Royal Albert Edward Infirmary

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question good. At this assessment, the rating has changed to requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

There were ongoing shortfalls in staffing levels, training and professional support. Overall mandatory training compliance was below the trust target of 95%. Processes for temporary escalation spaces (TES) were not consistently followed, and some staff were unclear about the required risk assessments in these areas.

However, staff demonstrated a clear understanding of safeguarding processes and how to protect vulnerable people. Incidents were investigated, and learning was shared across teams to reduce the risk of recurrence. Staff monitored patient deterioration using nationally recognised tools and maintained clear, accurate and accessible care records. Most ward areas appeared clean, well-organised and free from clutter.

We have not awarded this service a score for Safe.

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

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to identify and embed good practice.

Staff were supported to report, learn and improve, with systems in place to identify themes, implement actions and embed learning across the service.

Staff raised concerns and reported incidents using the electronic incident reporting system in line with the trust’s policy. Most staff told us they felt safe to speak up without fear of blame and described an open and transparent culture. Concerns were raised proactively to prevent risks, were taken seriously by ward leaders, and staff felt confident to act to prevent harm when immediate risks were identified.

Staff provided examples of reporting incidents and near misses. Ward managers showed good awareness of safety risks within their areas, including the most common incident types, and described how these were monitored and addressed. The service had a structured process to ensure mortality reviews were completed for patients who had passed away whilst in their care.

Learning was shared both locally and across the trust through emails and team discussions. There were no never events reported within medical care services between May 2025 and May 2026. Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them.

Staff demonstrated a good understanding of the principles of the duty of candour (DoC) and described how they were open and honest with patients and their families when incidents occurred. They told us they provided clear explanations, offered appropriate support, and kept people informed throughout the investigation process. At the time of our assessment, the trust had a ‘Being Open / Compassionate Engagement and Duty of Candour’ policy in place that was current and in date. The policy supported a culture of openness, transparency and compassionate engagement, ensuring patients and families were involved in discussions when things went wrong. It also set out clear requirements and timescales for verbal and written DoC notifications, alongside arrangements for follow-up meetings to share the outcomes of investigations and lessons learned.

A recent independent assurance audit reviewed the completion of key fields within incident reporting forms, including the DoC section and supporting evidence. The audit found these were being appropriately completed and monitored. DoC was recorded as completed or not applicable in 96% of incidents. Staff told us they were able to access support when needed and provided examples of this. We also reviewed examples of written DoC communications, which had been appropriately completed and followed up with verbal communication.

Patient safety alerts were displayed in clinical areas. Managers described how these were implemented, monitored and used to direct staff to further guidance. Themes and trends were reviewed collectively rather than in isolation. The most reported incidents were falls, followed by pressure injuries and moisture-associated skin damage. Staff told us oversight and improvement were supported through dedicated groups, including the falls steering group and the skin integrity group.

The trust used an electronic system to monitor safety actions. This supported a coordinated approach to reducing risk and preventing future harm. We reviewed a selection of incidents of varying types and levels of harm and saw evidence that all had been investigated, with learning identified. Actions included additional training for staff, reminders about processes and procedures, and improvements to handover practices. There was also evidence of actions involving the Freedom to Speak Up Guardian (FTSUG) and the patient experience team.

An audit conducted in May 2026 reviewed the use of the system’s action module in relation to patient safety reviews (PSR) and patient safety incident investigations (PSII). This assessed whether actions were completed within agreed timescales, whether appropriate evidence was recorded, and whether clear ownership was assigned. The audit demonstrated improvement in the timeliness of action completion over the previous 6 months. Some actions were overdue, with the earliest due for completion in January 2026, however this represented significant progress compared to earlier audits.

In April 2026, a total of 632 incidents had been reported within the medical division. Of these, 442 had been recorded as investigated, approved and closed with appropriate actions implemented. The remaining incidents were still under investigation. Of the ongoing investigations, 175 related to incidents resulting in no or low harm. Due to the requirement for more detailed review, 15 incidents involving moderate, severe or fatal harm had been escalated to the divisional patient safety reporting group for further investigation.

We reviewed 100 incident notification entries across 11 medical wards and found that all had been investigated. There was evidence of learning and improvement.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work consistently with people and healthcare partners to maintain safe systems of care, monitor people’s safety, or ensure continuity of care during transitions between services.

