Royal Oldham Hospital

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We assessed 5 quality statements and their ratings were combined with previous scores for quality statements not reviewed during this assessment.

The service did not always ensure that outcomes were positive and consistent. Action plans to drive improvement from local and national audits were not always completed to a good standard.

The division undertook audits as part of the trust’s inpatient assessment and accreditation system. However, reassessments across the wards were still not carried out in a timely manner.

Most of the policies we reviewed were comprehensive, in date and in line with national guidance.

Staff were involved in the assessment of patient’s needs and provided support where needed. There had been recruitment to key roles within the nutrition team which staff said had improved patient outcomes.

At our last assessment we rated this key question requires improvement. At this assessment the rating remained the same.

This service scored 54 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Most patients told us that their needs had been assessed appropriately and felt involved in the assessments undertaken.

Staff were involved in the assessment of patient’s needs and provided support where needed. We reviewed 10 patient records and found good compliance with the completion of risk assessments and care plans updated. This included risk assessments for falls, IPC, cognitive impairment, bowel care, oral care and pressure care.

The trust provided patient record audit data but did not supply audit evidence relating to risk assessments or timeliness. As a result, we were unable to report on the effectiveness and consistency of risk assessments or the promptness of care delivery.

Managers assessed and tracked the needs of patients awaiting bed allocation through daily executive safety huddles. For example, they highlighted the top 5 longest waiting patients, what their care needs were and what medical speciality they needed. They also discussed any other patients that needed to be escalated for support.

We reviewed 10 patient records and found good compliance with completing fluid balance charts. However, audit data from January to July 2025 showed that oversight and performance varied across the medical wards. For example, F10, F7 and GMU had the highest compliance against a target of 80%. In comparison, data for T4 showed that the target was met for only 3 out of the 7 months but this had improved to 94% in July 2025. AMU had 4 months of data collection and had not met the target for any months and scores ranged from 37% to 58%. Due to staff sickness on F11, fluid balance audits were only available for 2 months and there was no data provided for ward F9.

We reviewed data from matron quality audits for G2 (gastroenterology) from September 2024 to June 2025. Food chart audits showed that the 90% compliance target was achieved only once during this time period. However, performance had improved from 45% in February 2025 to 82% in June 2025.

Audit data for pain relief on G2 showed compliance between February and April 2025 averaged 95% which met the 80% target and as of June 2025 compliance was close to the target (79%). The frequency of pain audits and performance also varied across the medical wards. For example, between January and June 2025 F9 provided no audit data, F8 had 2 months of audit data with a compliance score of 50%. Ward T4 had not met the target for any months and scores ranged from 53% in March 2025 and 61% in June. However other wards showed good compliance over 4 or 5 months; F11, F10, F7, GMU and had all met the trust target.

The trust had policies and procedures in place to support patients with eating disorders which referenced national guidelines and best practice. There was a consultant allocated to patients who had eating disorders to provide wrap around support. The overall compliance rate for staff trained in supporting patients with eating disorders for the division was 90%.

Wards had protected mealtimes, which allowed nurses, HCA’s and sometimes volunteers to be available to support patients.

Staff told us they followed policies and guidelines to deliver care. Staff showed us how they could access policies on the trust’s policy hub via the intranet.

Staff explained any changes to practice or policies were discussed regularly in team huddles and the practice-based educators would implement training when required. Staff were able to provide recent examples of guidance/practices being updated.

The endoscopy service was not awarded Joint Advisory Group on Gastrointestinal Endoscopy (JAG) accreditation when it was assessed in September 2023. At our last assessment, some key actions were still outstanding. However, progress with actions had now been made. For example, 3 key leadership roles had been filled between January and June 2025 including the clinical endoscopy lead. Leaders told us that they were working towards reaccreditation based on the new JAG standards being launched in October 2025.

People requiring non-invasive ventilation (NIV) were only admitted to the acute medical unit (AMU) and the respiratory wards (F9 and F10). Staffing levels on these wards were adjusted in order to facilitate a 1:2 nurse to service user ratio, in line with British Thoracic Society (BTS) guidelines.

Whilst the medical care services did not have a stand-alone dedicated unit for non-invasive ventilation (NIV), a business case had been developed to combine wards F9 and F10 into a combined acute respiratory unit and increase nurse staffing levels.

We saw evidence to show the nursing staff involved in NIV had documented training and maintained competencies relevant to their roles. Staff could also seek advice and support from the critical care outreach team if needed.

Newly published or updated NICE guidance was reviewed clinically for relevance to each area/speciality and baseline assessments completed where appropriate. This meant that gaps could be identified and associated action plans developed. We saw examples of baseline assessments and action plans that had been undertaken.

