Rochdale Infirmary

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• 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

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 the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

The service had a vision and strategy in place and staff understood this.

Workforce equality, diversity and inclusion was valued.

The service worked closely with external partners and communities.

However, we found that some information, such as risk assessments, was not always easy to access and some policies had not been updated by the trust.

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 had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

There were strategies in place for the organisation, the Rochdale Care Organisation, and divisional priorities. The trust’s vision for the next 5 to 10 years was to be the safest and most effective organisation in the NHS and be the place people want to work, tackling inequalities and improving health outcomes and experiences. The trust had overarching objectives that were aligned to the trust’s vision, including improving population health, caring for and inspiring people and improving quality and performance. Care organisations and divisions had a vision and strategy linked to these.

The divisional strategy focused on the hospital’s membership of the multiagency local care organisation which brought together NHS, adult social care, voluntary sector and primary care services with shared objectives. Leaders reviewed progress against the strategy quarterly through divisional and directorate triumvirate meetings. They recorded progress on a PowerPoint template. At the time of our assessment, the quarter 1 review had not taken place, and leaders acknowledged they were slightly behind schedule.

The agreed objectives for 2025/26 related to; culture and wellbeing, people and learning, service improvement, and being well-led. These included specific targets such as reducing sickness absence by 2% and ensuring 95% of leaders accessed the accelerated leadership development programme.

Staff understood the provider’s vision and values and how these applied to their team’s work. Senior leaders successfully communicated the vision and values to frontline staff in this service.

Staff had opportunities to contribute to discussions about the service strategy, particularly when changes were planned. They could take part in a monthly team briefing. Staff also contributed their views through the annual staff survey and regular pulse surveys, which covered service delivery and job satisfaction. The division achieved a staff survey response rate of over 70%, well above the trust average. Most responses were positive and exceeded the trust average by 3% or more. Each team had an improvement plan based on staff survey results, focusing on agreed areas for development.

Most staff and leaders told us there was a positive culture within the division and that staff were supportive each other.

The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation.

Leaders had a good understanding of the services they managed and could clearly explain how teams worked to provide high-quality care. They were visible and approachable for patients and staff. Senior nurses carried out two-weekly formal walkarounds and told us they also did informal walkarounds more frequently. Leaders planned to structure some walkarounds to focus on specific topics such as nutrition, hydration, or dementia care.

Senior leaders held twice-daily check-in meetings with teams to provide support and discuss any issues informally. They showed a strong commitment to engaging with staff every day, even through informal conversations in communal areas.

Leaders had the skills, knowledge, and experience to perform their roles. Leadership development opportunities were available for all staff. The accelerated leadership development programme aimed for all band 6 staff and above to complete it, and around 60% across the location had done so. Many senior staff were taking part in a clinical leadership model programme in preparation for the transition to a new trust leadership model with a view to all senior staff being signed onto the programme.

Talent management and succession planning were ongoing. These processes helped identify colleagues approaching retirement and staff with leadership potential. Personal development was discussed during “My Time” one-to-one meetings to identify career goals and development opportunities.

Development programmes for lower-grade staff lasted 9–12 months and were reported as helpful. Staff we spoke with, including a healthcare assistant, told us they enjoyed working in the directorate, had access to training opportunities, and felt supported by visible leaders.

The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Freedom to speak up (FTSU) champions were in place across the site, along with an FTSU lead who staff could approach with concerns. At the time of our assessment, there were no ongoing cases for CAU, Oasis Unit, or endoscopy at Rochdale Infirmary. The lead met monthly with senior leadership to share any concerns.

Staff felt the champions and lead were visible and promoted their role effectively. The medical FTSU Champion was highlighted as particularly proactive in reaching out to staff to hear concerns.

Managers supported staff to raise concerns and viewed this as an important part of maintaining a positive culture.

The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Managers told us the staff survey had highlighted concerns from black and minority ethnic (BAME) staff about inequitable progression compared to non-BAME colleagues and that a development programme had been introduced as a result. They told us several staff had progressed to higher salaried roles after participating in the programme. In a more recent survey, more BAME staff reported feeling included and said they had access to development opportunities that were previously unavailable.

Staff gave positive examples of managers supporting staff, whose first language was not English to improve their language skills, to achieve NMC registration. Managers also provided practical support for staff from overseas, including help with housing, furnishings, school access for children, and GP registration.

Equality and diversity champions were in place within the service, including representatives for LGBTQ+ and BAME staff. Staff could apply for flexible working arrangements to accommodate personal circumstances such as caring responsibilities or health needs. Managers made reasonable adjustments to help staff carry out their roles.

The trust monitored equality and diversity within the workforce to ensure representation of patient groups. Sources included the staff survey, Workforce Race Equality Standard, and Workforce Disability Equality Standard, and senior divisional staff sat on the care organisation’s equality, diversity and inclusion (EDI) forum.

