Royal Albert Edward Infirmary

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

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

Staff were competent, had opportunities to develop, and followed national guidance in their care and treatment of patients. Teams across the service worked together well, particularly when liaising with community teams to ensure patients were well-supported upon discharge.

However, patients’ needs were not assessed sufficiently consistently, and the service did not appropriately monitor the performance of this key aspect of care. The service also did not always have sufficient oversight of its performance more broadly, as governance systems were not effective enough.

We have not awarded this service a score for Effective.

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

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

Policies and procedures were in place to guide staff with the assessments required on admission to the Emergency Department (ED).

Patients attending the department were streamed to the appropriate area and then underwent a triage assessment using a recognised tool. However, the tool that was in use was not the most current version available, as the IT system used to determine triage decisions and record patient notes had not updated it. The developers of the triage tool advised that “patients being triaged using previous editions may be at risk of mis-triage and may therefore have worse clinical outcomes”. The service had recognised this risk and had plans to work with the software provider to ensure this update could be introduced, although the latest edition had already been in release for multiple years.

Staff used a range of tools to assess and review people’s health needs, which had recently been supported by the implementation of a process to undertake electrocardiograms (ECGs) concurrently with a patient’s initial triage, to improve diagnosis and treatment for those presenting with cardiac symptoms. Some tools were used to make assessments of all patients (such as NEWS2 or PEWS, early warning tools to assess clinical deterioration), and we observed the use of other tools that were tailored to their individual clinical needs (such as the Clinical Institute Withdrawal Assessment for Alcohol, CIWA). Except fluid balance charts, all care records and assessments were created and stored on digital systems and were accessed on desktop computers or computers-on-wheels (COWs). Staff did not demonstrate any difficulty in accessing records or assessments for review.

Patients with mental health needs who remained in the ED rather than the mental health streaming area (the Makerfield Suite) could be referred to the mental health liaison team for review while within the department. The liaison team provided timely input and we observed care records that contained comprehensive mental health assessments and care plans. The Frailty Same Day Emergency Care (SDEC) area also worked with community partners to initiate Comprehensive Geriatric Assessments (CGAs) of appropriate patients to determine these patients’ medical, social and functional needs, alongside their discharge.

During the assessment, we observed care records that demonstrated that intentional rounding checklists (the ‘ED safety checklist’) were completed and recorded in digital records but this was not done consistently, which various staff across the service advised was due to operational pressures. In many cases, the safety checklist had been completed once around the time of initial presentation and then a variable but small number of times for the duration the patient remained in the department. We observed 1 example where a care record had 1 completed checklist in the 28 hours a patient had spent in the department. The service did not audit the performance or compliance with completing the checklist. This reduced assurance that patients’ changing needs, comfort, pain, nutrition, hydration and deterioration risks were being reviewed consistently during prolonged waits.

Patients with specific nutrition and hydration needs were assessed, and fluid balance and food charts were in place for patients identified as at risk. Pain relief was managed on an individual basis and staff assessed this as part of the ED safety checklist. Patients in the Majors and SDEC areas told us that staff gave them pain relief medicines when needed, although some patients in the main waiting room told us that they had to ask repeatedly and wait long periods before this was provided to them.

Comfort rounding documentation was completed inconsistently. Staff advised that comfort rounding would typically be documented in daily notes entries in the care record, but we observed notes that were brief in content and did not consistently describe typical comfort measures such as personal care, elimination or positioning. Patients in most areas of the ED confirmed with us that staff did check in to enquire about their comfort needs periodically. For example, we observed that blankets had been provided to a patient in the main waiting room who had told staff they were cold. However, inconsistent documentation meant staff could not always demonstrate that comfort needs had been identified, acted on or handed over reliably.

We scored the service as 3. The evidence showed a good standard. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Staff followed clinical guidelines and pathways that were based on national clinical guidance, such as that from the National Institute for Health and Care Excellence (NICE). The service used trust systems to store clinical guidelines, and these typically demonstrated appropriate document control and governance oversight, although this was not fully consistent across all guidelines. Staff knew how to access procedures and guidelines when required.