The service had introduced an ‘accelerated admissions’ process to support patient flow through the hospital. This involved using temporary escalation spaces (TES), either beds or chairs, on some of the medical wards and is an initiative adopted by several acute trusts experiencing high levels of demand for medical beds. The trust used the term ‘safer placement spaces’ (SPS) to describe these areas. This type of care is commonly described as ‘corridor care.’ The trust acknowledged that this approach should not be used as business as usual but said it was intended to reduce the risk to patients waiting for extended periods in the emergency department (ED). Up to 13 SPSs were used across medical wards that included Swinley, Winstanley and Aspull wards, and the Medical Assessment Unit (MAU). The trust had produced a standard operating procedure (SOP) for accelerated admissions which was approved in February 2026 however incident data and staff feedback indicated the practice had been in use for several months prior to this.

The standard operating procedure indicated that the accelerated admissions process would be used when the trust reached operational pressure escalation level 3 (OPEL3) and that SPS should not be counted within the trust’s bed base. However, we were unable to cross reference the SOP with the trust’s full capacity protocol as the existing protocol was 2 years past review date and was under review at the time of our assessment. We found that some staff had limited awareness of the SOP and were unclear about when the process would be triggered and whether SPS were expected to remain part of their usual bed base. In addition, some staff could not describe the exclusion criteria.

Although the SOP referred to individual patient risk assessments and checklists, the trust could not demonstrate that these were consistently completed before patients were placed in TES areas. This reduced assurance that patients were being assessed for suitability before transfer and increased the risk that patients with higher clinical, privacy, infection prevention and control, or end of life care needs could be placed in environments that were not appropriate for them.

Although ward staff could review the electronic patient records of patients due to be transferred into an SPS, some staff gave examples of patients who they felt had been transferred into a SPS inappropriately due to their clinical risks. In one example, a patient had rapidly deteriorated while in an SPS. Staff reported that risks were not always clearly identified or documented prior to transfer, and handovers were described as inconsistent. Staff reported that structured communication tools such as Situation, Background, Assessment, Recommendation (SBAR) were not always used, and electronic records were sometimes incomplete. For example, staff were not always told if patients required catheter care or were awaiting blood test results. Staff had acknowledged that practice had not always been safe or consistent and that, at times, inappropriate patients, including those receiving end-of-life care, had been placed in TES areas. This increased the risk of delayed treatment, avoidable deterioration and poor patient experience.

The SOP referred to the trust’s fire safety team having assessed the viability of SPS on each ward and that some consideration had been given to the implications for infection prevention and control (IPC). However, the trust did not provide environmental risk assessments for each SPS, therefore we could not be fully assured that each SPS had been fully assessed in terms of fire safety, IPC and privacy and dignity.

The trust was unable to provide an audit or formal evaluation of TES use, stating these spaces had been newly introduced in February 2026. However, staff feedback and patient safety data indicated the approach had been in place prior to this.

Patient transfers from the ED and assessment areas were coordinated using real-time bed availability and oversight of expected and confirmed admissions. Structured processes, including daily safety briefings, ward rounds and board rounds, provided oversight of patient flow, bed occupancy and discharge planning. However, some staff told us these processes were not always well understood or consistently effective in maintaining continuity of care and flow. While on site, the patient flow team told us there was scope to increase the volume of discharges through ongoing discharge improvement work. They highlighted ongoing delays with patient transport services (PTS), operated by a separate provider, noting that these delays were occurring even when transport had been booked the day prior. During the assessment, we were given an example whereby 2 of 16 patient journeys had not been arranged on time, despite being booked in advance.

Portering services supported patient transfers and contributed to maintaining patient safety and continuity of care. However, staff in some areas, including the discharge lounge, told us that portering provision had recently been reduced, resulting in delays to patient transfers and impacting flow of discharges.

The service had a comprehensive range of clinical pathways, procedures and policies in use across the medical specialties. These supported referrals, specialist input and senior review, and were aligned with national guidance.

There were clear and well-developed pathways for specific conditions. These included a Greater Manchester stroke referral flowsheet, a chest pain pathway aligned to acute coronary syndromes (ACS) guidance, and a primary percutaneous coronary intervention (PCI) assessment checklist to support rapid identification and transfer of patients requiring urgent specialist intervention. There was also a ‘Treat and Return’ pathway for cardiology patients undergoing coronary angiography.

