Royal Albert Edward Infirmary

On this page

• 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

The service had a positive safety-focussed culture. Safety incidents and complaints were managed well, and lessons learned. Care and support was planned and organised with people and stakeholders to maintain safety and continuity of care. The service had enough nursing and support staff to keep patients safe. However, during the inspection we identified 5 regulatory breaches relating to the key question for safe, where we have told the service it needs to make improvements. We found the service did not effectively manage risks for patients with sepsis. Parts of the service did not have suitable and well maintained furnishings. Key risks relating to consultant numbers and availability had not been effectively identified and mitigated. Mandatory training compliance in specific subjects was significantly below trust targets. Staff appraisal compliance was below trust targets.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

People who used the service and their relatives, we spoke with, told us they knew how to raise a complaint or concern.

Staff had a good understanding of how to use incident reporting systems. Staff were aware of the key themes which had arose from recent complaints and incidents and felt confident to raise issues and concerns when they arose. Senior members of staff and leaders were involved in reviewing complaints and incidents. Safety huddles and patient experience meetings provided staff with a forum in which incidents and complaints were discussed. Reviews of incidents had led to improvements according to staff and leaders.

Safety was a top priority that involved everyone, including staff as well as people using the service. The service had the relevant policies and procedures in place for incidents and complaints. Risks were not overlooked or ignored. Safety incidents and complaints were investigated as an opportunity to put things right, learn and improve. Managers kept staff aware of safety incidents and complaints, with learning shared through daily safety huddles. Lessons were learned, resulting in changes that improved care for others. Staff understood the duty of candour. They were open and transparent, and gave patients and families a full explanation if and when things went wrong. However, complaint responses were not always completed in a timely manner.

Most patients were satisfied there was a joined up, collaborative approach to safety that involved them and their loved ones. Patients we spoke with told us their time to triage had been timely. Corridor care patients told us they understood their treatment plan and who was reviewing their care.

Leaders acknowledged the shortage of medical consultants and health care assistants within the service and explained that recruiting to these positions was difficult. They were confident health care assistants could be filled with bank and agency staff and had uplifted some middle grade doctors to speciality grades. They had plans to develop their own medical staff to become consultants. Staff told us that despite the nursing establishment being positive, there were some challenges with skill mix which was impacting upon the service. Some staff said the department skill mix had been a contributory factor in ambulance handovers being delayed, due to more junior staff working in this area. Leaders acknowledged this and were providing additional competency training to upskill staff here. Staff told us that overall, there were appropriate levels of nurse staffing. Leaders explained there had been an international recruitment drive for nurses which had enabled nurse staffing levels of 1:4 patients for majors and 1:2 for resus. Staff felt they received the support from senior members of staff to deliver safe care. They felt they had the opportunity to develop in their roles and had opportunities to learn.

We received a mixed response from mental health professionals working in the Makerfield Unit. Some staff felt communication between the mental health team and the emergency department could be improved. The ambulance trust staff met regularly with the service in which safe systems of care were discussed.

Patients could access emergency support at any time of day or night. Patients were triaged using the Manchester triage system by adult and paediatric trained triage nurses. The average time for triage was worse than the national standards between April 2023 and March 2024. Patients could be streamed internally to the urgent treatment centre (UTC) and the same day emergency care (SDEC) service, The streaming services closed before midnight but there were plans to extend some of their opening hours. Patients could also be referred to the virtual ward, the frailty SDEC or the surgical SDEC. However, numbers of patients being streamed away from the emergency department were low but increasing, averaging 4.5 patients per day between January and March 2024. The service had 24-hour access to mental health liaison and specialist mental health support. The mental health unit was managed by the local mental health trust and located in the emergency department. The trust performed worse than national and regional averages for ambulance handover times. The trust consistently performed worse than the England average for the median time to treatment. The percentage of patients leaving before being seen was better than the national average. Staff had access to speciality teams who worked across the hospital, services such as the speech and language team (SALT) and the substance misuse service only operated on weekdays. Staff completed risk assessments for each patient on arrival and reviewed these regularly. Staff used nationally recognised tools to identify deteriorating adult and paediatric patients and escalated them appropriately. Staff followed sepsis six guidelines to manage adults and children with sepsis. However, recent audit records showed poor staff compliance against sepsis pathways, including for blood cultures being taken, antibiotics administered, and serum lactate taken within an hour of sepsis diagnosis.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

