Royal Albert Edward 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’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question good. At this assessment, the rating has remained good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

Teams worked well together across wards and services, with effective multidisciplinary team (MDT) meetings, safety huddles and board rounds. Most patients felt involved in decisions about their care, and records showed clear, appropriate consent processes, including for patients with reduced capacity.

The service delivered care and treatment in line with national guidance, and staff used evidence‑based policies to support safe and effective practice. Staff assessed patients’ needs on admission and used recognised tools to guide treatment, escalating concerns when diagnostic delays or changes in condition occurred.

Staff took part in audit and quality improvement activity, and findings contributed to changes in practice. Staff supported patients to make informed decisions about their treatment.

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 3. The evidence showed a good standard. The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing, and communication needs with them.

Upon admission to the wards, staff completed assessments to identify patients’ needs and risks. These included assessments for falls, pressure ulcers, venous thromboembolism (VTE), nutrition, and cognitive delirium. Patients identified as high risk were placed on appropriate clinical care pathways, and care plans were implemented to ensure they received the required level of care. We reviewed 27 patient records and found that most risk assessments had been completed and updated appropriately. However, minor gaps were identified in moving and handling and malnutrition universal screening tool (MUST) assessments.

Care records and personalised treatment plans were clearly documented following admission and were kept up to date to reflect identified needs. Care records contained documented medical histories, clinical assessments and plans of care. Appropriate referrals had been made to allied health professionals and relevant clinical pathways had been completed. Most records were structured, legible, comprehensive and up to date.

We observed ward rounds where staff collaboratively reviewed results, discussed treatment options, and involved patients in decisions about their care.

Patient needs were displayed on visual boards, including indicators for falls risk, skin integrity, dementia, and nutrition, which supported safe and individualised care. Staff used recognised symbols to document these needs.

Staff completed fluid balance and food charts to document patients’ intake and output over a 24-hour period. This information was used to inform clinical decision-making. Records reviewed showed that most fluid balance charts were completed and up to date.

Although staff generally assessed patients’ needs appropriately, they reported that staffing gaps and workload pressures impacted their ability to adapt care in a timely manner. One patient also reported that staff were not always available to assist at mealtimes.

Patient feedback regarding pain relief was mostly positive. Some patients reported delays in receiving pain relief, while others stated staff were responsive and had no concerns.

We reviewed the records of a patient living with dementia. These were clear and comprehensive and included Mental Capacity Act 2005 (MCA) assessments, Deprivation of Liberty Safeguards (DoLS) documentation, and a completed dementia ‘This is Me’ document. The patient was on enhanced patient observation (EPO), and all associated documentation was fully completed. Evidence showed the patient had been reviewed by physiotherapy and occupational therapy on admission. Staff kept both the patient and their relative informed of the care plan, and a specialist nurse attended during our assessment.

We scored the service as 2. The evidence showed some shortfalls. Not all systems and processes were in line with legislation and current evidence-based good practice and standards.

Several policies and clinical guidelines were beyond their intended review dates, which limited assurance that staff were consistently working to the most up-to-date evidence-based guidance. Examples included the Local Safety Standards for Invasive Procedures (LocSSIPs), World Health Organisation (WHO) checklist for gastrointestinal endoscopy, which had expired in 2021, the emergency acute aortic syndrome (AAS) referral pathway guide, which should have been reviewed in November 2025, the Handover of Patient Policy (Adult), which had been overdue for review since April 2021, and the Senior Review SOP – Medicine, which had expired in March 2023. The standard operating procedure for non-invasive ventilation (NIV), although aligned to national guidance, had also exceeded its review date in May 2025. While staff described delivering care in line with recognised practice, the trust could not demonstrate assurance that all policies and procedures remained current. This increased the risk of variation in practice and the potential for clinical decisions to be informed by outdated guidance.