A Community Assessment Unit (CAU) and Frailty Same-Day Emergency Care (Frailty SDEC) pathway supported the assessment and management of older people living with frailty. When clinicians identified patients presenting with clinical frailty, this could trigger comprehensive geriatric assessment and so ensured patients were reviewed by the appropriate multidisciplinary teams. Staff told us that the Frailty SDEC model was effective in supporting patient flow out of CAU, rather than onward transfer to inpatient wards. The hospital also had a discharge lounge, which supported patient flow by allowing patients to wait for transport or medication outside of clinical ward areas.

There were established policies for the transfer of critically ill patients within the hospital and between NHS organisations. These were comprehensive, up to date and aligned with national guidance. Staff reported that the critical care outreach team responded promptly when needed, typically within 5 minutes. Audit data from the 2025/26 period confirmed that 99% of patients received a timely response from the team, and 75% of referrals were deemed appropriate.

Patient flow continued to be significantly affected by delays in accessing community and domiciliary care. A high number of inpatient beds were occupied by patients awaiting onward care, which impacted the ability to admit new patients and maintain elective activity. There were also high numbers of patients who were clinically fit for discharge but no longer met the criteria to reside, including older people classed as ‘stranded,’ someone who has remained in hospital for 7 days or more (23%) or ‘super stranded’, someone who has remained in hospital for 21 days or more (8%). These challenges were largely system wide. Despite this, staff worked proactively with system partners to manage risks, maintain continuity of care and escalate concerns.

We scored the service as 2. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. However, medical staff did not always keep up to date with training.

The trust’s electronic patient record (EPR) did not include a safeguarding flag function to alert staff, at a glance, to a potential safeguarding risk about the patient. The trust safeguarding lead acknowledged this meant staff needed to proactively look at the safeguarding information tab but felt this was an established process and that flag functions posed governance risks in terms of ensuring information was still relevant.

Due to variations in local authority referral processes, staff were not always able to upload safeguarding referral documents to the electronic system and instead recorded reference numbers in the safeguarding tab on the EPR.

We identified a potential risk of delays in ward staff reviewing safeguarding risks identified in the Emergency Department (ED). In one example, significant safeguarding information was recorded in a patients’ written handover but had not been reviewed by nursing staff when the patient was admitted to the ward due to the capacity of the nursing staff on the bay. We saw the information had also not been added to the safeguarding tab on the EPR prior to the patient’s transfer to the ward. We discussed this with staff during the assessment. Although the case was unusual and time sensitive, this example showed that safeguarding information was not always transferred or reviewed promptly. This could delay protective actions for patients with safeguarding risks

Safeguarding training compliance across the service showed an overall compliance rate across all levels of training of 64%, which was below the trust target. This was primarily because the compliance for ‘Think Family’ safeguarding level 3 package (which covered both adults and children’s safeguarding together) was only 29%. This was raised with the trust during the assessment. Leaders advised this was due to some training modules requiring manual upload and staff needing to complete prerequisite levels 1 and 2 training courses. Leaders provided assurance that staff knowledge and competence had been maintained, supported by high compliance rates with Level 3 safeguarding training.

Safeguarding Children Level 2 had a compliance rate of 91%, while Safeguarding Children Level 1 compliance was lower at 63%, with a small number of staff either not accredited or with expired training.

Data provided for safeguarding adults training indicated high compliance with Levels 3 and 4, whilst compliance with Levels 1 and 2 remained lower. No clear rationale for the lower compliance rates at these levels could be identified from the information available.

Staff demonstrated a good understanding of safeguarding procedures and were confident to use reporting systems to raise alerts and make referrals. They were able to provide examples of occasions where they had escalated concerns appropriately. In the 6 months prior to our assessment, there were 29 safeguarding notifications submitted across 10 medical wards. The primary theme identified, related to patients requiring additional care and support at the point of discharge.

Safeguarding link nurses were established in ward areas. They shared information with ward staff and acted as a point of contact for advice and escalation. The trust had a ‘Think Family’ service comprising 35 staff, including a lead, 4 named nurses (for children, adults, maternity, and children in care), and 2 Independent Domestic and Sexual Violence Advisers (IDSVAs). The safeguarding team provided a weekday duty service offering advice and frontline staff completed their own referrals to local authorities.

