Royal Albert Edward Infirmary

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This meant we looked for evidence that the service met people’s needs.

At our last assessment we rated this key question good. At this assessment, the rating has changed to requires improvement. This meant people’s needs were not always met.

The service generally responded to people’s needs and supported timely access to care. Most patients told us staff listened to them, involved them in decisions about their care, and provided clear information regarding treatment and discharge arrangements. Staff used structured processes during board rounds to identify individual priorities, monitor progress, and plan care effectively. Patients with additional communication needs were supported through access to interpreters, translation services, and communication aids to help them understand their care and make informed decisions.

However, responsiveness was not consistent across all wards. Some patients and families told us they had not received regular updates. Although specialist services and referral pathways were available, delays and inconsistent involvement of specialist teams sometimes affected the timeliness of care and discharge planning for patients with more complex needs.

Staff and patients reported that the continued use of escalation beds had negatively impacted patient experience. Patients who were cared for on wards outside their specialty area, including surgical wards, did not always receive specialist review and support as promptly as expected. This had the potential to affect the continuity of care, delay specialist input, and impact patient flow.

We have not awarded this service a score for Responsive.

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

We scored the service as 3. The evidence showed a good standard. The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Patients told us that staff had listened to them and had taken time to understand what mattered most during their stay. They described staff as attentive and said conversations had been held in private, which helped to maintain their dignity and confidentiality. Families had been involved where patients wished this, and end of life discussions, including do not attempt cardiopulmonary resuscitation (DNACPR), had been conducted sensitively in line with patient preferences.

Staff had used structured tools during board rounds to identify individual priorities and ensure care had been coordinated. Pathway reviews confirmed that patients with complex needs, such as cognitive impairment or frailty, had been referred appropriately to therapy teams, occupational therapists and palliative care services. Staff told us they supported patients to understand their diagnosis, treatment options and follow-up arrangements, however feedback from some patients indicated that they were unaware of the plans in place for their care.

A review of learning disability and autism training compliance showed overall compliance for the eLearning component was 75%, below the expected standard. Face-to-face training compliance was 16%. Staff leads advised that work was underway to implement ‘Happy Smiles’ training to improve staff awareness of learning disabilities and autism. The trust had also undertaken an independent review of learning disabilities and neurodivergence in 2025 and reported that work was in progress to implement the recommendations to strengthen practice and improve patient outcomes.

Care had been delivered in a way that was responsive to individual needs. Reasonable adjustments had been provided on a patient-specific basis. These included access to specialist equipment, personalised information and documentation, and the provision of quiet or low-stimulation environments. We saw evidence that patients’ impairments and specific requirements had been documented within personalised care plans and nursing records to support continuity of care.

Staff had access to appropriate communication support. This included face-to-face and on-demand video remote British Sign Language (BSL) interpreters, as well as portable hearing loop systems across services.

Services had been adapted to support patients with learning disabilities. Patients were encouraged to bring a hospital passport to share important information about their needs and preferences. Where this had not been available, staff had provided a blank passport and supported completion with the patient and/or carer. The trust’s safeguarding team and community learning disability team were notified when patients with a learning disability had been admitted to ensure appropriate oversight and support.

The trust had an ‘All Age Learning Disability and/or Autism Policy’ that was in date. Link nurses were in place across specialties, including mental health, physical disabilities, autism, dementia and bariatric care.

Data from the most recent ‘Accreditation System Providing Improvement and Recognition in the Care Environment’ (ASPIRE) audit showed the average score for person-centred care across medical wards had been 87%, with Astley ward scoring 92%.

A corporate ‘Reasonable Adjustment Task and Finish Group’ had been established in December 2025 to strengthen the delivery of person-centred care. The group had met monthly and included both internal and external stakeholders, including representatives from the Royal National Institute of Blind People (RNIB). Its work had focused on improving identification of patients who required reasonable adjustments, strengthening recording systems, enhancing staff training and awareness, and improving processes for implementation and audit.

The trust had a service user strategy in place that included training and resources to support staff in meeting the needs of patients who were deaf or had reduced hearing. Staff demonstrated an understanding of the communication needs of people with disabilities or sensory loss. We saw communication boards being used on wards, alongside posters providing staff with information on easy-read resources and online tools using images to support communication.

