Rochdale Infirmary

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This is the first assessment of this service under this provider. We assessed 6 quality statements. This key question has been rated good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

Policies we reviewed, except one, were comprehensive, in date and in line with national guidance, and teams worked together well to organise appropriate multidisciplinary care.

However, audits demonstrated that the service did not consistently meet national or local targets in some areas. We also observed that information and patient risks were not always identified and communicated appropriately on the clinical assessment unit.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The evidence showed some shortfalls. The service did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

Records we reviewed showed assessments had been completed in a timely way when patients were admitted to the ward, and staff told us lead nurses completed daily checks to ensure this was the case. However, on the clinical assessment unit (CAU), we found patients’ assessments were not always easy to find, and not all staff were able to easily review or contribute to them. We reviewed 3 patient records on the clinical assessment unit (CAU) and 3 on the Oasis unit.

The service used multiple documentation systems, including bed bay notes, electronic records, and paper medical records stored in the doctors’ office. While nurses had access to electronic records, healthcare assistants (HCAs) did not. Also, HCAs did not always attend daily safety huddles. This meant that there was a risk HCAs were not always fully aware of patients’ risks, additional needs, or care plans. We spoke with one family member who felt staff caring for their relative were not well informed about their plan of care. Staff told us HCAs were encouraged to contribute to patients’ paper notes; however, we saw this was not done consistently.

Staff used bedside boards with symbols on them to identify patients with additional risks or needs such as falls or cognitive impairment. However, we saw this was not always complete or did not match the patients in the bed at the time. For example, we saw a patient whose falls risk had not been identified on their bedside board, and a patient with cognitive impairment who did not have an identifier for this. Additionally, we spoke with a nurse who was unfamiliar with what the symbols represented.

On the Oasis Unit, despite the number of systems, we found information about patient risks and needs was better organised and easier to find. We saw evidence of prompt assessments where staff had considered the needs of patients alongside their families. The assessments took account of family and carer’s needs, mental capacity and regularly assessed changes in behaviour which were appropriate to the cohort of patients on the unit. We spoke with a relative on the unit who gave positive feedback about the way their needs were recognised and met by staff.

On the Oasis Unit, we saw patients were encouraged to be up, dressed and engaged in activities to avoid deconditioning. Staff also encouraged patients to choose where and when they wanted to eat and were supported to do so. However, on CAU, we saw many patients were not dressed and some patients who experienced difficulty eating because they were laid too flat in bed so those people’s nutrition needs were not being met. We spoke with staff at the time who then repositioned patients to enable them to eat more easily.

The evidence showed a good standard. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

The trust had a process in place for reviewing new and updated NICE guidance to inform policies and procedures. Staff participated in clinical audit, benchmarking and quality improvement initiatives.

Most of the policies we reviewed were comprehensive, in date and in line with national guidance. Staff explained any changes to practice or policies were discussed regularly in team huddles and they were able to provide examples of guidance/practices being updated. The service held monthly meetings attended by leaders where quality and performance were discussed. We saw from minutes of these meetings that updates to clinical practice and how the service planned to respond and implement these changes could be discussed.

The endoscopy service was not currently accredited with the Joint Advisory Group on Gastrointestinal Endoscopy (JAG).

The units had access to relevant link nurses and other healthcare professionals with experience in specialisms such as safeguarding; pain; patient safety; environment; nutrition; end of life care; medicines management; person centred care; tissue viability; communication; infection prevention and control and people management.

Staff assessed and met patients’ needs for food, drink, and specialist nutrition and hydration. They used a catering whiteboard to record bed numbers and dietary requirements. The team implemented the red tray system to indicate patients who required mealtime support. Families attended during meals, which staff designated as protected times. One nurse reported that visitors were asked to leave during meals, however the clinical lead told us visiting hours had been revised to allow access at any time. We raised this inconsistency with the lead nurse at the time of our inspection.

The evidence showed a good standard. The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

The units included, or accessed, a range of specialists required to meet patients’ needs. In addition to doctors and nurses, community teams provided an in-reach service. Therapists from the home in a day team supported CAU and the Oasis Unit. The team included speech and language therapists, occupational therapists, dietitians, a respiratory nurse, tissue viability nurses, and physiotherapists when required.

Staff held regular and effective multidisciplinary meetings. We observed a ward round on CAU that included senior ward staff, doctors, nurses, pharmacists, specialist nurses, the local hospice doctor, occupational therapists, transfer-of-care staff, and integrated discharge staff.

Staff discussed each patient’s individual needs, whether they were medically optimised, and the ongoing care required. They considered likely future care needs, relevant background, patient history, family support networks, personal needs, expected length of stay, allergies, and safeguarding concerns. Staff updated care plans on the “safer care” boards in the doctor’s office. The medical consultant demonstrated good knowledge of each patient’s condition and background and advocated for enhanced care on discharge.

Staff shared patient information effectively at handover meetings within the team, such as shift-to-shift handovers. Teams maintained effective working relationships and good handovers with other relevant teams in the organisation, including care coordinators, discharge teams, and specialist teams.

The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Patients we spoke with felt staff supported them to manage their own health, care and wellbeing needs.

Staff assessed each patient’s health when admitted and provided support for any individual needs to live a healthier lifestyle. For example, staff supported people to take part in smoking cessation schemes and alcohol and drug cessation programmes. Smoking cessation, alcohol and drug teams were based in the urgent treatment centre and provided in-reach services to the medical wards daily or when required. Dementia carers attended the wards when needed, and staff made leaflets available for other conditions, such as continence clinics.

