The Christie Pathology Partnership

On this page

• 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

Leaders within the service were knowledgeable, experienced, and had the skills required to manage the laboratory effectively. They demonstrated a good understanding of service delivery, risks, and priorities, and were visible and approachable to staff. Staff spoke positively about managers and felt supported in their roles, contributing to a positive working culture.

There were elements of governance and oversight in place; however, these were not consistently effective across all areas. In particular, governance systems for monitoring environmental safety were not always robust. Auditing processes relating to cleaning, infection prevention and control, and the control of substances hazardous to health (COSHH) were not consistently implemented or maintained. This meant there was limited assurance that these key areas were appropriately monitored and addressed.

These gaps indicated that, while leadership was strong at an individual level, governance structures required further strengthening to ensure consistent oversight and compliance across the service.

The service was in breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as systems and processes were not adequately established or operated effectively to assess, monitor and mitigate risks. We have asked the provider for an action plan in response to the concerns found at this assessment.

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

The provider had a clear vision, strategy, and culture based on transparency, equity, equality, human rights, diversity and inclusion, engagement, and an understanding of the needs of people and their communities.

The organisation’s vision stated that by 2027 it aimed to become the UK’s leading laboratory diagnostics provider, with people, quality, and innovation at its core. Its values included being customer-centred, striving for excellence, promoting innovation and improvement, and demonstrating accountability and integrity. The service displayed these values clearly through posters and communications across the laboratory.

Leaders told us the service established its vision, values, and core purpose in 2023 through staff engagement, including roadshows, focus groups, and online surveys. Staff demonstrated awareness of these values and told us they had seen them displayed prominently within the work environment.

The laboratory manager explained that the service’s goal was to provide exceptional patient care by meeting turnaround times. However, limited space within the current laboratory restricted growth and capacity. Managers told us a new facility planned for the following year would allow the service to expand, improve workflows, meet contracted KPIs, and introduce additional tests. They also highlighted that an improved environment would support staff wellbeing and motivation.

Due to current limitations, the service could only process a set volume of samples and needed to refer some tests to external providers. Managers explained that the new facility would allow the service to repatriate some of these tests in the future.

Managers described a culture that was open and transparent, where staff felt comfortable raising concerns and sharing ideas. The service held monthly dialogue meetings to give staff the opportunity to take part in open discussions. To maximise attendance, managers scheduled these meetings at different times and on different days. While these meetings were not formally minuted, managers maintained action logs to track progress and outcomes.

The service also held monthly empowerment meetings, chaired by a senior manager. These meetings were minuted and provided staff with the opportunity to discuss developments within the laboratory. Managers told us these meetings resulted in changes and improvements. For example, the service supported a wider 10-year strategy that aimed to improve patient access by enabling blood samples to be taken closer to home. As part of this, the service piloted an additional late-shift role over a 3-month period to support extended operating hours.

Managers acknowledged that the late shift was less popular with staff and reviewed its impact on work-life balance. They told us they would reconsider the approach if staff were dissatisfied. However, staff responded positively, reporting that the change improved training opportunities and enabled more equitable participation in rota systems.

Staff told us they attended meetings where they felt encouraged to make suggestions and contribute to service development.

Overall, the service demonstrated that it had a clearly defined vision and strategy, supported by staff engagement and a culture that encouraged involvement and continuous improvement.

Leaders demonstrated inclusive, compassionate, and effective leadership at all levels of the organisation. Leaders had the skills, knowledge, experience, and credibility required to lead effectively and acted with integrity, openness, and honesty.

Staff told us leaders were visible and accessible. Managers based themselves within the laboratory and regularly walked the department, which enabled them to maintain oversight and provide direct support. Staff said they could approach leaders at any time and felt confident raising concerns or discussing ideas. Leaders encouraged open dialogue during team huddles, where staff discussed challenges, shared new ideas, and identified opportunities to improve processes and streamline ways of working.

Leaders fostered a supportive and inclusive environment where staff felt listened to and valued. Staff described managers as approachable and responsive, with leaders actively encouraged collaboration and innovation. This approach supported a positive culture, where staff felt empowered to contribute to service improvements.

Managers at all levels were experienced, motivated, and committed to delivering high-quality services. Managers also confirmed that they undertook leadership development programmes provided by the organisation to strengthen leadership capability and support delivery of the service’s strategy. We reviewed the file of 1 director and confirmed the provider had completed all Fit and Proper Person Requirement (FPPR) checks, including Disclosure and Barring Service (DBS) checks, insolvency checks, and references.

Leaders and staff spoke openly and honestly about the challenges facing the service. Despite these challenges, staff expressed pride in their work and demonstrated a strong commitment to delivering high standards of care. They also showed enthusiasm and optimism about future developments, including the planned move to a new unit, and remained focused on driving continuous improvement.

