The Christie Pathology Partnership

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 generally demonstrated a positive safety culture. There were systems and processes in place to identify and manage risks. Staff recognised and responded appropriately to safety concerns, and incidents were reported and investigated. This reflected a culture of openness and learning to improve safety.

The service had enough suitably qualified, skilled and experienced staff to keep people safe. Staff received appropriate support, supervision and training to carry out their roles effectively. Safe recruitment practices were in place. Staff worked well together and described a cohesive team approach.

However, the provider had not fully addressed concerns identified at the previous inspection under Regulation 15 (Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 Premises and Equipment). At this assessment, we found insufficient improvement. Systems to ensure the environment was clean and safe were not consistently effective. Cleaning schedules and equipment checks were not always completed or recorded in line with service requirements. In addition, infection prevention and control measures and the control of substances hazardous to health (COSHH) were not robustly monitored or maintained. These issues meant the provider could not be assured that the environment was consistently safe and well maintained.

Find out what we look at when we assess this area in our information about our new Single assessment framework.

The provider promoted a positive safety culture based on openness and honesty. Staff actively raised concerns and reported incidents and managers investigated these. The service used learning from these events to improve practice and embed safer ways of working.

The service had systems in place to manage non-conformances and incidents reported by both the laboratory and the partner NHS trust. Non-conformance referred to any failure to meet company, customer, or regulatory standards, such as equipment faults, data inaccuracies, or documentation errors. These were identified through sources which included internal audits and external quality assurance (EQA) processes.

The provider had policies in place to support the identification and management of non-conformities, complaints, incidents, and duty of candour. Staff were encouraged to report incidents, near misses, errors, and non-conformities. Investigations focused on identifying root causes and implementing corrective and preventative actions to reduce the risk of recurrence and support continuous improvement.

At the time of inspection, there were 9 open incidents which had been reported by the NHS trust, including 8 categorised as no harm and 1 as low harm, which remained under review. There were an additional 8 open incidents reported by the laboratory, including 6 low priority and 2 medium priority cases. Four incidents had not been completed within their target timeframes. Between June 2025 and April 2026, the service recorded 369 non-conformances. These included complaints, supplier issues, training gaps, equipment faults, and EQA findings. Most non-conformances (136) were identified through audits. We saw that the service analysed this data to identify trends, recurring issues, and opportunities for improvement.

We reviewed examples of internal investigations, which clearly documented the non-conformance or incident, identified root causes, and detailed remedial, corrective, and preventative actions. Investigations also considered clinical risks, patient impact, and included management sign-off.

The service received 7 complaints between 1 May 2025 and 1 May 2026. Of these, 3 were categorised as no harm and 4 as minor events. Five complaints related to delays in reporting results, while 2 related to systems and processes.

Staff understood how to raise incidents, although reporting approaches varied. Some staff reported concerns directly through electronic reporting systems, while others escalated issues to line managers for support. Staff shared examples of recent incidents, including delays in turnaround times and a leaking fridge, and described how the service shared learning and implemented improvements. The service promoted incident reporting through visible QR codes in work areas and through regular team reminders.

The service supported communication and shared learning effectively. Staff received feedback through daily huddles, emails, and newsletters. These updates included learning from incidents, such as delays in urgent cases, and reinforced expectations for meeting targets. Staff told us that they could contribute ideas for improvement and that managers responded positively to suggestions. For example, managers supported new staff to rotate between departments more quickly once they demonstrated competence, which improved the training experience. Staff described clear escalation processes and reported that they felt listened to when raising concerns. They escalated issues to line managers or senior staff as needed.

The provider worked collaboratively with healthcare partners to establish and maintain safe systems of care across the patient pathway. Where tests could not be performed on site, staff referred samples to specialist laboratories in line with established policies. The provider ensured that referral laboratories met required quality standards, including UKAS ISO 15189 accreditation, and monitored their performance, including turnaround times and sample requirements.

Staff followed clear and well-established procedures for the safe handling, transport, and receipt of specimens. Samples were transported in compliance with the Carriage of Dangerous Goods Regulations (2009), using appropriate packaging materials, including UN3373 and UN2814 compliant containers. On receipt, staff checked samples against request forms to confirm patient identification, suitability of specimen type, volume, stability, and condition. Samples that did not meet acceptance criteria were rejected and managed in line with standard processes, with clinical teams notified where required. Staff described consistent processes for sample logging, preparation, and processing, tracking through the laboratory information system.

