Royal Oldham Hospital

On this page

• 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

We rated well led as requires improvement. We assessed 7 quality statements.

Although there was a shared vision and strategy for the trust, there was no divisional strategy in place. Leaders at all levels had the skills, knowledge, experience and credibility to lead effectively but some staff told us that they did not feel acknowledged by senior leaders. The service fostered a positive culture where people felt that they could speak up, but some staff told us they did not always feel heard.

The leadership did not have effective systems and processes in place to assess, monitor and improve the safety and quality of the CFM, or to evaluate the impact of the model on inpatients and ward staff. Key risks had not been assessed and mitigated.

However, the service valued diversity in the workforce and worked towards an inclusive and fair culture by improving equality for people who worked for them. Staff and leaders understood their duty to collaborate with partners, so services worked seamlessly for people. The service focused on continuous learning, innovation and improvement across the organisation and the local system.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff feedback about culture was mixed. Some people told us work was a ‘happy, good and comfortable environment with supportive staff.’ In contrast, some staff told us they felt unappreciated and scrutinised by leaders. They felt some grades of staff were undervalued and undermined by more senior staff on the wards.

Ward managers had a good understanding of the vision and strategy for the hospital. Leaders told us staff were reminded of the vision and strategy for the trust via the appraisal process and regular 1:1 meetings they had.

Leaders told us divisional strategies; action plans and work plans had been created for the division following an away day in collaboration with staff. Leaders explained the strategy was reviewed annually.

The trusts 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.

We requested the divisional strategy and meetings related to the division delivering the strategy and any associated plans, but we did not receive these. The lack of a divisional vision and strategy was identified at the last inspection.

However, the division had objectives which aligned to the trusts vision statements. The division was focused on improving performance and flow, quality improvement, financial sustainability and workforce and wellbeing.

Staff completed pulse surveys quarterly. The division’s results for quarter 2 (2024-25), based on answers from 58 respondents, showed staff did not feel well informed about important changes within the organisation, and did not feel they received feedback which helped them to learn and develop. Only 10% of respondents stated they had been involved in discussions with their teams or areas of work about results from the NHS staff survey.

The division performed worse than the trust average on the staff survey, 41% of respondents scored more than 3% below the trusts average and 35% scored up to 3% below. The division had a staff survey action plan which looked to address the concerns raised with timescales and owners for each action.

The trust had a people and culture council who met monthly. Their aims were to improve the staff survey response rate and to focus on improving 3 areas where the trust had improved the least which were having a voice that counts, compassion and inclusivity, and staff engagement.

Staff told us they had good working relationships with their ward managers who they described as approachable and visible. Staff feedback in relation to senior leaders’ visibility and helpfulness was mixed. Some staff were complimentary about leaders, especially the associate directors of nursing (ADNS) and lead nurses but they did not feel acknowledged by the senior leadership team. Some ward staff were unable to name senior members of the organisation such as the chief nurse and deputy chief nurse. Most ward managers felt supported by the lead nurses and senior leaders within the division.

Leaders were knowledgeable about challenges and priorities for the service and could access appropriate support and development in their roles. They explained challenges such as recruitment and retention of medical staff, significant volumes of less experienced nursing staff, bed capacity, and financial sustainability.

The divisional senior leadership team were experienced and there were no vacancies within other key leadership roles within the division. There were clear reporting structures and key roles were supported by deputies or associate roles.

The division had a structure which ensured support for ward managers and associate directors of nursing.

Quality leadership was sustained through safe, effective and inclusive recruitment and succession planning. There were accelerated leadership development programmes in place for ward managers. Workshops were held which provided staff with information about leadership roles. There was a competency framework in place for directorate managers.

Senior leadership in the division supported ward managers where improvements were needed. Support was more intensive for those wards performing poorly on the nursing assessment and accreditation scheme. For example, additional support from an ADNS had reduced the number of falls harms on the ward, improved staffing sickness rates and staffing levels. However, some wards were still not improving on the nursing assessment and accreditation audits. Managers were concentrating on bringing improvements to the scores.

The hospital ensured there were leads, who offered specialised oversight, direction and support within specific areas such as safeguarding, learning difficulties, infection prevention control and sepsis which the division utilised.

Overall, the staff we spoke with told us they were aware of the Freedom to Speak Up (FTSU) process, who the guardian was for the trust and who the champions were in the division. Staff showed us they could access the guidance and policy on the trusts intranet easily.

Not all staff told us there was a culture of speaking up when staff had concerns. Some staff members said despite providing feedback via incident reporting and through meetings with senior staff they did not always feel heard. Others did not feel confident raising concerns with leaders.

Leaders told us staff were encouraged to raise concerns via various channels including the intranet, posters and via meetings. The FTSU process was explained to new members of staff on their induction.