The provider fostered a positive culture where staff felt able to speak up and were confident their voices would be heard.

The service did not have a Freedom to Speak Up Guardian. However, managers told us they actively encouraged staff to share feedback, raise concerns, and suggest improvements. Staff told us they would usually raise any concerns with their line manager in the first instance and felt able to escalate concerns to senior managers, including service managers and general managers, if needed.

The provider operated a Speak Up service through an independent third-party supplier to ensure confidentiality. Information about this service was clearly displayed on posters within the workplace, including the message, “If it’s not right, speak up. If we know about it, we can fix it.” Staff could access a confidential hotline, staffed by trained call handlers, available between 08:30 and 18:00, Monday to Friday. They could also raise concerns via email, including a dedicated whistleblowing email address.

Managers told us they were not aware of any Freedom to Speak Up concerns raised in the previous 12 months. Staff described the organisation as approachable and supportive, and said they felt confident using available routes to raise concerns if required.

Leaders promoted equality, diversity, and inclusion (EDI) within the workforce and took steps to develop an inclusive and fair culture. The provider demonstrated a commitment to improving equity for staff and embedding inclusive practices across the service.

Staff completed equality, diversity, and inclusion training on an annual basis and understood their responsibilities in promoting inclusive care and working environments. Staff consistently spoke positively about their working environment and described a strong sense of belonging, referring to the team as a “family.”

The service had established a diversity committee and identified 2 equality, diversity, and inclusion champions. These champions met monthly with organisational leads to review activity, monitor progress, and identify priorities. They promoted advocacy, awareness, education, and guidance, and supported the development of an inclusive workplace culture. Champions acted as visible role models across the service, engaging with departmental and organisational initiatives. They accessed ongoing training, resources, and support from the central EDI lead and were recognised for their contributions through development opportunities. Corporate EDI leads visited the service to support local champions, strengthen engagement, and ensure alignment with organisational priorities.

The service celebrated cultural diversity and supported awareness events. Staff described activities to mark occasions such as Eid and wider campaigns including Black History Month, breast cancer awareness, and mental health initiatives. Staff demonstrated strong engagement in these activities, including organising events such as “Movember” to raise awareness of men’s health.

The provider also promoted wider health and wellbeing initiatives. During Women’s Health Month in May, the service organised activities to raise awareness of physical and mental health, including information boards with personal stories and guidance. Staff were encouraged to reflect on their own wellbeing and actively engage in available support.

Overall, staff felt valued, respected, and supported. They demonstrated strong engagement with equality, diversity, and inclusion initiatives and spoke positively about the provider’s commitment to creating a fair, inclusive, and supportive working environment.

Leaders did not consistently establish clear roles, responsibilities, or effective systems of accountability and governance. The service did not have oversight of cleaning schedules, monitoring processes, and compliance with safety systems. Managers did not implement robust systems to oversee Control of Substances Hazardous to Health (COSHH), and the service did not complete COSHH, IPC or cleaning audits. The lack of effective governance processes meant that issues with staff compliance with policies for removing out‑of‑date reagents had not been identified.

Leaders did not fully implement the requirements of the Dangerous Substances and Explosive Atmospheres Regulations (DSEAR). Cupboards did not consistently contain inventories to prevent overfilling, with only 20% completed. Staff had not commenced segregation guidance in line with SHG71, although leaders had allocated this work in January 2025. The service had installed only 50% of required spill kits, and not all staff demonstrated competence in their use. Leaders also did not develop sufficient written procedures to ensure DSEAR compliance, despite allocating this work in January 2025.

The provider used an electronic quality management system to manage standard operating procedures, risk assessments, and COSHH documentation. The system flagged documents approaching expiry, which supported review and ongoing compliance. Staff were required to read and acknowledge updates for policies and procedures. However, in May, several staff members had more than 100 outstanding acknowledgements. Managers attributed this to limited time, new staff, and staff annual leave. Managers told us that after taking action, the number reduced to 1 staff member with over 100 outstanding acknowledgements. However, this continued to indicate gaps in oversight of compliance with mandatory documentation. Leaders also completed a range of assurance activities, including equipment audits, spot checks, and competency assessments, which operated on a rolling programme.

Managers maintained oversight of quality and safety systems through regular monitoring. They held monthly performance review meetings to assess audit findings and identify trends. Each issue required a corrective and preventative action (CAPA), which examined what had happened, why it occurred, how it was resolved, and how recurrence would be prevented. This structured approach aligned with international organisation for standardisation (ISO) quality management principles and focused on addressing root causes.

