Royal Oldham Hospital

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

We rated safe as requires improvement. We assessed 8 quality statements.

The trust’s CFM was not managed well and was not always applied to the most appropriate patients to ensure that the process was safe, and risks were minimised. Our concerns about CFM are reflected in the safe systems, pathways and transitions quality statement.

Staff did not always have easy access to the equipment they needed, and this was not always checked in line with guidance. The service did not always manage specific risks well, for example early management of sepsis.

However, the service had a positive safety-focussed culture. Safety incidents and complaints were managed well, and lessons learned. Staff were compliant with mandatory training. Staff quickly acted upon patients who were at risk of deterioration.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patients told us they felt safe, knew how to raise concerns and felt confident they would be treated with compassion and understanding if they did so.

Staff knew what incidents to report and how to report them. Most staff felt confident and safe reporting incidents. However, some healthcare assistants (HCAs) on the acute medical unit (AMU) told us they did not have access to the incident reporting system and therefore incidents would need to be discussed with senior staff who would input them. Some staff shared concerns regarding reporting incidents as they were apprehensive about how senior staff would respond.

Staff and leaders understood the duty of candour and gave patients and families a full explanation and apology when things went wrong. The duty of candour requires registered providers to act in an open and transparent way with people receiving care or treatment from them.

We spoke with 20 staff members from different wards about learning culture, most felt safety was a priority for the division and there was a culture of safety and learning.

Most staff felt incidents were appropriately investigated, reported and lessons were learned through huddles, meetings or correspondence including the ward monthly newsletter. Staff were able to provide examples of incidents which had occurred recently on their ward.

The division regularly reviewed incident data. From February 2024 to August 2024, 2925 incidents were reported in relation to medical care, with the most frequent type being falls, slips, and trips. Since January 2024, the division reported 3 never events. Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them.

The division conducted reviews of incidents and carried out patient safety incident investigations when necessary. We examined the last 3 completed reports, which were detailed and included appropriate improvement actions.

The division had a structured process to ensure mortality reviews were completed for patients who had passed away whilst in their care.

Systems were in place to ensure staff were made aware of incidents and any resulting learning.

The wards we visited displayed noticeboards which highlighted examples of how lessons from incidents were applied in practice.

There were some concerns raised regarding the trust’s continuous flow model (CFM) in relation to learning culture. Information on CFM is reported under the safe systems, pathways and transitions and governance, management and sustainability quality statements.

Patients who were transferred as part of the CFM told us communication regarding their care journey was lacking. For example, 1 family told us they felt worried about their elderly relative who had been moved from the acute medical unit (AMU) to a ward without being told they did not have a bed. On the first day of our on-site assessment, most CFM patients told us they did not receive a letter which explained the CFM as per the trust’s process. However, on the second and third days of our assessment, more patients received this.

Other patients did not feel their views had been considered regarding the CFM. One patient told us they felt it was ‘undignified’. Patients told us how they had waited on chairs for long periods of time whilst they awaited a bed. We observed patients being changed and toileted in publicly accessible toilets.

Patients understood the pressure the division and hospital were under to discharge patients but sometimes felt pressured to ‘get better quickly’ as they felt they were burdening staff and the division.

Staff had concerns regarding how safe the trust’s CFM was. They explained how CFM patients were often inappropriate and provided examples including a patient with an alcohol addiction and others with a diagnosis of dementia.

Staff said CFM patients were not always provided with privacy and dignity, for example they told us how the spaces and equipment used did not always offer enough privacy.

Three members of ward staff told us about occasions where patients with high acuity had been transferred to the wards without agreement from the ward manager.

Four members of ward staff told us they had tried to challenge transfers they believed were inappropriate due to acuity, individual need, or ward staffing levels but their concerns were not acted on.

Staff said patients were not always aware they would be displaced on to the ward and communication between teams was often lacking, for example staff told us it was not always communicated if a patient required bay tagging.