The endoscopy service at the hospital did not have Joint Advisory Group on Gastrointestinal Endoscopy (JAG) accreditation at the time of our assessment. Information provided by the trust indicated this was due to estates-related issues, specifically a lack of single-sex recovery facilities. Although leaders told us work was being planned to address this, no confirmed completion date had been agreed.

Despite these concerns, staff had access to clinical pathways aligned with national standards and best practice guidance. Policies and clinical guidelines were available in both paper and electronic formats, and staff demonstrated how they accessed these through the trust's intranet policy centre. Staff told us changes to policies and practice were communicated through team huddles, with additional training provided where necessary to support implementation.

Staff were able to describe examples of evidence-based guidance being introduced into practice. These included face-to-face blood-taking teaching delivered by the critical care outreach team and ward-based ‘tea trolley training,’ where practical demonstrations were delivered at the point of care. Staff also described training relating to nasogastric (NG) tube management. They told us these approaches supported competence and helped embed changes in practice.

Care records and observations demonstrated good specialty-specific practice, including advanced care flow planning and adherence to cardiology protocols and pathways. Key clinical guidance, documentation templates and risk assessment tools were displayed across ward areas to support consistent practice, and compliance against policy was monitored through the trust's annual audit programme.

Staff assessed and managed pain appropriately in line with national guidance and individual patient need. There were clear escalation processes for deteriorating patients, and managers could deploy enhanced one-to-one observations where required. Environmental risk assessments were completed, and staff upheld the rights of patients subject to the Mental Health Act 1983 through appropriate referrals to mental health liaison services.

The respiratory ward delivered non-invasive ventilation (NIV) in accordance with a standard operating procedure. Staff told us patient acuity was reviewed regularly throughout the day and that clear escalation processes were in place, including out of hours, weekends and bank holidays. Patients requiring enhanced respiratory care were reviewed daily by a respiratory consultant and at weekends by the on-call registrar.

Pathways and guidelines reviewed, were aligned to national guidance, including National Institute for Health and Care Excellence (NICE) pathways relating to chest imaging, stroke and transient ischaemic attack. The division maintained oversight arrangements to ensure NICE baseline assessments were completed, and services had undertaken audits against NICE standards, including audits of community-acquired pneumonia management and verbal consent for blood transfusions. These audits included action plans and re-audit dates.

Discharge planning followed evidence-based principles. Staff ensured patients understood their treatment plans, medicines and follow-up arrangements, and made referrals to community services where ongoing support was required to promote continuity of care and reduce the risk of readmission.

Overall, while staff generally delivered care in line with recognised evidence-based standards and national guidance, weaknesses in policy review processes and lack of JAG accreditation meant the service could not always demonstrate that evidence-based care was delivered consistently across all areas. This increased the risk of variation in practice and avoidable impacts on patient outcomes.

We scored the service as 3. The evidence showed a good standard. The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Stakeholders, partners and most patients described a collaborative culture, with strong multidisciplinary team (MDT) working across the medical division. Effective coordination between ward teams, the transfer of care team, and specialist services supported planned discharges. Structured discussions took place ahead of specialist assessments, which helped to reduce repetition for patients and carers.

Patient records we reviewed showed evidence of good MDT working, including documented family meetings, board rounds, and walk rounds. Staff attended routine MDT meetings and daily safety huddles to review deteriorating patients and identify those who were medically fit for discharge, alongside participation in hospital-level and trust-wide meetings.

Handover processes supported continuity of care, and nursing staff reported positive and improved working relationships with consultants, doctors, and advanced clinical practitioners. We observed effective handovers with clear patient knowledge.

Staff described effective cross-department working to meet individual needs. For example, care was adapted for patients with complex mobility needs through advance planning and coordination between teams and mental health liaison support was accessible, with clear referral information available on wards.

Staff at all levels described mostly positive teamwork across nursing, medical, allied health professional (AHP) and pharmacy teams.

Therapy services were available 7 days a week. However, weekend and bank holiday provision was limited to priority patients only. ‘Home First’ support services and Community Assessment Unit (CAU) therapy services operated Monday to Friday only.

