Rochdale Infirmary

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

This is the first assessment of this service under this provider. We assessed 8 quality statements. This key question has been rated good. This meant people were safe and protected from avoidable harm. The service had a positive safety-focussed culture, and staff completed mandatory training. However, staffing levels were not always aligned to service and patient need.

This service scored 72 (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 had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

From January to June 2025, the medical division at Rochdale Infirmary reported a total of 236 incidents. Staff used an electronic incident reporting system to record incidents, and we saw all staff knew what incidents to report and how to report them.

The clinical assessment unit (CAU) reported 168 incidents in this period, the endoscopy unit reported 4 incidents (general communication; infection prevention and control and IT equipment), and the Oasis Unit reported 64 incidents.

The top 5 types of incidents in the CAU and Oasis Unit were slips, trips and falls (56 incidents); pressure ulcer or injury (26 incidents); skin injury other than pressure ulcer (17 incidents); general communication (16 incidents) and medicine related (13 incidents). Incidents were investigated by managers.

In the 12 months prior to our assessment, the division had not commissioned any patient safety incident investigations (PSII).A patient safety incident investigation (PSII) is undertaken when an incident, near-miss, or collection of these, indicates significant patient safety risks and potential for new learning.

Similarly, the division reported that no “never events” had taken place in the 12 months preceding our assessment. Never events are defined as serious incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers.

Staff received feedback from investigation of incidents, both internal and external to the service. Incident details and outcomes were shared at handovers and in safety huddle documents. Managers told us that themes stayed on the handover sheet for 2 weeks to ensure that all staff received important messages.

Risk information was shared between units in the hospital to support the understanding of patient needs when transferred between departments., for example, the risk of falls.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if things went wrong.

Quality Statement Score: We scored the service as 3.

The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met.

Staff told us that handover information included risk information, for example, a history of falls and cognitive impairment.

We saw that patient risk assessments were generally carried out within an hour of a patient arriving on the ward.

The clinical site manager had oversight of transfer of care in the hospital. There was an agreement that the clinical assessment unit would admit a minimum of one patient per day from Royal Oldham Hospital. This would almost always be a resident of Heywood, Middleton or Rochdale and the aim was to enable the patient to be cared for nearer to their home. The trust had identified that 30-40% of patients attending Fairfield Hospital emergency department and 25-30% of patients attending Royal Oldham emergency department were residents of Heywood, Middleton or Rochdale.

There was a standard operating procedure in place that set out that patients transferred from Royal Oldham or another hospital had to be clinically appropriate, a resident of Heywood, Middleton or Rochdale and would ideally be transferred from the emergency department or acute medical unit rather than a medical ward where they may already be settled.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties.

However, one patient that we spoke with was unclear about the reasons they had been transferred to Rochdale Infirmary since they had to travel back to the hospital they had been transferred from for neurosurgery appointments. Staff also told us that some patients did not know why they had been transferred to Rochdale when they arrived, however, they told us this may be an issue with communication at the hospital they were transferred from.

Most patients admitted to the clinical assessment unit were from the urgent treatment centre or same day emergency care unit at Rochdale Infirmary, though some patients were transferred from the trust’s other hospitals or were social admissions where respite was needed from the home environment. The unit also enabled admissions directly from local GPs, but the manager told us that this rarely happened and was not promoted.

Similarly, the Oasis Unit also accepted social admission patients, those referred by GPs and referrals from other hospitals in the trust.

Patient transfers from same day emergency care (SDEC) to CAU or the Oasis Unit were identified at the earliest opportunity by a medical registrar and the manager of SDEC liaised with the wards regarding bed availability. The consultant from CAU attended SDEC to discuss the appropriateness for admission and a clinical management plan and a transfer SBAR (situation, background, assessment and recommendation) form was completed with a face to face or telephone handover. This initial handover included whether the patient was on any time-sensitive medicines.

From July 2024 to June 2025 the CAU directly admitted 1042 patients (averaging 87 patients per month) and also received 567 transfers from other wards (averaging 47 patients per month). The Oasis Unit directly admitted a total of 83 patients during the same period (averaging 7 patients a month) and also received 133 transfers from other wards (averaging 11 patients a month).

