by a consultant in palliative medicine, there was a bereavement specialist nurse, a gold standards framework (GSF) facilitator and two EOL champions on each ward.

There was evidence of the service delivering treatment and care in line with best practice, including the individual plan of care (IPOC) document which facilitated support for the dying person in the last days and hours of life. The service was starting to implement the gold standard framework (GSF) and had appointed a facilitator to introduce and embed this in the two pilot wards. We saw that the service had made changes to their practice to address some of the targets not met in the last National Care of the Dying Audit of Hospitals (NCDAH), May 2014 and there was evidence that some actions were in place as a result of other clinical audits however there were not always action plans in place which met the criteria for being specific, measurable, achievable, realistic and timely (SMART). This meant there was a potential risk that some recommendations or findings from audits may not be translated into actions in a timely manner or may be missed altogether.

We saw evidence that pain relief and nutrition and hydration needs for patients were being met. The SPC team provided a seven day service and worked well, across all the hospitals, with other teams and disciplines.

EOL care services were provided by compassionate, caring staff who were sensitive to the needs of seriously ill patients. The service was delivered by staff who were committed to providing a good service and there was good clinical leadership from a consultant in palliative medicine. There was a coordinated approach across the Wigan borough to design EOL services to meet the needs of the local population. There were systems in place to prioritise EOL patients for side rooms at RAEI and this was working well. Facilities and systems were in place to minimise stress for families staying with their EOL relatives and to allow them to spend as much time as they wished with them in their last days and hours. This included the use of the swan logo which identified EOL patients and their families, enabling staff to treat them accordingly.

The visibility of senior management was good and staff felt well supported and there was an open door policy by senior staff.

Areas for improvement included completion of uDNACPR forms which were inconsistent in their quality. An action plan should be developed to address the shortcomings identified in the trust’s uDNACPR audit.

Updated 4 August 2023

Updated 22 June 2016

We found the services of the outpatients and diagnostic imaging to be good overall. Patients had clear access to the clinics and radiology, though car parking was an issue. Areas were visibly clean and waiting times for appointments were short. The departments had sufficient staff and where shortfalls existed there were plans in place to ensure continuous service. There was some weekend clinics and acute radiology services was open 24 hours a day. The outpatient waiting area was dated but the new cancer centre, opened in January 2015, was bright and spacious in comparison.

Staff at Royal Albert Edward Infirmary told us they were proud of where they worked and would recommend it as a workplace and a place to treat their family. Staff training was up to date and the trust encouraged learning. Incidents and errors were treated as a learning opportunity to keep patients safe in the future. Patients told us that staff were caring and compassionate and they were given sufficient information about their treatment.

The management were visible and approachable to staff. Audits to assess the departments were continuous and innovation and change was promoted. Staff felt supported by the managers.

Updated 26 February 2020

Our rating of this service stayed the same. We rated it it as good because:

• The hospital had enough staff to care for patients and keep them safe. Staff had training in most key skills and understood how to protect patients from abuse. The hospital controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The hospital managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
• 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 services and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
• Staff 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 hospital planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the hospital when they needed it and did not have to wait too long for treatment.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The hospital engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However,

• The use of facilities and premises did not always meet with updated standards to keep people safe and we found hazardous substances stored in unlocked rooms which were accessible to patients and visitors and there were not always effective processes in place to ensure that sundries used by staff were in date and safe to use.
• Training compliance for paediatric life support for theatre staff was low and there was a risk that there were not enough staff who had the required level of training.
• Patient records were not always stored securely and could be accessed by unauthorised persons.
• Senior leaders in the division were not always visible and approachable in the service for patients and staff.
• The surgical service did not have a clear vision for what it wanted to achieve or a strategy to turn this into action. The vision and strategy were dependent on progress in regional developments within the wider health economy.
• Risks we identified during our inspection had not been identified and mitigated through the risk management processes.

Updated 14 September 2017

• Records were not always completed fully by medical and nursing staff.
• Despite tools being available to help staff manage risks to patients, they were not always used effectively. For example, in records we reviewed we saw no evidence of clinical observations, early warning scores and risk assessments in some records. We also had concerns that some of the guidance relating to managing risk was unclear.
• Mandatory training figures for staff did not always reach the trust target of 95%. Training for safeguarding was particularly low.
• Dispensers storing sanitising gel were empty in the main reception area. 
• A room storing major incident equipment was also being used to take blood samples from patients. The room was a less than ideal environment.

However

• There was a culture of reporting and learning from incidents amongst staff.
• Medicines were managed, stored and checked correctly with automatic systems in place.
• Staff were 100% compliant in mandatory training topics including anti-fraud awareness, emergency planning, conflict management and dementia training.
• Major incident information was clearly displayed for staff, who were supported by a trust policy.
• All the areas we reviewed were visibly clean and tidy. Cleaning schedules were used and adhered to.
• The right equipment was available for staff caring for patients.