Staff across the service used a range of care pathways that referenced and aligned with national guidance, such as for the treatment of head injuries in adults and children, potential spinal injuries, and managing trauma and fractured neck of femur presentations. We reviewed a selection of care pathways and found they were mostly up to date and reflected national guidelines. However, the service’s chest pain pathway guidelines did not contain references to the relevant NICE clinical guidelines or other alternative sources for such presentations. The trust’s standard infection prevention and control precautions policy was also overdue for review and as such, did not reference the most recent mandatory NHS England guidance.

Staff demonstrated a good understanding of patients’ various nutrition and hydration needs and could act on these in line with guidance. As such, appropriate clinical staff completed mandatory training modules in bowel management and in the safe use of insulin. Patients in the main waiting room and across the service had good access to drinking water, and patients had access to appropriate and nutritious food where this was offered as part of trust policies.

Staff told us they felt supported to be up to date with national legislation, clinical good practice and required standards. Additional training and resources were available for staff to access as part of their development plans, and leaders helped to facilitate this for all staff. A piloted scheme in the Frailty SDEC had increased its capacity and allowed for the improved implementation of comprehensive geriatric assessments (CGA) alongside community partners, in line with British Geriatrics Society guidance.

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

Some alternative management and staffing arrangements were being trialled during the assessment such that the Majors area and the main waiting room area had dedicated coordinators and were considered as different areas. Staff had felt well-informed about these changes and understood their roles and lines of responsibility in relation to others. Staff told us that there had been some historical difficulties between different staff groups, which had likely worsened due to high workforce pressures. However, many people including ambulance staff attending from the associated local ambulance NHS trust felt that there had been meaningful improvements to relationships across the service in the previous year, which had led to a more positive working environment.

We observed routine communication amongst teams within the ED that included separate nurse and medical handover meetings, which took place during shift changes.

Medical handovers were structured and led by an appropriate consultant who encouraged participation and collaboration from all attendees, including advanced clinical practitioners. While a key focus was on ensuring capacity and flow across the department, senior staff supported more junior team members by identifying learning opportunities and areas of further discussion. Medical staff we spoke with felt well-supported in their routine work.

Nursing handovers were briefer by comparison, with a more operational and staffing focus, and allocated roles and responsibilities to staff for each shift. Opportunities for questions or concerns to be raised were provided, although we observed that by this point some staff who had been allocated roles had already left to proceed with their duties. We also observed that only limited information about 1 patient potentially requiring enhanced supervision was provided at the handover. The patient was also referred to as their bed number, which was not patient-centred language.

Whilst improved, disagreements had continued between how the service operated with the mental health streaming area (the Makerfield Suite), run by a separate mental health NHS foundation trust. Representatives of the Makerfield Suite and staff from across the ED felt that the relationship was on a positive trajectory and highlighted how input from the mental health liaison team could be accessed quickly, but many staff felt that the exclusion criteria of the Makerfield Suite meant that the overall responsibility arrangements for patients presenting with both mental health and physical needs were not clear or effective.

However, communication between the ED and the UTC, SDEC and Frailty SDEC was effective. While SDEC and Frailty SDEC staff advised that there were not routine dedicated meetings between their teams and the ED, they felt that working arrangements were robust and that further meetings would not be a good use of time. Members from the Frailty SDEC were visible in the ED routinely, and the matron of the ED also oversaw the adjoining UTC and attended the area regularly.

We scored the service as 3. The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

Patients told us they could access information around healthier living. Staff told us they routinely discussed health promotion and lifestyle choices with patients when this was clinically indicated. Health promotion information was displayed on notice boards and in information leaflets that were readily available across the areas we inspected.

The trust had invested considerable effort in admission avoidance schemes to mitigate capacity concerns in the ED. The Access to Community Services (ACST) team were available from 8.00am until 6.00pm, 7 days a week and comprised a multidisciplinary team of nurses, occupational therapists and physiotherapists. Like other areas, the team could independently screen patients in the ED who would benefit from their approach. This included input into a wider comprehensive geriatric assessment (CGA) that could include cognitive assessments, transfer and mobility assessments, and referrals to community teams and social workers to ensure patients were unlikely to require readmission.