CAU had a set of exclusion criteria so that patients were admitted safely. These included immobile bariatric patients; pregnancy of more than 32 weeks; persons under 16 years old; early warning scores greater than 6; patients requiring breathing apparatus, and patients who had undergone an organ transplant within the previous 12 months.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge.

When the CAU was full, the Wolstenholme Intermediate Care Unit (WIMCU) was able to accommodate 2 medical outliers in escalation beds. Continuity of safe care was maintained as these patients were covered by the same doctors as the CAU patients. There were clear criteria for any transfers as outliers. Patients had to be medically optimised and already awaiting another placement elsewhere. The CAU identified those patients who could be placed as medical outliers by use of a blue dot system, where a blue dot on their records or bed boards identified that they were safe to move.

Patients could also transfer from WIMCU to the CAU or Oasis Unit if their medical care needs increased with the same transfer of care standards expected.

The medical division used “This is me” documents for patients living with dementia to identify their needs and wishes and patient passports for other medical patients.

The evidence showed a good standard. The service worked with people and healthcare partners to protect them from abuse.

Staff received safeguarding training, understood how to make referrals, and did so when appropriate.

The trust set a target compliance rate of 90% for safeguarding training. On the clinical assessment unit (CAU), 100% of registered nurses and healthcare assistants completed safeguarding adults training levels 1 to 3, and safeguarding children training levels 1 and 2. One staff member had yet to complete safeguarding children level 3, with overall compliance at 97%. All nursing staff and healthcare assistants completed training on preventing radicalisation and attended an associated workshop.

On CAU, 92.31% of medical staff (12 out of 13) completed safeguarding adults levels 1 and 2; 88.89% (8 out of 9) completed level 3. For safeguarding children, 76.92% (10 out of 13) completed levels 1 and 2, and 88.89% (8 out of 9) completed level 3.

On the Oasis Unit, all staff completed the required safeguarding training.

On the endoscopy unit, 100% of nursing staff completed safeguarding adults training levels 1 to 3. For safeguarding children, 96.15% (25 out of 26) completed levels 1 and 2, and 80% (12 out of 15) completed level 3. All staff received training on preventing radicalisation, and 68.75% (11 out of 16) attended the workshop.

Staff provided examples of how they protected patients from harassment and discrimination, including those with protected characteristics under the Equality Act. They described specific instances where they made safeguarding referrals.

Between 1 January and 17 July 2025, the medical division identified four safeguarding concerns. These included a community-acquired pressure ulcer observed on admission, a witnessed fall, verbal abuse towards a partner, and a fracture sustained from hitting a stationary object.

Staff recognised adults and children at risk of, or experiencing, significant harm and worked in partnership with other agencies to safeguard them.

Staff followed safe procedures for children visiting the service.

The evidence showed a good standard. The service worked with people to understand and manage risks. Staff provided care to meet people’s needs that was safe and supportive.

Staff told us known risks were documented on admission. For example if patients had a history of falls at home. Staff told us they discussed risks such as pressure sores and falls with patients and explained how bed rails and call bells could be used to reduce these. They also supported patients to understand how they could reduce their risks at home, such as using walking aides and wearing appropriate footwear.

Staff used equipment to reduce the risk of falls such as anti-slip socks; bay tags and Ramblegard alarms to alert staff when patients had got out of bed or a chair unaided. However, there were not always enough staff to meet the requirements of bay tagging with a member of staff in bays with identified patients at risk at all times.

The home in a day team carried out home assessments to enable safe discharge and often took patients home with a small food package and ensured that patients were settled back at home.

Staff were expected to complete patient risk assessments within fixed timescales following their admission. Nursing assessments for falls and pressure ulcers were expected to be completed within 6 hours whilst the Malnutrition Universal Screening Tool (MUST) was expected to be completed within 12 hours. We reviewed 3 sets of notes for new patents that showed that their risk assessments had all been completed within appropriate timescales.