We scored the service as 2. We scored the service as 2. The evidence showed some shortfalls. There were some shortfalls in how the service understood the diverse health and care needs of people and their local communities, so care was not always joined-up, flexible or supportive of choice and continuity.

Systems and processes did not always ensure continuity, coordination and oversight of care when responsibility transferred between services. Staff described challenges when arranging ongoing care for patients who lived outside the local area, as differing referral criteria, documentation requirements and variations in community service capacity sometimes delayed onward care and discharge arrangements.

Staff told us that patients generally received appropriate clinical assessment and care planning. However, challenges with patient flow, escalation processes, coordination with external providers and the underutilisation of alternative care pathways meant continuity and integration of care were not always consistent.

The trust had a full capacity protocol in place, but this had been due for review in 2024. At the time of our assessment, the trust was in the process of replacing this with a new trust escalation procedure. Development of the first version had commenced in November 2025 and remained within the approval process. As a result, the trust could not demonstrate that the revised escalation arrangements had been fully implemented or embedded in practice, and we were unable to confirm whether the proposed procedure accurately described escalation processes.

Staff and managers told us that patient flow within medical services remained challenging due to consistently high bed occupancy and limited inpatient capacity. Leaders described actions being taken to address these issues, which included reviews of ward configurations. The service had implemented several initiatives, including the Medical Receiving Unit (MRU), with the intention of supporting timely assessment, treatment and discharge, and improving patient flow through the hospital. However, during our assessment we observed examples of patients remaining in the MRU for longer than the unit's intended purpose. Similar issues were evident within other assessment units such as Lowton Ward, which appeared to function in a similar way. Poor patient flow meant that these areas were not consistently able to operate as designed.

We also found instances where patients experienced multiple ward moves during a single admission. For example, patients could be transferred from the MRU to an assessment unit, then to another inpatient ward before finally reaching the appropriate specialty ward. These multiple transitions increased the risk of fragmented care planning, reduced continuity of care, and staff told us this created the potential for delays in communication and decision-making between teams.

Patients had access to a virtual ward service, which supported personalised care by enabling some patients to receive acute monitoring and treatment within their own homes rather than being admitted to hospital. The service supported both admission avoidance and earlier discharge for patients and provided care for up to 14 days, alongside a 72-hour rapid response pathway where admission became necessary.

However, performance data demonstrated that virtual ward occupancy rates had generally remained lower than those of comparable services during the previous year, even though the trust had higher overall capacity. Leaders acknowledged that the service was underutilised and told us that redesign work was underway. This included engagement with frontline staff from a range of specialties to ensure the model was safe, effective and met the needs of patients.

The service also operated a community-based fracture liaison service, which offered advice and triage for both routine and urgent referrals. Clear referral pathways, eligibility criteria and guidance regarding required investigations were available to primary care clinicians.

We reviewed 10 patient records across 4 medical wards to assess the quality and continuity of care planning and clinical review. Records demonstrated that patients had generally received timely consultant reviews within the medical division.

However, staff described ongoing challenges with the timely completion of discharge letters. Although discharge documentation was expected to be completed before 1:00pm, staff told us this was often delayed due to ward rounds and competing clinical priorities. These delays resulted in some patients missing patient transport service (PTS) collections and care package cut-off times, which in turn delayed discharge. Staff reported that this issue had been escalated on several occasions. While divisional leaders had issued reminders to support earlier completion of discharge documentation, staff felt there had been limited improvement.

Stakeholders and partner organisations described positive working relationships between acute, specialist and community services, and gave examples of effective collaboration to support patient care across organisational boundaries.

We scored the service as 2. The evidence showed a shortfall. Although staff had access to appropriate communication resources and generally supported patients and relatives to understand their care, information was not always communicated in a timely, consistent or effective way.

Patients did not always receive clear information about their care, treatment plans, expected length of stay or discharge arrangements.

The Accessible Information Standard (AIS) is a legal requirement introduced in 2016 to ensure that people with a disability, impairment or sensory loss receive information they can access and understand, and that any communication support needs are identified, recorded and met. The service was compliant with the Accessible Information Standard. Staff had access to a trust-wide interpretation and translation service, supported by an up-to-date policy which provided clear guidance on how to obtain this support.