However, across the division, baseline assessments were not always timely. At the time of our assessment, there were 9 guidelines identified and 7 had been rag rated red indicating they were past their due date for assessment. Leaders told us that more complex assessments requiring cross divisional and organisational input can experience delays to fully complete. These were highlighted to the divisional team, reported through the monthly status report and supported by the NICE guidance compliance facilitator to completion.

Most of the policies we reviewed were comprehensive, in date and in line with national guidance. Pathways and guidelines reviewed were also found to be in line with national guidance.

Staff protected the rights of patients subject to the Mental Health Act and followed the Code of Practice. At handover meetings, staff routinely referred to the psychological and emotional needs of patients, their relatives and carers.

Patients generally felt staff and that staff teams worked well together.

We observed nursing handovers where staff demonstrated good patient knowledge and team working. The handovers used both verbal and written communications and a safety briefing for the whole team highlighting patient risks and what control measures were in place.

Staff held regular and effective multidisciplinary meetings to discuss patients and improve their care. This included daily huddles to review deteriorating patients and identify patients who were medically fit for discharge. Huddles included nursing, medical, pharmacy and discharge staff.

Staff worked well together on discharge planning. The transfer of care team attended the ward each morning to identify those patients where they could start planning their discharge. At ward level, discharges were monitored through huddles and board rounds.

At our previous assessment there had been an under representation of nutrition and dietetics on the wards. However, there was now a nutrition nurse and a trainee advanced clinical practitioner (TACP) dietician within the nutrition team. Staff told us that this had made a big improvement to patient care. For example, staff felt that nasogastric tube placement had improved and reduced reliance on medical staff.

Partners and stakeholders told us that the integrated discharge team worked effectively to support patients with safe and timely discharges. The team included transfer of care nurses and social workers who linked in with housing support. Despite challenges posed by the trust’s IT systems, they observed effective multidisciplinary teamwork.

Staff at all levels said there was a positive culture and teamwork between nursing staff, HCA’s, AHP’s and medical staff. Nursing staff told us they worked well with the pharmacy technician who supported the wards with medication administration.

The division had access to alcohol services and physiotherapy services 7 days a week. Speech and language therapy and tissue viability nurses were available 5 days a week.

Staff referred patients for mental health assessments with the mental health liaison service when they showed signs of mental ill health. There was information on the medical wards with information on how to refer patients to this team.

We did not look at this quality statement during this assessment. The score for this quality statement is based on the previous rating.

Managers told us the division took part in national and local audits and that outcome data was formally reviewed and action plans developed to improve indicators which did not meet expected national outcomes.

The division participated in relevant national audits. Trust data from 2023 to 2024 for 10 national audits showed that performance was mixed. We observed that 6 out of 10 audits had more metrics meeting national standards than not. These included the national audit of cardiac rehabilitation (NACR), the myocardial ischaemia national audit (MINAP), national audit of dementia, the national adult asthma audit and the national pulmonary rehabilitation audit.

Outcomes for patients with diabetes varied significantly depending on whether they were diagnosed with type 1 or type 2 diabetes. Data from the national diabetes core audit (NDA) showed that for type 1 diabetes, all 11 metrics met national targets. However, for type 2 diabetes, only 1 out of 11 metrics met national targets. The associated action plan attributed the decline in positive outcomes for type 2 diabetes to an increase in referrals and lack of capacity within the team. The action plan included a quality improvement project that was ongoing to look at service provision and where to prioritise care and improve efficiency.

The trust provided evidence of action plans to drive improvement for most of the national audits. However, they were not always fully completed or effective. For example, the NDA action plan to drive outcomes for type 2 diabetes had sections that were blank such as the date, the review date and when it had been approved and by whom.

We observed audit metrics that were below national targets with existing action plans in place from the previous year. However, there was a lack of improvement in performance. For example, there were 4 out of 7 metrics that did not meet national targets for the chronic obstructive pulmonary disease (COPD) audit. The lowest scores had not improved when compared to the previous year. Data from the national heart failure audit (NHFA) showed 12 out of 15 metrics had not met national targets.

Data showed that for patients with asthma, the metric ‘respiratory review within 24 hours of arrival at hospital’ had an existing action plan. Performance had not improved from the previous year and remained at 10%.

Trust data from the national diabetes inpatient safety audit (NDISA) showed that 12 out of 25 metrics had not met national targets and there was no evidence provided of an action plan. Leaders confirmed in the divisional operations and quality assurance meeting (April 2025) that this action plan was outstanding.

As the audit data related to the period from 2023 to 2024, we requested more current information from audit leads regarding progress and improvements across nine national audits. Progress was reported across several national audit metrics, supported by increased recruitment, training completion, newly implemented strategies, and job plan reviews.

