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 assessed 8 quality statements.

Staff did not consistently follow policy for the My Next Patient (MNP) process or complete patient safety checklists prior to transferring MNP patients to temporary escalation spaces. We found that some MNP patients had been transferred when they were not suitable and did not meet the inclusion criteria.

Although nursing staff met mandatory training targets, medical staff did not always keep up to date with mandatory training and role-specific training.

We saw patients on some medical wards did not always receive the 1:1 care they required due to a shortage of staff.

However, staff reported serious incidents clearly and in line with trust policy. Systems were in place to ensure staff were made aware of incidents and any subsequent learning.

We observed staff actively encouraging good IPC practices among colleagues and visitors. All medical wards had health and safety and fire risk assessments in place and were in date.

Although there were still significant vacancies for health care assistants (HCA’s), medical and nursing staffing levels had improved.

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

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff we spoke with could tell us about the process for reporting incidents and felt confident to raise concerns and report incidents. They told us they received feedback and learning relevant to their area of work. Staff were able to provide examples of incidents which had occurred recently on their ward and what actions had been taken.

Staff and leaders understood the duty of candour (DoC) process. The DoC is the legal obligation for healthcare services and professionals to be open and honest with patients about any incidents that affect their care and treatment. Staff gave examples of when they had apologised to patients and families when an incident had occurred leading to unintended harm.

We reviewed DoC compliance data from June 2024 to June 2025 for 38 safety incidents. The data showed that appropriate processes had been followed, for example initial verbal contact and follow up letters had dates recorded. However, this was not always timely and in line with trust guidance. The trust DoC guidance stated that following a safety incident, patients should receive a verbal explanation and apology within 10 days of the incident being identified. Some of the incidents for inpatient falls showed that initial verbal contact ranged from 1 working day to 32 working days.

Systems were in place to ensure staff were made aware of incidents and any subsequent learning. Staff told us they attended daily safety huddles and received patient safety alerts. We observed safety huddle notes from July 2025 across the medical wards. Safety huddles took place twice a day so that staff on different shifts could attend. The safety huddle notes showed that recent incidents and themes were discussed. The huddles were also used to allocate staff to specific areas during an emergency such as lead roles for defibrillation, airways and IV fluids.

From January to June 2025, there had been 1565 incidents reported in relation to medical care. The most frequent type being falls (11%) staffing related issues (10%), medicines related (9%), transfers (7%) and infection prevention and control (6%).

The division regularly reviewed and investigated incident data in line with good practice and Patient Safety Incident Response Framework (PSIRF) guidance. The trust had a comprehensive patient safety incident response policy in place. The process for reporting and triaging incidents included targets, for example incidents should be reported and triaged within 24 hours. The divisional governance team participated in daily meetings to triage incidents and determine the required level of investigation. For example, immediate learning review (ILR), patient safety review (PSR) or a full patient safety incident investigation (PSII).

We observed recent PSII reports that had been completed by an appropriate lead investigating officer (assistant director of nursing), learning response lead and supported by the divisional governance team. The PSII reports showed family concerns were collected and included in the investigation process. DoC had been completed by the divisional clinical director with the patient’s families. We observed associated action plans that had been updated to show progress against each action and patient care alerts shared with staff to aid learning across the trust.

However, the division had a backlog of overdue incidents. Leaders told us that overdue incidents had been reviewed through the daily triage process but had not been fully investigated. We reviewed May and June 2025 data from divisional operations and quality assurance meeting minutes. The trust’s target was to investigate and close incidents within 14 calendar days, unless a full investigation was required. Data for the division showed that across 8 medical wards there was a total of 46 incidents that were overdue in June 2025. This had increased from 37 incidents in the previous month.

The timeframe for completion of PSR’s was 45 working days. While meeting minutes for June did not include a breakdown of overdue PSRs, data from May 2025 indicated that general and specialist medicine had 15 open PSRs -11 of which were overdue and 4 within the expected timeframe. This meant learning and implementing improvements from the incidents was delayed.

Overdue incidents and their progress were monitored weekly by the division team, and discussed at the weekly incidents, complaints, coroner, action meeting (WICCAM) and safety summit with the divisional and executive team.

Actions to address the backlog included protected time for the governance team to focus on the incidents and to enable more local investigations to reduce ILR’s and PSR’s. Specialty-level meetings were held with nursing, medical, and operations teams from each area to review and monitor the progress of actions being implemented.

