Royal Albert Edward Infirmary

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that leadership, management and governance supported high-quality, person-centred care, learning, innovation and an open culture.

At our last assessment, this key question was rated good. At this assessment, the rating has changed to requires improvement. This meant governance and oversight processes were not consistently effective in identifying, monitoring and addressing risks across the service.

Staff generally described ward leaders as visible, approachable and supportive, and felt able to raise concerns. However, governance processes were not consistently embedded, resulting in variation in oversight and follow-up across wards and departments. We found out-of-date policies and patient information leaflets, and audit action plans that lacked clear ownership, timescales and evidence of completion. This limited leaders' ability to demonstrate that risks and quality concerns had been effectively addressed.

Staff participated in quality improvement initiatives and learning from incidents was shared. However, leaders could not always demonstrate that improvement actions were consistently implemented or resulted in sustained improvements.

Ongoing bed pressures, discharge delays and breaches of medical outlier thresholds showed that challenges relating to patient flow remained. Overall, while leaders were committed to improvement and staff spoke positively about local leadership, governance and oversight arrangements did not always provide effective assurance that high-quality, person-centred care was being delivered consistently.

We have not awarded this service a score for Well-led.

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

We scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The trust had produced ‘Our Strategy 2030’, a strategic plan for the decade 2020-2030, which consisted of priorities and themes intended to guide how services should develop. Leaders told us the strategy had been co-produced with stakeholders and was used to inform annual objectives. However, because the strategic plan was developed 6 years ago and was since unmodified, its aspirations were not always reflective of the current healthcare context.

The trust’s overarching objectives were aligned to this vision and focused on delivering safe, personalised and compassionate care, creating an inclusive and people-centred working environment, and improving outcomes for the local community.

A People and Culture Strategy (2025–2028) was in place, setting out shared values including putting people at the heart of care, listening and involving others, being kind and respectful, and working as one team. Leaders told us these values were embedded through staff engagement initiatives and leadership behaviours.

A divisional people plan for 2026/27 had been implemented that was linked to trust corporate objectives and values and developed based on staff survey responses. It recognised staff health and wellbeing as a priority and included actions to improve absence due to sickness, provide wellbeing support, and reduce burnout. It also focused on strengthening staff development through appraisals, succession planning, and apprenticeship opportunities. Leaders had also prioritised inclusive engagement with actions to improve positive staff recognition and increase opportunities for feedback through listening events. We saw how the people plan was being implemented, with quarterly areas of focus.

Staff we spoke with were mostly positive about the culture within their immediate work environment and described effective teamwork across services. Most staff reported that they felt respected and valued by their direct line managers and spoke positively about local leadership. Staff consistently described themselves as motivated, committed and passionate about delivering high-quality patient care.

Staff told us that teams worked collaboratively and supported one another during periods of increased demand and staffing pressures. They described a culture of mutual support within clinical teams, which helped maintain patient care despite operational challenges. However, while the culture within individual teams was largely positive, this was not always reflected consistently across the wider service.

There was evidence of a shared understanding of organisational priorities across the trust and within the medical division. Leaders told us that divisional priorities were aligned with the trust’s strategic objectives, including improving population health, enhancing partnership working, and embedding the principle of ‘right patient, right team, right place, first time.’ Staff were able to describe these priorities and how they contributed to improving patient care.

The trust had also developed a ‘Live Well and Urgent and Emergency Care People Plan,’ which outlined a phased approach to workforce and cultural improvement. The programme set out clear workstreams, milestones, and timelines between October 2025 and April 2026. Early priorities focused on improving staff wellbeing, reducing absence, supporting staff through training and appraisal, and sharing staff survey results to inform action planning. Later phases aimed to strengthen engagement with equality, diversity and inclusion networks and to support service development.

Leaders promoted a culture of collaboration and multidisciplinary working. This was reflected in improvement programmes such as the inpatient flow initiative, which emphasised team-based approaches, shared accountability, and coordinated patient care. The development of shared performance frameworks and common priorities across operational, nursing, and medical teams supported a consistent and aligned approach.

