Royal Infirmary of Edinburgh
Older people in acute hospitals unannounced inspection
Inspection dates: 27-29 August 2012
We carried out an unannounced inspection to the Royal Infirmary
of Edinburgh from Monday 27 August to Wednesday 29 August 2012.
Before the inspection, we reviewed NHS Lothian’s self-assessment
and gathered information about the Royal Infirmary of Edinburgh
from other sources. This included Scotland’s Patient Experience
Programme and other data that relate to the care of older people.
Based on our review of this information, we decided to focus the
inspection on the care of people with dementia and cognitive
impairment, and preventing and managing pressure ulcers. Due to
concerns we had during the inspection, we also focused on the
nutritional care and hydration for patients.
On the inspection, we spoke with staff and used additional tools
to gather more information. In seven wards, we used a formal
observation tool. We carried out 13 periods of observation during
the inspection. In each instance, members of our team observed
interactions between patients and staff in a set area of the ward
for 20 minutes.
Areas of strength
We saw evidence on one ward that staff were confirming with the
Office of the Public Guardian about proxy powers held by patients’
appointed welfare power of attorney. This is someone who is
appointed to make decisions on someone else’s behalf when they are
unable to do so themselves.
Patients can access a hot meal if they are off the ward at
mealtimes. Staff are able to offer alternative options to patients
if they are unhappy with the meal they received. Snacks for
patients are available out of hours.
A tissue viability service is available to provide advice and
support to staff on wound care and pressure ulcer prevention and
management. Education is provided to staff on induction and through
an annual staff training day
Areas for improvement
We found that further improvement is required when providing
care to older people in acute hospitals.
We are concerned about how staff are making sure patients’
dignity and comfort are maintained at all times in the combined
assessment area. This is a mixed sex area and patients can be there
for a number of days before being discharged or transferred to a
ward. We had to intervene on three occasions whilst inspecting this
area of the hospital. Due to the busy nature of the ward, we saw
instances where nursing staff would start to care for a patient and
then be called away before they were able to complete their tasks.
Patients were interrupted on several occasions while treatment and
care was given.
Some mealtimes seemed poorly organised. Patients who needed help
with their meals waited for a long time before that help was
provided. We had significant concerns about the provision of meals
across several wards and how some patients were assisted to eat
their meals. On a number of occasions, we had to intervene and ask
staff to provide help for patients at mealtimes.
There is no routine screening for cognitive impairment taking
place when patients are admitted to hospital. Staff in the accident
and emergency department confirmed that they do not routinely carry
out cognitive screening on all patients over 65 years of age.
We also found that risk assessments for nutritional care and
hydration, and to determine whether patients were at risk of
developing a pressure ulcer, were not being carried out within the
We found no information in the care plans outlining the
individual needs of older people. This means that there is no
information for staff on how they can provide care to meet those
Across the hospital, the ward environments inspected were not
helpful for people with dementia and cognitive impairment.
This inspection resulted in four areas of strength and 23 areas
for improvement. A full list of the areas for improvement can be
found in Appendix 1 on page 20.
The improvement action plan for this inspection has now been
removed from the HEI website, as the inspection took place more
than 16 weeks ago. Please contact NHS Lothian for further
information on progress against this action plan.
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