The evidence showed a need for improvement. The service routinely monitored people’s care and treatment to continuously improve it. However, outcomes were not always positive and consistent and did not meet both clinical expectations and the expectations of people themselves.

Managers told us the division took part in national and local audits and that outcome data was formally reviewed and action plans developed to improve indicators which did not meet expected national outcomes.

Both the clinical assessment unit (CAU) and Oasis Unit took part in a monthly Quality Assurance Audit (QAA), which looked at 14 key elements including infection control, nutrition and hydration, and pain management. The average overall score of the QAA between July 2024 and June 2025 for the CAU was 91%, narrowly above the target of 90%. We noted the period between February and June 2025 showed a mix of partial and non-compliance particularly with fluid balance standards, although this data was likely affected by a very small sample size. QAA findings for the Oasis Unit across the same timeline were comparatively better and more consistent, with an average overall compliance score of 92%. Action plans were produced that ran alongside and in response to the findings of the QAA and discussed monthly for assurance. Action plans were completed to a good standard, with a responsible person assigned to each action, appropriate review dates, and progress information clearly provided.

The service participated in relevant national audits, including the National Diabetes Core Audit (NDA), the National Heart Failure Audit (NHFA) and the Sentinel Stroke National Audit Programme (SSNAP). The trust provided evidence of action plans to drive improvement in national audits, although these did not fully address all areas of non-compliance and were vague in their recommendations. For example, an action plan in response to the 2023 NDA had only 2 recommendations and neither of which were SMART targets as labelled.

We observed various audit metrics that were significantly below national targets, particularly in the NHFA. For example, the 2023/24 data (which was the most current available) showed that out of 15 metrics, 10 assessed at Rochdale Care Organisation had not met the national target. This included only 8% of patients with heart failure having consultant cardiology input and 17% having specialist input, against a target of 90% and national averages over 50% and 80% respectively.

Results from other national audits contained some positive findings. For example, the National Audit of Dementia demonstrated that their 2023/2024 data (which was the most current available) showed that delirium screening and pain assessment compliance was above average, although discharge planning was less consistent. The results of the NDA showed that all care processes for type 1 diabetes were above national compliance levels, although this was not the case for type 2 diabetes.

Audits were also undertaken as part of the trust’s inpatient assessment and accreditation system. The audits measured the quality of nursing care delivered by individuals and teams across 14 standards. Areas included patient safety, infection control, safeguarding, person centred care and several other key care standards. We looked at the assessments and scoring across the CAU and Oasis Unit and found that they were both rated amber, which demonstrated a deterioration in both areas for their previous assessment. We observed the associated action plan for the CAU and found that while many appropriate actions had considered, these had not been updated in a timely way, and many actions were still “in progress” beyond their target achievement date.

The evidence showed a need for improvement. The service told people about their rights around consent but compliance with the policy on cardiopulmonary resuscitation was not consistent and not improving.

The service had a uDNACPR (unified do not attempt cardiopulmonary resuscitation) policy in place that was comprehensive and in date, which contained a summary flowsheet to ensure good understanding. When patients lacked capacity, staff made decisions in their best interests and considered the person’s wishes, feelings, culture, and history. Families helped complete “This is me” documents.

Staff assessed and recorded patients’ capacity to consent appropriately when they might have had impaired mental capacity. They carried out assessments on a decision-specific basis for significant decisions and involved the patient’s family in decision-making. Staff received training in MCA (Mental Capacity Act 2005) and Deprivation of Liberty Safeguards (DoLs), included as part of their safeguarding training. Compliance rates are reported under the safeguarding quality statement.

The trust completed an audit which measured how compliant staff were with the Mental Capacity Act 2005 (MCA). The audit was undertaken across a selection of medical and surgical wards for participating care organisations. We reviewed audit data for the Rochdale care organisation that showed that in quarter 3 and 4 of the 2024/2025 cycle, average compliance across all the audited standards had fallen to 82%, narrowly below the trust target of 85%. The trust had organised additional in-person training sessions from January to October 2025 and advised that previous action plans created by the Rochdale Care Organisation were to be reviewed.

For patients at the end of life, staff started discussions with the patient and their family as early as possible about their preferred place of death. The trust followed the SWAN model, a values-based framework for end-of-life and bereavement care that focused on dignity and personalised care through Signs, Words, Actions, and Needs.

The trust completed an audit which measured how compliant staff were with the trust’s uDNACPR policy. The audit was undertaken across the Rochdale Care Organisation alongside other participating care organisations, with a target of 100% compliance in meeting the set standards in the trust policy. The audit highlighted overall areas of poor compliance and that there had been little improvement since the previous audit in 2023, although results across the Rochdale Care Organisation were comparatively better on average than other care organisations. At the Rochdale site, standards with the lowest scores showed that 77% patient notes were found to contain evidence of a discussion and explanation of uDNACPR, and only 7% had evidence that a copy of the uDNACPR leaflet was provided. Standards with the highest scores showed that 100% of audited patients had the reason for their uDNACPR recorded, and 100% of audited patients had notes which contained uDNACPR decisions that were appropriately dated, timed and signed. There was a trust-wide associated action plan to drive improvement and scheduled for review in December 2025.