Royal Albert Edward Infirmary

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• 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.

The environment of the main waiting room and assessments of patients did not always ensure that they were kept safe and that their needs were met. The service did not have sufficient facilities to meet the needs of children and young people who presented with mental health needs, or adults who presented with mixed physical and mental health needs. The service did not always identify and manage cases of potential sepsis in a sufficiently timely way. Infection prevention and control compliance was variable and lacked clear governance.

However, staff were aware of current risks, and the service overall demonstrated a commitment to learning from mistakes and continual improvement. Staff were familiar with safeguarding processes and had good support to help them identify and act on concerns. While operational and staffing pressures remained, there had been recent changes that staff felt had improved their ability to work and treat patients more safely.

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 continually identify and embed good practice.

Staff understood how to recognise and report incidents using the hospital’s electronic reporting system, and most staff we spoke with considered this a routine part of their practice. For significant incidents or where learning could be identified, outcomes were discussed with staff and systems to support them were in place.

In the 2025/26 period, just under 3000 incidents had been reported across the ED department of which 12 were recorded as having caused severe or fatal harm to the patient. At the time of the assessment, 199 incidents were overdue for review by senior staff, which represented approximately 5% of the total annual incidents. However, most incidents were reviewed and actioned in a timely way.

Incident investigations were conducted by senior staff and aligned with Patient Safety Incident Response Framework (PSIRF) guidance. Investigations we reviewed were effective and included details of how duty of candour and compassionate engagement requirements were met. Areas for improvement and action plans were clearly demonstrated in investigation reports, and it was possible to see how incidents had led to changes in the department in response.

Trends and themes in incidents were analysed, which led to broader thematic reviews. For example, a review of patients attending the department with stroke symptoms had led to several improvements such as focused clinical education sessions and changes to CT scan referral processes. Actions in the department’s ongoing urgent and emergency care (UEC) improvement plan were also linked with trends in findings from incidents.

Monthly departmental newsletters had a section dedicated to information and learning from incidents and key findings were discussed at team meetings and nurse handovers, where this was appropriate. Staff told us they were aware of learning and that incidents were regularly discussed, both formally and informally across the service.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to establish and maintain safe systems of care. They did not always manage or monitor people’s safety. They did not always make sure there was continuity of care, including when people moved between different services.

All walk-in patients attending the ED saw a nurse streamer who would identify if the patient could be streamed to the Urgent Treatment Centre (UTC) or Same Day Emergency Care (SDEC) areas. Otherwise, the patient was triaged to determine if they required escalation or were safe to remain in the waiting room. All children were streamed directly to the co-located Paediatric Emergency Care Centre (PECC). Staff had access to flow diagrams and algorithms that identified pathways for various presentations, such as chest pain, mental health crises, or trauma. A system had recently been implemented where patients could access an electrocardiogram (ECG) directly from the point of streaming in the main waiting room, to help expedite diagnosis and care for patients presenting with high-risk cardiac symptoms. However, the tool associated with the software used to determine triage decisions and record patient notes was not the most current version. This is discussed further in the ‘assessing needs’ section of the report.

Walk-in patients who were not streamed directly to UTC or SDEC were assessed to determine whether they could safely wait in the waiting room. Patients needing Majors-level care were escalated to the Majors coordinator. However, because the Majors area rarely had capacity to immediately accept these patients, they were usually required to remain in the waiting room until a bed became available.

As a result, both patients deemed safe to wait and those requiring escalation were generally managed in the same waiting room environment. Although the Majors coordinator retained overall responsibility for escalated patients, their care was overseen by the waiting room coordinator while they remained in that space. In practice, the pathway did not effectively separate patients according to the urgency of their condition unless they deteriorated and required emergency intervention.

Because the associated full capacity protocol was significantly beyond its intended review date of December 2024, the description of maximum operating levels of each ED area in the full capacity protocol did not reflect what we observed during the assessment. For example, it indicated the Majors area had a maximum capacity of 24 beds before escalated areas needed to be implemented, but during the assessment we saw only 16 beds and noted that patients were escalated to the adjacent corridor when these had been filled. This meant that that staff were not using current, reliable guidance to manage escalation safely.

Patients in the main waiting room would be retrieved for consultation, assessment and treatment in the Clinical Decisions Ward (CDW). Dedicated single-patient cubicles were used for clinical assessments and shared seated cubicles were used for treatments. Patients could also be allocated to CDW chairs in adjacent cubicles for further care. However, it was not clear from the operating procedure or from staff how the care for these patients differed from others, or why they were classified as admitted patients.