The service worked collaboratively with GPs through established referral pathways, referral guidance, and advice services to support access to care. Staff also worked in partnership with a range of local organisations to support patients and their carers both during admission and following discharge. These included carers’ support services, Home First support services, and local hospice providers. Staff told us these partnerships helped to promote continuity of care and ensure patients received appropriate support at home where required.

The evidence showed a good standard. 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.

Patients we spoke with felt staff supported them to manage their own health, care and wellbeing needs. The service had relevant information that promoted healthy lifestyles and support on the wards and units. Associated information leaflets were readily available for patients if they required them.

Staff assessed each patient’s health when admitted and provided support for any individual needs to help them live a healthier lifestyle. For example, staff supported people to engage with smoking‑cessation services, alcohol and drug recovery programmes, and mental health support services. However, the current ‘Help for Smokers in Hospital’ patient information leaflet was overdue for review since September 2023.

We scored the service as 3. The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

The service demonstrated a comprehensive and structured approach to monitoring outcomes through active participation in both national and local clinical audits, alongside ongoing quality improvement initiatives.

During the 2025/26 period, the provider participated in 55 national clinical audits and 17 national confidential enquiries, which enabled services to benchmark against national standards and identify opportunities to improve patient care.

Outcomes from these audits were routinely reviewed, with clear evidence of learning and improvement. For example, the service used the Sentinel Stroke National Audit Programme (SSNAP) to monitor the quality and effectiveness of stroke care. Audit findings identified high levels of direct admissions to the stroke service, with the introduction of an ongoing improvement programme to address capacity challenges, repatriation processes, and a wider service redesign.

The medicine risk register also identified stroke service provision and non-compliance with elements of the SSNAP audit as an ongoing risk. Although SSNAP scores had previously deteriorated, the ‘Clinical Audit and Effectiveness Quarterly Report,’ which included data up to April 2026, demonstrated an overall improvement in performance. This indicated that actions being taken by the service were beginning to have a positive impact, although further work was required to achieve sustained compliance and improvement.

The National Emergency Laparotomy Audit (NELA) highlighted gaps in elderly care reviews for frail patients. Following improvements to the referral processes and digital pathways, evidence showed that compliance increased significantly from 18% to 100%, alongside improved diagnostic reporting times.

The Chronic Obstructive Pulmonary Disease (COPD) audit identified low compliance with the provision of discharge bundles. Subsequent interventions that included digital alerts had led to improved adherence and earlier patient review.

In addition to national benchmarking, the service completed 345 local clinical audits, demonstrating an internal focus on continuous improvement. These resulted in measurable improvements in patient outcomes and service delivery, such as an improved referral quality to ophthalmology services with a 39% increase in appropriate referrals following targeted staff education and revised guidance. Comprehensive geriatric assessments had also improved, with increased access to specialist input and enhanced patient flow.

Where areas for improvement were identified, the service implemented clear action plans, including pathway redesign, digital solutions, workforce development, and enhanced clinical oversight. Progress was monitored through re-audit, regular reporting, and ongoing governance processes to ensure improvements were embedded and sustained.

The ‘Corporate Clinical Audit and Effectiveness Forward Plan 2026–2027’ outlined the trust’s statutory and organisational audit requirements. This included mandatory audits, NHS England quality accounts projects, and Healthcare Quality Improvement Partnership (HQIP) commissioned programmes. It also identified trust-wide priority audits aligned with corporate objectives, patient safety learning and NICE guidance.

Key audit areas included duty of candour documentation, patient consent processes, early warning score monitoring, do not attempt cardiopulmonary resuscitation (DNACPR) documentation, LocSIPPs adherence, and learning from incidents, complaints, inquests, and claims. Additional areas of focus included pressure ulcers, mortality reviews, new NICE guidance, hand hygiene, and pharmacy safety audits. These audits were led by designated teams and reported through relevant governance groups.