Ward managers or quality matrons carried out monthly quality assurance audits to check that risk assessments were completed and met the required timescales. The electronic patient record system flagged outstanding risk assessments to support compliance.

However, we found that the falls risk identifier was not consistently completed in bed bay notes. This document should have been completed with the patient to ensure they were involved in discussions about falls risk and understand the care plan in place. It also supported the completion of individualised falls risk assessments. In addition, although falls socks were intended for use over a three-day period, there was no system in place to monitor how long patients had worn them.

Performance data for risk assessment results from January 2025 to June 2025 for the Oasis and CAU units showed varying compliance rates across months. Oasis had lower scores in January 2025 but improved significantly by June showing 100% of assessments had been carried out for nursing assessments; elimination; MUST; falls; Purpose T and bed boards. CAU maintained consistently high scores for all the risk assessments, with a dip in March and February.

Action plans were completed after each audit and discussed at a monthly quality assurance meeting with other service leads to share the learning.

The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

On the clinical assessment unit and Oasis Unit, most patients and relatives we spoke with said they were happy with the ward environment and how it met their needs.

We observed that patients had call bells within reach and emergency pull cords were situated in bathrooms. Corridors were kept clear of clutter and computers were locked away when not in use.

On the clinical assessment unit (CAU), some side rooms were located behind the reception desk. However, a window allowed staff at the desk to view these rooms. The ward manager’s office was situated next to the side rooms. A further three side rooms were less visible from the reception desk and bay areas.

Bay areas on CAU contained four to five beds. Each bay included a small nursing station and wall-mounted storage for bed bay notes. These notes were accessible to anyone if no nurse or healthcare assistant (HCA) was present. Although staff were allocated to each bay, not all bays had staff present at all times.

The ward had a secure buzzer entry system, but during our inspection, the door failed to lock. We reported this and staff told us the malfunction had just occurred, and a repair request had already been made.

In the Oasis Unit, the ward area was spacious, allowing patients to move around safely. A communal area included a television, armchairs, dining table, kitchen area and access to a garden. Access to the garden was via a key-operated lift, and patients were supervised at all times while in the communal area and garden.

The ward layout supported patient observation. Nurses positioned themselves where they could monitor patient rooms while completing paperwork.

We checked equipment stores on each medical ward and found items stored tidily. Sampled items were in date. Oxygen was stored appropriately. Staff checked resuscitation trolleys daily, and all equipment on them was in date.

In the Oasis Unit, we found thickener in an unlocked cupboard in the kitchen area. However, staff told us they were always present when patients were in this area.

Environmental safety on the medical wards formed part of the monthly quality assurance audit carried out by a senior nurse. These audits provided oversight and assurance that care delivery met clinical standards and patient safety expectations.

The environmental safety element of the audit showed overall compliance scores of 91% for CAU and Oasis Unit in April 2025, 97% in May 2025 and 98% in June 2025. Environmental safety scores had improved consistently over the previous six months. Each ward maintained an action plan to address any issues identified in the audits. We saw that these plans were up to date, and most actions had been completed within the proposed timeframe.

Observe, Listen and Act inpatient reports had been completed for each ward. Key themes included the ward environment and patient safety. Both CAU and the Oasis Unit received a green score and excellent feedback when the audit was last carried out in February 2025 and November 2024 respectively.

We saw staff held a twice-daily safety huddle on both CAU and Oasis Unit. These huddles gave staff access to essential patient safety information before bedside handovers. Staff completed huddle documents daily, which also identified safety roles for the day, such as cardiac arrest team roles, fire marshal, ramblegard monitor, bleep holder and red tray monitor.

Cleaning audits were carried out monthly, and staff completed daily cleaning checklists. Cleaning audit scores for endoscopy, CAU and Oasis Unit consistently exceeded 98%.

Staff undertook annual health and safety inspection checklists and recorded any actions on action plans. Monthly fire safety checks were carried out by the fire marshal, and the most recent audits for the medical wards showed good compliance.

Legionella flushing of taps showed 100% compliance over the past 12 months for CAU and Oasis Unit.