Staff told us doctors did not attend the CFM huddles so there was no clinical input into the decisions being made about who was suitable for transfer under the model. They said staff making the decisions about whether to send a patient to non-clinical areas of the wards were unaware of the ward’s current position or capacity to admit another patient.

Some senior staff members told us patients with a high National Early Warning Score (NEWS2), or acuity would not be transferred under the CFM. However, following a review of incident data we identified examples of patients with NEWS2 scores of 5 being transferred under the model.

Aside from the CFM, staff also told us they felt not having digital notes was also a risk. They felt it impacted their ability to work effectively with other trusts due to not being able to track a patient’s journey due to multiple electronic record systems, as well as paper-based notes. Staff said this also caused difficulties for some audits.

Partner agencies told us that hospital staff attended system meetings around safeguarding, quality, patient pathways and accessibility regularly, and worked with stakeholders around opportunities to improve patient flow. However, local care services told us they were often unable to trace where their residents had been admitted to, and they felt there were several occasions where their residents had been discharged from a medical ward unsafely.

The trust’s CFM draft standard operating procedure stated, ‘transfers should be arranged in line with the transfer policy’, which stated ‘patients living with dementia or other cognitive impairments should not undergo routine internal transfer between wards’ unless there was ‘significant clinical need.’ The CFM standard operating procedure did not reference specific patient groups with additional needs. CFM incident data included examples of patients with additional needs being transferred under the model.

The trust’s CFM draft policy stated, “the continuous flow huddle was attended by the AMU coordinator, the emergency department coordinator, a medic and site management.” However, senior clinicians were not present when we observed the huddles.

The CFM process meant wards would be allocated patients at designated times throughout the day. This was not tailored to meet the needs of patients or availability of the wards. For example, on F10 we saw an available bed in a male bay, however 2 female patients were sent to the ward.

More generally, we found the division had reduced the number of discharges after 5pm and 8pm and had dedicated consultants to support the timely discharge of patients during the day. We also found that, generally, patients were reviewed by consultants in a timely way following admission. However, in quarter 4 for 2023/2024, the average length of stay for several conditions exceeded trust benchmarks, with stays ranging from 0.6 to 3.2 days above target. In some cases, the lack of nutrition team was impacting on patients’ access to timely treatment.

All patients we spoke to, or provided a questionnaire to, stated they would feel confident to raise concerns if they felt unsafe or had concerns about other patients’ safety. Six patients told us they all felt safe on the wards they were on.

Staff knew how to identify adults and children at risk of, or suffering, significant harm and worked with other agencies to protect them. They knew how to make a safeguarding referral and who they could contact if they had concerns. Senior staff demonstrated a good understanding of the safeguarding processes.

Staff had a good understanding of Deprivation of Liberty Safeguards (DoLS) and when restraint would and would not be used.

Staff were confident in explaining that patients with medical emergencies in eating disorders (MEED) would be referred to the safeguarding team, a dietician and the mental health liaison service.

The trust had adequate policies and procedures in place relating to safeguarding adults and children as well as policies specific to particular types of vulnerability.

The mandatory training policy provided clear instructions to staff explaining which level of safeguarding training they required and how frequently this should be repeated.

The medical division had a safeguarding lead who was an assistant director of nursing.

The training compliance rate for levels 1, 2 and 3 safeguarding training for adults and children for the division was 95%.

The Mental Capacity Act (MCA), DoLS and female genital mutilation training were embedded in to safeguarding level 3 training for which overall staff compliance was 89%.

However, the trust’s internal audits demonstrated that safeguarding processes were not always followed as expected. The division carried out nursing assessment and accreditation system audits for each of the wards. The nursing accreditation and assessment system audits were scored as red, amber or green and corresponded to a compliance score. At the time of the assessment, for safeguarding, 25% of wards were scored green, 50% amber and 25% red. Areas of concern included patients not having a relevant passport of care completed within 48 hours and patients under enhanced patient observations (EPO) not always having their risk assessments completed.

Most patients told us they were aware of their treatment plan and felt involved in developing this with staff. They said they were informed of any risks and how to keep themselves safe.