However, some improvement programmes were at an early stage of implementation. While there was a clear shared direction and intent, there was limited evidence at the time of the assessment to demonstrate that all initiatives had been fully embedded or were consistently delivering sustained improvements across the division.

We scored the service as 2. The evidence showed shortfalls. Over the previous 12 months, there had been significant changes within senior leadership and divisional structures, with several leaders newly appointed and a number of key leadership posts vacant. As a result, leadership approaches, expectations and ways of working were still being embedded, and the service could not demonstrate that compassionate, inclusive and values-based leadership was consistently established across all areas.

Although ward-level leaders were visible, supportive and committed to developing staff, the service was experiencing a period of significant leadership transition. Multiple vacancies and interim arrangements within senior leadership teams meant leadership capacity and visibility were not consistently sufficient to provide clear direction, engagement and oversight across all care groups.

The Live Well and Urgent Care Division had a defined leadership structure with clear lines of accountability. This was supported by an interim divisional director of operations and a transformation delivery manager, providing a framework for governance, oversight and delivery of strategic priorities. Care groups had been established to support focused operational and clinical leadership.

However, leadership capacity was not consistently maintained across all care groups. At the time of our assessment, several key leadership positions remained vacant, including operational manager roles within ‘Emergency Care,’ ‘Ageing and Complex Medicine,’ and ‘Specialty Medicine 2’, as well as the clinical site lead role within the ‘Flow Care Group’. Only 1 of 5 care group operational manager posts had been substantively filled. Meeting minutes and governance documentation reflected ongoing changes within executive, divisional and care group leadership teams, highlighting a prolonged period of organisational transition.

Staff across several wards described uncertainty relating to interim leadership arrangements and were not clear about leadership roles, responsibilities and decision-making processes. While staff understood local reporting structures, some felt that frequent changes in leadership had affected communication and consistency.

Ward managers and matrons were consistently described as visible, approachable and supportive. Most staff told us they felt respected and valued by their immediate line managers and were able to access support when needed. Staff spoke positively about local leadership and described leaders who listened to concerns and promoted teamwork within their areas.

However, many staff reported limited visibility of senior leaders, and some were unable to identify members of the senior leadership team. Staff told us this made engagement with senior decision-makers more difficult and reduced opportunities to understand how concerns were being addressed at a divisional level.

Leaders acknowledged that visibility had been affected by limited leadership capacity and ongoing vacancies. They described actions to improve engagement and accessibility, including regular ward visits, staff engagement forums and increased leadership presence across sites. However, these initiatives were still being embedded and had not yet resulted in consistently positive staff perceptions of senior leadership.

The most recent national staff survey 2025 reported lower-than-average results relating to compassionate leadership and culture, indicating that staff experience did not consistently reflect the organisation's leadership ambitions.

There was evidence that leaders supported workforce development and progression. This included succession planning initiatives, leadership development opportunities, specialist training programmes and support for medical staff progressing into consultant roles. In addition, the patient experience and engagement group enabled frontline staff to share patient stories directly with senior leaders to inform improvement work and decision-making.

Following our assessment, leaders advised that vacant senior leadership posts within the division had been filled. However, these appointments were recent, and it was too soon to assess their impact or determine whether leadership capacity, visibility and consistency had improved across the service.

We scored the service as 2. The evidence showed some shortfalls. People did not always feel they could speak up and that their voice would be heard. Staff did not always feel confident to raise concerns because they did not always receive feedback and responses when they did speak up.

The trust encouraged staff to provide feedback through a range of mechanisms, including annual staff surveys and pulse surveys.

However, results from the most recent staff survey 2025 showed lower-than-average scores for staff feeling able to speak up and confidence that concerns would be listened to and acted upon. This reflected the concerns raised by some staff during our assessment and demonstrated that a consistently open and psychologically safe culture had not yet been fully embedded across the service.