Medical equipment on the wards was included in a rolling service programme for the hospital, operated by the medical equipment team. In July 2025, all equipment requiring servicing was identified and serviced.

The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff to meet the needs of patients.

There were low and reducing numbers of healthcare assistant (HCA) and nursing vacancies. There was no use of agency nurses in the medical division. Where necessary, unfilled shifts were covered by bank staff. The last staffing review had taken place in January 2025 and concluded that the nursing establishment on the medical wards did not need to be increased.

The clinical assessment unit was staffed with healthcare assistants, registered nurses and medical staff. At the time of our assessment there were 17.24 HCAs against an establishment of 18.57 staff with a vacancy of 1.33 (7.16%). This was a reduction of 2.8% since December 2024 and there was a 0.96 HCA due to commence work at the end of July 2025 that would reduce the vacancy to 0.37. There were 14.31 registered band 5 nurses in post against an establishment of 18.45 with a vacancy of 4.14 (22.44%). There were 1 registered nurse and 2 student nurses due to commence in post, reducing the number of vacancies to 1.14.

Data showed that from January to June 2025, the staff absence rates for CAU was 5.79% for HCAs and 5.36% for registered nurses and the turnover rates were 8.7% for HCAs and 5.71% for registered nurses.

Although the division deemed CAU to have a sufficient nursing establishment, we saw that the number of staffing requirements for the different shifts did not align to peak activity on the unit. Rotas showed that for day shifts there was a requirement for 5 registered nurses and 4 HCAs; the late shift required 5 registered nurses and 3 HCAs, and the night shift required 4 registered nurses and 3 HCAs. However, staff told us that most admissions to CAU occurred between 6pm and 8pm daily when the same day emergency care (SDEC) department closed and patients were admitted to the ward to complete tests. This meant that patient assessments needed to be carried out on the late or night shift when there were less staff on the ward. We were told that patients who were already sleeping would often be disturbed because less staff meant that necessary assessments took longer to carry out.

Additionally, staff we spoke with told us they did not always have time to meet patients’ needs in a timely way as they were required to oversee patients on more than one bay at a time as well as some side rooms. We saw there was not always a staff member in each bay, sometimes for prolonged periods. This meant staff were not always able to comply with bay tagging requirements. Bay tagging is a patient safety initiative that involves assigning staff members to monitor specific areas to enable continuous observation and reduce risks such as falls. Staff told us they were often required to cover more than one bay as well as side rooms, even on the most heavily staffed shifts (early shift).

The Oasis Unit was staffed with healthcare assistants, registered nurses and medical staff. At the time of our assessment there were 8.28 HCAs against an establishment of 10.91 staff with a vacancy of 2.63 (24.11%). This was an increase of 1.7 HCAs since December 2024. This was expected to increase by 1.48 HCAs in August 2025 which would reduce the vacancy to 1.15. There were 7.52 registered band 5 nurses in post against an establishment of 8.66 with a vacancy of 1.14 (13.16%). There was 1 registered nurse due to commence in post, reducing the number of vacancies to 0.14.

Data showed that from January to June 2025, the staff absence rate in the Oasis Unit was 10.04% for HCAs and 7.56% for registered nurses and the turnover rates were 8% for HCAs and 11.76% for registered nurses.

The endoscopy unit was staffed with healthcare assistants and registered nurses who worked across two of the trust’s endoscopy suites (Rochdale and Oldham). At the time of our assessment there were 5.13 HCAs against an establishment of 5.63 staff with a vacancy of 0.50 (8.88%). These figures had been the same since at least December 2024. There were no HCA vacancies being advertised due to the low vacancy rate. There were 11.60 registered band 5 nurses in post against an establishment of 13.45 with a vacancy of 1.85 (13.75%). There was 1 registered nurse due to commence in post, reducing the number of vacancies to 0.85.

Data showed that from January to June 2025, the staff absence rates in endoscopy was 12.08% for HCAs and 6.07% for registered nurses and the turnover rates were 0% for HCAs and 9.09% for registered nurses.