The medical division had reported 1 never event between July 2024 and July 2025. Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. We saw that a patient care alert and action plan had been developed promptly following the never event. The alert shared the immediate learning and recommendations with staff across the trust and immediate actions had been taken to reduce the risk of recurrence.

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

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

Staff reported incidents related to the use of temporary escalation spaces which has been reported under safe systems, pathways and transitions.

At the time of our previous assessment in October 2024, the trust used a process called Continuous Flow Model (CFM) to support flow through the hospital and balance the risks of crowding in the emergency department (ED). The process of CFM involved the transfer of patients from the ED to temporary escalation spaces (TES) on medical wards. A temporary escalation space is when a temporary additional bed, or chair, is placed in a dedicated space until a bed becomes available. However, our previous assessment found that CFM was not managed well, and was not always applied to the most appropriate patients to ensure that the process was safe. Following our last assessment, in response to our concerns, the trust paused the use of CFM to make improvements to the safety, quality and governance of the process.

The trust relaunched the use of TES spaces within the medical division in April 2025 with a new process called My Next Patient (MNP). The process was piloted at Royal Oldham Hospital and, at the time of our assessment, MNP was only being used to transfer patents from the emergency department (ED) to the acute medical unit (AMU). The temporary escalation area in AMU was still located in the reception area however environmental changes, such as the addition of curtains, had been made to improve the privacy and dignity of patients using the spaces. The area had capacity for 3 beds/chairs.

The intended maximum duration for MNP patients to stay in a TES was 6 hours. Staff maintained a paper-based logbook to record what time patients arrived in and left MNP TES spaces so that they could incident report any stays that exceeded the threshold. This process was intended to support oversight of patient flow and monitor adherence to escalation protocols. However, we saw the number of patients who remained in a MNP TES space over 6 hours had increased since MNP was launched.

Data provided by the trust showed that in June 2025 there had been 49 occasions when MNP patients had been placed in a TES. Time spent in the space ranged from 25 minutes to 21 hours. The length of stay had increased since April (maximum 11 hours) and May (maximum 12 hours). According to the trust’s MNP policy, patients should have a risk assessment when they are moved to a TES. Data for June 2025 showed that 89% of patients had a risk assessment completed and this had increased from April (88%) and May (78%).

While previously the CFM process operated every day, the MNP process for using temporary escalation spaces was triggered when the trust reached operational pressures escalation Level 3 (OPEL). Leaders told us this was determined by operational pressures such as the number of patients on ED corridors, ambulance offload delays and other estate pressures. The MNP process had not been triggered on the days we inspected.

There was a MNP policy in place that explained the process including staff roles and responsibilities. The number of MNP patients transferred to a TES on AMU was limited to one at a time. There was also a staffing escalation process. This meant ward staff could contact their responsible lead and inform them that their ward was unable to accommodate an MNP patient due to staffing levels. Staff on AMU gave examples of when they had followed this process.

However, we found that staff did not always follow the MNP policy and associated checklists. We reviewed MNP records for April to June 2025. We observed the patient safety checklists had been used in most cases where an MNP had been transferred to a TES, however we found occasions when the checklists had not been completed, and in 2 of those cases the patients were not suitable and should have been excluded based on the MNP exclusion criteria outlined in the MNP policy.

In addition, following a review of incident data from April to July 2025 we identified examples of MNP patients whose infection status and drop in oxygen levels had not been communicated from ED staff to AMU staff prior to transfer to the AMU temporary escalation area. These patients were subsequently not suitable following the transfer. Another incident involved staff raising concerns with ED staff about the suitability of a patient with cognitive impairment for MNP. The patient had been transferred to the temporary escalation area without a handover.

However, the incident data did demonstrate areas of good practice in terms of reporting incidents related to MNP. Between April and July 2025, staff had reported 75 incidents, the data showed all incidents had been confirmed as no harm, staff had worked well to mitigate risks and manage delays over 6 hours. Staff stated they had reported incidents to aid awareness of the use of MNP. Incidents also showed instances where MNP patients had been fully informed about the process and had been risk assessed.

Staff on AMU told us that the MNP model was better than the previous CFM process because it was more planned, less reactive and more patient focused. They said that assessments of the area, patient acuity and staffing capacity were considered prior to transferring patients. Staff we spoke with told us they had received training on the new MNP process by practice-based educators and were aware of the criteria for patient suitability. Staff reported having more control about decisions to receive patients into the AMU temporary escalation area and could refuse if they felt the patient wasn’t appropriate.