The division had regular audits completed by the head of patient experience. Recent audits between November 2023 and July 2024 indicated 90% of patients were involved in the decisions made about their treatment.

Staff understood how to identify and manage risks. They told us they would escalate any deterioration in a patients’ condition to senior staff. They told us they discussed any concerns with colleagues and communicated effectively with the patient and their families.

Staff understood the importance of recognising the signs of sepsis early and knew how to escalate this.

Staff knew about and dealt with any specific risk issues. For example, staff completed risk assessments for pressure ulcers, infection, prevention and control, bed rails, falls and the malnutrition universal screening tool (MUST).

Staff told us they had access to mental health liaison and specialist mental health support services when required.

Although staff were able to articulate the management of most risks, and training compliance was mostly high, audit processes did not always demonstrate compliance in practice.

Staff demonstrated high compliance with sepsis training, exceeding the trust target of 90% across most staff groups, including HCA’s (94%), consultants (95%), and staff nurses (100%). Staff utilised the NEWS2 tool effectively to identify deteriorating patients, supported by a patient tracker system which flagged when assessments were due. Audits by the quality nurse showed 92% compliance with the trust’s NEWS2 policy between January and August 2024. Most staff were compliant with basic or intermediate life support training.

The division completed sepsis audits between January and April 2024. Of the 45 patients reviewed, all received appropriate antibiotics, and those with a NEWS2 score of 1–6 were reviewed appropriately. However, timely registrar reviews for patients scoring a NEWS2 of 7 or above were inconsistent. In January 2024, 33% of these reviews were completed on time, increasing to 45% in April 2024. Leaders attributed this to limited availability of registrars or senior medical staff. A NEWS2 score of 7 or above signifies a critical level of illness, requiring urgent senior clinician assessment to mitigate the risk of deterioration or critical complications.

The AMU demonstrated clear oversight of individual patient risks, including nutrition, hydration, NEWS2, repositioning, and one-to-one care. Staff shared information during handovers to ensure patient safety, and the division had access to mental health liaison and specialist support 7 days a week. Staff shared key information to keep patients safe when handing over their care to others. However, nursing accreditation and assessment system audits and lead nurse audits demonstrated some areas for improvement including ketone screening and falls which had doubled from January to June 2024.

Most patients and relatives we spoke with explained they were pleased with the environment and how it met their needs. According to the patient experience survey between 22 July and 22 August 2024, 55% of 207 patients strongly agreed and 29% agreed they were happy with the environment they were treated in.

Most patients we spoke with told us they had not experienced any issues with equipment used to support their care or treatment and all told us their call bells worked, and they could reach them. However, some patients did not feel staff had enough working equipment. For example, a patient on T4 told us blood pressure machines were broken, and staff were having to borrow equipment from other wards.

Staff told us the wards were safe and designed to meet the needs of patients. However, they did acknowledge the issues with the flow of patients causing additional demand on the space available and the ageing estate which meant some patients were not always visible to staff on reception. They felt this was mitigated by ensuring bay tagging was in place.

Staff told us they completed daily safety checks of specialist equipment.

Ward entrances were unlocked. We raised this at the triumvirate interview with senior staff who told us it was the trusts policy to keep them open during the day except during protected mealtimes.

We received mixed feedback from staff, dependent on which ward they were based on, regarding access to equipment. For example, staff from the AMU were pleased with the amount of working equipment they had and the processes to reorder stock, whilst staff on the general medical unit (GMU) told us they often had to borrow equipment from other wards.

We observed fire doors being obstructed on wards T4, F9 and the GMU. We accessed an open storage room on F9 which had access to scissors and staff payslips and an unlocked storage room on F10 which had scissors, needles and bandages which could have been used as a ligature. On the same ward, there was access to bottles of blood culture solution in an unlocked cupboard. A further storage room on G2 was open with the digital lock not being used.

Medical wards were made up of a mix of side rooms and same sex bays. Several medical wards had side rooms and bays which were not visible from the nurse’s station. Staff told us bay nursing was used as this allowed for increased observation of patients who may be at risk of falls.

