Royal Lancaster Infirmary

On this page

• 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

This means 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 requires improvement. At this assessment the rating has changed to good.

Good: This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

The service provided effective care and assessed people’s health, care, wellbeing and communication needs. The service planned and delivered people’s care and treatment with them, including what is important and matters to them. The service worked well across teams and services to support people to manage their health and wellbeing to maximise their independence by delivering person-centred care and treatment.

However, the service did not always routinely monitor people’s care and treatment through audit to continuously improve it.

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 maximise the effectiveness of people’s care and treatment by assessing and reviewing their health, care, wellbeing and communication needs with them.

We scored the service as 3. The evidence showed a good standard. The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

We reviewed 18 sets of patient notes and found all contained the required information and were completed fully and without any errors or omissions. The patient records were reviewed were comprehensive and included risk assessments as appropriate. Situation, Background, Assessment, and Recommendation (SBAR) charts showed evidence of good practice. These included patient observations, tasks, completed and outstanding plans. There was four hourly sign off for ‘seen and safe’ rounding for comfort, pain, food & drink, pressure care, mouth care and toileting.

Staff completed a comprehensive health assessment of the patient in a timely manner at, or soon after, admission.

Care plans were personalised and holistic. We observed staff completing care plans with patients and their families.

We saw that all care plans were updated in all 18 records that we reviewed.

We plan and deliver people’s care and treatment with them, including what is important and matters to them and in line with legislation and current evidence-based good practice and standards.

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 assessed and met patients’ needs for food and drink and for specialist nutrition and hydration. We saw that diet and hydration needs were included in all records that we reviewed. Food and drink were available for patients to meet their dietary needs.

The frailty team consisted of specialist therapists and specialty doctors. Staff told us that they could access specialist input when required for their patients. Staff were experienced, qualified and had the right skills and knowledge to meet the needs of the patient group.

New staff and temporary staff undertook an induction, all staff we spoke with had received a full induction when joining the department. Managers provided staff with supervision (meetings to discuss care management, to reflect on and learn from practice, and for personal support and professional development) and appraisal of their work performance. All nursing staff reported that they were supported by their senior leaders. Managers ensured that staff had access to regular team meetings. If staff were not available to attend then senior leaders would ensure that all staff received meeting minutes by email.

The percentage of nursing staff that had had an appraisal in the last 12 months was 81% at the time of inspection. Managers identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge. The practice educator would regularly work with staff to help them develop and improve. Managers ensured that staff received the necessary specialist training for their roles. The practice educator led on specialist training and would ensure all staff had the opportunity to attend specialist training.

Managers dealt with performance issues promptly and effectively. We were given examples of how staff performance was identified and the steps taken to offer support and adaptations.

Care and treatment was aligned to National Institute for Health and Care Excellence (NICE) guidance There were reference guides such as flowcharts and algorithms are displayed in relevant locations. Staff participated in clinical audit, benchmarking and quality improvement initiatives. There was an audit programme that included both internal and external audits.

The service completed Royal College of Emergency Care (RCEM) audits, and we received information for the six months prior to the onsite inspection. For seen and safe audits these had improved from 84.8% to 93%, however the most recent reported was 87.2%. Paediatric pain and vital signs audit had fluctuated between 80% and 100%, with the most recent reported as 96.4%. The paediatric triage audit was consistently 100%. For the Modified Early Obstetric Warning Score (MEOWS) audit the compliance was 90% to 100% (although three omissions). For the National Early Warning Score (NEWS2) audits, results were generally above the 90% target except for one result of 89.7%. The most recent reported result was 100%. There were four omissions for the mental health triage assessment audit. Results had declined from 97.3% to 84.3%. There was an action for the patient to monitor and support. For the same day emergency care (SDEC) NEWS2 compliance was between 91.7% and 100%. There were monthly matron assurance checks for the minor treatment unit (MTU). Compliance ranged between 84.6% and 100% (although three omissions). The most recent reported was 96.2%.

We received a list of internal audits that had taken place, in the 12 months prior to inspection. Audits had included ‘consenting practice’, ‘fascia iliac block’, ‘NICE QS74 head injury’, ‘NICE Q174 emergency and acute care in over 16’s’ and ‘QS42 headaches in over 12’s. There were actions to complete, and timescales set, however there were no details about the audit results.

We were told that policies and standard operating procedures were reviewed at specialty quality meetings, however we did identify policies that were passed their date for review. We were told that updates for the department were shared with staff at shift handovers, huddles, in governance and staff meetings.

We work effectively across teams and services to support people, making sure they only need to tell their story once by sharing their assessment of needs when they move between different services.

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.