During quarter 4 of the 2025/26 period, 149 audits were registered and 110 were presented, with 28 audit meetings held. Specialty-specific meetings and training sessions also took place, and 36% of projects were re-audited. Audit outcomes were categorised into assurance levels: 19% achieved full assurance, 56% achieved full or significant assurance, 33% were rated as limited, none were rated very limited, and 6% were not applicable.

Several audits in medicine and general medicine were rated as limited due to issues such as poor documentation, incomplete investigations, delayed or inappropriate clinical decisions, and inconsistent adherence to guidelines. Examples included audits on hyponatraemia management, venous thromboembolism (VTE) risk in autoimmune haemolytic anaemia, non-invasive ventilation compliance, nutritional management of patients who were recorded as nil by mouth, and prolonged hospital stays.

Common improvement actions included the development or updating of clinical guidelines, implementation of electronic tools and order sets, improvements in documentation and clinical decision-making processes, increased staff awareness and education, and the introduction of standardised pathways.

Many actions were ongoing, with several re-audits planned or in progress to assess improvement and sustainability during 2026.

We scored the service as 3. The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

People who used the service were supported to make decisions in line with relevant legislation and guidance. Most patients we spoke to told us that their treatment plans had been explained to them in a way they could understand, enabling them to make informed decisions about their care and treatment.

Patient records showed that consent forms were clear and legible, avoided abbreviations, were fully completed, and documented that risks and benefits had been explained to patients. We observed staff seeking verbal consent before providing care or treatment.

When patients had reduced capacity, we saw evidence that adjustments were made to improve communication and understanding. This included the use of hearing aids, interpreters, family support, adjusting the time of day for specific conversations and care interventions, using a quiet environment, and adapting the wording of questions.

An endoscopy audit of consent had been completed, which included a sample of 50 patients undergoing procedures requiring consent. Data showed that all patient records evidenced that consent had been discussed and documented.

Staff received training in the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS), which was included within safeguarding training. Compliance rates have been reported under the safeguarding quality statement. Staff also completed ‘understanding consent’ training; however, compliance was 61.5% in March 2026, which was below the trust target of 90%. The trust completed an audit measuring staff compliance with and understanding of the Mental Capacity Act 2005 (MCA). Staff were asked to name the 5 principles of the MCA and results showed that staff were on average able to name 3 out of the 5 principles.

However, patient records demonstrated that, where applicable, MCA assessments and best interest decision-making had been completed and appropriately recorded.

Records also showed that Deprivation of Liberty Safeguards (DoLS) decision-making processes and approvals were in line with legal requirements. There was appropriate documentation to show that DoLS had been removed when no longer applicable.

The trust completed an annual DNACPR audit, which was measured against standards set out in the trust’s ‘Northwest DNACPR Policy’ (which was in the process of being updated).

The 2025 audit reviewed 36 DNACPR forms issued during admissions to the ASU and Astley, Ince, Standish and Winstanley Wards. The audit aimed to ensure forms were completed correctly and were valid for their purpose and included patient identification details, clear and valid medical reasons, consultant validation within 24 hours, and communication with patients and relatives. The audit showed that all main demographic details were included, reasons for DNACPR were appropriate, decisions were made by appropriately graded doctors, and all forms were timed, dated, and legible.

We reviewed 27 patient records and found that DNACPR documentation was in place where appropriate, and records were up to date, signed, and fully completed. The service also had a DNACPR policy in place that was comprehensive and within its review date.

The service used the trust’s ‘Think Family Safeguarding Service: Assessment of Mental Capacity standard operating procedure (SOP),’ which included MCA and DoLS guidance and was in date.

There was a policy in place for enhanced observation of patients. Staff we spoke with described an MDT approach to making best interest decisions, which involved clinicians, the safeguarding team, patients, and their families or carers.

Nursing staff were able to give examples of when DoLS would be appropriate and how they would identify and escalate concerns. Staff told us they could escalate concerns to the safeguarding team and senior nurses to obtain accurate advice on MCA and DoLS.