The SDEC and Frailty SDEC 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. ED staff were also able to make referrals to the SDECs themselves and highlighted this as a stronger area of the service. They told us that this worked well overall, although we spoke to some medical staff who were unfamiliar with the exclusion criteria for the SDEC and so had made referrals during the day that had been rejected.

For patients who were appropriate for the Urgent Treatment Centre (UTC), they were provided with a paper form to book into the service, which was located next door. For patients who attended outside of UTC opening hours, streamers could either direct them to wait in the department until opening or arrange for them to be booked into a limited number of slots to return the next day.

As transformation plans were ongoing, the department had interim procedures for managing patients presenting to the ED whose primary needs related to mental health. Upon entering the department, such patients could be streamed from the ED to the mental health streaming area (the Makerfield Suite), which was co-located in the ED but run and staffed by a separate NHS mental health foundation trust. However, patients with both physical and mental health needs would be seen by the ED. Whilst they could usually access timely input from the associated mental health liaison team, individual responsibilities of each trust and the clinicians involved for these patients were not embedded or well-understood and had led to disagreements and misunderstandings between staff previously.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and could share concerns quickly and appropriately when there was a concern. However, staff were not always compliant with targets for higher levels of safeguarding 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.

Staff we spoke with knew how to identify people at risk of, or suffering, significant harm or abuse and the service worked with other agencies to protect them. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act 2010.

Staff knew and could demonstrate how to make safeguarding referrals where this was appropriate and were familiar with the trust’s safeguarding team. The trust team, which included Independent Domestic and Sexual Violence Advisors (IDSVAs) attended both the Paediatric Emergency Care Centre (PECC) and ED areas on a regular basis, to address specific patients and to ensure they were visible and accessible to all staff. Named safeguarding link nurses were also present across the department.

During our assessment, we reviewed notes of children in the PECC and confirmed that staff completed safeguarding checklists and escalated concerns when necessary. Key safeguarding risks and if the patient was a child in care were queried and documented at the initial point of streaming.

The trust had an effective safeguarding training policy. Staff across the service demonstrated broadly good compliance with core safeguarding training, with rates above the target of 90% in both safeguarding vulnerable adults and safeguarding children levels 1 and 2, and above the target of 85% in Prevent (safeguarding from the threat of radicalisation) training.

However, compliance with the trust’s ‘Think Family’ safeguarding level 3 package (which covered both adults and children’s safeguarding together) was 73%, below the target of 90%. While leaders acknowledged this was below the target, they advised that this was partly because some staff were still undertaking levels 1 and 2 as prerequisites for the Think Family training (particularly new starters, who are permitted 12 months to complete the training in full) and that some staff were still transitioning to the new Think Family training package after it was formally released in 2025.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Patients received a standard bundle of risk assessments at the point of treatment in the ED, which included falls and bedrails assessments, malnutrition universal screening tool (MUST) assessments, and pressure ulcer assessments (Waterlow score and the “Surface, Skin inspection, Keep moving, Incontinence, and Nutrition”, SSKIN bundle). We reviewed patient records that all demonstrated appropriate pressure ulcer assessments and most demonstrated falls risk assessments. People’s allergy statuses were recorded on all medicines records we looked at. In the Majors area, each bay contained a patient information board (known locally as “Maisie Boards”) which highlighted specific safety needs, such as sensory impairments or dementia, high falls risks, or patients approaching the end of life.

Staff used the National Early Warning Score (NEWS2) and National Paediatric Early Warning System (PEWS) to identify adults and children at risk of deterioration, and appropriate observations were recorded in all patients’ records we reviewed. However, staff felt that this finding was reflective of comparatively lower pressures in the department during the assessment, and an audit of NEWS2 compliance in February when operational pressures were higher demonstrated a compliance of 75%. Recommendations in response to this audit included ensuring sufficient staffing levels were maintained to support good record-keeping, and further staff education.

The trust had a sepsis recognition, screening and sepsis 6 pathway management policy and an associated operating procedure, and sepsis link nurses were present in the department. However, there were concerns about the timeliness of review and treatment of suspected sepsis in the ED. We reviewed 4 patient records that successfully identified potential sepsis and activated the sepsis bundle appropriately, but in no case had this been completed within 1 hour, in line with guidelines. In 2 cases, the patients had been in the department for 18 and 21 hours respectively and the sepsis bundle had still not been completed.