The service had effective systems to manage clinical risk throughout the pathway. Staff escalated urgent and abnormal results promptly to senior clinicians or on-call medical staff, ensuring timely clinical decision-making. Results were recorded on the laboratory information system and made accessible to users to support continuity of care.

Standard operating procedures (SOPs) and user guidance supported safe and consistent practice. These included detailed information on test requirements, minimum sample volumes, turnaround times, reference ranges, and escalation thresholds. The provider regularly reviewed and updated guidance documents, and staff were required to acknowledge significant changes.

The service maintained oversight of quality and reliability through participation in internal quality control (IQC) and external quality assurance (EQA) programmes across all test areas. These arrangements supported the delivery of accurate, timely, and consistent diagnostic results.

Overall, systems and processes were well established and supported the safe management of samples throughout the pathway, from receipt and analysis to reporting and onward clinical care.

Staff told us they had completed mandatory e-learning training and understood safeguarding principles. They were able to describe examples of safeguarding concerns and explained how they could raise issues either individually with managers or within team discussions. Staff reported that they had not needed to make any safeguarding referrals.

At the time of inspection, 108 out of 114 staff (95%) had completed their mandatory adult safeguarding training. Staff were not required to complete safeguarding children training due to the nature of the service.

The service manager confirmed that no safeguarding referrals had been made in the previous 12 months.

The service had a safeguarding policy in place, which included guidance on whistleblowing. Staff could also raise safeguarding concerns anonymously through an external agency. The policy required all staff to maintain awareness of safeguarding issues, supported by reference to the policy and completion of online training.

Leaders worked with people to understand and manage risks effectively. The service had clear procedures in place to respond to requests for clinical advice and to report results. Staff primarily reported results through the laboratory information management system (LIMs), which supported consistency and traceability.

For urgent results, the service applied defined escalation processes. These included clear criteria outlining which results required immediate communication, which staff were authorised to report them, and who should receive the information.

The service maintained a comprehensive local risk register, which included cross-site comparisons to support effective monitoring and review of risks. Leaders used this to identify trends, prioritise actions, and ensure risks were managed consistently across locations.

The provider had a local business continuity plan in place, which identified critical services and defined the maximum acceptable downtime in the event of disruption. The plan outlined clear processes to maintain service delivery as far as reasonably practicable and included recovery arrangements to restore full service. It covered a range of potential risks, including staffing shortages, failure of essential utilities, IT system disruption, restricted access to facilities, and fire.

Leaders used multiple assurance processes to monitor and manage risk. These included daily internal quality control schedules, participation in external quality assurance programmes, and peer-to-peer comparison. These systems provided ongoing oversight of performance and supported the early identification and mitigation of potential risks.

Leaders had identified risks within the care environment relating to limited space and had recorded these on the service's risk register. Despite this, the ongoing space constraints continued to present challenges in relation to storage, cleanliness and safe working practices, and effective mitigation of these risks was not always evident.

Although access to the service was controlled through swipe card entry, we observed the pathology laboratory door was propped open during our inspection, which compromised security and allowed unauthorised access. The entrance corridor was cluttered with cardboard boxes, wooden crates, and an out-of-service water machine. Staff confirmed these items had remained in place since an incident in November 2025, demonstrating a lack of timely action to address environmental risks.

The provider had systems in place to manage equipment, including external maintenance contracts through the estates team and an electronic asset register with assigned ownership and annual review dates. Staff completed daily maintenance tasks, including cleaning equipment after use; however, responsibilities for some cleaning activities were unclear. For example, not all staff knew who was responsible for cleaning sinks, which resulted in inconsistent cleaning practices.

Staff monitored refrigerator temperatures and maintained calibration logs. They used pre-calibrated thermometers replaced every 2 years and a master thermometer checked every 6 months. However, staff did not always complete temperature records consistently, and we identified gaps in monitoring documentation.

Fire safety risks had been identified through both internal and external assessments in 2025. These highlighted significant concerns, including issues with fire alarms, escape routes, and fire doors. Leaders implemented an immediate action plan and addressed the identified risks promptly. However, risks associated with combustible materials remained due to limited storage space.