While systems were in place to support staff to raise concerns and there was evidence that issues were investigated and acted upon, not all staff felt confident to challenge decisions or speak up openly. Staff survey results and feedback from staff indicated that they did not always feel comfortable to speak up or feel listened to.

Some staff told us they did not always feel comfortable challenging decisions, particularly in relation to operational pressures and the use of the discharge lounge. Staff described concerns about the discharge lounge being used overnight to manage pressures elsewhere in the hospital but did not always feel empowered to question these decisions.

Staff also reported that uncertainty about the future of services, leadership changes, ward reconfigurations and frequent redeployment to cover staffing shortages had negatively affected morale and wellbeing. Staff told us these ongoing pressures sometimes made it more difficult to raise concerns and contributed to feelings of frustration and fatigue.

Staff had access to the trust's Freedom to Speak Up (FTSU) Guardian and leaders had promoted the service through a range of communication methods, including emails, posters, drop-in sessions, social media and engagement events. However, some staff were unclear whether FTSU champions were available across all areas and how these roles could support them.

The trust had established processes for managing concerns raised through FTSU. Quarterly reports were received by the board and information on themes, trends and actions was shared with care groups and human resources teams. Within the previous 12 months, 15 FTSU concerns had been raised within the medical division, that had been reviewed and action taken.

Concerns raised included patient safety issues such as delays in escalation, the management of deteriorating patients and care delivered in environments staff considered unsuitable. Concerns relating to culture and leadership included reports of lack of management support and incivility between colleagues, including senior staff members.

Leaders had processes to investigate concerns and implement local actions. Issues were escalated to appropriate managers and divisional leaders, with action plans, monitoring arrangements and support through human resources processes where required. However, recurring themes had been identified relating to leadership behaviours, incivility and sustained workforce pressures.

We scored the service as 2. The evidence showed some shortfalls. Despite action to promote equality, diversity and inclusion, workforce data showed some staff groups continued to experience poorer outcomes and higher levels of discrimination, meaning equitable experiences were not yet consistently achieved.

Some staff experiences suggested that not all individuals felt their views were consistently heard, valued, or acted upon. Some staff reported a lack of meaningful engagement and communication from leaders, which affected their confidence in contributing to workplace improvements and service change.

Staff told us they had put forward suggestions aimed at improving wellbeing at work; however, they reported that these had not been implemented and that they had not received meaningful feedback from leaders explaining the reasons for this. As a result, they felt their views had not been fully considered.

Another member of staff reported that changes to patient pathways and ward-based services, including the withdrawal of phlebotomy services, had been introduced without prior consultation. They reported having insufficient time to prepare for these changes, which contributed to feelings of anxiety and uncertainty regarding the impact on patient care.

We reviewed the trust’s Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) 2025 annual report and survey results. Data showed that ethnically diverse staff reported significantly higher levels of discrimination at work from managers or colleagues (24%) compared with White staff (7%). The trust's performance was worse than the NHS benchmark median of 16%. This represented a deterioration compared with the previous year's result for ‘ethnically diverse staff (21%) and indicated a workforce cultural issue requiring further action.

The percentage of staff who believed the trust provided equal opportunities for career progression or promotion was lower for disabled staff (52%) than for non-disabled staff (55%). Although this had improved from the previous year (49%) and was comparable with the benchmark median of 51%, the disparity indicated that disabled staff did not consistently experience opportunities in the same way as their non-disabled colleagues.

The trust had recognised these challenges and had implemented actions to improve workforce equality outcomes. This included the development of an anti-racism strategy to support the anti-racism agenda, the introduction of a ‘Culture and Engagement Toolkit’ delivered through ’lunch and learn’ sessions to promote open communication and staff-led culture development, and the launch of a flexible working policy in June 2025 to support work-life balance and the needs of a diverse workforce. However, the impact of these initiatives had not yet resulted in consistent improvements across all workforce groups.

The organisation had achieved the Armed Forces Covenant Silver Employer Award, recognising employers that demonstrate significant support for the armed forces community, including reservists. The organisation had demonstrated a sustained commitment to supporting defence personnel through flexible working arrangements, supportive human resources policies and active promotion of its Armed Forces Covenant commitments both internally and externally.