Patients felt the waiting area was overcrowded and did not have enough suitable space to accommodate the amount of people attending the emergency department. Corridor patients acknowledged the environment they were located was not designed to meet their needs. For example, patients reported the environment not being ideal due to the noise, the amount of people walking by and the lighting above their trolley which stayed on throughout the night. However, patients and their relatives told us the environment was safe and the condition, appearance and maintenance of the service was good apart from some cracked flooring.

Leaders were aware the estate was not designed to accommodate the amount of people currently attending the department and acknowledged the environment was not appropriate for corridor care patients but had implemented processes to ensure environments were safe. Staff told us audits were regularly completed which reviewed equipment and the environment. They said equipment needed for care and treatment was readily available and any faulty equipment was replaced promptly. However, some pressure care equipment such as repose mattresses were high in demand, and they did not always have enough. This was acknowledged by leaders, and they had purchased additional repose mattresses.

Patients were not always cared for in an environment that was suitably designed to meet their needs. The emergency department was at full capacity, and we observed 16 patients on trollies situated on the corridors. Corridor patients did not have access to a call bell, no piped medical gases, there were no sinks or hand sanitising stations, and it was brightly lit and noisy. One nurse was allocated to every 4 corridor-based patients. Patients were triaged and risk assessed as safe for corridor care. The service did not have a quiet room for patients with additional needs, however it did for paediatric patients. Facilities, equipment, and technology were well maintained. Staff carried out daily safety checks of specialist equipment. We reviewed the contents of the resuscitation trolleys. which contained the appropriate equipment for adult and paediatric patients. Equipment used to deliver care and treatment was suitable for the intended purpose, stored securely and used properly. There were arrangements in place for the handling, storage, and disposal of clinical waste, including sharps.

The service monitored the safety of the premises and equipment. We saw fire risk assessments for each area of the emergency village and local evacuation plans, evidence of equipment servicing testing. Corridor patients were looked after in areas that were not designed to meet their needs. The service had completed checks which ensured the environment was safe and had procedures and protocols which detailed the associated risks. Equipment used to deliver care and treatment was stored securely and used properly. We saw evidence of a safety inspection checklist from October 2023 in which staff were found to have complied fully with the Control of Substances Hazardous to Health (COSHH) practices. Each department within the emergency department completed internal audits on a weekly basis. We reviewed a sample of audits, and these showed a high level of staff compliance.

Patients told us they felt there was an appropriate level of staff although they experienced lengthy waiting times. People using the service and their relatives told us that nurses, medical staff, and domestic staff had all been visible.

Leaders acknowledged the shortage of medical consultants and health care assistants within the service and explained that recruiting to these positions was difficult. They were confident health care assistants could be filled with bank and agency staff and had uplifted some middle grade doctors to speciality grades. They had plans to develop their own medical staff to become consultants. Staff told us that despite the nursing establishment being positive, there were some challenges with skill mix which was impacting upon the service. Some staff said the department skill mix had been a contributory factor in ambulance handovers being delayed, due to more junior staff working in this area. Leaders acknowledged this and were providing additional competency training to upskill staff here. Staff told us that overall, there were appropriate levels of nurse staffing. Leaders explained there had been an international recruitment drive for nurses which had enabled nurse staffing levels of 1:4 patients for majors and 1:2 for resus. Staff felt they received the support from senior members of staff to deliver safe care. They felt they had the opportunity to develop in their roles and had opportunities to learn.

During the inspection we saw from staffing rota and our observation there were shortfalls in some areas. Nurse staffing in the majors area was 1:5 patients when it was planned to be 1:4. There was 1 less health care assistant for the UTC and the ISAT area did not have a consultant on shift. We observed nursing huddles and bed flow meetings where staff numbers across the emergency village were reviewed. However, we did not observe medical representation on the bed flow meetings. We observed that staff attending to corridor patients did not always have their breaks covered by other staff. We saw that staff had person centred positive interactions with patients despite the demands due to capacity and patient flow. Staff were available throughout the day to respond to patients in a timely manner. Staff worked efficiently together. We saw senior staff supported junior staff their professional development and worked in collaboration with each other.