However, feedback about staffing capacity was mixed. Some staff gave examples of when MNP patients had not been accepted into the AMU temporary escalation space due to staffing capacity. However, staff reported instances during night shifts where MNP patient transfers proceeded despite concerns raised regarding the lack of additional staffing.

Some staff felt that the exclusion criteria did not consider patients with mobility issues. For example, a patient with low mobility would need additional hygiene and toileting support which was not considered as part of the MNP process. Staff had transferred patients to an accessible bathroom to provide personal care which they felt still impacted on privacy and dignity. Staff had raised this issue with ED staff, but it had not yet been formally included in the assessment criteria.

We spoke with 5 patients who had been transferred from ED into a temporary escalation space on AMU as part of the MNP model. They had not received a letter which explained the process as per the MNP policy, however staff had given them a verbal explanation. Most patients told us that they had been in the temporary escalation space for less than 6 hours and spoke positively about that part of their care journey. Another patient said that communication from staff had been good on AMU but was less effective when they had moved to different medical wards.

The revised MNP approach placed greater emphasis on risk management. There were now environmental risk assessments in place for temporary escalation spaces across the relevant medical wards. We saw that all medical wards with potential temporary escalation spaces had fire risk assessments completed and most of the spaces did not obstruct fire doors. However, we asked staff on F10 to show us their potential temporary escalation space and we felt that it could impact access and flow through the fire door. We escalated this to management at the time. Leaders informed us that fire risk assessments both prior to and following our assessment showed the area did not impact access and flow.

We observed the risk assessment for AMU and it noted that one additional nurse would be required to accommodate additional patients. The assessment covered IPC, fire safety, health and safety and privacy and dignity. All areas were compliant with required standards and had been signed off by the respective leads.

ED staff were responsible for completing patient safety risk assessments before transferring patients to temporary escalation areas on a medical ward. This process was supported by using clinical exclusion criteria and a psychological suitability checklist. The checklist stated patients with IPC concerns requiring isolation, oxygen requirements, or cognitive impairments would be unsuitable for transfer to a temporary escalation space. Patients who were end of life or had a learning disability were also excluded.

The division had standards and policies in place for when critically ill patients required a transfer to another department within the hospital or to another NHS hospital. The policies were comprehensive, in date and in line with national guidance.

Patients of unplanned admissions were initially reviewed by the admitting consultant or acute medical consultant, with appropriate specialty input. There were daily consultant-led ward rounds on the AMU and updates were discussed at multidisciplinary team (MDT) board rounds. Ward bed requests were coordinated by the clinical site team. Specialty in-reach services included cardiology, gastroenterology, respiratory, and acute frailty. Patients with complex needs or extended length of stay were prioritised for transfer to specialty wards, such as G2 (gastroenterology), based on clinical urgency. Transfers from AMU to specialty wards were carried out in line with the patient transfer policy and bed availability.

Prior to this assessment we had received concerns about patients being discharged to care homes in unsuitable clothing and without medication. In response, improvements had been made in this area and the number of incident’s had now decreased.

The trust had safeguarding policies in place for adults and children to help staff recognise and report abuse and neglect. These were available on the trust intranet.

Staff knew how to identify adults and children at risk of, or suffering, significant harm and worked with other agencies to protect them. We observed safeguarding incidents that had been reported between January and June 2025. Data showed that staff had identified different types of abuse including physical and financial abuse and had taken appropriate action to safeguard patients.

Staff knew how to make a safeguarding referral and that they could contact the safeguarding team via the intranet to raise concerns. The medical division had a safeguarding lead who was an assistant director of nursing.

Patients who had a safeguarding referral submitted were identified using a discreet symbol on patient information boards.

We observed safeguarding information displayed throughout the medical wards with contact details.

However, the trust’s internal audits demonstrated that safeguarding processes were not always followed as expected. The division carried out inpatient assessment and accreditation system audits for each of the medical wards. The audits were scored as red, amber or green and corresponded to a compliance score. At the time of our assessment, the scores for the safeguarding element had declined from the previous year. Data showed that 44% (4) of wards were scored red, 44% (4) amber and 11% (1) green. This showed a decline in performance compared to July 2024, when 25% of wards had achieved a green rating for safeguarding. We observed that all assessments had an associated action plan in place to drive improvement, and they all included the safeguarding metric.