All safeguarding-related policies we reviewed were clear and comprehensive.

Data received from the trust after our onsite assessment, indicated an increased level of compliance within the medical division.

We scored the service as 2. The evidence showed some shortfalls. Staff identified and managed risks, but practice was not always consistent. Gaps in monitoring and prevention reduced assurance that risks were always managed effectively.

Staff carried out risk assessments on admission and throughout patients’ stays to identify and manage risks associated with their care. This included assessments for risks such as falls, pressure damage, malnutrition, sepsis, and clinical deterioration. The assessments informed care planning and determined the level of monitoring required. They also supported the involvement of patients and those close to them in identifying and managing risks and promoting safe care delivery.

However, we were not fully assured that all risks associated with patient deterioration and pressure damage were consistently managed. Compliance with observation frequency in line with NEWS2 had improved from 59% in Quarter 2 to 71% in Quarter 3 of 2025/26 but remained below expected levels. The most recent NEWS2 audit identified 1 patient whose observations were not repeated for 8 hours despite requiring closer monitoring, and documentation was poor. This increased the risk of delayed recognition of deterioration and reduced assurance that the patient was receiving safe and effective monitoring in line with their assessed needs.

The service undertook monthly trust-wide sepsis audits and had systems in place to support the identification and management of sepsis, however, we were unable to gain full assurance regarding improvements in compliance. The trust provided sepsis screening and management data covering the period April 2023 to March 2025. The information did not include sufficiently detailed or current audit findings to demonstrate whether areas of low compliance identified during 2024/25, including blood culture completion, had improved. As a result, it was unclear whether actions taken had been effective in improving performance across all aspects of the sepsis pathway.

However, staff demonstrated awareness of the importance of early sepsis recognition and escalation. The service had a comprehensive and up-to-date sepsis policy, sepsis information was displayed in clinical areas to support staff awareness and education, and a sepsis practitioner and sepsis and deterioration champions were available to support escalation and patient management.

The trust’s most recent Accreditation System Providing Improvement and Recognition in the Care Environment (ASPIRE) annual pressure ulcer audit showed compliance had declined from 76% in 2025/26 to 64% in 2026/27. While the number of severe and deteriorating pressure ulcers remained low, variation in lower-category ulcers and deep tissue injuries indicated a need for more consistent implementation of preventative measures, including risk assessments, repositioning, and skin monitoring. Data from April 2026 showed deep tissue injuries were the most frequently recorded form of pressure damage, with the highest numbers reported on Winstanley Ward (6 cases).

However, following our assessment, the trust advised the 2026/27 data did not include all areas covered by the 2025/26 audit programme, as some areas had not yet been audited.

Falls data for April 2026 indicated that most incidents resulted in no harm and only a small number resulted in low or moderate harm. Moderate-harm incidents were rare, with only 2 reported trust-wide. Some areas, including the MAU, Pemberton Ward and Winstanley Ward, reported very low overall incident numbers.

Staff used recognised systems and processes to identify and respond to risks. Staff used the National Early Warning Score (NEWS2) tool to identify patients at risk of deterioration. This included monitoring respiratory rate, temperature, blood pressure and pain scores. An electronic patient tracking system supported this process by alerting staff when observations were due. We reviewed 27 patient records across respiratory, AMU, general medicine and cardiology wards and found mostly good compliance with NEWS2 recording.

The trust’s most recent NEWS2 audit included 13 medical wards and a sample of 100 patients selected from the critical care outreach referral database. The audit focused on patients following cardiac arrest, peri-arrest referrals and those with high NEWS2 scores. It assessed escalation, timeliness of clinical review, clarity of management plans and observation frequency. Overall compliance across medical care services was 91%, demonstrating improvement from the previous year. All patients received a timely response from the parent or on-call team, and nursing teams were compliant with care management plans in 91% of cases. Overall ward performance ranged from 83% to 100%.

The most recent ASPIRE nutrition and hydration annual audit (May 2026) found overall compliance of 72% across the medical division for nutrition and hydration assessments and documentation. Compliance varied significantly across ward areas, ranging from 55% to 90%. This variation indicated that patients were not always receiving consistent assessment, monitoring and documentation of their nutritional and hydration needs. Poor compliance in these areas increased the risk of malnutrition, dehydration, delayed recovery, avoidable deterioration and longer hospital stays, particularly among vulnerable patients and those with complex health needs.