We saw notice boards across the medical wards containing information for staff, patients and visitors. Information leaflets were readily available and could be provided in different languages or alternative formats, including braille and easy-read versions, where required. Staff had access to a range of communication resources, including communication books, picture-based materials and QR codes which could be scanned to access additional information. Information relating to the medical wards had also been available on the trust’s website.

Staff we spoke with knew how to request verbal and written interpretation services, including British Sign Language support. The trust’s website had been accessible in over 200 languages and included tools to adjust text size to meet individual needs.

Although patient information leaflets were readily available, some leaflets had exceeded their review dates and required updating to ensure patients and relatives had access to the most current information. Medical division compliance data from March 2026 showed that only 62% of patient information leaflets were within their review date. Examples of out-of-date leaflets identified included ‘Reducing the Risk of VTE (Blood Clots) Version 8’, which had expired in March 2025, and ‘Taking Strong Opioids (Painkillers) for Pain Control Version 5’, which had expired in July 2025.

Most patients told us they had been involved in planning their care. Most relatives said they had received updates regarding changes to care either during visits or by telephone. One patient commented, “if I have any questions, staff always answer them or go away and come back and find out the answer.”

However, some patients reported they had not always received clear explanations regarding their plan of care, expected length of stay or the next steps in their treatment. One patient told us, “I feel I have been here for days with no further information,” whilst another said, “The doctors seemed too rushed to give you any information; it is very frustrating.” This feedback indicated that information was not always communicated consistently or in a way that met patients’ needs.

The ‘standard operating procedure (SOP) (Appendix 4) for Temporary Escalation Spaces (TES)’ stated that a letter should be provided to patients and their families explaining their placement within these areas. However, we did not see evidence of this process being consistently implemented during our assessment, and no patients or relatives we spoke with reported receiving this information. This meant patients and families may not always have received timely information to support their understanding of the care environment and ongoing care arrangements.

Work undertaken in relation to patients experiencing prolonged lengths of stay identified that some had not received sufficient consultant or senior clinical review. This was reported to have contributed to delays in progressing discharge plans. Evidence indicated that patients were regularly reviewed by registrars but were not consistently seen daily by consultants, this meant patients did not always have up to date information from the doctor leading their care.

However, we saw examples of staff communicating effectively with patients and relatives. For example, we saw a doctor explain investigation results and next steps clearly and sensitively to a patient and their relative. The doctor was polite, informative and allowed sufficient time for questions. When the patient raised a query regarding medication on discharge, the doctor provided an initial explanation and appropriately contacted the pharmacy team to arrange further support.

We also saw a pain specialist nurse clearly explaining medication and next steps in a patient’s treatment. The nurse allowed the patient time to ask questions and supported them to make an informed decision in line with their preferences and treatment goals.

Records and patient feedback demonstrated patients had been provided with information relating to medicines, discharge arrangements and follow-up care prior to leaving hospital.

We scored the service as 3. The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

The service had sought feedback through a range of methods, including informal conversations, surveys and comment cards. Patients told us they had been informed about how to raise concerns and felt confident that staff would listen and respond appropriately. Staff described how learning from complaints and compliments had been shared within teams to support improvements, and patients reported that positive feedback had been recognised and valued.

Staff protected the rights of patients subject to the Mental Health Act 2005 and followed the code of practice. During handover meetings, staff routinely reflected on patients’ psychological and emotional needs, as well as those of their relatives and carers.

People and their families had been encouraged to share feedback about their care and told us they felt listened to when concerns were raised. We saw evidence of this in practice. For example, following a formal complaint from a patient’s family member regarding insufficient therapy input after a ward had transitioned from a surgical ward to a medical ward, the service had responded promptly. A joint review identified that therapy provision had not adequately met patients’ needs. As a result, action had been taken to improve the service, which included the frailty therapy team assuming responsibility for delivering care. Staff had maintained open communication with the family member and provided updates on the actions taken and the family member reported satisfaction with the outcome, which demonstrated that concerns had been listened to, acted upon and used to drive meaningful change.

We saw posters displayed across wards providing information about how to access the Patient Advice and Liaison Service (PALS) and how to make a formal complaint.

Staff understood the complaints policy and knew how to manage concerns appropriately. Ward managers demonstrated a good understanding of how complaints were reviewed, investigated and fed back. They were able to describe common themes and the improvements made as a result.

The service had a Patient Advice and Liaison Service (PALS) and complaints handling policy in place, which was in date. During the previous 12-month period, 283 formal complaints had been opened, of which 239 had been closed.

