Rochdale Infirmary

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This is the first assessment of this service under this provider. We assessed 7 quality statements. This key question has been rated good. This meant people’s needs were met through good organisation and delivery.

Person-centred care was delivered with a multidisciplinary approach.

Staff ensured patients had access to clear and accurate information.

The service dealt with concerns and complaints responsively and encouraged the raising of concerns by patients or relatives at the earliest opportunity.

This service scored 71 (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 a good standard. The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

We looked at patient feedback data in the clinical assessment unit (CAU), Oasis Unit and endoscopy service between July 2024 and June 2025. While endoscopy had a sample size of 736 responses, the CAU only had 63 responses (averaging 5-6 per month) and the Oasis Unit had even less at 12 responses (averaging less than 1 per month). The Oasis Unit had not obtained sufficient data to draw meaningful conclusions from the feedback, and as a result the service could not be assured from this metric that care provided was patient-centred.

Results from the endoscopy service showed that 707 of 736 responses (93%) felt listened to and involved in decisions about their care, and responses from CAU patients showed a similar proportion. 57% of endoscopy patients identified as having additional needs, and 92% of these either ‘agreed’ or ‘strongly agreed’ that their needs were met by the service. 97% patients identified as having additional needs on the CAU, and the same proportion of patients at 92% felt their needs were met, demonstrating a strong performance in patient feedback in providing person-centred care.

Patient feedback was gathered through an initiative called ‘observe, listen and act’ with a focus on listening and acting on patient experiences. Feedback focused on a range of areas such as person-centred care and patient safety. We looked at patient feedback reports for both the CAU and the Oasis Unit and found most patients reported a good experience of person-centred care. For example, patients were positive about the welcome packs they received and noted that care had been person-centred. One area for improvement included patients missing opportunities to discuss their care plan.

We looked at the person-centred care metric within the nursing accreditation and assessment system audits. The CAU and the Oasis Unit had scored green in its person-centred care metric,

Staff compliance with the eLearning component of learning disability and autism training was meeting or close to the trust target. However, the trust had not yet implemented the face-to-face element of the training that some staff were required to undertake in line with national requirements.

Staff used ‘this is me’ documents to record important details about patients living with dementia, such as their likes and dislikes. We saw evidence that these were filled out appropriately and considered the patients communication and mobility as a component part.

There was no on-site mental health liaison team. Staff submitted online referrals for patients requiring mental health support. Patients presenting with mental health conditions typically remained in the urgent treatment centre until assessed and allocated a suitable bed if admission was necessary.

The evidence showed a good standard. The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

The Home in a Day Team comprised occupational therapists, physiotherapists, and other allied healthcare professionals. They supported discharges from the clinical assessment unit (CAU) and Oasis Unit. The team operated 3 vehicles and had a dedicated stockroom. They held daily huddles that also served as opportunities for continuous professional development and sharing best practice. Working in pairs, team members conducted comprehensive home assessments once patients were ready for discharge. They could refer patients to the short-term assessment team (a reablement service) and determine appropriate discharge pathways, including home, home with care support, or transfer to other trust services such as Wolstenholme Intermediate Care Unit or Tudor Court which are both operated by the trust. The team maintained up-to-date knowledge of patients across both units and initiated discharge planning as soon as patients were medically fit. The Transfer of Care Team coordinated discharge pathways using a daily app and monitored patients with no right to reside.

Audits of documentation were undertaken as part of the trust’s inpatient assessment and accreditation system. The communication standards as part of the assessment for both the CAU and Oasis Unit were rated green, and results showed that 100% of new admissions had their associated documentation completed in full, and that patients were informed of their clinical progress and discharge plans appropriately. The CAU audit also showed that there were allocated link workers (or ‘champions’) covering a broad variety of areas, including tissue viability, nutrition, end of life, and patient experience.

The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Staff ensured patients had access to clear and accurate information. Leaflets were available on the wards in languages spoken by patients and staff made interpreters and signers available when needed. Information covered treatments, local services, patients’ rights, and how to complain.

The Accessible Information Standard (AIS) is a legal requirement introduced in 2016 to ensure that adults and children who have a disability, impairment or sensory loss receive information in a way that they can access and understand, and any communication support that they need is identified, recorded and provided. The service complied with the Accessible Information Standard. Nurses assessed patients for learning disabilities and cognitive impairments and used traffic light documents and checklists to guide care.

The service also provided communication aids in clinical areas, which included hospital communication books that provided pictures to assist those with additional communication needs, such as non-verbal patients. Wards also had assistive listening devices such as communicators to assist those with unaided hearing impairments.

The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

Patients and their relatives on the CAU had the opportunity to attend a listening clinic from Monday to Friday if they wished to discuss any concerns or had any complaints. This was held with the ward manager and consultants.