The service operated controlled access to its information systems. Staff completed training before gaining access and were issued individual log-in credentials. Access levels were role-specific, ensuring staff could only view information relevant to their duties. This included the ability to view patient results, while clinical teams could also access results from other sites to support continuity of care.

The service did not consistently complete daily environmental monitoring. We identified gaps in formaldehyde monitoring records, which managers stated occurred because the responsible staff member was on leave. Following the inspection, leaders addressed this by allocating environmental monitoring tasks within daily and weekly rotas. Records also showed that a fume cabinet did not function correctly and produced prolonged poor air quality readings. We saw that staff had escalated the issue to estates on several occasions over a 4-month period, which demonstrated delays in repair and a lack of timely resolution.

These gaps indicated that, while leadership was strong at an individual level, governance structures required further strengthening to ensure consistent oversight and compliance across the service.

The service was in breach of Regulation 17 (Good Governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, as systems and processes were not adequately established or operated effectively to assess, monitor and mitigate risks.

Leaders held quarterly health and safety committee meetings that reviewed risk registers, inspection findings, incidents, reporting of injuries, diseases and dangerous occurrences regulations (RIDDOR) reports, external inspections, fire management, training, and legislative updates. The service also held monthly quality and governance meetings, which included action logs and monitoring of non‑conformities. Although leaders had tracked, completed or progressed most actions, there remained 5 overdue risk assessments that had a target date of February 2026, which indicated delays in risk management processes.

Leaders also held monthly clinical governance meetings; however, some audits and non‑conformities remained outstanding, which showed that further progress was required to achieve full compliance. Despite this, the service demonstrated improvement compared to the previous year, including a reduction in overdue audits and documentation, improved key performance indicators, and increased identification and reporting of non‑conformities.

The service operated a comprehensive meeting structure consisting of 21 forums, ranging from daily huddles to formal committee meetings covering health and safety, training, operations, quality, and innovation. These forums had clearly defined attendees and supported effective communication and information sharing across the service.

Leaders developed and recently updated a business continuity plan that clearly highlighted amendments and included contingencies for staffing shortages, utility failures, IT disruptions, restricted access, and fire. The service also maintained a specific histopathology business continuity plan.

Routine team meetings enabled staff to discuss operational issues and performance. Senior leaders monitored and shared performance information through meetings, emails, and newsletters. The service maintained an electronic quality management system to store and monitor policies, standard operating procedures, protocols, and validation records, supported by established document control processes.

Leaders described how the service worked with other NHS organisations. This required close collaboration, particularly as partners used different systems and interfaces. Leaders implemented workarounds to manage these differences while a longer-term project to improve system compatibility progressed.

The service formed part of the Greater Manchester (GM) pathology network, which linked hospitals across the region. Staff participated in a range of network working groups, including haematology, blood transfusion, digital, and workforce groups. Leaders explained that the network continued to evolve, with joint working initiatives in development.

The provider gave a positive example of collaboration through workforce planning for biomedical science (BMS) student placements. The service worked with 2 universities and 7 NHS trusts across the GM network to coordinate placements. The service received high volumes of applications for these posts.

Leaders promoted a culture of continuous learning, improvement, and innovation across the service. They encouraged staff to contribute ideas and supported creative approaches to improve quality, safety, and outcomes for people.

Staff told us they felt confident to speak up and share ideas for improvement. They gave examples where leaders listened and implemented changes. For example, staff addressed a backlog of specimens by introducing a structured storage system using metal drawers to organise blocks in numerical order. They further improved efficiency by adding a simple magnet system to clearly identify the sequence of oldest to newest cases, which reduced the time spent opening and closing drawers and improved workflow.

The service had an established research and innovation committee, which met monthly. The committee maintained action logs with clear responsibilities and timescales. It included 11 research and innovation champions from biomedical and clinical scientist roles, who attended on a rotational basis. The committee reviewed current research developments and promoted evidence-based practice. Leaders demonstrated strong engagement in research, with the registered manager having contributed to internationally published research and links to an academic health science centre.

Leaders prioritised staff development and invested in external training, seminars, and conference attendance. They had introduced improvements to the approval process to ensure that training investment aligned with service priorities and delivered maximum impact.

The provider maintained oversight of emerging guidance and best practice through the central health and safety team. This formed a standing agenda item at quarterly health and safety committee meetings, which ensured leaders remained informed and responsive to changes in legislation and guidance.

Leaders communicated learning, improvements, and innovation activity effectively. Staff received a newsletter every 2 weeks, which included updates and shared learning. In addition, a monthly transformation communication programme kept staff informed about ongoing service improvements under the new contract, which supported engagement and transparency.

Overall, the service demonstrated a commitment to learning, innovation, and continuous improvement. Staff actively contributed to improvements, and leaders supported the development and implementation of ideas to enhance service delivery and outcomes.