The ED and SDECs also had access to a variety of specialist services, many of which encouraged and supported patients to make healthier choices to help promote and maintain their health and wellbeing. This included alcohol specialist nurses, respiratory and asthma nurses and a heart failure nurse, who were accessible Monday to Friday.

We also saw evidence of participation across the service in campaigns to help support healthier living and stress management. This included the ICON campaign to help support and inform parents to prevent abusive head trauma in babies.

We scored the service as 2. The evidence showed some shortfalls. The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

Following the assessment, we asked for service-level audit schedules and action plans that had been produced following these in response to any findings but did not receive sufficient information to demonstrate that all aspects of care and patient’s outcomes were sufficiently monitored.

Services at the location including the ED used audit management and tracking systems, and we saw evidence of these in use in the form of ‘Accreditation System Providing Improvement and Recognition in the Care Environment (ASPIRE)' audits. These were presented at a divisional level, although highlighted low scoring areas in the 2025/26 period. The ED was highlighted as a low scoring area across a wide range of different audited areas and compliance results appeared significantly lower than other areas at the location. For example:

• The annual safeguarding audit demonstrated a compliance of 24% in the 2025/26 period against a target of 90% in the ED, whereas other comparable areas at the location such as the Medical Assessment Unit (MAU) had recorded a compliance of around 60 to 70%.
• The annual pressure ulcers audit demonstrated a compliance of 25% in the 2025/26 period against a target of 90% in the ED, whereas other comparable areas had scored between 60 and 90%.
• The annual nutrition and hydration audit demonstrated a compliance of 18% in the 2025/26 period against a target of 90% in the ED, whereas other comparable areas had scored between 40 and 70%.

This is not an exhaustive list, and other areas of concern included environmental safety (a compliance of 30%), medicines management (a compliance of 30%), and communication (a compliance of 42%). The lowest compliance rate observed was the annual organisation and management of the clinical environment audit, where the ED had scored only 11% against a target of 90%.

We saw limited evidence of action plans with a focus on improving these metrics. While leaders demonstrated that they considered these as quality indicators and had aspirations to improve, it was unclear how the service would achieve this without designated action plans for each non-compliant area. The Urgent and Emergency Care (UEC) transformation plan had various themes and tasks that when implemented may improve compliance with the suite of aspire audits undertaken in the ED, such as the ‘IPC/Elimination’ theme and the ‘Environmental Safety’ theme, but audit results were not generally considered outcome measures to assess the effectiveness of any such changes. We did see an exception in the department’s sepsis improvement plan that had been developed alongside the UEC transformation plan, and leaders advised this was leading to sustained improvements. However, without clearer audit ownership, action plans and outcome measures, leaders could not be assured that repeated low compliance was being addressed effectively or that improvements were being sustained.

We spoke with leaders who told us that departmental ED audits were completed weekly by ward leaders and monthly by the matron and that compliance was monitored closely, and that findings had demonstrated improvement in recent months.

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

Staff followed trust policies around consent and understood how to obtain informed verbal and written consent from patients before providing care or treatment.

Clinical staff completed level 1 and level 2 mandatory training modules in the Mental Capacity Act 2005 (MCA) which included the basic principles of the MCA, capacity assessments, best interest decisions and Deprivation of Liberty Safeguards (DoLS). Staff in the department routinely undertook capacity assessments, although advised DoLS processes were generally actioned following a patient’s admission to a ward, where necessary.

Staff had the skills and knowledge to ask patients for consent and were able to explain how they sought verbal, implied and informed consent before providing care and treatment. Care records we looked at showed verbal and written consent was recorded prior to undertaking care and treatment. Patients told us staff explained what they were doing and asked for their consent before delivering care and treatment. We spoke with the family of a patient who lacked capacity, who told us that they had been appropriately involved in decision-making.