The mandatory training policy outlined the specific level and frequency of safeguarding training that staff needed to undertake in line with national guidance.

Nursing and medical staff received mandatory safeguarding training specific for their role. Trust data showed nursing staff had met the 90% compliance target for safeguarding training. Safeguarding adults level one and two compliance was 97%, and level three was 96%. Compliance for safeguarding children level one and two was 94%, and level three was 90%.

However, for medical staff compliance varied across the specialities and fell below the trust target of 90%. Trust training data showed that for medical staff, safeguarding adult’s levels one compliance was 88%, level two was 88% and level three was 87%. Compliance for safeguarding children level one was 86%, level two was 85%, and level three was 80%.

The division had recorded child and adult safeguarding on the risk register due to inconsistent support from the safeguarding team and difficulties monitoring training compliance. There were actions to mitigate risk and a review date of August 2025.

The Mental Capacity Act (MCA), Deprivation of Liberty Safeguards (DoLS) and female genital mutilation training were embedded in to safeguarding level 3 training. Staff we spoke with showed a good understanding of the MCA and DoLS.

We asked for feedback from partners and stakeholders who told us that named nurses for safeguarding adults and children from the trust attended system level meetings such as the quality, safety and safeguarding group (QSSG). Other staff included the Oldham Care Organisation director of nursing and associate director of governance. They told us that this promoted joint working between health and social care bodies within the local area. They said this also meant that outcomes and achievements were understood at a system level and supported the system to learn and develop.

The division had regular audits completed by the head of patient experience. Recent audits between October 2024 and July 2025 included patient feedback about how involved they were in the decisions about their care. Audit results showed that 8 out of 9 medical wards had been rated green which indicated all the requirements had been met for this metric. Feedback included “I felt very involved all the time” and “I was fully involved, staff have taken time with me”.

We looked at patient feedback data across 10 medical wards between 1 July 2024 and 30 June 2025. The data included responses from 1427 patients. The average score for the medical wards was that 63% of patients strongly agreed and 30% agreed that they felt involved in decisions about their care.

Upon admission to wards, staff carried out risk assessments to identify patients at risks. Patients at high risk were placed on care pathways and care plans were put in place to ensure they received the right level of care. The risk assessments included falls, pressure ulcers, venous thromboembolism (VTE), and nutrition. We reviewed 10 patient care records and observed that relevant risk assessments for these areas had been completed electronically and had been updated.

Staff completed fluid balance charts and food charts to document a patient's fluid and food input and output within a 24-hour period. This information was used to inform clinical decisions. We reviewed 10 patient records and found that fluid balance charts had been fully completed and were up to date. Daily hydration risk assessments had also been completed well.

We observed patient boards on medical wards that held information about individual patients and risks. The boards featured a folding cover to protect patient identity and maintain confidentiality. However, we observed that the board was not always updated timely, and staff used a more up to date duplicate paper copy for each patient. For example, one patient’s dietary requirements had changed to a normal diet on the paper copy but soft diet was still recorded on the patient board.

Staff told us that if a patient had mental health issues they would complete a risk assessment and care plan. They could describe the escalation process and how to access support from the mental health liaison team and specialist mental health support services when required.

The service had a comprehensive sepsis policy that was in date. Staff understood the importance of recognising the signs of sepsis early and knew how to escalate this. Nursing staff demonstrated good compliance with sepsis training (90%), which met the trust target of 90%. However, medical staff compliance was 79%.

Staff utilised the National Early Warning Score (NEWS2) tool to identify deteriorating patients. This was a basic set of observations such as respiratory rate, temperature, blood pressure and pain score used to alert staff to any changes in a patient’s condition. This was supported by an electronic patient tracker system which flagged when observations were due. For example, red indicated that observations were overdue, while amber signalled that they were approaching. The system identified high NEWS2 scores and promptly escalated the concern to medical staff and the critical care outreach team. A coordinator monitored the board to maintain oversight of observations. We observed some amber flags on the screen.

Although the medical records we reviewed demonstrated good compliance with recording NEWS2 observations, audit data revealed inconsistent performance across the medical wards. We reviewed audits undertaken by the quality lead nurse across 9 medical wards between October 2024 to June 2025. Data from the NEWS2 audit showed that average scores over this time period ranged from 71% (F7) and 94% (F10). The target was 90% and only 3 out of the 9 wards had met this standard. Overall compliance for the medical wards was 85%. We observed associated action plans in place to drive improvement.