The division completed various local audits including quality of discharge summaries on AMU.Although the audit was completed in July 2024, the final report and recommendations were not issued until January 2025, resulting in delays to shared learning and the implementation of improvements. The action plan was not comprehensive and clear. The progress on actions and review dates were blank which meant it was unclear if actions had been completed by their target dates. An area that scored 100% was listed as an area of concern requiring recommendations.

Other local audits showed limited assurance that patients had good outcomes based on national guidance. For example, an audit that evaluated whether follow-up chest x-rays were performed on adults diagnosed with community acquired pneumonia (CAP) radiologically. Results showed that all 3 standards audited had not met the target of >95%. Scores for the 3 standards ranged from 41% - 48%. For example, only 45 out of 100 patients (45%) fulfilled the national guidelines for undergoing follow-up chest imaging with in the 6-week timeframe. This meant that potential lung cancer diagnosis could be delayed. It was unclear from the action plan if the actions had been completed by target date of October 2024.

Some local audits demonstrated more positive outcomes and had effective action plans. For example, an audit to review the diagnostic imaging technique to assess for pulmonary embolism (PE) showed high compliance with 2 out of 4 metrics. The audit had taken place between July and October 2024 and the action plan showed timely actions were on track by December 2024.

However, most action plans we looked at from local audits were not completed to a good standard. For example, one action plan had actions with no responsible person recorded and others had blank approval dates, review dates and no progress information against the actions.

The division undertook audits as part of the trust’s inpatient assessment and accreditation system. The audits measured the quality of nursing care delivered by individuals and teams across 13 standards. Areas included patient safety, infection control, safeguarding, person centred care and several other key care standards.

We looked at the assessments and scoring across 9 medical wards and found that 3 had been rated red, 3 were amber and 3 were green. All assessments had associated actions plans in place but they varied in quality and timeliness of actions.

Some wards had action plans with clearly defined target dates, which were regularly updated to reflect progress and marked as completed in a timely manner. However, AMU was rated red and had set target dates for actions that were 7 months after the action plan start date. This had since been reviewed by leaders who said the action dates would be brought forward. Ward T4 was rated red and had a 2 month delay before starting the action plan. F11 was rated green had some red and amber metrics that had gone 10 months past the planned target date and still recorded as in progress. G2 rated amber in June 2024 had some actions with no set achievement dates and were recorded as in progress with no updated information.

All patients we spoke to told us they had consented to being an inpatient and to any treatment they had. They told us their treatment plan had been explained to them in a way they could understand so they could make informed decisions about whether to proceed with treatment.

The trust completed an annual audit for patients with ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) documentation in place. We reviewed data taken from 100 cases in 2024 that were audited for the Oldham Care Organisation. Data showed a decline in performance from 2024 compared to the previous year. Audit data showed that out of 19 metrics only 3 met the trust target of >95%, 4 metrics had increased compliance but 14 metrics had decreased from 2023. Standards with the highest scores included ‘the reason for DNACPR decision being recorded’ (98%). The standard with the lowest score was ‘not evidencing the discussion and with a clear explanation’ (57%). There was a trust wide associated action plan to drive improvement and scheduled for review in December 2025.

The service had a DNACPR policy in place that was comprehensive and in date.

We reviewed 10 medical records and noted that 6 records had DNACPRs. Most forms had been completed correctly. However, we observed one form that had no evidence that staff had spoken with the patient or next of kin. This was escalated to staff at the time. Another form had not been updated as per policy. Nursing staff told us they normally check the DNACPR date to ensure it is current/valid.

The trust completed an audit which measured how compliant staff were with the Mental Capacity Act 2005 (MCA). The audit was undertaken across a selection of medical and surgical wards for participating care organisations. We reviewed audit data for the Oldham Care Organisation that showed that between April and December 2024, compliance met the trust target of 85%. However, between January and March 2025, this had decreased to 50%. During our previous assessment in October 2024 there was already an action plan in place to address shortfalls in compliance. Managers had reviewed the previously developed action plan and identified ongoing learning needs. The trust had organised additional training sessions from January to October 2025.

Staff received training in the MCA and Deprivation of Liberty Safeguards (DoLs). This was included in the safeguarding training. Compliance rates are reported under the safeguarding quality statement.

Staff explained how to access the relevant paperwork online for DoLS. They were aware of the policy and how they would get advice on the MCA and DoLS.

Additional consent training sessions were made available every three months from January to October 2025, providing regular opportunities for staff to refresh and enhance their knowledge.

We reviewed 10 medical records and found that 7 patients who required capacity assessments had them completed and that these had been updated appropriately. For patients who had lacked capacity to consent, records showed that all patients had best interest meetings place. For example, for an MRI scan and for the use of bed rails. However, we observed an occasion when a patient had a nasogastric tube insertion and the best interest meeting had not referenced this.

All DoLS applications (6) had been completed accurately and were up to date. Staff told us they maintained a log of when DoLS are due for review (7 days) and were updated before they expire.