RIE Oct 12


"We observed areas where NHS Lothian is performing well including the provision of a service to advise and support staff on wound care and preventing and managing pressure ulcers. However, we also identified a considerable number of areas for improvement. For example, staff should ensure that patients’ experience of attending the hospital is as positive as it can be, and that they are treated with dignity and respect at all times. We expect NHS Lothian to address the areas for improvement we have identified as a matter of priority."

Ian Smith - Acting Chief Inspector

Royal Infirmary of Edinburgh

Older people in acute hospitals unannounced inspection

Inspection dates: 27-29 August 2012

Summary of inspection

We carried out an unannounced inspection to the Royal Infirmary of Edinburgh from Monday 27 August to Wednesday 29 August 2012.

We inspected the following areas:

  • combined assessment area
  • ward 101 (medicine for the elderly – stroke ward)
  • ward 106 (general/vascular surgery)
  • ward 109 (orthopaedic trauma)
  • ward 201 (medicine for the elderly)
  • ward 202 (medicine for the elderly)
  • ward 203 (medicine for the elderly), and
  • ward 204 (respiratory ward).

We also visited the accident and emergency department and the discharge lounge.

We focused 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.

Areas of strength

We noted areas where NHS Lothian was performing well in relation to the care provided to older people in acute hospitals.

  • 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 correct timeframes.
  • 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 individual needs.
  • 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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Royal Infirmary of Edinburgh overview

Find out more about this hospital, including the latest inspection report, on the Royal Infirmary of Edinburgh overview page.

Types of inspections

Inspections may be announced or unannounced and will involve physical inspection of the clinical areas, and interviews with staff and patients. We will publish a written report 8 weeks after the inspection.

  • Announced inspection: the service provider will be given at least 4 weeks’ notice of the inspection by letter or email.
  • Unannounced inspection: the service provider will not be given any advance warning of the inspection.
  • Follow-up inspection: the NHS board and hospital may or may not be given advance notice of the inspection. A safety and cleanliness follow-up inspection will take place no later than 26 weeks from the publication of the initial report.