We observed sepsis information on boards to aid education and awareness. There was a sepsis practitioner and sepsis and deterioration champions available to support patients who needed to be escalated for review.

We requested sepsis audit results for medical wards. The service provided sepsis audit data for one medical ward (F10) and data from a trust wide sepsis compliance review. The audit for F10 was dated January 2025 and took place over a 12 week period. Overall, results were positive and showed staff had mostly followed processes and care pathways for sepsis recognition and management. Of the 30 patients reviewed, all patients had been screened for sepsis as required and all patients had been escalated for review appropriately depending on NEWS scores. All patients received antibiotics where clinically indicated, and a plan of care was in place by medical staff for all patients within the audit.

However, 30% of patients audited did not have blood cultures taken and 25% of patients did not have sepsis screening flags saved on the digital patient safety alert system. There were associated actions and recommendations following the audit to support ongoing improvements.

We have not reported on the trust wide sepsis compliance review because it was not specific to the medical division and the sample size was small (10 patients). As the service did not share sepsis audit data for the other medical wards it meant we could not compare compliance. It was unclear how the service was assured that staff across the division were compliant with sepsis policies and processes.

Most patients and relatives we spoke with explained they were pleased with the environment and how it met their needs. We looked at patient feedback data across 10 medical wards between 1 July 2024 and 30 June 2025. The data included responses from 1427 patients. The average score for the medical wards was that 92% of patients either strongly agreed or agreed that 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.

At our previous assessment we found that some medical wards had fire risk assessments that were out of date and fire doors had been obstructed. At this assessment we found improvements. All medical wards had health and safety and fire risk assessments in place and were in date.

Staff told us that they had completed competency training for using standard and specialist equipment. For example, on ward F9 (respiratory) we saw evidence of competencies for airways management equipment, urine analysis equipment, blood pressure machines, tracheostomy and chest drains.

Medical wards were made up of a mix of side rooms and same sex bays. Staff were aware of the need to report breaches of the standards for mixed sex accommodation.

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.

All medical wards we visited had sufficient shower and bathroom facilities. Toilets were clearly identified for different genders. The ward areas were free from clutter, and we saw that equipment and consumable items were stored appropriately. Stock rotation was generally good across the medical wards. However, we observed some gaps in stock rotation on AMU. For example, we found a breathing mask filter past the use by date (August 2022) and a valved disposable mask with a use by date from 2023. These items were given to staff and removed.

We observed a tracheostomy trolley on AMU that had swabs and equipment past its service date. These items were also handed to staff and removed. Staff told us the tracheostomy trolley had not been used for several years and was no longer in use.

We checked equipment across the medical wards and found that they had been serviced appropriately with stickers to show the date they had been serviced and due dates.

Medical wards had resuscitation equipment readily available. There were systems in place to ensure it was checked and ready for use. Records indicated that daily and monthly checks of the equipment had taken place on the wards we visited.

We observed that oxygen cylinders were in date and stored securely.

Staff disposed of clinical waste safely and appropriately. Dirty utility areas were organised and clear from clutter. Sharps bins that were situated in these areas were dated correctly and were not overfilled.

We observed data from July 2025 for equipment across 9 medical wards. The average compliance with safety checks was 95%.

Training

Staff received mandatory training and required learning on a rolling programme in areas such as infection control, sepsis, information governance, learning disability and autism training. Practice educators and managers monitored staff training, however levels of compliance varied across different staff groups and medical specialties.

Some staff told us that there had been a decrease in face to face training due to unavailability of course such as moving and handling and immediate life support (ILS) training. We reviewed the mandatory training compliance rates for nursing staff and found that most training modules had met the trust training target of 90%. Across nine of the ten medical wards, nursing staff compliance rates met or exceeded the trust’s target, with individual ward performance ranging from 87% to 100%. Although compliance rates for adult basic life support (BLS) training was 91%, adult ILS training was 81%.

We reviewed trust training data that showed the required nursing and medical staff had completed training specific to their medical specialties. For example, cardiology, chemotherapy and tracheostomy training.

However, we reviewed the learning needs analysis for nursing staff across 8 medical wards and saw that compliance with competency training was mixed. Some modules showed good compliance, for example sepsis training compliance was 90% and other modules that were close to or exceeded the trust target included falls awareness, blood transfusion competency and nasogastric feeding tube insertion.