Sepsis audits also demonstrated poor compliance with trust targets, which were for 95% of suspected cases to have senior review and antimicrobials to be prescribed within 1 hour, and for 50% of suspected cases to have blood cultures to be collected within 1 hour. Data from a selection of audits undertaken between November 2025 and April 2026 demonstrated that none of the trust sepsis targets had been met and that no improvement in performance was identifiable. NHS England also identified a higher-than-expected summary hospital-level mortality indicator (SHMI) for septicaemia from December 2024 to November 2025 sampled data. In response, the trust had produced their ‘ED Sepsis Plan’ in March, which focused on further training, process changes and quality improvement projects.

We scored the service as 1. The evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The main ED waiting room was not able to accommodate the number of patients that accessed the department and their needs. Due to operational pressures, the area typically contained patients who presented with a broad range of conditions and vulnerabilities who were often at different stages of their care journey, and in some cases had been waiting for a bed for over 24 hours. During the assessment, we saw patients in mental health crisis, patients with intravenous (IV) fluids being administered, patients in dressing gowns and nightwear, and patients attending from prison with a police escort all sharing the same space.

The main waiting room had a capacity of 30 people and staff told us that this was exceeded regularly, meaning that people would fill the adjacent corridor and that patients and their carers/families could not always remain together. Refreshments and vending machines were available for patients in the main waiting room, although it was a cold environment to sit in for long periods, and it could be colder still during the winter period. Waiting times were communicated on a whiteboard in the main waiting room, but we were told this was not updated frequently enough to be informative. During the assessment, we spoke with a patient who had returned to their car overnight in order to lie down, as there had been no room to do this in the waiting room.

The capacity of patients in the Majors area was also a concern. While documentation advised the capacity of this area was 24 patients, we observed only 16 beds during the assessment, with no reasonable space to hold a further 8 beds. We were advised by staff that patients from the Initial Senior Assessment Triage (ISAT) area (who had attended the ED by ambulance) would be moved into the Majors area on trolleys when the capacity of the ISAT area was exceeded, after ambulance teams had handed over the patient. Staff showed us how multiple trolleys would occupy the Majors area on such occasions, which would fill up most of the free floor space such that it risked safe care and treatment and patients’ privacy and dignity.

The ED did not have enough appropriate facilities for all patients presenting with mental health needs. While patients could be streamed to the co-located mental health streaming area (the Makerfield Suite) which was a dedicated environment with appropriate facilities, this area had an exclusion criteria and capacity limitations which meant some patients with mental health needs would still need to be seen in areas across the ED routinely.

However, there were no clearly identified spaces for patients with mental health needs who were not accepted for the Makerfield Suite. We inspected 2 rooms in the Clinical Decisions Ward (CDW) which staff told us could be used to separate patients from others for safety reasons, but these did not meet Psychiatric Liaison Accreditation Network (PLAN) standards and during the assessment had been set up for other purposes.

Similarly, the Paediatric Emergency Care Centre (PECC) had a sensory room which had previously been used to accommodate patients with mental health needs. While this recent change was positive for patients in need of a more specific sensory environment, this also meant that there were no dedicated spaces to safely accommodate high-risk young people with mental health needs or behavioural disturbances. This was not in line with the Royal College of Paediatrics and Child Health (RCPCH) Facing the Future standards and posed risks to both patients and staff in the PECC.

Further, we saw that the ED including the PECC had considered the risks associated with ligature points, which broadly considered the risk and controls across services. However, documentation did not contain evidence of the use of any ligature point risk assessment tools, which suggested that no specific potential ligature points or high-risk areas had been considered or mitigated. There had been 3 recorded ligature incidents in the past 12 months in the department.

Most clinical equipment and resuscitation trolleys were easily available to staff and were regularly checked and serviced appropriately. However, during the assessment we found 4 radiation level meters that were not used routinely but may be needed as part of the hospital’s emergency preparedness, resilience and response (EPRR) duties, which had not been calibrated or serviced since 2005. This meant that services could not be assured these worked as intended and so could not provide safe care and treatment to patients who presented to the department following exposure to hazardous radiological substances. In response, leaders advised that they were looking at how these could be calibrated.

However, all areas of the service were visibly clean and tidy environments, and cleaning and housekeeping staff were accessible throughout. Furniture and fittings were mostly in good condition and staff routinely raised works orders where these did not meet acceptable standards.

Control of Substances Hazardous to Health (COSHH) were being stored and disposed of correctly, and clinical equipment was in good condition and within service dates. Local fire evacuation plans were effective, and the department was implementing improvements following a recent fire safety risk assessment. Resuscitation trolleys were all easily available to staff and checked and documented routinely, in line with requirements.