Leaders told us they had a good understanding of the concerns which had been raised through FTSU and that they were assured there were no common themes or trends identified.

The divisional director of medicine was the FTSU lead for the division and had attended ward manager meetings to explain the speaking up processes. The division also had a FTSU guardian and 10 FTSU champions.

The FTSU guardian had attended listening events for staff to introduce themselves and encourage referrals.

The FTSU lead attended meetings with the human resources director and associated director of governance to escalate cases and obtain progress updates on cases. The FTSU lead attended quarterly meetings with the chief officer.

The trust had a FTSU policy which provided staff with details of what they could speak up about, who to speak to and what the process would be if they did. The policy outlined the roles and responsibilities of the FTSU champions and guardian.

The division displayed FTSU information so that staff knew how to raise concerns about service user or staff safety confidentially.

However, the divisional pulse survey results for quarter 2 (2024-25) showed 72% of respondents knew how to speak up, however 58% said they would not speak up if they had a concern.

Leaders told us the trust continuously monitored and actively worked to improve its organisational culture, particularly focusing on equality and inclusion for staff with protected characteristics. Actions taken to address disparities included establishing divisional representatives across staff networks, such as groups supporting LGBTQ+ individuals and those from ethnic minority backgrounds, to promote inclusion, foster open dialogue, and support the unique needs of diverse groups.

Leaders demonstrated an understanding of the Workforce Disability Equality Standard (WDES) and Workforce Race Equality Standard (WRES) and were well-informed on the organisation’s performance against these.

Leaders were aware of how to support disabled staff by implementing reasonable adjustments, such as modifying duties to reduce physical strain and offering flexible scheduling options, including longer or additional breaks based on individual needs.

Leaders highlighted specific initiatives such as a project led by an associate director of nursing about understanding the impact of menopause on staff well-being. Staff reported engagement in awareness events, like mental health awareness week, which they felt promoted a positive, inclusive culture.

Staff expressed confidence in their ability to raise concerns around workforce equality, diversity, and inclusion. They were aware of cultural ambassadors and divisional representatives, including a lead nurse for culture.

Leaders promoted equality, diversity and inclusion. The trust published workforce race equality standard (WRES) and workforce disability standard (WDES) data and produced associated action plans annually. However, the trusts 2024 action plan was limited in detail and there was little improvement in the data compared to the previous year.

The trust had relevant policies to promote equality, diversity, and inclusion, including a Dignity at Work policy. The hospital also facilitated bi-monthly equality, diversity, and inclusion (EDI) meetings for staff, chaired by senior leaders. The assistant director of nursing for urgent and emergency care presented the divisional report for information and noting to the committee. Examples of updates include international nurses being offered the opportunity to become the Black, Asian and Minority Ethnic (BAME) lead, the launch of LGBTQ+ and health and wellbeing virtual learning events and updates on mental health and autism awareness events.

The hospital had monthly staff networks for members of staff with disabilities and those from LGBTQ+ and ethnic minority backgrounds.

In 2023, the trust launched a program to support the safety and well-being of women in the workplace. This program aimed to understand the unique challenges faced by female staff, engage them in discussions to identify necessary improvements, and develop a co-designed plan to ensure their safety and professional development. The trust plans to host its first women's staff network conference in March 2025.

The division did not have effective systems or processes in place to monitor and improve the safety of the CFM. Staff we spoke with were not sure if there was inclusion or exclusion criteria used in the decisions about whether patients were appropriate to transfer to non-clinical spaces under the model, or whether there was documented guidance about this. They told us they did not know if there were risk assessments in place for the non-clinical spaces used for CFM patients. Multiple ward staff told us they had raised concerns about CFM but did not feel they were listened to, or that they submitted incidents about CFM but did not feel they were reviewed and acted on. They also gave examples of times patients were transferred to non-clinical spaces despite ward staff’s concern about how ill they were, or patients who remained in non-clinical spaces despite there being a bed available on an appropriate specialty ward.

We were told the trust’s infection prevention and control team were not involved in the planning or implementation of CFM and had raised concerns about the possible risks the model posed to infection prevention control, but they were unsure whether leaders had made plans to mitigate these.

Aside from the concerns identified with the CFM, lead staff were knowledgeable about the specific risks within their wards and the division. They knew about ongoing actions to address these risks to promote patient safety. Leaders attended relevant meetings to ensure risks and issues were escalated to the appropriate forums within the hospital’s committee structure. We were told ward staff meetings, outside of the usual handovers and safety huddles, were available but that many staff did not participate in these.

Managers told us they reviewed system generated reports about nursing assessments compliance to ensure all inpatients had the necessary nursing assessments in place.

The division did not have effective systems or processes in place to monitor and improve the safety of the CFM.