However, modules such as diabetes training and end-of-life care were mainly below the trust’s target. Compliance for end-of-life care training on some wards varied between 3% and 19% whilst others were between 76% and 98%. Clinical skills training was delivered across the medical wards, including blood culture and cannulation. Trust data showed that on average only 1 out of 12 clinical skills modules had met the compliance trust target of 90%. Some ward specific training for nursing staff such as male catheterisation, cannulation and ECG on ward G2 (gastroenterology ward) had compliance rates below 30%. This was an area of focus by the practice educators to improve compliance in this area.

Medical staff did not always keep up to date with mandatory training and role-specific training. We reviewed the mandatory training compliance rates for medical staff and found that most training modules had not met the trust training target of 90%. Across the medical specialities, the average number of training modules was 31, of which 12 modules on average met the compliance target. Overall compliance rates for medical staff varied across the specialities and ranged from 69% to 98%.

Compliance with life support training was below the trust target for medical staff. Average compliance rates across the specialities were 68% for adult BLS, 71% for adult ILS training and 61% for advanced life support training. Other modules included sepsis training (79%) and nasogastric feeding tube insertion practical (80%).

Medical staff were given study days to focus on continuing professional development. For example, away days, conferences and training courses specific to their medical speciality

Staffing levels

Although there were still significant vacancies for health care assistants (HCAs) since our previous assessment, medical and nursing staffing levels had improved. Managers used a safe staffing tool and professional judgment framework to review and determine the number and grade of nurses and HCAs required for the wards. This was in line with national guidance and best practice. Staffing meetings took place twice a day with an additional trust wide staffing call. The trust had relevant staffing policies which included the escalation framework for periods when the division is under increased internal pressure.

However, staffing levels did not always meet the required establishment, or provide flexibility to meet the specific needs of patients. We saw patients on some medical wards did not always receive the 1:1 care they required due to a shortage of staff. We reviewed trust data from January 2025 to June 2025 for 139 incidents related to staffing shortfalls across 9 medical wards. The highest reporting wards for staffing issues were AMU (29%) and respiratory wards F9 (29%) and F10 (22%).

The most common incident themes related to staffing across the medical wards were staffing levels (51%) and movement of staff (24%). Incidents related to lack of staff to support 1:1 supervision was lower (12%) and mostly reported by ward F9.

Nursing staff and health care assistants (HCAs)

We reviewed the nursing vacancy report that showed as of July 2025 there were 11.53 WTE vacancies across the medical wards.

The six-month average vacancy rate between January and June 2025 for nursing staff across ten medical wards ranged from 4% (F8 coronary care) and 12% (G3 endoscopy). The six-month average vacancy rate for HCAs for the same time period ranged from 0% (F11 haematology) and 26% (endoscopy and the general medical unit). The average vacancy rate was 8% for nurses and 12% for HCAs.

Unfilled nursing shifts dropped from 583 in January to 373 in June, with the highest gaps in AMU and F9. In July, sickness rates were 8% for nurses and 11% for HCAs, exceeding the trust’s 5% target. Turnover was 5% for nurses and 11% for HCAs.

Staff reported challenges covering sickness, sometimes resulting in 1:8 nurse-to-patient ratios. During the assessment, a nurse from F9 was redeployed to AMU, and the F9 ward manager stepped in to maintain safe staffing.

We reviewed the most recent vacancy report for HCAs, which showed that as of July 2025, there were 41.3 WTE vacancies, with 4.64 WTE candidates currently progressing through recruitment.

However, there had been an increase in the HCAs establishment on ward G2 (gastroenterology). A recent staffing review meant that 5 HCAs were required on the day shift and 4 HCAs on the night shift. Staff told us this had reduced the need to use agency staff for enhanced observations or 1:1 care.

Allied health professionals (AHPs)

Between January and June 2025, unfilled AHP shifts dropped from 357 to 223. The service had experienced recruitment challenges for band 6 level staff across multiple AHP professions.

As of July 2025, the AHP medical team had a shortfall of 6.58 WTE, with 28.54 WTE funded establishment and 21.96 WTE actual staffing. Vacancies included 3.66 WTE in dietetics and 2.03 WTE in speech and language therapy.

The average AHP vacancy rate was 17%, compared to 8% for nurses. In June, sickness rates were 7% (medical AHP) and 4% (hospital AHP). Turnover for hospital AHPs was 11.68%, and no bank or agency staff were used in the past year for the medical AHP team.

