Royal Lancaster 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

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

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.

The service had a shared vision, strategy and culture. The service had inclusive leaders at all levels who understood the context in which they delivered care and treatment. The service valued diversity in their workforce. The service shared information and learning with partners and collaborated for improvement. The service focused on continuous learning, innovation and improvement across the organisation and local system.

The service was still in breach of the legal regulation in relation to good governance. Staff did not always feel they could speak up and that their voice would be heard. Senior leaders did not always act on the best information about risk, performance and outcomes.

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 have a shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and our communities.

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.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. Senior leaders were able to articulate how their role aligned with the trust values of Purpose, Visions, Values and Strategy. The trust’s purpose was “to deliver compassionate care and the best possible results for the people of Morecambe Bay with “compassionate, respectful & inclusive, ambitious and open, honest & transparent” values.

Departmental mangers had an ‘open door policy’ for staff which was enabled by their offices being close to the staff room. Staff told us they felt listened to and heard by department and divisional managers and leaders and were encouraged to communicate and feedback. We received mixed feedback about decisions that were made how the department was run by senior leaders. Staff told us they did not always understand why decisions were made or had the opportunity to speak with senior leaders about these decisions. An example was provided related to an initiative from the local NHS ambulance trust regarding ambulance handover times.

Staff could explain how they were working to deliver high quality care. All staff could articulate the trust values and how they fitted into delivering high levels of patient care. There was a suggestions box to encourage staff to provide their thought, ideas and improvements.

We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Nursing and medical staff across the emergency department understood the key risks to patients within the department. Staff told us the emergency departmental leads and senior managers were approachable, visible, and provided them with good support but not all staff thought that communication was effective.

Staff understood the reporting structures and leaders understood their key roles and responsibilities. Leaders also fully understood the key risks and challenges faced by the emergency department. Leaders were able to demonstrate how they worked as part of a multidisciplinary team within the service and how they collaborated with partners such as the local NHS ambulance trust. They told us they worked well together and there was regular engagement to review performance and identify improvements to services.

Leaders had the appropriate range of skills, knowledge, and experience to carry out their roles. There was a triumvirate leadership structure at departmental and divisional level with medical, nursing, and operational leads.

Leaders, in the department, had the skills, knowledge and experience to perform their roles and were visible in the service and approachable for patients and staff. Leaders had a good understanding of the department they managed. They could explain clearly how the teams were working to provide high quality care.

Leadership development opportunities were available for staff.

Staff we spoke with told us that local leaders were very supportive.

There were team building days and staff regularly brought home made cakes for colleagues to share. They were hoping that an inner courtyard area could be transformed as a social space to share at break times.

Department managers told us that despite escalating concerns about staffing levels not meeting department requirements they didn’t feel listened to or supported by senior leaders.

We create a positive culture where people feel that they can speak up and that their voice will be heard.

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.

Staff had access to freedom to speak up (FTSU) champions in the department. The trust FTSU policy detailed the process and how staff could access the champions. Since July 2024 to time of inspection, there were 10 instances where staff had reported to FTSU although it was not clear which of the three sites they related to. These were mainly concerns re scheduling of staff both nursing and medical. Staff told us rather than using the FTSU process, they would report concerns directly to local managers, as they felt they were being heard.

We requested a copy of the trust Whistleblowing policy, however, did not receive it.

Department managers and staff had access to the feedback from patients, carers and staff and used it to make improvements. Managers told us about improvements that had been made, for patients such as increasing space in the waiting room and reviewing vending and drinks options. Staff had a dedicated area to take their breaks but were hoping to improve an outside space for staff to use.

However, staff told us that they did not always feel that their voices were heard about issues that affected the running of the department that required senior leadership input. Staff reported that concerns raised about numbers of staff in the department had been raised frequently but not always addressed.

In the 2024 annual NHS staff survey the trust scored lower than other trusts for staff raising concerns which indicated staff felt safe to raise concerns, but lacked confidence action would be taken.

We value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for people who work for us.

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.

The service promoted equality and diversity in daily work and provided opportunities for all staff to develop. The trust had implemented a divisional triumvirate leaders development programme and encouraged staff from the global majority to apply. The programme had been designed to increase trust, encourage healthy challenge, and drive commitment and accountability within the triumvirate.