The complaints policy outlined a target to respond to formal complaints within 25 working days of receipt.

There had been a 32% increase in complaints within the medical division, rising from 31 in February to 41 in March. Despite this increase, complaint handling activity had improved. Complaint closures had risen from 28 in January 2026 to 36 in March 2026, representing a 28% increase. As a result, the division achieved a complaints performance rate of 60% in March compared to a trust-wide performance of 76%.

During our assessment, we reviewed 3 recent complaint responses completed by the division. These included appropriate apologies, and the complaints had been thoroughly investigated by relevant staff, such as a lead nurse, with oversight from the divisional director of nursing. Where complaints had been upheld, responses included clear action plans and identified learning.

All complaint responses provided information on how to arrange a local resolution meeting (LRM) with service managers if required. They also included details on how to escalate concerns to the Parliamentary and Health Service Ombudsman (PHSO) if complainants remained dissatisfied, as well as an option to provide feedback on their experience of the complaints process.

The service recorded lessons learned from complaints. Improvements had been identified in areas such as communication, including providing clearer information to patients, managing expectations regarding referrals and waiting times, and ensuring learning was shared more widely across teams.

Leaders routinely reviewed patient experience data, demonstrating that themes from complaints were monitored and used to inform ongoing improvement work within the medical care service.

The trust had also implemented ‘Martha’s Rule – Adults Standard Operating Procedure’ documentation, with the next review scheduled for 2029. Martha’s Rule is a patient safety initiative to support the early detection of patient deterioration by ensuring the concerns of patients, families, carers and staff are listened to and acted upon. The hospital was one of 143 pilot sites for Martha’s rule with the initiative being in place at most of these by March 2025.

We found the service had established clear processes to support patients, relatives and carers to raise concerns about a patient's condition. The critical care outreach team (CCOT) acted as the first point of contact for all escalations made under Martha’s Rule. To support the implementation of the programme and meet component 1 of Martha’s Rule guidance, a patient wellness questionnaire was introduced, enabling patients to share their views about their wellbeing and any concerns regarding their condition.

We saw evidence that wards displayed Martha’s Rule banners. These provided information to patients, families and carers about how they could escalate concerns if they believed a patient’s condition was deteriorating.

The trust monitored the implementation of Martha’s Rule and reported that, between June 2025 and April 2026, it received 24 telephone calls from patients, relatives, and carers. None of these contacts required escalation of care under Martha’s Rule, and none met the criteria for a formal Martha’s Rule escalation. Instead, the concerns raised were primarily related to care quality, discharge planning, and communication. This indicated that patients and families were aware of the available channels for raising concerns and seeking support when needed. However, it also highlighted the need for further work to ensure that patients and families had a clear understanding of the purpose and scope of the Martha’s Rule initiative.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that people could access the care, support and treatment they needed when they needed it.

The trust was among the lowest-performing organisations for delayed discharges. However, the trust was unable to provide audit data or evidence of oversight and improvement actions relating to delayed discharges at ward level within the medical division, as this was not routinely monitored. As a result, there was limited assurance that delays were being systematically reviewed, and that opportunities to identify, address and learn from issues were being effectively acted upon.

Ongoing capacity pressures affected patient flow through the medical pathway, which resulted in delays in patients accessing the right care, in the right place, at the right time. This impacted the trust's ability to ensure equitable access to services.

Patients did not always experience a consistent discharge pathway. Staff described variation in how the discharge lounge was utilised, with decisions regarding access based on individual clinical judgement rather than clearly defined and standardised criteria. As a result, patients did not always have equitable access to the same discharge environment and support processes.

Staff also reported that the discharge lounge was frequently used overnight as an escalation area due to capacity pressures and was often staffed by bank and agency nurses. Staff told us that some agency staff were not familiar with the needs and complexity of all patients accommodated there. The use of the discharge lounge in this way reduced its availability for its intended purpose the following day, as patients required transfer back to inpatient wards before discharge processes could continue. This created delays in patient flow and increased the risk that patients ready for discharge could remain in hospital longer than necessary.