Equipment was not always well maintained, or guidance adhered to. For example, we observed computers being left unattended with patient details left on the screen on 2 occasions on F9 and F11. We reviewed the fridge temperature recordings for the fridge which held patients’ food and drink and found that in June 2024, 8 recordings were missing and in July 2024, 9 recordings were missing.

However, we found most wards within the division had spaces to hold private conversations, resuscitation trolleys were correctly stocked, oxygen cylinders were full, and suction machines and defibrillators were in working order. Staff disposed of clinical waste safely. Sharps bins were clean, not overfilled and were partially closed when not in use.

Risk assessment and audit data showed that processes and practice were not always in line with expected standards.

The division did not provide sufficient fire risk assessments for all ward areas.

The division provided fire risk assessments for the AMU, F7, F8 and T4 and a fire marshal checklist for the GMU. The division did not provide any further fire risk assessments for other wards. The fire risk assessments for the AMU and F8 had expired.

The fire risk assessments for T4 and the GMU from February 2024 and August 2024 stated escape routes were poorly managed; we observed fire doors were obstructed by equipment.

Audit data showed ward equipment compliance was 81% and medical equipment compliance was 62% which suggested 19% of the ward equipment and 38% of the medical equipment did not fully comply with the expected standards.

Nursing accreditation and assessment system audits highlighted areas of concern relating to bed rails, falls, and moving and handling.

Audits completed by the patient experience team suggested half of the wards (F11, F10, F7, F8, GMU and T4) were clutter free.

However, data also demonstrated that audits relating to resuscitation trollies, waste management, and control of substances hazardous to health (COSHH) had higher levels of compliance. Furthermore, a mini nursing accreditation and assessment system audit showed 100% compliance between January 2024 and August 2024 for call bells being in reach of patients and reasonable adjustments being recorded for those unable to use the call bell.

There were some concerns raised regarding the CFM in relation to safe environments. Information on CFM is reported under the safe systems, pathways and transitions and governance, management and sustainability quality statements.

We received mixed feedback from patients about staffing levels, and the ability of staff to meet their needs. We spoke with a mix of patients across the wards and collected information using questionnaire’s completed by patients and their families and/ or carers. Feedback suggested that patients felt they were able to get attention from staff when they needed it, and that staff were competent to meet their needs. However, most patients we spoke with told us they felt there were not enough staff on the wards.

We were told there was a significant shortage of HCAs for the division with 20 vacancies on F9 and T4. Staff had concerns about the impact on patient safety, including an increase in falls related incidents.

A safer staffing review was completed in June 2024 which highlighted the need for further HCA staff. There had been a temporary freeze on recruitment but T4 were in the process of recruiting 11 HCA’s.

Staff told us patients were often not receiving 1:1 care when needed, ward managers told us bay tagging was used to mitigate this.

Most staff told us there was adequate nursing staff but there was a problem with the skill mix with lots of staff being junior. On certain wards staff told us it was common for bank and agency staff to be used.

Staff told us medical cover was fine during the week, but at weekends there were only 1 or 2 trainee doctors for the whole hospital. Staff described medical staff working on a ‘skeleton rota’. Staff also raised concerns about the levels of locum doctors being used. Leaders told us there were medical staff shortages.

Senior staff told us there was a full complement of matrons for the division.

Staff kept up to date with mandatory training and any role-specific training or education. They had effective supervision and annual reviews of their work, and discussions about future learning and development opportunities.

Some staff told us additional training in supporting patients with mental health difficulties and those displaying violent and aggressive behaviours was required. Senior staff told us that in June 2024, the trust approved mental health courses which will be added as a mandatory training requirement.

Staff told us the training offered by the practice-based educators was helpful in them being competent in their roles.

All staff we spoke with had completed an induction when they started on the ward.

Staff on certain wards told us there were lots of staff off sick.

We observed nursing huddles and bed flow meetings where staff numbers across the medical division were reviewed.