Mandatory training compliance for medical staff was significantly below trust targets for resuscitation (48%), infection, prevention, and control level 2 training (52.5%) and safeguarding children level 3 training (57%). Mandatory training compliance for nursing staff was significantly below trust targets for paediatric resuscitation level 3 (33%), resuscitation level 3 (42%) and resuscitation level 2 (50%). The appraisal completion rate for staff across the department was 50%. There were 12 consultants employed by the service. However, Royal College of Emergency Medicine (RCEM) guidance recommends that an emergency department with more than 100,000 attendances per year should have a minimum of 16 to 18 consultants. The service did not achieve 16 hours on site consultant presence 7 days a week, in line with RCEM recommendations. Medical staff rotas showed consultant presence in the initial senior assessment triage (ISAT) was occasional. This meant the ISAT was not always consultant led. Shortfalls in consultant staffing had not been identified as a risk on the divisional or trust-wide risk registers. The service had enough nursing staff, advanced practitioners and support staff with a low vacancy, sickness and turnover rate, to keep patients safe. However, the service had recently recruited 16 nurses, which impacted the nursing skill mix. Shift cover for unplanned sickness or leave was provided by bank or agency staff. The department did not have a dedicated Paediatric Emergency Medical Physician (PEM); however, there was a consultant with specialist interest in paediatrics and consultants from the nearby children’s ward provided support and guidance when needed. The service had safe recruitment practices to make sure all staff were suitably experienced, competent, and able to carry out their role. Staff underwent induction and completed competency based training.

Patients, including corridor patients told us they found the emergency village to be clean and tidy. They told us domestic staff were busy and visible. The trust scored 100% for cleanliness, condition, appearance, and maintenance on the PLACE audit.

Leaders were aware of the concerns regarding IPC raised by staff and people who use the service. The lack of sinks and hand sanitising stations for corridor patients had been raised with the trust infection, prevention and control team. Leaders also acknowledged the flooring issues as an IPC concern and had arranged to have this repaired but due to the capacity of the department this had been unachievable. Staff were aware of the importance of cleanliness and hygiene and followed trust procedures when they identified concerns relating to infection, prevention, and control. Staff told us the IPC leaders were visible and approachable and explained some of the projects to improve IPC compliance. Staff explained the complexities of managing IPC when there was overcrowding in the department. They knew how to isolate any patients who had infectious diseases. Staff said they had plentiful supplies of personal protective equipment.

Throughout the emergency village we observed damaged flooring which was a risk to infection, prevention and control. Department leaders were aware of this and had planned in November 2023 to complete estate repairs and a deep clean in the emergency department. However, flooring repairs had not been completed due to the daily service activities in the department. Some equipment, including a bed in a consultation room in the UTC and a chair on majors had puncture holes which posed an infection risk for patients. Corridor patients were located closely together with very little room between their trolleys. They did not have access to hand sanitising stations or sinks to wash their hands, although we did see nurses responsible for a cohort of corridor patients providing hand sanitiser from a portable plastic bottle. However, the premises and equipment were mainly kept clean and hygienic. We saw equipment with ‘I am clean’ stickers on them and cleaning records all demonstrated that areas had been cleaned regularly. We observed most staff following IPC principles, including the use of personal protective equipment and being bare below the elbow.

The emergency village monitored key metrics in relation to infection rates, including MRSA, MSSA and E. coli. The trust performed better than expected and in the top 25% of all trusts nationally. The emergency village completed departmental level audits for IPC. Overall, the emergency village scored an average of 95% in January and February 2024. This included domestic, estates and nursing cleaning scores. IPC leads and the health and safety team completed walkarounds which had resulted in actions including increasing the amount of waste bins for patients. Information about the risk of infection was shared appropriately with relevant partners, including agencies, people using the service and visitors. The trust ensured patient led assessments of the care environment (PLACE) audits were completed annually. Overall, the trust scored 100% regarding cleanliness and infection control which ranked them 1st nationally.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.