However, most patients and relatives we spoke with told us their nutrition and hydration needs were met. Staff told us protected mealtimes were in place to ensure patients received support with eating and drinking when required.

Staff used nationally recognised assessment and screening tools including venous thromboembolism (VTE) assessments, falls risk assessments and pain assessment tools to support clinical decision-making and identify deteriorating patients. Care records demonstrated clear assessment, evaluation and care planning, and showed most patients were reviewed by a consultant within 24 hours of admission and reviewed regularly thereafter.

The service monitored and recorded pressure damage incidents across the division, including deep tissue injuries, deteriorating pressure ulcers and hospital-acquired pressure ulcers. No medical device-related pressure ulcers were reported, indicating effective management of risks associated with medical devices.

Overall, staff assessed and managed a range of patient risks and had systems in place to support the early recognition of deterioration. Audit data demonstrated generally good compliance with NEWS2 processes and timely clinical responses. However, gaps in observation monitoring, declining pressure ulcer audit compliance, limited assurance regarding improvements in sepsis performance, and inconsistent compliance with nutrition and hydration assessment standards meant the service could not consistently demonstrate that all identified risks were being managed effectively across all wards.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure environment, equipment, facilities and technology supported the delivery of safe care.

Some patients requiring telemetry monitoring (electronic monitoring of heart rhythms and vital signs, with information transmitted to healthcare staff for real-time observation) were cared for on wards outside of the coronary care unit (CCU), resulting in these patients being dispersed across multiple ward areas. Staff were unaware of any coordinated approach to cohort these patients or any formal policy or standard operating procedure to support their management.

Not all ward areas had dedicated quiet rooms available for patients or relatives. In one area, a room designated as a quiet room was being used for storage purposes.

Patients had access to call bells, and staff responded promptly when assistance was requested. However, staff advised that call bell access was not always available for patients located in TESs.

The most recent cleaning and audit data indicated that environments across the medical division were maintained to a reasonable standard, with several areas achieving good or excellent compliance. Hand hygiene, resuscitation equipment, peripheral cannula care, bathrooms and toilets, and furniture all achieved 100% compliance, demonstrating consistent adherence to key cleanliness and safety standards.

However, several areas required improvement. Compliance with personal protective equipment (PPE) requirements was 33%, indicating inconsistent use and an increased risk of infection transmission. Decontamination practices (67%) and waste disposal processes (71%) were below expected standards. General equipment and clinical rooms (both 75%) showed gaps in cleanliness and maintenance, indicating that equipment was not always consistently safe or ready for use. Dirty utility areas (82%) and sharps handling (83%) also required improvement, particularly given the higher risks associated with these areas.

Ward kitchens (93%) and patient areas (89%) were generally clean and well maintained.

Documentation management and linen handling (both 86%) were appropriately managed in most cases. Compliance with isolation procedures (86%) and urinary catheter management (84%) reflected generally good infection prevention and control practices.

Staff disposed of clinical waste safely, and sharps bins were used and stored in accordance with national guidance. Most ward areas were free from clutter, and equipment and consumables were stored appropriately.

The service demonstrated awareness of the additional risks associated with increased patient numbers, including pressures on staffing and the use of mixed-sex accommodation. Measures to mitigate these risks included clear admission criteria and bay-tagging systems to prevent male patients from being admitted to female-designated areas. Separate bathroom facilities for male and female patients were available, and staff understood the requirement to report any breaches of mixed-sex accommodation standards.

Access to all wards was controlled through a secure buzzer and camera entry system. All fire exits observed were free from obstruction, and fire safety equipment was clearly signposted, regularly tested, and maintained. Fire alarms were tested weekly.

Equipment was maintained through a planned preventative maintenance programme in accordance with manufacturer guidance. Staff also completed daily safety checks of specialist equipment. Records reviewed for emergency resuscitation trolley checks were complete, with no gaps identified, and staff reported that trolleys were routinely checked and stocked. Oxygen cylinders were in date and stored securely.

Staff told us they had sufficient and appropriate equipment to provide safe patient care, including resources to support bariatric patients and safe moving and handling practices. Most patients also reported no concerns regarding the equipment used to support their care and treatment.

All wards visited during the on-site visit had sufficient washing and bathroom facilities, including emergency pull cords that were operational. Toilets were clearly designated for male and female patients.