Staff were able to access trust-wide equality, diversity and inclusion (EDI) staff networks including ‘Black and Minority Ethnic,’ disability and LGBTQIA networks, which provided peer support, promoted awareness and helped raise issues affecting diverse staff groups.

Equality and diversity champions supported inclusive practice across clinical areas, and visible signage across hospital sites reinforced a zero-tolerance approach to racism. Staff told us they knew how to report concerns relating to discrimination or inappropriate behaviour.

The trust also demonstrated recognition of cultural and religious diversity through activities such as celebrating Black History Month, supporting a diverse international workforce and sharing communications to mark religious and cultural events throughout the year.

Despite these positive initiatives, workforce equality data demonstrated that some groups continued to report less positive experiences than others, particularly in relation to discrimination and inclusion. This indicated that, while leaders had taken action to promote equality, diversity and inclusion, further work was required to ensure all staff experienced a consistently inclusive culture and equitable opportunities across the organisation.

We scored the service as 2. The evidence showed shortfalls. While governance structures and reporting arrangements were in place, these were not consistently effective in providing oversight of quality, safety and performance. Leaders could not always demonstrate clear accountability, consistent governance processes or effective management of operational and clinical risks across all areas.

The medicine wards we assessed sat across several care groups. Although formal governance structures were in place, these were not operating consistently effectively and oversight varied between care groups. The care group governance model had not been fully embedded, resulting in inconsistent governance processes, a lack of clarity around leadership accountability and variation in the management of risks and performance.

Staff described confusion regarding governance arrangements. They reported inconsistent meeting structures and limited oversight of clinical effectiveness. Although some governance forums had been newly established, staff told us these processes were still developing and had not yet provided effective assurance.

There were ongoing risks to the sustainability of safe systems and effective patient flow. These included inappropriate patient placement, prolonged lengths of stay within short-stay and discharge areas, and inconsistent safety arrangements within escalation spaces. Flow pressures were further increased by patients who were medically fit for discharge, remaining in hospital due to delays in accessing community services, affecting the service's ability to maintain efficient patient flow.

The lack of routine audits and oversight of issues, such as delayed discharges, limited the service's ability to fully understand the extent of the risks, evaluate the effectiveness of actions taken, and identify opportunities for sustained improvement.

Senior leaders attended monthly performance meetings held jointly with a partner care organisation, where they reviewed performance metrics, divisional risks and system-wide capacity pressures. Performance against key standards was monitored, and actions were identified in response to emerging concerns. However, despite these governance arrangements, persistent issues relating to patient flow, the use of escalation areas, workforce pressures and oversight indicated that existing processes had not been consistently effective in mitigating risks or delivering sustained improvement.

Policies and procedures were not consistently up to date. Key policies relating to patient flow and capacity management remained unapproved at the time of assessment. In addition, several policies and standard operating procedures had exceeded their review dates, including the LocSSIP WHO checklist for gastrointestinal endoscopy that had expired in July 2021, the ‘Shift Handover Procedure’ that had expired April 2025 and stroke guidelines relating to fever management and cardiac monitoring following acute ischaemic stroke that had expired in February 2026. This reduced assurance that staff were consistently working to current guidance and approved processes.

The medicine division risk register demonstrated that leaders had identified and recorded key risks. Most risks had assigned leads, review dates and mitigating controls, and evidence showed that many risks had been updated and progressed appropriately. However, 2 risks originally recorded in 2021 and 2024 for diabetes and phlebotomy service concerns, had review dates recorded for 2025, with no evidence of subsequent review, escalation or action. This limited assurance that all significant risks were being actively monitored and managed.

During the assessment we raised concerns regarding the management of temporary escalation spaces (TES). The service was unable to provide assurance that all TES were subject to individual risk assessments. Staff demonstrated variable understanding of when risk assessments and supporting documentation should be completed, indicating inconsistency in the application of governance arrangements.