We witnessed staffing on wards being as planned or slightly under what had been planned. We observed high levels of bank staff use on some wards. For example, ward F6, which was a temporary general medicine ward, was fully staffed by bank staff. This was documented on the divisional risk register. However, most bank staff were experienced and were familiar with the wards they were working on.

We saw patients on some wards did not always receive the1:1 care they required due to a shortage of HCA/EPO staff.

However, we saw physiotherapists, occupational therapists, and volunteers supporting patients and staff on some of the wards we visited.

Levels of training compliance were displayed on most wards via notice boards.

The overall mandatory training compliance for the division was 92%. However, Foundation Year 1 doctors and Salaried General Practitioners were less than 70% compliant.

Nursing staff had clear competencies and job specific training. Compliance with this training was good.

The trust had relevant staffing policies which included the escalation framework for periods when the division is under increased internal pressure.

A safer staffing tool determined the amount of nursing and HCA’s required for the wards.

Staffing levels were reviewed at huddles and bed flow meetings.

Approved staffing numbers for nurses and HCAs were mostly achieved; however, use of bank and agency staff was high, and skill mix was an issue of concern on specific wards.

The average fill rate for allied health professional (AHP) staff, including the speech and language team, dietetics and other teams between February and July 2024 was 96%.

There were a substantial number of vacancies for the division. In July 2024 there were 33 vacancies for doctors and 44 vacancies for nurses. A workforce strategy in January 2024 had identified a shortage of specialist and general medical staff. Since this review there had been active recruitment, but leaders acknowledged locum usage was still too high.

The trust’s turnover target following the 1 April 2024 was 9% or below. In July 2024, the divisions turnover of doctors was slightly worse than the target (10%) and better than the target for nursing staff (7%).

The trust’s sickness target following the 1 April 2024 was 5% or below. In July 2024, the divisions sickness rate for doctors was 5%, for nurses 9% and for AHPs 8%.

The hospital had access to an EPO team which included 35 HCAs who had been trained in providing holistic and patient centred care. However, they were being reabsorbed into the acute medical ward HCA worker establishment to meet a shortfall of staff on the wards.

Eighty eight per cent of nursing staff and 87% of doctors had received an appraisal.

All patients and relatives we asked told us they had witnessed frequent cleaning by domestic staff, had seen staff washing their hands regularly and wearing aprons when providing food. No patients or relatives we spoke with had any concerns regarding infection prevention and control.

Staff were aware of their roles and responsibilities around infection prevention and control.

Overall staff did not have concerns regarding infection prevention and control practices and procedures.

Senior staff were looking to address low compliance rates with local audits in relation to infection, prevention and control. For example, senior staff with the domestic lead were completing fortnightly walkarounds of the medical wards. Changes had been made to some of the domestic rotas and leaders planned to review whether this had a positive effect.

Staff on T4 told us they did not have a housekeeper for the ward which meant health care assistants were required to take on further tasks.

Most medical wards were visibly clean, and we observed staff cleaning during the assessment. Cleaning records were up to date and demonstrated areas had been cleaned regularly.

Most items in cupboards were stored on shelves, however on the AMU we saw pillows situated on the floor in a linen cupboard.

There were hand wash sinks across all the wards we visited including posters which displayed the correct hand washing technique.

We observed side rooms where patients were being treated for an infection, or were at risk of infection, had doors which could be closed and had an orange triangle sticker to indicate the risk of infection.

We saw most staff followed infection control principles including the use of personal protective equipment (PPE) apart from 1 occasion we saw a doctor with their sleeves rolled down whilst attending to a patient. We observed staff wearing the correct PPE, apart from on 1 occasion we saw a HCA provide food and drink to patients without an apron on.

We observed staff cleaning equipment after patient contact and equipment was labelled to show when it had last been cleaned. Staff used ‘I am clean stickers’ to indicate equipment had been cleaned.

Wards had noticeboards which displayed infection, prevention and control data including infection rates and audit compliance data.

