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 service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment, the rating has changed to requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

While recent improvements showed promise, staff had not always felt sufficiently engaged or involved with decisions made across the service, which had led to more negative staff experiences compared to other areas of the trust as demonstrated by the last staff survey. The service did not demonstrate that is always identified and managed key risks, and areas of poor performance were not managed or improved in a timely way. Outcomes and experiences from partnership working were variable.

However, robust transformation plans were in place that identified and targeted many areas requiring improvement, and oversight of this was strong. While starting from a poor position, morale and culture showed early signs of improvement and staff across the service were optimistic about upcoming changes.

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. 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.

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 were well-informed about operational performance and gave examples of times in the past where the culture of the service and morale amongst staff was very poor, which most staff felt was reflective of the persistent operational pressure they experienced. This had included disputes with leadership and between different groups of staff, with misaligned and competing priorities. A small number of staff described a history of interpersonal conflict and unprofessional behaviour amongst staff at various levels of seniority.

However, both staff and leaders across the service were highly motivated by recent improvements and were positive that these could be sustained. Various staff we spoke with, who had previously considered leaving the service or the profession entirely, described a turnaround in the previous year, particularly in the 6 months prior to the assessment. This had incentivised them to contribute to the improvements and long-term success of the service. As such, most staff felt that the culture amongst staff was positive, with no ongoing conflicts within different groups of staff or leadership.

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 and ways of working were still being embedded. Previously, leaders had not always embodied the culture and values of their workforce and organisation.

Leadership within the service had appropriate qualifications and experience, although were each very new to the role, having been in place for only a few months prior to the assessment. Staff were broadly positive of the new service leadership and felt that the current team had so far been inclusive and approachable, but some strongly negative views had persisted about upper management that were informed by poor experiences with how change was managed in the service in previous years. This was true both across the ED and amongst staff in the Same Day Emergency Care (SDEC) areas. While there was an understanding that broader budgeting and operational pressures had meant that service changes were necessary, various staff felt that they had been poorly engaged with during these processes and that concerns had not been responded to or acted upon.

Results from the most recent staff survey in 2025 were aligned with these reports. Overall scores across the ED for compassionate leadership and line management were significantly below the organisational averages and usually amongst the bottom areas of the organisation. For example, 51% of staff across the trust felt that they were satisfied with the recognition they got for good work, against 36% of staff in the ED. Further, while 70% of staff agreed that their immediate manager valued their work, only 48% of staff in the ED felt the same way.

We saw that senior trust leaders were present in person across the service during the assessment. Staff could easily identify the senior leadership team and most staff felt they were visible across the service, particularly during times of heightened pressure.

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.

While the trust had established processes for managing ‘Freedom to Speak Up’ (FTSU) concerns, staff survey results and feedback from staff during the assessment demonstrated that staff had not always been empowered to speak up about concerns.

We discussed various issues covered throughout this report with staff. In many cases, particularly regarding the safe management of patients with mental health presentations or the conditions in the main waiting room, staff were fully aware of the challenges but felt “helpless” to make or suggest changes. Staff were broadly aware of the trust’s FTSU arrangements, but few staff we spoke with felt this would lead to meaningful change. A smaller number of staff felt as though their concerns would not be treated anonymously in line with their wishes or that they would face repercussions as a result of whistleblowing. However, we found no evidence of this in practice, and leaders demonstrated robust procedures to protect anonymity, although acknowledged that anonymous concerns were typically harder to investigate and act on.

Across the ED and other acute medical areas such as the Intensive Care Unit (ICU) and Medical Assessment Unit (MAU), a total of 8 FTSU concerns had been raised in the 12 months before the assessment. While leaders advised that the preferred way for staff to raise concerns would be to feel safe to discuss this with their manager rather than use the FTSU process, the low number of FTSU concerns in conjunction with the staff feedback we heard during the assessment indicates that the voice of staff was not being heard sufficiently. In line with the feedback we heard, trends in FTSU concerns related to recurring reports of incivility between staff and poor leadership behaviours in the previous year.

The most recent staff survey results from 2025 also demonstrated that staff in the ED were not empowered to speak up. Compared to the organisational average of 69%, only 44% of staff in the ED felt that their immediate manager asked for their opinion before making decisions that affected their work. Similarly, compared to the organisational average of 49%, only 27% of staff in the ED felt they were involved in deciding on changes introduced to their work area.