Staff with protected characteristics felt empowered and confident that raising concerns or ideas led to positive change. Initiatives included hearing loss awareness sessions with audiologists and information stalls, which identified staff with previously undiagnosed hearing loss. Men’s mental health wellbeing events were also held and well received.

The hospital worked with a local school for pupils with additional needs to provide volunteer placements, supporting pathways to employment after education.

The evidence showed some shortfalls. The service had clear responsibilities, roles, systems of accountability and risk management. However, information was not always easy to access, and not all policies were in date.

There was a clear framework for team and directorate meetings to ensure essential information, such as learning from incidents and complaints, was shared and discussed. Each directorate held meetings that fed into divisional meetings, which in turn fed into organisation-level meetings.

The directorate overseeing medical care at Rochdale Infirmary held a monthly performance, quality assurance and risk meeting (PQARM). This fed into divisional quality, people, and finance and performance groups, which then reported to organisational-level groups. Other monthly directorate meetings included the budget review meeting and the falls steering group.

Staff carried out local clinical audits, which provided assurance and highlighted areas where improvements were needed. Staff understood arrangements for working with other teams within the provider and external partners to meet patients’ needs.

Risk, issues, and performance were managed effectively. Systems were in place to monitor risks. Risks scoring 12 or above were escalated to divisional level, and those scoring 16 or above were reviewed weekly. Staff maintained and accessed risk registers at ward or directorate level and could escalate concerns when required.

At the time of our assessment, the Oasis Unit had two low risks: incomplete fire risk assessments and insufficient healthcare assistants in the ward establishment, which could compromise patient safety and care. The Clinical Assessment Unit (CAU) had four moderate risks, all scoring below 12: incomplete fire risk assessments, lack of nightshift medical cover, insufficient nurses in the establishment, and risk of incorrect IV fluids being given if removed from original packaging. All risks were reviewed regularly, had an identified owner, and action plans to minimise risk.

There was a trust wide work stream to update and harmonise policies. However, we found examples of some key policies that had not yet been updated. For example, the adult patient observation policy was out of date by 5 years.

Information was not always easy to access. The trust did not have a single electronic patient record system and used multiple IT systems to record patient information. This meant there was no one point of contact for information about patients. For example, staff used one IT system to record NEWS2 observations and a separate electronic patient system to record admissions, risk assessments and care plans. Paper based notes were used for daily nursing notes including pain charts, fluid balance charts and enhanced patient observations for 1:1 care. We found that the use of multiple IT and paper-based systems was burdensome and inefficient, making it difficult to locate essential information.

The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Directorate leaders engaged with external stakeholders, including commissioners, partner agencies, consumer champions and patient forums.

The directorate worked closely with the transfer of care team, intermediate care unit, and adult social care providers. Meetings focused on reducing delayed discharges and managing patient expectations around choice, available options, and discharge times.

The local hospice joined system pressure calls three times a week to share capacity and “hospice at home” availability. Managers told us there was positive collaboration between the hospital, district nurses, the hospice, and GPs to avoid admitting end-of-life patients to hospital against their wishes.

A senior manager was part of the Greater Manchester care coordination group, which included urgent and emergency care, acute medicine, and the ambulance service. This work aimed to prevent inappropriate admissions to medical wards.

Other admission avoidance initiatives included working with care homes on falls prevention and upskilling staff on insulin management. Care homes were encouraged to contact the urgent response team before calling an ambulance. Urgent community response services managed non-injurious falls promptly in the community, avoiding unnecessary hospital admissions.

The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

Staff had time and support to develop improvements and innovations, which led to changes in care delivery.

In the Oasis Unit, learning and innovation improved the management of enhanced patient observations. In quarter 1 of 2024/25, £83,800 was spent on additional staff for enhanced observations. This was financially unsustainable and affected continuity of care, patient safety, and experience.

A robust improvement plan addressed environmental changes, staff routines, practices, and training. This helped the team make better decisions about observation levels and apply the least restrictive, safe approach. As a result, costs reduced significantly to £28,300 in quarter 2 of 2024/25. There had been no increase in incidents or harm to patients since changes were introduced. Patient observations were still carried out with staff or patients positioned differently through the ward.

Staff contributed to the improvement plan. Simple changes had a large impact, such as all staff helping patients get up, dressed, and settled in communal areas, freeing time for nursing documentation. Nurses positioned themselves where they could observe patients more easily. The activity coordinator extended their working hours to support patients experiencing sundowning (increased confusion and agitation in late afternoon and evening for people living with dementia). The team also worked to increase volunteer support.

Staff had opportunities to participate in research and use quality improvement methods, which they understood and applied effectively.