Patient feedback data for the medical division, collected between January 2025 and February 2026 and based on 9,051 responses, showed that 77% of patients provided positive feedback regarding the environment.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. Not all staff had completed required mandatory training, including sepsis, end of life care and understanding consent.

For the 6 months before our assessment, data showed significant staffing shortfalls in several areas, particularly discharge and escalation services. The Discharge Lounge and Brynn North escalation ward recorded the largest deficits, with staffing levels more than 50% below plan in some areas. Other wards, including Shevington, Lowton, and the MAU, also showed notable shortages.

Some areas operated closer to planned levels, such as the ASU and CCU, while a small number, including Orrell Ward and the Virtual Hub exceeded planned staffing levels.

As of May 2026, the medical division employed approximately 753 whole time equivalent (WTE) nursing, nursing support and allied health professional (AHP) staff.

Staffing requirements were calculated using a recognised safer care process. Ward managers held daily safety huddles to review staffing levels, discuss risks, and escalate concerns. They provided examples of how pressures were managed, including reallocating bay responsibilities to maintain safe cover. Staffing information was displayed at ward entrances, showing planned versus actual staffing levels, enabling transparency for patients and visitors. However, the service did not always have sufficient nursing and support staff to ensure patient safety. On the wards we visited, planned and actual staffing levels did not consistently match, which staff reported as a regular occurrence.

A staffing escalation process was in place. When staffing levels fell below requirements, local leads escalated concerns to the on-call manager for medicine. The manager redeployed staff from other wards, requested bank staff, and advertised unfilled shifts. Agency staff were also used and allocated where required. Nurse staffing was recorded as a risk on both divisional and trust risk registers. Staff reported frequent redeployment and concerns that staffing decisions did not always sufficiently consider patient acuity or the number of boarded patients.

Fill rate data describes how many of the planned staffing hours were delivered, with a 100% fill rate meaning wards and units were staffed exactly as planned. Data showed that most shifts were filled, although some wards relied on bank and agency staff. While rotas were often completed in advance, staffing levels did not always reflect requirements based on the patient acuity on the wards. For example, on CAU, staff reported caring for up to 10 patients each, which they felt was unsafe.

Between May 2025 and May 2026, 42 staffing-related incidents were reported across the medical division, with the highest numbers recorded on Winstanley, CCU, and Orrell Ward.

Feedback from patients, relatives and staff indicated concerns regarding staffing levels. Some patients and relatives told us that there were not always enough staff to meet care needs. Staff told us that high workloads and shortages affected their ability to provide good care. Some staff in particular expressed concerns regarding staffing levels within the CAU. This view was shared by the patient flow team, who felt that staffing did not always align with the acuity and complexity of patients being managed on the ward. They advised that this had been raised on several occasions, including during safer staffing reviews the previous year, although it was unclear whether this had been formally captured on the risk register. Staff described the CAU as operating in practice as an additional assessment and patient care area rather than solely as an assessment unit. This meant that patients were frequently assessed, monitored and cared for within the area for extended periods.

However, staff reported that current staffing models did not always reflect this level of activity or acuity, creating a potential mismatch between the demands placed on the unit and the staffing resources allocated to support safe and effective patient care.

Newly qualified nurses were provided with a supernumerary period; however, some reported that they were occasionally included in staffing numbers during periods of short staffing.

Despite these pressures, resident doctors described positive experiences of supervision and support, both in and out of hours. Staff confirmed that revalidation and peer supervision were up to date, and trainees reported they could access guidance when needed.

The service offered a range of professional development opportunities, including preceptorship programmes, apprenticeships, specialist training and postgraduate study. Student paramedics were supported to learn within ward environments, and ward-based training and study days were available.

Sickness absence in the medical division remained above the organisational target for most of the year at 7.0%, although it had improved to 6.0% by March 2026. Long-term sickness was the main reason for absences during this period.

Absence rates between March 2025 and March 2026 varied across staff groups within the medical division. Nursing and midwifery absences had improved, reducing from 8.56% to 7.08%.

Overall staff turnover remained stable and close to targets at 9.0%. However, a higher number of staff left within their first year, with a peak in February 2026. Nursing turnover also improved, and some groups, including AHPs, reported no staff leaving.