We scored the service as 2. The evidence showed some shortfalls. While service made sure staff received effective support, supervision and development, the service did not always make sure there were enough qualified, skilled and experienced staff. They did not always work together well to provide safe care that met people’s individual needs.

Staff induction and training:

Staff told us that they had received an effective induction to the department upon starting and worked as supernumerary staff for up to 8 weeks (or longer if there was a development need). Staff completed induction checklists to ensure competence before unsupervised practice and there were clear lines of support for new starters in the department. After being signed off to work competently, new starters also had quarterly preceptorship meetings where performance could be reviewed. The department also had accessible clinical nurse educators who scheduled and participated in regular training updates.

The overall compliance with core mandatory training amongst non-medical staff across the service was mostly good at 89%, although medical staff by comparison was lower at 77%. Training which incorporated a face-to-face learning component, such as “Fire Safety Level 2” (with 43 non-compliant staff) and “Resus Level 2” (with 31 non-compliant staff), demonstrated higher rates of non-compliance. For e-learning core modules, the average number of non-compliant staff generally varied between 5 and 15 staff members across the service, which was within or close to trust targets.

Leaders told us that, due to operational pressures, there were times when certain mandatory training sessions would be rescheduled and the risks of doing this would be assessed. However, we also heard that certain modules were ring-fenced as the risks of non-compliant staff practicing in the ED had been considered too high.

Staffing levels:

Achieving safe staffing levels had been a previous concern across the department, although staff we spoke with felt that pressures had more recently improved. Staff broadly felt that while current levels were sufficient to provide safe care to patients in the moment, this was not usually sufficient to meet all typical demands. Most staff did not feel they had enough time to review and document the holistic needs of all patients, which meant that recording and actioning these needs (such as by using dementia ‘This is me’ leaflets or hourly intentional rounding documentation) could not always be completed.

We reviewed recent staffing levels of the Resus area in the department against the Royal College of Nursing (RCN) and Royal College of Emergency Medicine (RCEM) guidelines regarding nurse-to-patient ratios. The Resus area had an appropriate establishment of 3 registered nurses to care for 5 patients. In the month prior to the assessment, this had been met 90% of the time, which demonstrated an improvement from 76% of the time in the 2 months prior to this. However, we noted that in the previous 3 months, 26% of the days had required support from nursing staff who were redeployed from other areas or who were acting in a leadership role across the service, and some staff we spoke with were concerned about the appropriateness and sustainability of this practice. However, we noted that processes were in place to ensure that redeployed staff had been appropriately inducted to the ED and could demonstrate the appropriate competence to work there.

The Majors area had consistently maintained a nurse-to-patient ratio of 1-to-5 in the 3 months prior to the assessment, meeting this establishment 96% of the time and only requiring redeployed staff to support this establishment on 10% of days. We also observed during the inspection that 1 healthcare assistant (HCA) was allocated to support each nurse with their 5 patients while on shift. During our assessment, we found that the ED as a whole was established for 15 nurses and 7 HCAs during day shifts and 16 nurses and 8 HCAs during the night shift. This was met appropriately.

We reviewed recent staffing levels of the Paediatric Emergency Care Centre (PECC) against the Royal College of Paediatrics and Child Health (RCPCH) Facing the Future standards. The PECC was typically staffed by 3 registered children’s nurses with the support of a HCA during the day, which satisfied RCPCH standards. However, the PECC did not have a Paediatric Emergency Medicine (PEM) subspecialty-trained consultant, and instead relied primarily on non-specialist emergency medicine consultants, with support where required from paediatric medical consultants who were based elsewhere on site. The RCPCH standards advise that there are currently insufficient PEM-trained consultants to meet this requirement in all emergency care centres, nationally.

We reviewed consultant staffing levels of the ED against RCEM guidelines, which advise a ratio of 1 consultant to every 3,600 to 4,000 annual patient attendances. As the service sees approximately 80,000 annual attendances, RCEM guidance indicates approximately 18 to 25 full-time consultant staff would be needed. However, the department only had 10 such consultants, which was well short of the recommendations.