The service's arrangements to improve discharge planning were not consistently embedded across all areas. Staff described challenges with consultant engagement in discharge planning processes and further intervention from senior leaders had been required to improve participation. While discharge planning huddles and whiteboard processes had been implemented across several areas, including MAU, Ince and Winstanley Wards, adherence remained inconsistent on some wards and required ongoing oversight and support. This meant that patients did not always receive a consistent discharge experience, with arrangements varying according to the ward in which they were cared for.

Workshops had identified a lack of clarity regarding the roles and responsibilities of teams involved in discharge planning, including the transfer of care hub, integrated discharge teams and family coordinators. In addition, we identified gaps in staff knowledge and understanding of discharge processes among some nursing staff during the assessment.

We requested information about the number of patients placed on wards that were not best suited to meet their needs (referred to as outliers). During periods of escalation, the bed escalation plan was activated to open up to 8 additional medical beds within surgical areas. Nursing care was provided by surgical staff while medical oversight remained with the general medical team. Managers told us they had taken steps to minimise the number of medical patients placed on non-medical wards and had arrangements in place for the medical review of these patients. However, due to sustained capacity pressures, this had not been consistently achieved. At the time of our assessment, medical staff reported that 10 medical patients were being cared for on surgical wards.

Staff told us the expected maximum number of medical outliers was 8 patients per day, based on available consultant cover. This limit was exceeded during our assessment and on several occasions during the preceding 6 months.

In the 6 months prior to the assessment, a total of 617 medical outliers had been recorded, with an overall average of 4 per day. Although there was an overall reduction in outlier numbers, decreasing from a peak of 161 in November to 66 in February, figures had risen slightly in March and April. Despite this improvement, the service continued to exceed the locally agreed threshold on occasions, indicating ongoing pressures relating to capacity and patient flow.

Staff caring for medical outliers reported difficulties contacting the on-call specialty consultant or medical teams via the switchboard despite an agreed escalation process being in place.

Staff told us that discharge delays were primarily due to a lack of suitable care placements and patients with complex social needs. At the time of our assessment, key contributing factors included limited availability of home-based and bed-based rehabilitation and reablement services, delays in pathway decision-making and outstanding referrals.

We reviewed data from May, which showed that delays for patients recorded as having no criteria to reside (meaning they were medically fit to leave hospital and no longer required an acute hospital bed) ranged from 7 hours to 23 days.

The most recent NHS England data for 2025 indicated the trust had been operating at high bed occupancy levels, estimated at around 90% to 94%, with general and acute beds frequently exceeding 92%. This was above the 85% level generally considered safe and indicated sustained operational pressure. Trust board papers suggested an approximate 2% improvement in this metric in June 2026.

Between May 2025 and April 2026, patients' lengths of stay varied across ward areas, with no consistent improvement over time and evidence of worsening performance in several wards during early 2026. The acute stroke unit on Billinge and Standish Wards consistently recorded the longest lengths of stay, typically between 12 and 18 days, increasing to 34 days in April 2026. Standish Ward also showed sustained long stays, increasing to 24 days in April 2026. Orrell Ward increased from 4 to 15 days, and Pemberton Ward had risen to 15 days in March and April 2026. In contrast, coronary care, the MAU and Lowton Ward generally maintained shorter lengths of stay between 2 and 6 days. During the assessment, patients' lengths of stay on Lowton Ward ranged from 6 to 18 days.

This variation indicated ongoing pressures in patient flow and discharge processes, with delays concentrated in specific ward areas. Staff told us these pressures reduced bed availability for new admissions and meant not all patients had equitable access to specialist wards designed to provide ongoing medical care.

Astley Ward staff told us that approximately 6 patients had been medically fit for discharge but remained in hospital due to delays in accessing community or social care support. This contributed to extended lengths of stay and ongoing pressure on bed capacity.

The service had introduced a range of processes intended to improve future care planning and reduce discharge delays, including escalation arrangements for patients who were medically fit for discharge, daily transfer of care huddles and a complex discharge panel for patients with prolonged lengths of stay. Length of stay reviews were undertaken through local governance meetings and performance was benchmarked using national data.

The bed management team maintained oversight of confirmed and potential discharges, supported by twice-daily reviews from the discharge management team. Ward-based discharge liaison officers, therapy teams and the patient flow team worked collaboratively with community partners to support discharge, rehabilitation and continuity of care, helping to reduce the risk of readmission.