Overall mandatory training compliance remained below the trust’s 95% target, at approximately 90% overall. Medical staff overall compliance was significantly lower, around 75%. There were 2,065 outstanding training completions in March 2026, including low compliance in safeguarding, resuscitation and fire safety modules. Personal Development Review completion rates were also low, fluctuating between 72% and 75%.

Vacancy rates showed a slight increase in early 2026, reaching 5% in March. Vacancy levels within AHP and medical staff groups showed improvement over the same period.

Agency and bank staff were frequently used to cover shifts, although senior staff aimed to use regular personnel to maintain skill consistency. Agency staff received an induction, and structured handovers ensured key risks such as deteriorating patients, falls and incidents were communicated effectively.

The trust had plans to reduce agency use in line with national expectations, aiming for zero agency spend by 2029/30.

Staffing levels for unregistered roles such as healthcare assistants was inconsistent, with both surpluses and significant gaps in different areas. For example, Brynn North escalation ward and discharge areas recorded substantial deficits, while several wards exceeded planned activity.

Medical staffing rotas were in place and included out-of-hours cover and staffing levels were appropriate at the time of the assessment. However, some staff reported that they could not always review patients promptly due to their cohort being allocated across multiple wards. This created a risk of delays in assessment and treatment.

Patients reported limited access to doctors at weekends, although medical cover, which included a consultant-level on-call presence overnight, was available.

The service employed 172 substantive medical staff and 52 trainee doctors. The use of locum medical staff remained variable and had increased to 17% in April 2026 during industrial action. Doctors told us they regularly worked more daytime hours than had been planned or rostered, indicating ongoing pressure on services and demand for medical input. In contrast, data showed night-time medical staffing levels were generally closer to those expected and required.

We scored the service as 2. The evidence showed some shortfalls. The service assessed and managed the risk of infection. However, staff did not always follow guidance around hand hygiene and use of personal protective equipment. Routine audits showed poor staff compliance in some infection control standards.

We saw patients with infection risks were appropriately isolated in single side rooms. Appropriate signage was displayed on doors to discreetly alert staff to potential risks and support effective infection prevention and control (IPC) practices.

We saw most staff followed good hand hygiene practice and ‘bare below the elbow’ guidance. However, there were instances of poor hand hygiene and inappropriate use of personal protective equipment (PPE) when staff moved between clinical and utility areas. For example, we observed a member of staff leave a side room, where additional infection control precautions were in place to reduce the risk of infection transmission, while still wearing gloves and an apron. The staff member then used the telephone at the nurses' station without first removing the PPE. On another ward, we observed a clinical member of staff wearing nail varnish. We raised these concerns with staff at the time of the assessment.

The ward environments we visited appeared clean and sanitary. There were sufficient handwashing facilities, including sinks that were adequately stocked with soap and hand towels, and hand sanitiser dispensers. PPE was readily available across all ward areas. We spoke with patients and relatives about ward cleanliness. None that we spoke with raised concerns regarding IPC.

We observed that equipment was clearly labelled to show it had been cleaned, with staff routinely using ‘I am clean’ stickers to support this process.

Staff were required to complete mandatory IPC training. Data reviewed for March 2026 across nursing staff in the medical division, which included respiratory, stroke, cardiology, endoscopy and care of the elderly, showed compliance rates of 93% for IPC level 1 and 86% for IPC level 2, against a trust compliance target of 95%. There were 157 staff non-compliant with training requirements, and 31 staff had never completed the training. This meant the service could not demonstrate that all staff had received the mandatory training necessary to support safe practice and mitigate risks to patients.

We reviewed IPC audit results across multiple wards between April 2025 and June 2025. Most wards demonstrated good standards of cleanliness and infection control, with audit scores ranging from 80% to 94%. Action plans had been completed consistently, and follow-up processes were in place to monitor improvement. We saw evidence that action plans had been completed across all areas, indicating that identified issues had been addressed in a timely way.

A small number of wards initially scored lower and required targeted improvement work before achieving higher standards on re-audit. At the time of audit, most wards demonstrated consistently strong performance, including Astley (92%), ASU (92%), CCU (92%), Pemberton (93%), Shevington (94%) and Standish (93%).