Leaders had taken steps to improve ventilation, including installing additional extractors and filtration systems. However, risks remained. During inspection, one extractor had been switched off due to noise, although managers stated air quality remained within acceptable limits. In some areas, temporary extraction systems had been routed through open windows, which reduced the effectiveness of ventilation and introduced dust and contaminants into the environment. Following our inspection the managers told us sealed windows had been installed for an airtight connection for the extractor. Monitoring of air quality was not always consistent, and records showed gaps in daily checks.

We observed that formaldehyde levels had occasionally reached amber thresholds. On these occasions, staff followed appropriate processes by vacating the area, rechecking levels within 1 hour, and escalating concerns where required. Managers explained that the highest exposure occurred during tissue processing and that monitoring was undertaken at key times; however, continuous monitoring had not been implemented, and the approach remained risk based.

A review of ventilation data showed that 1 fume cupboard had not functioned correctly, with repeated red alerts over a 4-month period. We saw that managers had escalated concerns on multiple occasions; however, the estates team had recorded the equipment as functional. This demonstrated delays in resolving environmental risks and weaknesses in oversight and verification processes.

Storage and management of hazardous substances did not consistently meet COSHH requirements. Cupboards were damaged, corroded, and lacked appropriate spill containment. Some chemicals had expired, and COSHH audits had not been completed regularly. Although COSHH risk assessments were held within the electronic system and supported by overarching policies, these had not always been translated into consistent practice.

Following our inspection, leaders undertook a review and implemented corrective actions, including more frequent audits and improved monitoring systems. They also installed new flammable storage cabinets and strengthened labelling and segregation processes.

Training compliance did not meet organisational targets, with 81% of staff completing COSHH training and 77% completing fire safety training against the providers 95% target.

A Dangerous Substances and Explosive Atmospheres Regulations (DSEAR) assessment completed in January 2025 identified several required actions, including implementing inventory limits and segregation guidance; however, progress on these actions remained limited at the time of inspection.

Clutter within the laboratory increased safety risks, including trip hazards and there had been reported incidents involving falling objects. Leaders told us that some items were removed following our inspection, but that storage remained a risk due to limited space.

Although the building was scheduled for demolition and major capital works were not proportionate, leaders acknowledged their responsibility to maintain safe day‑to‑day operations. They continued to deliver both planned and reactive maintenance. Staff demonstrated a proactive approach to safety by raising fire concerns through local audits. Leaders responded promptly by commissioning an external assessment, which identified several extreme risks, and they acted immediately to rectify these issues.

Overall, while leaders recognised the limitations of the current environment and had plans to relocate to a purpose-built facility in 2027, risks relating to space, storage, and environmental safety were not consistently managed. These risks required further mitigation to ensure a safe environment.

Leaders ensured there were enough qualified, skilled, and experienced staff to meet the needs of the service. Managers supported staff through supervision, training, and professional development, and staff worked collaboratively to deliver safe, effective care tailored to individual needs.

The service delivered 34 mandatory training topics tailored to staff roles. For example, only finance staff completed anti-money laundering training. Other topics included basic life support, COSHH essentials, cyber security, equality, diversity and inclusion, General Data Protection Regulation (GDPR), health and safety, managing stress, and the code of conduct. Overall compliance with mandatory training was 89.3%, which was below the providers target of 95.6%.

We reviewed 5 staff files and found all required pre-employment checks had been completed. Records included references, photographic identification, qualifications, signed contracts, health checks, and induction documentation. All records met the required standards.

The service followed appropriate processes to assess DBS requirements. Laboratory staff without direct patient contact were not required to hold a DBS check. The service used a DBS eligibility tool and completed 35 role-based assessments, considering access to identifiable data, patient contact, and positions of trust. Only 1 staff member required a DBS check, and this was in place. This approach aligned with national employment guidance.

The service maintained clear competency frameworks. Staff completed structured competency assessments, with 100% compliance reported. Locum staff followed the same processes as permanent staff. We reviewed records for 1 locum staff member and found they had completed all required competencies. Leaders used a red-amber-green rating system to monitor compliance, with competencies reviewed every 2 years. Staff described structured induction processes, including competency logs and supervised practice with sign-off by senior staff.

At the time of inspection, the service had 3 vacancies, including 2 management roles and 1 laboratory assistant post. Leaders actively recruited to these roles and mitigated risks by redistributing responsibilities, appointing locum staff, and securing temporary management cover. One team leader had been appointed and was due to start, while another manager was absent due to sickness. Leaders acknowledged that reduced management capacity had impacted quality management during this period.