Staff demonstrated awareness of the challenges faced by patients and communities, including language barriers, sensory impairment and digital exclusion. Interpreters and communication aids were available where required, and written information could be provided in accessible formats.

The service also considered the needs of the armed forces community. Staff told us they had received awareness training to support understanding of military culture and the potential impact of service-related issues on patients and families, helping to promote inclusive and equitable access to care.

Transport arrangements were in place to support transfers to and from virtual wards, helping to ensure patients with limited mobility or reduced personal support were not disadvantaged. Review meetings monitored compliance with service level agreements for timely assessment, demonstrating oversight of access performance.

Patients told us they had been able to access care when needed and did not feel discriminated against or delayed due to personal characteristics.

We scored the service as 2. The evidence showed some shortfalls. Staff and leaders did not always actively listen to information about people who are most likely to experience inequality in experience or outcomes. This meant people’s care was not always tailored in response to this.

Staff within the service demonstrated they understood the communities they served and who were most likely to experience inequality in experience or outcomes within their community. We spoke with patients from a variety of backgrounds who did not describe experiencing inequality or discrimination on account of their protected characteristics.

The trust’s clinical strategy recognised that a significant proportion of the local population lived in areas of high deprivation and experienced poorer health outcomes and barriers to accessing care. These barriers included geographical challenges, digital exclusion, low health literacy, and increasing levels of acuity and complexity. Senior members of staff demonstrated an understanding of how these factors contributed to health inequalities.

There was evidence that the service did not actively seek out people who are most likely to experience inequalities or review if their outcomes were different from others, and so these considerations were not embedded across all activity. Friends and Family Test (FFT) data did incorporate some protected characteristics information within its standard question set. However, we were provided recent analysis of this data which did not demonstrate any consideration for inequality in patient experiences or outcomes, instead looking at trends in overall responses.

Compliance with equality, diversity, inclusion and human rights training was strong overall. Within the medical care division, 94% of staff were compliant against the trust target of 95%.

Staff were able to describe the processes in place to embed equity and confirmed they did not discriminate when making care and treatment decisions, including on the grounds of protected characteristics in line with the Equality Act 2010.

Staff gave examples of how they respected the individual wishes of people with protected characteristics. This included supporting patients with disabilities, mental health needs, and those with communication or language difficulties to ensure their preferences and needs were appropriately met.

We reviewed trust documentation that contained equality impact assessments (EIAs), which were appropriate for the content. However, we noted local documentation did not always demonstrate due regard to equalities considerations in line with the general duty of the equality act, such as local clinical guidelines or departmental standard operating procedures.

We scored the service as 3. The evidence showed a good standard. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

We observed that staff planned and considered care and treatment plans, including transfer or discharge arrangements for their patients, which included the completion of Situation, Background, Assessment and Recommendation (SBAR) forms for each ward admission.

The service supported people to plan for their future care needs, including discussions about treatment preferences and escalation of care. Staff recorded these discussions appropriately and care plans were visible within clinical records to inform multidisciplinary decision-making. Advance care plans were used for patients receiving palliative and end of life care, and staff followed the ‘Signs, Words, Actions, and Needs’ (SWAN) model to promote dignity, respect and compassion. Staff described how they had supported prompt discharges for patients wishing to receive end of life care outside of hospital. Specialist palliative care, bereavement, counselling and multi-faith chaplaincy services were available to support patients and those close to them.

Staff we spoke to were familiar with end-of-life processes, in line with effective trust policies for care in the last hours of life and after death. There were also rapid discharge procedures in place to ensure that patients who wanted to receive end-of-life care in their preferred location, such as their home, could do so.

Quality matron checks for end of life care included reviews of SWAN resources, such as end of life boxes, spiritual care boxes and individualised care plans. Audit findings showed a compliance rate of 97% across the medical wards visited. All staff were able to recognise and manage end of life symptoms and knew how to access additional resources and services. Staff told us doctors were readily available for medical reviews and escalations when required. A range of supportive resources were available for patients and families, which included faith boxes, knitted hearts, fingerprint keepsakes and hair lockets.

We observed care records where patients had Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) documentation in place, and where a DNACPR decision had been agreed with a family and patient during care. Patient record systems flagged DNACPR decisions from the point of triage, and patient information boards in each bay were also used to highlight if the patient was approaching the end of life. The records we observed were all current, complete and documented involvement from the patient or their relatives or carers as part of the process.