Recruitment efforts had focused on band 6 dietitians and speech therapists, using events, updated adverts, and social media. Recent successful recruitment included a trainee advanced clinical practitioner (TACP) dietician within the nutrition team and two ‘eating disorder’ dietitians seconded from the mental health trust to support the dietetic team in particular gastroenterology.

Medical staff

Staff told us that medical staff vacancies had been high within gastroenterology over the previous 12 months. However, the department was now fully staffed with 3 new consultants and a specialist doctor. The service had also recruited to consultant posts in geriatrics, respiratory, diabetes and endocrinology.

Leaders told us that the haematology team was also now fully staffed. They acknowledged there were still consultant vacancies that needed to be filled. They expressed an intention to have a larger combined respiratory and generalist team because endocrine consultants were supporting a significant number of general medical cases.

There were 6.8 vacancies for specialist, associate specialist and specialty (SAS) doctors and resident doctors (total establishment 110). Leaders told us that plans for recruitment were in place and gaps were filled by agency interim roles. A chief registrar had been appointed the previous year to provide leadership and support to senior specialty trainee doctors.

Leaders told us that across the division of medicine, the medical staff establishment across all grades was 172. Data showed that between April and June 2025, the service averaged 2,608 clinical shifts per month, with a 95% fill rate—73% permanent staff, 22% locum, and 5% unfilled.

Medical establishment data from January to June 2025 showed that, as of June, the total establishment had been 172 WTE, with 168.3 WTE in post, reflecting a vacancy rate of 3.7 WTE. Staffing had been split between AMU and general and specialist medicine, which included general medicine, diabetes and endocrinology, respiratory, and care of the elderly (CoTE). The six-month average vacancy rate had been 21% in AMU and 9% across general and specialist medicine.

Locum use had varied across specialties. Haematology had 7 consultants with no locum use between February and June 2025, while AMU had 12 consultants, including 4 locums. The diabetes and endocrinology rota included T4 (general medical ward) and was staffed with 2 specialty doctors and 6 consultants, 1 of which was locum.

Medical staff we spoke with told us that there were no gaps in the medical rotas. Due to the number of specialities areas across the division of medicine, there were multiple medical staffing rotas ranging from consultant down to junior grade. Rotas reviewed from February to June 2025 in specialties such as haematology, AMU, diabetes, and endocrinology showed that all day and evening shifts had been covered by substantive staff and locums. Some specialties, including haematology, gastroenterology, and AMU, had maintained specific on-call rotas, and medical registrar rotas had provided 24/7 cover.

The service had introduced annualised self-rostering for on-call shifts among registrar and middle grade doctors in general and specialist medicine. Feedback had been positive, with improved fill rates for hard-to-cover shifts and reduced reliance on bank and agency staff.

The service had an induction policy and staff could access a full induction tailored to their role before they started work. This included volunteers, agency and bank staff. Nursing staff we spoke with confirmed they had received an appropriate induction and 2 week supernumerary period which had prepared them for their roles. Students had given positive feedback on the support, mentorship, and preceptorship programme.

Appraisal compliance had continued to improve, with nursing staff achieving an average of 90% and doctors reaching 97% across the medical wards.

We spoke with patients and relatives about the cleanliness of the wards. No patients or relatives we spoke with had any concerns regarding infection prevention and control (IPC).

Overall staff did not have concerns regarding infection prevention and control practices and procedures. Staff we spoke with were aware of their roles and responsibilities around IPC. We observed staff actively encouraging good IPC practices among colleagues and visitors. They demonstrated confidence in speaking up when IPC practices were not followed, contributing to a positive culture of safety and shared responsibility.

Staff completed IPC training as part of mandatory requirements with a trust target of 90%. For IPC level one, for the medical division, there was on average 90% compliance for both nursing and medical staff across the specialities. For IPC level two, there was 90% compliance for nursing staff and 82% for medical staff.

There were sufficient hand wash sinks and hand gels. Hand towels and soap dispensers were adequately stocked. Personal protective equipment (PPE) and hand sanitisers were readily available across all wards. The wards we visited were visibly clean and free from odour.

We observed that patients with IPC risks were appropriately isolated in single side rooms. An orange triangle symbol was displayed on the door to discreetly alert staff and support effective infection control measures. Additional signage was placed on doors to signal any airborne risk, for example, restricted access and instructions on PPE for staff.

We observed that patients’ IPC status was also recorded discreetly via a symbol on the patient boards, which staff updated regularly. The boards featured a folding cover to protect patient identity and maintain confidentiality.