However, trust ASPIRE infection control insight data for the medical division (produced on 27 May 2026 for the 2026/27 period) showed an overall compliance rate of 72%, which did not meet the trust target. Compliance for ‘all staff adhering to the five moments of hand hygiene’ had decreased to 60%, from 75% in 2025/2026. Compliance for ‘PPE worn and removed appropriately in line with current guidance’ was 40%, reduced from 50% in 2025/2026. Winstanley ward showed the lowest compliance at 47%, down from 81%.

Where follow-up audits had been undertaken, there was evidence of improvement. For example, Ince Ward had improved from 84% to 97%, Lowton Ward had improved from 80% to 95%, and MAU had improved from 81% to 96%.

The service had an up-to-date Standard Operating Procedure (SOP) for Aseptic Non-Touch Technique (ANTT) for clinical aseptic procedures. However, the Standard Infection Prevention and Control Precautions Policy had not been reviewed in line with the service's review schedule and was 10 months overdue at the time of the assessment.

Medical wards used standardised daily cleaning schedules and checklists, which provided instructions for cleaning responsibilities. Staff attended daily safety huddles where IPC was a standing agenda item. The service had an identified IPC lead who provided support and advice on infection risks, outbreaks and safe management. The lead was involved in audits, training and risk assessments.

We observed cleaning staff working on the wards during the assessment. Cleaning records were up to date and demonstrated that areas were cleaned regularly. Ward noticeboards displayed IPC guidance, including best practice information, infection rates and audit compliance data.

The service monitored key infection metrics, including methicillin-resistant Staphylococcus aureus (MRSA), Escherichia coli (E. coli), and Clostridioides difficile (C. diff).

Data relating to C. diff infections across the organisation showed that, during the 2025/26 period, there were 77 cases across the trust, exceeding the national target threshold for the trust (set by NHS England) of 62 cases. This indicated that the organisation had not met expected targets for reducing infection rates.

Of these, 25 cases were attributed to medical wards, demonstrating that inpatient areas continued to contribute a significant proportion of hospital-acquired infections. Astley, Lowton and Orrell Wards each recorded 4 cases, Pemberton Ward recorded 3 cases, MAU recorded 2 cases, and Ince, Shevington and Standish Wards each recorded 1 case.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

We reviewed medicines records for 16 patients and spoke to ward managers, nursing staff and members of the pharmacy team. The wards were supported by the pharmacy team 5 days a week, Monday to Friday to undertake medicines reconciliation when patients were admitted to the ward, review patients’ medicines, speak with patients about their medicines if needed and facilitate discharges.

Medicines reconciliation is the process of accurately listing a person’s current medicines. Medicines reconciliation rates supplied to us by the trust showed only 44% of patients having this completed within the first 24 hours and 73% of patients within 48 hours (latest data provided from April 2026). The National Institute for Health and Care Excellence (NICE) recommends that inpatients in an acute healthcare setting have their medicines reconciled within 24 hours of admission. This is to reduce the risk of medicine errors occurring. To address this, the pharmacy department had a clear staff rota to ensure that pharmacy support was available to wards, and an active improvement programme to improve the processes and medicines safety. A prioritisation system was in use by the pharmacy team to help identify and prioritise patients requiring medicines reconciliation and ongoing reviews and monitoring.

Records of fluids given were not always complete and accurate. We also found inconsistent records of thickening powder being added to drinks for people with swallowing difficulties. This meant we could not be assured that people’s drinks were always prepared to the correct consistency. This increased the risk of choking, aspiration and avoidable deterioration for patients who needed modified fluids.

We saw that in most instances, time critical medicines were given on time. A safety improvement programme was being undertaken by the pharmacy department to improve this further.

Risk assessments for venous thromboembolism (VTE) were completed promptly and medicines were prescribed appropriately.

Patients’ allergy status were recorded on all medicine records.

We saw evidence that when rapid tranquilisation (an injectable medicine to help calm a person who is distressed) was required, staff followed guidance from NICE on monitoring and observation following rapid tranquilisation.

Although oxygen prescribing had improved at the trust, we found some instances where oxygen had not been prescribed. This increased the risk that patients might not receive oxygen therapy in line with their clinical needs or that staff may not have clear instructions about the correct target oxygen saturation range.

Medicines including controlled drugs and intravenous fluids were stored securely. Temperatures of treatment rooms where medicines were stored and medicine fridges were monitored regularly to ensure they were kept according to manufacturers’ guidance.

Ward staff knew how to obtain medicines that were not routinely stocked on wards and out of hours.