Royal Albert Edward Infirmary

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

We looked for evidence that the service met people’s needs.

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

Capacity and flow performance concerns meant that not all patients were seen in a timely way or in the appropriate place. Operational pressures across the service prevented staff from fully implementing and documenting individualised care, and patients were not sufficiently informed to understand their care plan or what choices were available to them.

However, the service had implemented resources to improve the offering for patients with individual needs. Also, the Urgent Treatment Centre (UTC) and Same Day Emergency Care (SDEC) areas worked effectively to improve performance and the patient’s experience. The SDEC models in particular supported patients to avoid unnecessary admission and to access care and treatment in their home.

We have not awarded this service a score for Responsive.

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

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure people were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

Trolleys were present in the Majors area that contained items to support individual needs and improve the sensory environment for people who needed this, which included falls socks, ear defenders and sunglasses. A separate dementia trolley also included supportive equipment such as pictorial communication tools and sensory activity toys such as ‘busy boards’ and ‘twiddle muffs’. Staff were familiar with dementia ‘This is me’ leaflets and hospital passports, which were available to complete for patients in the department.

For children and young people, a specialised sensory room (‘The Otis Suite’) had been developed following feedback from patients and named as such following a patient’s experience in the Paediatric Emergency Care Centre (PECC). This was in line with the Royal College of Paediatric and Child Health’s (RCPCH) latest standards for paediatric emergency care.

However, while these resources were present to support staff to deliver patient-centred care, operational pressures meant that this was not conducted or documented consistently. We reviewed various care records in the Majors area, which included nursing assessments and patient notes entries, that contained no person-centred information or care planning. When we discussed this with patients and staff involved in their care, it was clear that some partnership working and individualised care took place, although this was informal and could not be handed over to other staff consistently. As such, staff could not identify a recent patient in the department where a dementia ‘This is me’ leaflet had been completed.

Staff completed mandatory training on learning disability and autism which was in line with the Oliver McGowan code of practice, and the trust had an effective learning disability and autism policy. Compliance with the e-learning component of the training was at 86%. However, compliance with the face-to-face component was considerably worse at 22%, which was also below the organisational average of 26% compliance. The meant that leaders could not be assured that staff had the right attitudes, skills and culture to deliver care and support that is safe, appropriate and tailored to people with a learning disability and autistic people. We acknowledged that ensuring compliance with the face-to-face component of this training is a national issue due to the limited availability of suitable trainers.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure people were at the centre of their care and treatment choices and they did not always work in partnership with people, to decide how to respond to any relevant changes in people’s needs.

The capacity and flow of patients between areas in the Emergency Department (ED) and other areas of the hospital was a longstanding concern, although leaders at all levels demonstrated an understanding of this and were motivated to improve.

The Majors area comprised 16 substantive beds, and throughout the assessment we observed that the significant majority of patients occupying these were waiting for long periods, regularly over 24 hours, for admission to medical specialty wards and so were not in the best place to receive care and treatment. This had the further consequence that patients in other areas of the ED such as the Resus area, Initial Senior Assessment Triage (ISAT) and main waiting room could not always access the most appropriate and timely care in the dedicated Majors area, although clinicians would flexibly review such patients regardless of their location, if this was needed.

We saw at medical handovers that clinical staff worked to identify opportunities to streamline or expedite care to support capacity and flow. Further, bed management meetings and updates were communicated to relevant staff throughout the day, although the full capacity protocol had exceeded its review date. However, in line with the limitations described above, over 900 patients in the month before our assessment had remained in the ED for over 12 hours and 735 patients had been placed in escalation spaces (seen in beds or trolleys on the corridor) during their attendance.

Other systems to ensure patients were seen in the most appropriate setting and to avoid unnecessary admissions were effective. The Same Day Emergency Care (SDEC) and Frailty SDEC areas used a ‘pull model’ whereby staff in those units actively queried the patients in the ED throughout the day and were able to independently accept appropriate patients in support of the broader ED waiting list. Patients could also be streamed at the point of entry to the ED directly to the Urgent Treatment Centre (UTC) or booked into dedicated UTC slots the following day if it was outside operating hours and this was safe to do so.