Leaders told us that monthly executive listening events and walkabouts were planned across the ED service, and that departmental listening events had taken place previously. We asked for the “number of FTSU/wellbeing drop-in sessions that were held for UEC staff in the last 12 months”, but the service did not record this information. We saw the service’s ongoing transformation plans did incorporate a workforce theme with an aim to “ensure staff have safe space to raise concerns and issues without fear of repercussions” as an ongoing action, and to reinforce an ‘open door policy’.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

We reviewed the trust’s Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) 2025 annual report and survey results. The trust's performance on reported discrimination of ‘Black and Minority Ethnic staff’ from colleagues or managers was worse than the NHS benchmark median of 16% and represented a deterioration compared with the previous year's result of 21%. Compared to the comparatively positive performance in reported abuse from the public or service users, this represented a cultural issue within the organisation.

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.

Staff were able to access trust-wide staff networks including ‘Faith and Minority Ethnics (FAME)’, ‘Disability and Wellbeing Network (DaWN)’ and ‘True Colours’ LGBTQIA network, which provided peer support, promoted awareness and helped raise issues affecting diverse staff groups. During the assessment, we spoke to staff from a variety of backgrounds and with different protected characteristics who agreed that these networks were sufficiently visible and accessible, and that they did not feel discriminated against while working.

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.

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.

We scored the service as 2. The evidence showed some shortfalls. The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Governance processes had not always been effective in managing risk and performance issues across service. The service had a risk register that was regularly reviewed and rerated to reflect actions and further developments. However, not all risks acknowledged during the assessment were reflected in the risk register.

For example, the risk of violence and aggression in the department was a growing and commonly held concern amongst staff in the ED but did not feature in the risk register we reviewed. Following the assessment, we requested copies of the violence and aggression risk assessments that were in place but did not receive these. During the assessment, we found a paper copy of a violence and aggression risk assessment in the Paediatric Emergency Care Centre (PECC) which was 6 months out of date. There appeared to be errors in the risk calculation such that it was unclear if it had been graded as high or moderate risk. We also reviewed an associated ligature risk assessment in the same department, which had graded the potential consequence of the risk as a 2 out of 5 (indicating a minor injury), when ligature events would objectively be expected to cause more consequential levels of harm to the individual.

The clinical lead for the service advised that the establishment of consultant medical staff was significantly below national guidelines, as outlined in the ‘safe and effective staffing’ section of this report. This had made distributing the workload a persistent risk and limited consultants’ ability to participate in other work activity outside of immediate clinical requirements. This risk was not addressed in the service’s risk register. We asked for evidence of the service’s most recent nursing and medical staffing reviews but did not receive these.

The service did not always demonstrate that they had acted on previous risks and concerns to improve or mitigate them. For example, at our previous assessment we had identified that the service was short of emergency medicine consultant staffing recommended by Royal College of Emergency Medicine (RCEM) guidance and that sepsis compliance needed improvement. At the time of this assessment, there were fewer consultants than there were before, and the failure to reliably meet sepsis compliance targets had persisted. We also noted that despite its introduction in 2023, policies and procedures that directed ED staff on the service’s relationship and division of responsibilities with the mental health streaming area were yet to be ratified.

Document control systems did not always work to ensure that documentation was standardised or up to date. We found examples of process documents such as the ‘Walk-in Triage: Escalation Process’ document which did not include any document control details and so users could not be assured this was up to date and reflected current practice. We reviewed a ‘Wheeze Discharge Plan’ leaflet that was available to patients, and found this was a version that, while containing similar content to the trust’s approved leaflet, looked different and did not contain any document control information. We also spoke with a patient in the Urgent Treatment Centre (UTC) who showed us he had been given the ‘master copy’ of a leaflet intended to be photocopied, which we exchanged with staff for an appropriate version. These leaflets also did not contain any document control information, and so staff could not be assured these contained the most current available information.

The trust’s safe staffing escalation policy was over 18 months out of date, and the ED’s business continuity plan documentation (BCP) was also 10 months out of date. The BCP contained a list of staff contact details to be relied upon in the case of a critical incident with text highlighted ‘IMPORTANT – review every 3 months’, but this had not been reviewed as the details of the current matron, operations lead, or medical lead were not contained in the list. Because the BCP was intended to be used as a final contingency to guide staff in the case of a critical incident, this presented a significant risk to the assurance that continuity could be appropriately maintained if such an incident were to occur.