Staff reported that staffing levels had improved significantly over the previous 2 years, particularly within the laboratory, due to successful recruitment. The service supported apprenticeship programmes in partnership with local universities, enabling staff to complete degree qualifications while working. At the time of inspection, 2 trainees were enrolled.

Staff described strong teamwork and effective working relationships. They regularly rotated across different laboratory areas, which supported service resilience and skill development. Team cohesion was further supported through wellbeing and engagement activities, including departmental events, mental health awareness initiatives and group activities.

Staff told us the service was usually fully staffed. Although sickness and leave occasionally affected staffing levels, teams managed workload effectively, including busy periods. Staff said they enjoyed working within the service and valued the supportive and friendly environment.

The service monitored workforce performance indicators. At the time of inspection, appraisal completion was 84.8%, and mandatory training was 89.2%, both below the providers target.

Staff turnover was 13.04% over 12 months, and sickness was 6.05%, which were within expected ranges. Vacancy rates remained low at 5.6%, including newly approved transformation posts.

Overall, while leaders ensured sufficient staffing and strong competency management, some improvements were required to achieve compliance with mandatory training and appraisal targets.

The service had an infection prevention and control (IPC) policy in place. Cleaning staff employed by the partnered trust delivered the general cleaning services under a contractual arrangement and followed the trust’s IPC policy. However, the trust did not carry out IPC audits specific to the service, which limited effective oversight, although it did complete general cleaning audits. These audits were not tailored to the laboratory environment and instead included information relevant to ward settings.

The environment was not maintained to an acceptable standard of cleanliness. We observed significant dust accumulation, including on equipment and surfaces, as well as blood contamination on an analyser and on the floor. The service had not effectively monitored cleaning practices. Although domestic cleaning audits reported compliance rates above 98%, these findings did not reflect the conditions observed during inspection, indicating that audit processes lacked accuracy and effectiveness.

The service did not effectively monitor cleaning within the laboratory. Although staff were expected to clean workbenches daily and as required, there was no oversight to ensure these tasks were completed consistently. We observed significant accumulations of dust and dirt throughout the laboratory, including on windowsills, ceilings, worktops, flasks and spillage kits. As some windows were required to remain open (for temporary extractors), environmental contamination was an ongoing risk. The lack of effective cleaning oversight increased the risk of contamination of specimens and did not support the maintenance of a clean and safe environment.

We observed small blood droplets on the floor and on 1 analyser. Although the droplets were small and unlikely to present a significant public health risk individually, they indicated weaknesses in housekeeping and adherence to procedures.

The service had systems to manage waste and clinical specimens safely and followed an updated waste disposal policy. However, these arrangements did not fully cover all chemicals and reagents, which required separate collection processes. As a result, some expired chemicals had accumulated and were stored for up to 12 months. Formalin waste was managed through transfer to the histology department and appropriately contained and labelled, although this was a manual process.

Waste management practices were inconsistent. Some sharps bins were overfilled, unsigned, or contained inappropriate items. General waste segregation was not always followed, as staff sometimes used clinical waste bags for general waste. Spill kits were not routinely checked and were dusty, and some mask filters had expired in 2024. However, staff demonstrated knowledge of how to manage chemical spills appropriately and had documented previous incidents.

Staff had access to appropriate PPE and used it during laboratory work. We observed that staff wore individual laboratory coats, which they fastened correctly. Staff also wore disposable gloves; however, we saw that some staff continued to wear gloves while using computers, which increased the risk of cross-contamination between work surfaces and equipment. Eye protection was available for staff when required. Departments completed monthly health and safety checks that reviewed compliance with personal protective equipment (PPE) and adherence to policies.

The IPC policy stated that staff should launder laboratory coats weekly or sooner if contaminated. However, not all staff we spoke to understood these requirements. We saw that a recent audit had identified that some staff had not worn laboratory coats appropriately fastened. The service implemented learning in response, and during inspection we observed that staff wore their laboratory coats correctly, demonstrating that improvements had been embedded following this audit.

Leaders ensured staff received role-appropriate vaccinations, including tetanus, diphtheria, polio, measles, mumps and rubella (MMR), and hepatitis B. All staff underwent occupational health screening on appointment, and the on-site occupational health team administered outstanding vaccinations.

The service undertook water testing for legionella. A positive result in July 2025 was appropriately managed, with follow-up samples returning negative results.

The provider did not use medicines.