The service had appropriate IPC policies in place including decontamination of reusable medical devices. There was a cleaning policy in place which outlined guidance for hand hygiene, the use of PPE and the cleaning of equipment. The medical wards used standardised daily cleaning schedules and checklists with clear instructions on where to clean.

Staff attended daily safety huddles with IPC as a standing agenda item. The service had an IPC lead to offer support and advise on infection risks, outbreaks, and how to manage them safely. The lead was involved in audits, training and risk assessments.

We observed that equipment was clearly labelled to indicate it had been cleaned. Staff routinely used ‘I am clean’ stickers to support this process. Staff cleaned equipment after patient contact and disposable curtains on the wards we visited were dated to show they had been replaced within the last 6 months in line with national guidance. We observed a chair with ripped fabric in the AMU, which was subsequently removed. Minutes from a recent team meeting showed that this issue had been raised, and a need for replacements had been identified.

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

Wards had noticeboards which displayed IPC data including infection rates and audit compliance data.

The service monitored key metrics in relation to infection rates, including Methicillin-Resistant Staphylococcus aureus (MRSA), E. Coli and Clostridioides Difficile Infections (CDI). The division had 10 healthcare acquired CDI’s between January and June 2025. This had decreased from 18 during a similar time period in 2024.

There had been 6 confirmed COVID-19 outbreaks between January and June 2025 across various medical wards. The service had identified key themes and took appropriate actions in line with policies to control the outbreaks.

The division completed various IPC audits on a monthly basis. We reviewed audit data from January to June 2025. Data showed that targets (95-98%) were mostly met for all measures such as domestic, clinical and porter audits. Environmental audits covered 15 areas including patient areas, general environment and hand hygiene. The audits were scored as red, amber or green and corresponded to a compliance score. Data from January to June 2025 showed that medical wards on average scored 87% (amber) against a target of 90%. Associated action plans were in place and a plan to reaudit in 6 months.

However, compliance with some standards were not always being met. Data for 10 medical wards showed that the average compliance score was 80% for hand hygiene theory and 82% for hand hygiene observation. This was against a target of 95%. Other measures included staff utilising the appropriate PPE (82%), staff providing cannula care (83%) and catheter care (83%) in line with appropriate IPC measures. Compliance scores had not met the trust target of 95%.

AMU had a pharmacy team based on the ward seven days a week and a satellite pharmacy available to dispense medicines on the ward to cut down on delays to patients waiting for medicines. Clinical pharmacists attended ward huddles.

Pharmacy staff supported other medical wards on weekdays but there was not always a seven day service on the wards. Staff told us how they had access to support and medicines when needed including out of hours.

Staff followed systems and processes when safely administering, recording and storing medicines. The service used an electronic prescribing system to prescribe and administer medicines (EPMA). We saw that records contained information about people’s allergies. Areas used to store medicines had temperatures monitored.

Staff completed checks on controlled and emergency medicines.

Staff stored medicines in line with policy. Areas that stored medicines were secure. The trust completed quarterly audits on safe storage of medicines. Data showed that in Q2 2024 the hospital scored over 90% for all areas apart from management of prescription stationary, waste management and fridge monitoring. However, we saw no issues with this during our assessment.

Pharmacy staff followed current national guidance to check patients had the correct medicines on admission and the service had a process for supplying medicines on discharge. Audits showed that between January and June 2025, 76% 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 current guidance of 100% within 24 hours of admission.

Staff completed audits related to medicines management including storage, controlled drugs and antibiotic stewardship audits. For example, in Q4 2024/25 the audit showed that 70% of antibiotic prescriptions had a duration recorded and 84% of antibiotic prescriptions were reviewed within 72 hours. This puts people at the risk of being on inappropriate antibiotics or via an inappropriate route.

Medicines management training for staff was currently over 88% over all wards apart from one ward that was at 68%.

We observed patient care records that showed one patient had received rapid tranquilisation injections and oral doses on multiple occasions due to agitation and or aggression. Over one day it was observed that staff had administered above the recommended maximum daily dose. Guidance from the National Institute for Health and Care Excellence (NICE) recommends that staff monitor and observe the patient following rapid tranquilisation. The trusts investigation report showed that NICE guidance relating to the observation of patients following a dose of parenteral medication had not been followed. Staff had not recorded the incident on the trust incident reporting system. This placed the patient at risk of harm and meant there was lost opportunity to learn from this incident and take actions to mitigate future risk.