The trust and the hospital monitored key metrics in relation to infection rates, including MRSA, MSSA, E – Coli and C. Difficile. There were mixed outcomes in relation to how the division and hospital performed in relation to infection rates. The division had 18 healthcare acquired c - difficile infections between January and August 2024. Ten cases of MRSA had been reported for the hospital in 2024 which represented an increase of 5 cases from 2023. However, cases of CPE and MSSA had reduced by 50% and 44% respectively from 2023 to 2024.

At the time of the assessment, for infection, prevention control, the nursing accreditation and assessment system audits showed the wards for the division were 25% green, 25% amber and 50% red. The AMU, GMU, T4 and F7 had shown no improvement in their last two audits.

The trust had appropriate policies for infection, prevention and control practices, including an outbreak control, ward bay unit closure, and decontamination of reusable medical devices policies.

Cleaning schedules were in place for each ward.

The division completed infection, prevention and control audits monthly. For July 2024, the medical division (excluding F6) scored an average of 95% with regards to the facilities being clean, staff practicing good hand hygiene, staff utilising the appropriate PPE and staff providing cannula and catheter care in line with appropriate infection, prevention and control measures.

There were some concerns raised regarding the CFM in relation to infection prevention and control. Information on CFM is reported under the safe systems, pathways and transitions and governance, management and sustainability quality statements.

Records we reviewed showed people were given their medicines at the prescribed times, including medicines to be given at specified times throughout the day. However, 1 patient we spoke with told us their insulin was administered 3 hours late. One patient’s family told us, medicines were left on the table and not given to their relative and they were not able to take the medicines unassisted. When patients were prescribed a medicine to be given immediately or as soon as possible, records showed the medicines were generally given in a timely manner.

Two wards had pharmacy staff who supported the nursing team with the administration of medicines, and medicines optimisation. The AMU had a team of pharmacy staff to support with the medicines reconciliation process to ensure patients were prescribed their medicines in a timely manner. Documents showed the medicines reconciliation rates completed within 24 hours of admission were 61% in April 2024, down to 60% in July 2024. This was still within the trust’s target of 50%. Best practice guidance from the National Institute for Health and Care Excellence (NICE) quality statement for medicines reconciliation in acute settings, states people who are inpatients should have their medicines reconciled within 24 hours of admission. The trust’s nursing assessment and accreditation system audit had identified several areas for improvement relating to the management of medicines. The areas for improvement included staff unaware of the 4 categories of critical medicines, people not having allergy wristbands, and staff not always following procedures when administering controlled drugs. However, the trust did not share the audit action plan with us to show they were working to improve the areas identified. The trust had identified a need for improvement with the safe use of insulin compliance, work was ongoing in this area. One ward produced a newsletter to share learning from medicines incidents with the ward staff, however this was not shared with other wards and staff.

Pharmacy staff we spoke with on some wards, told us they felt integrated into the wider clinical teams. Nursing staff knew where to find medicines related policies and procedures and how to access medicines when the pharmacy department was closed.

We found medicines were stored securely within the relevant rooms on the wards, however we did observe topical preparations, such as creams, were not always stored securely. The temperature of some rooms where medicines were stored was above the manufacturer’s guidance for safe storage. When temperatures were outside of their normal range, staff had not always reported the issue in line with the trust’s policy.

We saw some patients left the wards without waiting for their discharge medicines. The time it took the pharmacy department to dispense a discharge prescription had improved from 90 minutes in May 2024, to 75 minutes in August 2024.

Policies and systems were in place to support staff; however, these were not always followed. We found staff did not always report medicine incidents in a timely manner. We saw 1 person was given a rapid tranquilisation injection due to agitation and/or aggression. Guidance from the National Institute for Health and Care Excellence (NICE) recommends staff monitor and observe the patient following rapid tranquilisation. The guidance was not followed, this placed the person at risk of harm. The trust’s policy to support staff when they had administered rapid tranquilisation did not provide enough detail to ensure the NICE guidance was followed.

Emergency trolleys were checked regularly to ensure they were ready for use.