The trust staff inclusion networks encouraged staff to join them if they identified with the group or as an ally. The networks included BAME (Black, Asian, and Minority Ethnic), Carers, Disability, Armed Forces, LGBTQ+ and Women Leaders.

Policies and processes were in place to ensure the service was inclusive and fair in the way it operated. Staff received training in equality and diversity and had a good understanding of cultural, social and religious needs of patients and demonstrated these values in their work.

The trust reported sickness, absence and retention rates in divisional reports to the board. The trusts staff sickness absence rate was 4.93% which was below the national average of 5%.

We have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.

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.

The evidence showed some shortfalls in governance and risk management. Systems and processes failed to manage risks effectively, particularly during periods of crowding, which compromised patient safety. The service was still in breach of the legal regulation in relation to good governance.

Staff continued to raise concerns about paediatric staffing levels and overcrowding. Despite some actions such as corridor reconfiguration to manage overflow, these measures only partially reduced risk and did not resolve the underlying issues. While staff escalations were acknowledged and support was offered, long-term solutions to persistent challenges with flow and staffing had not been implemented.

Escalation protocols did not alleviate crowding, which staff described as an accepted norm. Computer systems also contributed to difficulties with patient flow and identification. Although leaders set goals to manage these risks, they were unable to achieve them due to ongoing pressures.

Despite these challenges, leaders demonstrated proactive oversight through daily safety huddles and clinical site meetings, and escalated capacity concerns to the wider hospital. They used accurate information to inform decisions and employed tools such as a nationally recognised staffing tool.

Governance structures included departmental meetings feeding into the wider emergency care and medicine triumvirate. Leaders used a clear framework to ensure essential information such as learning from incidents and complaints was shared.

The departmental risk register reflected key concerns; overcrowding, paediatric staff cover, delays to patient treatments and budget constraints. The risk register included graded risks and action plans. However, some ongoing risks completion dates were overdue.

There was a “cross Bay” improvement plan for the emergency departments at the trust. This included issues identified as part of an action plan which included the time non-admitted patients spent in the department, the time they waited to be seen and the fourhour performance. A slight improvement on outcomes for patients had been demonstrated in the second quarter, April to June 2025.

Issues were escalated from the emergency department improvement group to the executive triumvirate and chief executive via the care group senior leadership oversight meeting, then to care group business and performance meeting and then the care group board and executive performance meeting. Key metrics were monitored including non-admitted time in the department, wait to be seen times, minor treatment unit utilisation, triage times, ambulance handover performance, corridor care, patient and staff experiences, falls and pressure ulcers.

Trust leaders engaged with improvement programmes and sought external advice. There were business continuity plans for emergencies and natural disasters.

Staff maintained clear roles and responsibilities, and systems ensured confidentiality of data used to monitor and improve care quality.

We understand our duty to collaborate and work in partnership, so our services work seamlessly for people. We share information and learning with partners and collaborate for improvement.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Leaders understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. The leadership team understood how their staff felt about delivering care that met both the physical and mental health needs of patients.

Staff and leaders worked in partnership with key organisations to support care provision, service development and joined-up care, such as the local NHS ambulance trust.

The trust’s strategy aligned to local plans in the wider health and social care economy, and services were planned to meet the needs of the relevant population. Directorate leaders engaged with external stakeholders. External stakeholders described positive working relationships with with the trust. Examples of joint working included projects looking at the mental health working and safeguarding.

We did receive some external feedback relating to the overcrowding in the department and delays responding to patient complaints, which corroborated evidence we found on inspection.

We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.

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 encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

Staff told us they were given the time and support to develop opportunities for improvements and innovation and this led to changes in care delivery. Practice educators worked with staff in the department to develop skills and also to support patient care delivery, freeing up staff.

Staff had opportunities to participate in research.

Staff participated in national audits relevant to the service and learned from them.

The Trust collaborated with Lancaster University looking at why people attended the emergency department exploring ways to manage the demand on services more effectively. The study identified ways to reduce unnecessary visits and signpost appropriate patients to same day emergency care.