The trust had invested in admission avoidance schemes to mitigate capacity concerns in the ED. The Access to Community Services (ACST) team worked across the service with the primary aim to avoid inappropriate admission and reduce readmissions to the ED. The team used a ‘Discharge to Assess’ (D2A) approach so that patients who had no medical need to remain in hospital but still had longer-term needs could be discharged safely. 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 to be readmitted. The SDEC areas also had processes to allow patients to return to the units after returning home where needed, to support further interventions without requiring re-triage and longer waits through the main ED.

Specialist services such as speech and language therapy (SALT), heart failure and cardiac specialist nurses, or asthma and respiratory nurses were also available. However, these could not be accessed outside of typical working hours (weekends and nights), which were often the busiest periods within the ED.

Input from mental health professionals provided by the separate NHS mental health foundation trust was effective. Recent developments had enabled streamers in the ED to quickly highlight and refer patients with mental health presentations to the mental health liaison team at the point of their attendance. The service had a target to review such patients with 1 hour 85% of the time and within 2 hours 95% of the time, and the service had recently been mostly compliant with this.

We scored the service as 2. The evidence showed some shortfalls. The service did not always supply appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Patient information leaflets were available in paper formats and the department had various posters with quick response (QR) codes on for people to scan with their phones to access health information, which were up-to-date. However, we found various paper handouts that did not demonstrate any document control details and so the date of last or next review could not be determined, meaning that staff could not be assured that the most up-to-date information was being provided. Leaders told us the trust was already in the process of reorganising their patient information systems into a new and improved system. This was planned to be fully implemented in July 2026, which would include policies and procedures to guide staff on how to produce and maintain patient information more consistently.

Displays were present across services with useful information about performance and key topics such as sepsis or safeguarding. A whiteboard was used in the main waiting room to provide key information to patients, including waiting times. However, this was not updated regularly enough to be informative or accurate, which had frustrated some patients we spoke with. Part of the Urgent and Emergency Care (UEC) transformation plan included a digital screen which could be used to present information in a timelier way. A mobile application (or 'app') was also in development which would display various waiting times metrics as well as information on how to raise a complaint.

While some patients understood their care journey and what they could expect, we spoke with other patients who were uncertain of what they were waiting for or what would happen next. For example, we spoke with a patient in the main waiting room who thought she was awaiting admission but had instead just found out she was being discharged, despite having waited several hours. We also spoke with patients who had not been given sufficient information about the care setting and so were confused as to why they were sharing treatment cubicles with unrelated patients in the Clinical Decisions Ward (CDW).

While not all conversations between staff and patients were conducted sufficiently confidentially, staff demonstrated that patient information was stored and reviewed in a way that protected their information. Information governance formed part of all staff mandatory training and staff were compliant with this across services. There had been no information commissioner’s office (ICO) reportable data breaches relating to the urgent and emergency services in the past 12 months.

Staff were also able to communicate with patients in ways that met their needs. We observed interactions and spoke with staff and patients from different backgrounds who felt that staff communication took place in a way that met their needs. Staff had sufficient knowledge and access to interpretation facilities, which included British Sign Language (BSL) where needed.

We scored the service as 2. The evidence showed some shortfalls. While the service had systems to make it easy for people to share feedback and ideas, complaints were not always responded to within the trust’s target time.

Patients told us they knew how to raise a complaint or concern through the trust’s Patient Advice Liaison Service (PALS), and we saw information about this displayed on posters and in literature across the service, which included complaints escalations procedures. Staff understood the policy on complaints and knew how to handle them. They told us information about complaints was discussed and learning shared through daily huddles, handovers and routine staff meetings, and trends in complaints had been used to inform the services UEC transformation plan. The most common themes identified from patient complaints were related to concerns about medical treatment and waiting times.

Managers told us they reviewed complaints, compliments and feedback from patient surveys to aid learning and improvement. However, of the 114 complaints that had been recorded across the service in the previous year, only 53 (corresponding to 46%) had been closed within the trust target timescales. This meant that patients who had raised complaints faced longer waiting times for a resolution than they should have.

The service routinely gathered other patient feedback in a variety of ways, including paper surveys, interactive voice messages (IVM) and text messages. In the previous year before the assessment, the service had recorded nearly 10,000 responses from across all areas, demonstrating a response rate of 10 to 15%. This showed over 6,800 patients reported a ‘good’ or ‘very good’ experience compared to over 1,900 who reported a ‘poor’ or ‘very poor’ experience.