The safer staffing establishment for medical staff on CAU was for 1 consultant; 1 specialist registrar on a long day; 2 junior clinical fellows and 1 specialist registrar on at night. At the time of our assessment, CAU had 5.47 doctors in post against an establishment of 11.52. This meant the service was reliant on locum staff to fill gaps. We were told job plans for the 4.5 vacancies had been developed and that there was a proposal to advertise 4 further vacancies. The medical staffing establishment for the Oasis Unit was 1 junior clinical fellow daily. Managers told us they recognised the need for speciality geriatricians to be recruited.

Data showed that, for January to June 2025, there had been 20 unfilled medical staff shifts on CAU and 9 on the Oasis Unit. However, we saw the volume of shifts filled by locums gradually reduced during this time and the medical staff absence rate was low.

We saw nurses and HCAs on both units completed appropriate mandatory training for their roles and compliance was above the trust target of 90%. However, medical staff compliance was below target at 85.53%.

The evidence showed a good standard. The service assessed and managed the risk of infection.

Staff maintained equipment well and kept it clean. We saw ‘I am clean’ stickers on equipment were visible and in date.

All ward areas were clean, had suitable furnishings and were well-maintained.

Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly.

Cleaning audits showed that scores were consistently above 98% compliance in CAU, endoscopy and the Oasis Unit which was above the trust target. The star rating for cleaning was displayed in each area for staff, patients and visitors to see with each area maintaining a five star rating throughout 2025.

Staff adhered to infection control principles, including handwashing and being bare below the elbows. There were enough hand gels and hand washing facilities on the wards. We observed that staff prompted visitors to wash their hands to reduce infection risks.

Any patients who showed signs of infection were cared for in side rooms and doors were clearly marked to indicate a possible infection risk.

Records showed that, in the six months prior to our assessment there had been 2 C-difficile infections in CAU and 1 in Oasis Unit, there was also 1 case of MSSA on CAU. These figures were very low compared to the overall trust figures.

There were 2 cases of Covid-19 in June 2025 on Oasis Unit where an investigation was undertaken to establish the root cause. All appropriate control measures were undertaken.

Housekeeping and nursing staff we spoke with were aware of all Infection prevention and control (IPC) processes and use of personal protective equipment (PPE) in side rooms where required. An on-call system for cleaners was available after housekeeping hours or for deep cleaning a room on patient discharge. We observed this being used to clean a specific room.

An IPC inpatient area audit for January to June 2025 showed the following results: for hand hygiene facilities CAU and Oasis Unit scored 92%; for hand hygiene CAU scored 88% and Oasis Unit 85%; for PPE CAU scored 93% and Oasis Unit 85%; for cannula care CAU scored 94% and Oasis Unit 85% and for catheter care CAU scored 95% and Oasis Unit 100%. The trust target was 90% compliance.

We saw evidence that privacy curtains were changed regularly.

The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Pharmacy staff supported wards during the week but there was no 7-day service on the ward. Staff told us how they had access to support and medicines when needed including out of hours.

Staff followed systems and processes for administering, recording and storing medicines. The service had processes in place to check patients had the correct medicines on admission.

The service used an electronic prescribing system to prescribe and administer medicines. Patch charts were documented on paper and we saw evidence patches were rotated in line with manufacturers guidance.

Staff completed checks on controlled drugs and emergency medicines.

Staff stored medicines in line with policy and followed guidance to ensure storage temperatures were monitored. The trust had a quarterly audit on safe storage of medicines which showed in Q2 2024 the hospital scored over 93% for all areas apart from the management of freezers that store medicines which scored 88%.

Staff completed audits related to medicines management including storage, controlled drugs and antibiotic stewardship audits. For example, in Q4 2024/25 100% of antibiotics prescribed had an indication and duration recorded and a review completed within 72 hours.

Pharmacy staff followed current national guidance supplying medicines on discharge. Audits showed between January and June 2025 52% of admissions had their medicines reconciled in 24 hours. This met the trust target of 50% in 24 hours following admission. However, this target was not compliant with national best practice guidance which requires 100% within 24 hours of admission.

Medicines management training for nursing staff and medical staff was 100%.