At the time of our assessment the trust’s standard operating procedure for CFM was incomplete. It did not contain inclusion or exclusion criteria to support staff to determine who was appropriate for transfer under the model, and did not align with relevant associated policies such as the transfer or escalation policies.

The trust did not have effective risk assessments in place to promote the safety or dignity of patients transferred under CFM or assess and mitigate the impact CFM had on environmental safety issues such as fire.

During our assessment, the trust was unable to provide evidence of any audits undertaken to monitor the safety or quality of the trust’s CFM, or that any work had been done to collate and understand incidents or complaints relating to the model.

Aside from the concerns identified with regards to the CFM, the division had established governance, management, and accountability structures with clear oversight across key areas, including quality, performance, research, and education.

Routine monthly governance meetings and risk register reviews supported leaders in identifying risks and challenges, including issues of capacity and patient flow, and determining targeted improvement actions.

The division’s risk register was regularly reviewed, with all risks updated and assigned risk owners. However, leaders had limited awareness of the risks posed by the governance gaps for the CFM, which was implemented in May 2023..

Data reporting and management practices were robust, with external notifications consistently maintained and minimal impact from information governance breaches.

Most patients felt staff worked in partnership with them and that they implemented improvements based on feedback. Most told us they would feel comfortable giving feedback on their care.

Leaders felt there was a good working relationship with partners. For example, they told us they had a good relationship with the mental health trust who provided the mental health liaison service within the hospital. They felt well supported by the trust and had regular meetings with their senior leaders.

Leaders said they worked closely with other system partners such as primary care and social care services.

Key stakeholders such as the Integrated Care Board (ICB) told us the trust have a good working partnership with them, both ‘strategically and operationally.’ The local ambulance service stated there was a good relationship grounded by learning and sharing to improve patient outcomes between themselves and the medical division. The care homes provided mixed feedback with 1 telling us that the division worked in partnership with them whilst another care home told us there had been occasions when they had not worked collaboratively which had contributed to unsafe discharges.

The trust were not able to provide evidence that they regularly supported patient engagement forums to contribute to decision making or improvements within the division. We requested minutes from ‘patient groups’ for the medical division for the last 6 months. We received an audit from November 2023 which reviewed patients’ opinions on approved treatment for cancer being provided in their homes. We did not receive any further evidence of engagement with ‘patient groups’.

We were told that patient engagement groups had not restarted following the pandemic, but the trust did have some experts by experience they could draw on if required. They told us patients had not been directly involved in the design or reviews of policies or pathways, but that complaints and incident feedback would have been considered.

Staff and leaders worked in partnership with key organisations to support care provision, service development and joined up care. Leaders attended system meetings to promote patient flow.

Staff and leaders across the division expressed a strong culture of learning, with a shared commitment to improving services for patients and their families.

Staff described clear processes in place to support learning from incidents, complaints, and even compliments, which were acknowledged by the director of nursing and shared with the relevant team or individual.

Staff demonstrated awareness of ongoing improvements and innovations. Examples of recent initiatives included printing handover sheets on light blue paper to make them more identifiable.

Quality improvement efforts were evident in nutrition and hydration practices on the wards. For example, new nutrition boards displayed essential service user nutrition information for staff, ensuring dietary needs were clearly visible and easily accessible. Additionally, we saw volunteers assisting patients with meals, a program initially trialled with ward dining champions. This initiative was successfully adopted to allow ward staff to do other duties while ensuring patients received dedicated support at mealtimes.

The division had established plans to drive learning, improvement, and innovation aimed at enhancing service delivery. The trust had plans to use the Patient Safety Incident Response Framework, to focus on priority areas such as managing deteriorating patients and nutrition and hydration.

The trust also engaged in the “Days Kept Away from Home” initiative, aimed at ensuring 90% of over 65-year-olds were discharged to their usual residence. Since its implementation in July 2024 the division had seen an improvement in the number of elderly patients who returned home in a timely manner.

In July 2024, 1000 staff members were trained in a quality improvement fundamental course (level 1), and 26 staff began a project lead course.

The AMU initiated a sustainability project to reduce waste, decrease the carbon footprint, and lower costs. The division had been involved in a trial between May 2023 and September 2023 which looked at the impact of visual bay tagging for patients likely to fall. Harm falls had increased within the hospital, and it was identified there had been an increase in falls with patients who lack capacity to maintain their safety. The trial found patients were not always readily identifiable by teams working in the bays and as such red tubing was applied to patient’s beds to give an immediate visual aid to identify EPO patients. Data from T4 showed a direct impact on the number of falls, whilst on F9 the introduction of red tubes was positive in terms of falls for the first 2 weeks, but the process was not sustained. Learning from T4 had been shared with other wards.

Overall, the division demonstrated a commitment to continuous improvement, though some challenges remained in achieving intended outcomes.