The service understood the importance of transparency and had established a consistent approach to disclosing incidents where harm had occurred in keeping with the Patient Safety Incident Response Framework (PSIRF). As such, the trust had effective policies and procedures for being open, compassionate engagement and duty of candour expectations and requirements.

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

In recent years the service had seen approximately 80,000 to 90,000 distinct attendances at the hospital each year. In the 2025/26 period, this included over 24,000 ambulance attendances and over 17,000 paediatric attendances.

For the 2025/26 period, the trust overall had consistently performed in the bottom quartile nationally in the percentage of emergency department attendances spending over 12 hours in the department. During the first day of assessment, we saw that 14 of the 16 patients in the Majors area were waiting for a specialty bed on a ward, 6 patients in the main waiting room were similarly waiting for a specialty bed, and 1 further patient in the Resus area was awaiting a specialty bed. Accordingly, the longest wait in the Majors area was a patient who had been there for 44 hours, during which most of that time had been spent waiting for a specialty bed. In the month prior to our visit, the service recorded 353 cases where a patient had waited more than 12 hours in the ED after a decision to admit them had been made, which represented an average of 12 patients each day that month.

During the same period, the trust also performed in the third or bottom quartile nationally in the percentage of emergency department attendances admitted, transferred or discharged within 4 hours. Further, over 6,000 patients attended the service and left without being seen, which indicated a slightly higher proportion than the England average of 5%. However, there were early signs of improvement in this metric, and in March 2026 the data evidenced that the trust was the most improved nationally, achieving a 4-hour compliance rate of 78.1%, which met the revised 2025 national NHS target of 78%. March 2026 data also demonstrated modest improvements in the time taken to initially triage a patient attendance compared to the equivalent 2025 period.

The trust’s absconding patient policy provided guidance for staff around managing patients who left the service without being seen, which included reference to the Herbert Protocol, a scheme to help find a person with dementia who goes missing. Patients at risk of absconding were assessed proactively in advance of any incident to determine monitoring requirements and appropriate responses.

Ambulance handover times also demonstrated persistent underperformance against national NHS standards. In the 2025/26 period, 20% of handovers exceeded the 45-minute standard, with worse performance as expected during the winter months. However, there were also early signs of improvement in this metric, with figures reported for April and May 2026 (21% and 11% respectively) showing approximately half the number of delays than in the same period of April and May 2025 (38% and 21% respectively), while facing slightly increased attendances.

Policies and procedures were in place to manage the capacity and flow of patients across the ED, including processes to maintain safe staffing levels in cases of extreme pressure. Staff were familiar with these procedures and their roles on these occasions, as initiating full capacity protocols was a regular occurrence in the ED. Leaders acknowledged that the department was originally built to accommodate much smaller patient numbers than those it currently faced, and improving flow and capacity was a key operational target that was overseen by the trust board.

Throughout the assessment, almost all patients in the Majors area were awaiting specialty beds, some with lengths of stay that significantly exceeded 24 hours. Further, we observed that patients in the Resus area, ISAT, and who were seated in the main waiting room were also a waiting specialty beds, which demonstrated the significant flow issues across the hospital. While not the optimum location for such patients, consultants from medical specialties attended to patients in the ED where required and could offer advice and guidance to staff on how to proceed with managing these patients while they awaited admission.

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

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

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

We saw evidence of thematic reviews that were linked to trends in incidents which in at least 1 case identified that potentially biased clinical viewpoints risked worsening patient outcomes, but did not consider how protected characteristics or inequalities affected this or suggest how this might be improved. We were informed that the ongoing Urgent and Emergency Care (UEC) transformation plan had been developed in response to a variety of information sources and data, but did not see evidence of how or if inequalities information had informed this plan and as such, there were no tasks or themes in the plan related to assessing or improving any variations in outcomes based on protected characteristics.

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

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

We saw that staff planned and considered care and treatment plans, including transfer or discharge arrangements for their patients, which included the completion of Situation, Background, Assessment and Recommendation (SBAR) forms for each ward admission. Staff and patients also understood discharge processes from the Same Day Emergency Care (SDEC) areas, and would typically stop accepting patients in advance of their closure to ensure that all patients could be effectively discharged without returning to the ED. However, on average in the last 6 months, 4% of patients who attended the Urgent Treatment Centre (UTC) returned to the ED near its closing time, representing around 5 patients each day.

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

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