We also noted staffing shortages in other areas, which the service had appropriately recognised as risks. This included the persistent absence of a designated major trauma rehabilitation coordinator role in line with trauma unit recommendations, and fragile nurse and ancillary staffing levels in SDEC areas that jeopardised the ability of staff to meet all their responsibilities. We inspected the Frailty SDEC and found that 1 HCA had temporarily been overseeing 10 patients in the unit while the allocated nurse and other visiting staff were undertaking duties elsewhere. While the service had not recorded any incidents due to falls in this area while it was being piloted, this arrangement presented a significant risk to the frail patients using this space as a lone staff member could not practically manage a situation where 2 such patients both required an urgent intervention to prevent a fall.

We scored the service as 2. The evidence showed some shortfalls. The service assessed but did not always manage the risk of infection. They did not always detect and control the risk of it spreading.

The trust had relevant and effective infection prevention and control policies in place, although the core ‘Standard Infection Prevention and Control Precautions’ policy was 10 months overdue for review at the time of assessment.

We observed that all areas of the service were visibly clean. Cleaning records were up-to-date and demonstrated that all areas were cleaned regularly. Staff were compliant with ‘bare below the elbow’ guidance and adhered to infection control precautions throughout our assessment, such as regular hand washing and using hand sanitiser when entering and exiting clinical areas and when caring for patients.

There were handwashing sinks and hand sanitiser stations available throughout the service. Soap and disposable paper towels were available next to all sinks and instructions on how to effectively wash hands were displayed throughout.

We asked staff how they would manage walk-in patients attending with isolation requirements or who were immunocompromised. Staff told us the arrangements they would typically make, which involved moving such patients into assessment cubicles in the Clinical Decisions Ward (CDW) or into side rooms where these were available. The Majors area had 2 side rooms available to use to meet isolation requirements for bedded patients, which had appropriate facilities and signage.

Sharps waste was segregated and stored appropriately. However, we found waste bins designated for offensive waste throughout the service that contained food waste and packaging, which we observed was because such bins were often being used by patients and visitors. This had also been a finding from previous clinical waste audits and spot checks conducted 6 months and 2 months earlier, which demonstrated minimal improvement. Actions plans had been produced, but these focused on improving staff training rather than mitigating the likelihood that patients and visitors were using the bins.

Monthly hand hygiene audits had been recently completed and demonstrated actions in response to findings appropriately. The findings of environment infection control audits were mixed, and the governance of these in the previous year was poor. The most recent audit of the Same Day Emergency Care (SDEC) area demonstrated 80%, but the area was 5 months overdue its re-audit date. Further, the most recent audit of the Majors area demonstrated a compliance of 87%, but this was also overdue its re-audit date and had followed an audit which had scored very poorly at 36%, following which the frequency of re-audit had not changed. Leaders told us the governance of infection control audits had since improved, being undertaken weekly by a ward leader and monthly by a matron for improved oversight.

The service had an 'Infection Prevention and Control Support Plan', which appropriately identified risks and was reviewed weekly. While this document contained objectives, targets for completion and some individual responsibilities, the document referenced that outcomes would be measured with “audits” or “spot checks” without specifying the nature or frequency of these. Audits across services had been conducted variably using different templates, which reduced the ability of leaders to have clear oversight in this area.

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. They did not always involve people in planning.

As part of the assessment, a medicines inspector reviewed the records of 10 patients and spoke to ward managers, nursing staff and members of the pharmacy team.

Whilst there was some pharmacist support available at the time of inspection, this was not consistent and there was no dedicated ED pharmacist or pharmacy service in place to support the service. This was not in line with the current guidance recommendations set out by the Royal College of Emergency Medicine (RCEM).

Medicines reconciliation is the process of accurately listing a person’s current medicines. Medicines reconciliation rates from April 2026 showed 44% of patients having had this completed within the first 24 hours and 73% of patients within 48 hours. 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 to reduce the risk of medicine errors occurring. Staff told us that not having a dedicated pharmacy service and longer patient stays in the emergency department impacted on these medicines reconciliation rates. This increased the risk that medicines could be omitted, duplicated or prescribed incorrectly, particularly for patients who remained in the ED for prolonged periods before admission.

Medicines, including controlled drugs and intravenous fluids were generally stored safely and securely. However, we found oxygen cylinders in clinical areas across the CDW which were not safely secured and had been left unattended.

We also found that for patients requiring oxygen therapy, oxygen was not always prescribed. Further, records of fluids given were not always complete and accurate and it was not always possible to determine what fluids were added to intravenous infusions, which was not in line with the trust’s policy. This meant staff could not always be assured that patients received oxygen and fluids safely and in line with their assessed needs.

However, medicines stock was regularly replenished, and critical medicines were stored in the department to avoid delays in administration. Staff knew how to obtain medicines out of hours.