However, there were routine governance meetings in place to discuss clinical safety, operational performance and risks across the service, with predefined agendas and comprehensive minutes. Action logs were in place, and we observed that progress against planned actions was reviewed at subsequent meetings. Staff told us information on performance, risks and governance was discussed during daily handovers, routine team meetings, and in monthly departmental newsletters.

There were effective arrangements for the availability, integrity and confidentiality of data, records and data management systems. Some partner services such as the ‘sister’ UTC at a different hospital site and the co-located mental health streaming area used different IT systems to the main ED, but staff demonstrated that they could mitigate these issues and access relevant information about patients’ care and treatment.

We scored the service as 2. The evidence showed some shortfalls. The service did not always understand their duty to collaborate and work in partnership, so services worked seamlessly for people.

The service worked as part of an array of different partners and evidence showed that the success of these partnerships varied.

A significant concern amongst many staff across the ED was the historical relationship with the co-located mental health NHS foundation trust, which had been ongoing since its inception more than 2 years prior to the assessment. Leaders from both the ED and the partner trust were positive about the recent direction of the working relationship and there had been operational improvements in the months prior to our assessment, but both parties were clear that key disagreements in working practices and responsibilities had led to a breakdown in the relationship in previous years.

We were provided with documentation which included the memorandum of understanding between both trusts regarding the mental health streaming area, alongside the associated interim standard operating procedures. Information within the documents indicated they had both been drafted in 2022 or 2023 but had still not been agreed upon and formalised by 2026. Both documents contained the phrase “In the absence of a mental health bed and a medical bed, medic cover will be supported by…”, without completing the sentence. We spoke to staff who advised that this lack of clarity in responsibility for such patients, or patients presenting with medical and mental health presentations together, was a persistent source of misunderstanding.

However, other partnerships in the service were more effective. The local ambulance NHS trust was positive about the service and engagement occurred between them and the service very regularly. We spoke with paramedics from the ambulance service who reported good relationships and communication with receiving staff. The Same Day Emergency Care (SDEC) areas also had an effective community liaison team (the Access to Community Service Team, ACST) who communicated with primary care and adult social care services to ensure that patients experienced continuity in their care, with an aim to avoid future adverse events and readmissions.

The ‘Better Lives Delivery Board’ also 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 addressing system-wide priorities.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They actively contribute to safe, effective practice and research.

Service leaders had a good understanding of the areas for improvement and as such had extensive service redesign plans underway at the time of assessment. This included process changes such as alterations to the staffing and division of responsibilities in the ED and an expanded Frailty SDEC, clinical changes such as the introduction of electrocardiograms (ECGs) at the point of triage, and the more extensive urgent and emergency care (UEC) transformation plan.

The transformation plan consisted of a programme of themes which each included ‘milestones’ with accountable staff and clear timeframes. The plan had been developed in response to a wide variety of information sources and included improvements to concerns that we had heard during from staff during the assessment. Themes included “Estates and Equipment”, “Patient Safety” and “Workforce”, and milestones included determining short-term plans to use vacant areas of the footprint, installing fixed chairs in the main waiting room, development of the sepsis action plan. Staff across the ED were aware of the transformation plan and invested in its success. The plan demonstrated that leaders were well-briefed about issues in the ED and how improvements could be achieved.

Staff across the service also took part in and contributed to research programmes. Recent examples included research into escalation areas in EDs conducted by the Trainee Emergency Research Network (TERN), contributing to a clinical trial to improve the diagnosis and treatment of acute coronary syndromes, and participating in the National Institute for Health and Care Research (NIHR) Spinal Immobilisation Study.

The service had also implemented a formalised approach to nurse training and career development in the first 3 years of starting, known as the ‘Overarching Education Plan’. Educational needs had been developed following the identification and analysis of trends in incidents, departmental strategy, staff performance evaluations and staff feedback. This included alignment with the Royal College of Nursing (RCN) ‘Competency Framework for Registered Nurses in Emergency Care’ and identified further specific training such as in triage, link nursing or in medicines patient group directions (PGDs) throughout the 3-year course.

Compared to some other themes of feedback in the most recent staff survey, scores for staff working in the ED were closer to organisational averages when asked about learning and development. For example, when asked if they felt they had opportunities to improve their knowledge and skills, 64.5% of staff in the ED agreed compared to an organisational average of 64.6%. Staff we spoke with across the service broadly agreed that there were sufficient development opportunities, although time pressures sometimes limited their capacity to take part.