The trust was also unable to provide audit data relating to the use of TES. Observations and staff feedback identified variation in practice between wards, including inconsistent oversight of how long patients remained within these areas. As a result, leaders could not demonstrate effective monitoring of the safety and appropriateness of TES use.

The medical division operated a formal governance structure intended to support oversight of quality, safety and risk. This included monthly divisional risk management group meetings, weekly patient safety review group meetings and regular patient experience and engagement meetings. Specialty governance meetings were established across cardiology, emergency medicine, gastroenterology, acute and elderly medicine and palliative care and fed into wider directorate governance arrangements.

The division reported no information governance breaches or reportable incidents to the Information Commissioner’s Office during the previous 12 months. However, staff described inefficiencies associated with using a combination of paper-based records and multiple electronic systems. This resulted in duplication of work, with assessments completed on paper before being entered onto electronic systems, and staff relying on manually generated handover sheets to support communication and patient management.

An information governance policy was in place and within review date. However, information governance training compliance was 89%, below the trust target of 95%, reducing assurance that all staff had received up-to-date training in the management and protection of information.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work together for people. They share information and learning with partners and collaborate for improvement.

Overall, leaders worked effectively with partners across the health and social care system with an aim to support service development, improve patient outcomes and facilitate joined-up care. There was clear evidence of collaborative working with local authorities, community services, integrated care partners and other healthcare organisations to address shared priorities and improve care pathways.

The ‘Better Lives Delivery Board’ met on a bi-weekly basis with system partners across the locality, including the local authority and Integrated Care Board (ICB). Agendas and meeting packs we reviewed demonstrated a coordinated approach to delivering the ICB ‘Urgent and Emergency Care Improvement Plan’ and was aimed at addressing system-wide priorities.

We saw specific examples of partnership working with the aim of improving outcomes for some patient groups with the medical care service. These included contributing to the Greater Manchester Long Covid Delivery Group, Endoscopy Diagnostic Network and Greater Manchester Integrated Delivery of Stroke Network.

The service participated in regular system escalation calls with partners to support timely patient discharge and effective patient flow. These meetings were held 3 times per week and increased to daily during periods of Operational Pressures Escalation Level 4 (OPEL 4). Records demonstrated that discussions, actions and updates were consistently documented and shared promptly through the Integrated Discharge Team (IDT) and discharge escalation communication channels, supporting coordinated decision-making and shared accountability.

Partners and stakeholders told us that leaders and managers worked in a collaborative way. They described positive relationships with most senior leaders with, shared priorities and collaborative problem-solving across organisational boundaries.

Managers described strong clinical leadership links with community, primary care and mental health services. These relationships supported continuity of care, integrated service delivery and joint working to meet the needs of patients across care settings.

We saw evidence of effective communication within services through monthly newsletters produced by a number of medical wards. These shared learning from incidents, training opportunities, service developments, social events and policy updates. Newsletters also promoted staff wellbeing initiatives and trust support programmes, helping staff access practical information and resources to support their physical, emotional and psychological wellbeing.

We scored the service as 3. The evidence showed a good standard. Leaders and staff demonstrated a commitment to continuous learning and improvement through quality improvement initiatives, service development and innovative models of care that enhanced patient outcomes and experience. Systems were in place to support learning and improvement, although implementation was not always consistent across all medical wards.

Overall, the service demonstrated a positive culture of learning and improvement. Staff were actively engaged in quality improvement work and leaders supported innovation to improve patient care, patient flow and service sustainability. While implementation of some initiatives varied across wards, there was clear evidence that leaders and staff were committed to learning from experience and driving service improvement.

We saw evidence the service was engaged with the Getting It Right First Time (GIRFT) programmes and had embedded local quality improvement programmes. This demonstrated an organisational commitment to evidence-based improvement, innovation and continuous learning. The service was progressing various workstreams aimed at addressing capacity and flow concerns. Examples included initiatives to improve direct admissions, speciality in-reach to the emergency department, antimicrobial stewardship and work to strengthen advanced care planning to help prevent avoidable readmissions.