Patients knew how to complain or raise concerns. When complaints were made, staff investigated thoroughly and provided feedback. We reviewed three complaint responses and found they were detailed and included offers of meetings with complainants. Duty of candour was applied when appropriate. Audits of patient communication were undertaken as part of the trust’s inpatient assessment and accreditation system and found that staff were aware of the service’s complaints procedure and PALS when patients asked.

In the six months prior to our assessment, five complaints were recorded across CAU, Oasis unit, and endoscopy. Two were closed, and three were resolved locally. No complaints were referred to or upheld by the Ombudsman. Staff received feedback on complaint outcomes and acted on findings. Learning was collated, but no significant themes were identified due to the low number of complaints.

The evidence showed a good standard. The service made sure that people could access the care, support and treatment they needed when they needed it.

The service made sure that people could access the care, support and treatment they needed when they needed it. Bed occupancy figures for the clinical assessment unit (CAU) between June 2024 and June 2025 were mostly satisfactory, typically either under the target occupancy of 87% or narrowly over, with the highest occupancy rate of 94% in January 2025 and lowest at 75% in August 2024. The average length of stay on the clinical assessment unit fluctuated by month during this time, whereas a modest increase from under 4 days to over 4 days was observed over the same June 2024 to June 2025 period.

Staff made reasonable adjustments for patients – for example, people with mobility issues were provided with walking aids or shower chairs where these were needed. The accessibility of the CAU and the Oasis Unit were audited as part of the service’s ‘observe, listen and act’ reports and the environment was found to be wheelchair accessible and free from obstructions, with relevant mobility aids kept within arm’s reach of patients. The trust had developed a d/Deaf Service User Strategy in line with its own values, regulatory and legislative requirements, and patient feedback. The strategy was comprehensive in its scope and recognised that d/Deaf service users cannot always use a phone for communication and that interpretation at short notice can be challenging to arrange, and devised workstreams to improve access accordingly. We saw evidence that d/Deaf service users needs were considered in audits undertaken as part of the trust’s inpatient assessment and accreditation system. Most patients and relatives we spoke with said they were happy with the ward environment and how it met their needs.

There was adequate medical cover day and night, a doctors could attend the ward quickly in an emergency. Staff planned for patients’ discharge, including good liaison with care managers/co-ordinators. Discharge summaries for the medical division at Rochdale Care Organisation, which included the CAU and Oasis Unit, were consistently above the target of 95% and typically very close to 100% compliance during the June 2024 to June 2025 period. Staff told us that the main case of delayed discharges was due to delays in discharging patients to suitable adult social care facilities.

The evidence showed a good standard. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

A core area of the trust’s 5–10 year strategy is to tackle inequalities that exist within the catchment population and improve access to services, care and support.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

Staff within the service and the wider organisation promoted a culture in which the people using the service felt empowered to give their views. As part of the service’s ‘observe, listen and act’ initiative, patients had been asked by someone outside of the service team if they felt that staff listened and respected their faith and religious beliefs, and both wards were rated green.

The provider had undertaken meaningful equality impact assessments of their policies and procedures to ensure they did not place vulnerable people or people with protected characteristics at a disadvantage. For example, the service’s Adult Patient Restrictive Interventions Policy contained consideration for the potential negative impacts to certain protected characteristics such as the patient’s ethnicity or age, and this had been reviewed and signed by a member of the Equality, Diversity and Inclusion (EDI) Team. Staff were trained in equality, diversity, inclusion and human rights as part of the trust’s mandatory training requirements and could demonstrate a compliance rate of 98% in this area.

People were supported to plan for important life changes, however this was not always documented appropriately, and communication was not always carried out in a timely way.

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. Audits of various aspects of end of life care were undertaken as part of the trust’s inpatient assessment and accreditation system, and recent findings on the Oasis Unit demonstrated that staff could complete the Individual End of Life Care Plan for the Dying Adult documentation and were aware of the process to follow for a rapid palliative transfer, and the service had obtained a green rating. The clinical assessment unit (CAU) had an amber rating however, because the audit had identified that there was no documented evidence of the appropriate end of life documentation or the SWAN model having been discussed with the appropriate end of life patients and their families.

We also spoke with one end of life patient and their family on CAU who told us communication about the patient’s discharge, and arrangements for them to be cared for at home had been slow. They also felt the relationship between the transfer of care, nursing team and patient transport service had seemed disjointed.

The service also had a uDNACPR (unified do not attempt cardiopulmonary resuscitation) policy in place that was comprehensive and in date, which considers in detail how discussions with patients and relevant others should take place when making anticipatory resuscitation decisions. A leaflet that could be made available in multiple languages could also be provided to support this process.