Doctors, nurses, and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide safe care. Staff held regular and effective multidisciplinary meetings to review patients and improve their care. We saw multidisciplinary working with services, such as occupational therapy, psychiatric liaison, and diagnostics to identify the most appropriate care and treatment for patients.

We observed effective communication between staff when handing over patient care at the beginning and end of shifts. We also observed staff huddles throughout the day when patients were discussed, and any concerns were raised as appropriate. We also noted the use of a flow navigator who linked all areas of the department effectively.

Multidisciplinary working was evident and effective within the department; however, we were given examples of communication between the department and other specialities within the hospital being less effective which impacted the patient journey and reduced access to specialist services.

There was “cross bay” working group for the division with attendance three times daily at patient flow meetings to monitor pressures in the emergency departments across the trust and its hospitals. These daily patient flow meetings were multidisciplinary and attended by representatives from all divisions. Concerns could then be escalated to the senior management team.

We were told that service managers work one day per week in the department, however staff we spoke with said senior managers were not always visible.

We support people to manage their health and wellbeing so they can maximise their independence, choice and control, live healthier lives and where possible, reduce their future needs for care and support.

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.

Staff supported patients to live healthier lives. There were posters signposting patients to alternative services to support patients including NHS 111, counselling, exploitation, abuse and other care partners.

There were leaflets available, in the department and the SDEC that had been produced by NHS Organisations or external agencies such as safe sleeping for babies, smoking cessation, groups to support a mental health crisis, spiritual support and abuse signposting.

Examples of leaflets provided following the onsite inspection showed that these were available in languages other than English if required. Staff told us that they would discuss health promotion with patients if there was opportunity, but this wasn’t consistently available due to pressures within the department

Patients fed back that staff shared details of partner and local community organisations with them to help them maintain their independence. This included obtaining equipment to promote self care.

We routinely monitor people’s care and treatment to continuously improve it and to ensure that outcomes are positive and consistent, and that they meet both clinical expectations and the expectations of people themselves.

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.

The trust were aware that the department did not meet the guidance for Royal College of Paediatrics and Child Heath (RCPCH) Facing the Futures Standards. However, there was an action plan and the trust completed the audit tool that indicated they had completed 54 (79.4%) of the applicable 68 standards with 11 (16.2%) standards partially met and three (4.4%) standards not met.

Staff used recognised tools to improve the detection and response to clinical deterioration in patients as a key element of patient safety and improving patient outcomes. We saw staff using a nationally recognised early warning system (NEWS2). We also noted that all patients had been assessed and escalated appropriately in all cases that we reviewed

Staff used technology to support patients effectively (for example, for prompt access to blood test results). However, staff reported difficulty with the trust patient record system which continually timed staff out of their session which meant they spent extra time documenting patient care taking them away from delivering it. A recent upgrade in the system had resulted in further accessibility issues for staff and difficulty recording patient observation. The trust were liaising with the supplier to rectify the issues and trust technology staff were on hand to provide advice, however we noted that this was not always written down by means of instruction for staff to follow.

Staff used recognised tools to improve the detection and response to clinical deterioration in patients as a key element of patient safety and improving patient outcomes. Staff had access to results such as blood tests and scan results 24 hours a day, seven days a week. In the most recent accreditation for the department was allocated a bronze award.

The Sentinel Stroke National Audit Programme (SSNAP) was in place to monitor compliance with care and treatment of patients following a stroke. Scores range from A (best) to E (poorest). In recent years including following the improvements made after the CQC enforcement action of Section 31 registration conditions, the stroke services had shown consistent improvements with SSNAP scores reaching an A. In 2024 the SSNAP dataset was revised which changed the metrics and aggregation for scoring. This resulted in a SSNAP score of D against the new metrics. The location was graded as a D for the time period of January to March 2025, however; this has deteriorated to an E for the period of April to June 2025. There had been a decline in the overall performance for hyperacute assessment in the emergency department.

We tell people about their rights around consent and respect these when we deliver person-centred care and treatment.

We scored the service as 2. The evidence showed some shortfalls. The service did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

There were policies for “Consent to Examination or Treatment – Adults & Children” and “Mental Capacity Act (2005)” as guidance for staff to follow particular if concerns are raised about a patients ability to consent. Staff took all practical steps to enable patients to make their own decisions.

For patients who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. They did this on a decision-specific basis with regard to significant decisions. When patients lacked capacity, staff made decisions in their best interests, recognising the importance of the person’s wishes, feelings, culture and history.

We were told that consent audits were not undertaken within the department. We were not assured that the trusts oversight of unified do not attempt cardiopulmonary resuscitation (UDNAR) forms was robust due to lack of assurance. We were told they were monitored through the deteriorating patient group, however; no results were provided about compliance or actions taken.