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

The division had introduced a new system called My Next Patient (MNP) for managing patient transfers to temporary escalation spaces (TES). The MNP process had resulted in notable improvements to patient safety and risk management. However, we identified an ongoing need for the service to ensure that improvements made to the use of MNP TES spaces are adhered to, and sustained, to ensure the level of risk remains reduced

Nursing assessment and accreditation scores across most medical wards did not show improvements over time and reassessments were not timely.

Action plans from national and local audits were not always fully completed or timely and existing action plans had not always driven improvement in audit performance.

However, the medical division now had a vision and strategy in place that was aligned to the trust wide strategy and objectives. Staff told us they felt well supported by both managers and senior leaders.

The senior leadership team demonstrated awareness of the key challenges and risks facing the service. Risks were aligned to the appropriate committees, including those for quality, operations, and performance.

Staff and leaders engaged with people, communities and partners to share learning with each other.

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

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.

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. The trust had overarching objectives that were aligned to the trusts vision, including improving population health, caring for and inspiring people and improving quality and performance.

The medical division now had a vision and strategy in place that was aligned to the trust wide strategy and objectives. The division had 6 priorities – UEC/flow, finance, pride in place, our people, planned care, prioritising partnerships and well led and managed.

Priorities had clear objectives and responsible leads assigned to oversee and monitor performance against the priorities. Objectives included: reduction of bank and agency spend by 30%, reduction of sickness absence by 2% and strengthen wellbeing and to achieve referral to treatment (RTT) standards for all specialties by March 2026.

Senior leaders actively monitored and reviewed progress against strategic objectives, and shared progress with staff through workshops.

Staff completed pulse surveys quarterly. The division’s results for quarter 1 of 2025 – 2026 (April 2025) was based on answers from 80 respondents. The data showed mixed results. For example, the largest decline compared to the previous year was related to how many staff felt that their manager took a positive interest in health and wellbeing (55% compared to 68%). Not all staff felt that the organisation was proactively supporting their health and wellbeing (53% compared to 60%). However, there were improved scores for how many staff would recommend the organisation as a place to work (49%) and for making improvements happen in work (49%).

We also reviewed the most recent NHS staff survey which collected feedback from staff between September and November 2024. We looked at results from 10 medical wards and focused on key themes such as compassionate culture, teamwork, staff development, work-life balance, and flexible working. The data showed that in most wards (7 out of 10), there were more metrics that had declined than improved compared to the previous year. The wards with the least improvement were G2 (gastroenterology), G3 (endoscopy), and F9 (respiratory), while F7 (general medicine), F11 (haematology), and GMU (general medical unit) showed the most positive changes across several areas.

Compared to the trust average, most wards did not perform better across the majority of metrics. However, wards F11 and GMU scores were better than the trust average on most measures.

For the metric “I would recommend my organisation as a place to work”, 6 out of 10 medical wards showed a decline in scores compared to the previous year, while 4 wards showed improvement. The largest declines were seen in wards G2 and G3, with drops of 27% and 24% respectively.

Following the results of the NHS staff survey in March 2025, general and specialist medicine had an action plan in place with target dates for actions starting from July 2025 and were all in progress at the time of our assessment.

Leaders told us they recognised that well-being and morale for gastroenterology (G2 and G3) staff had been linked to staff movement between endoscopy sites within the trust. A review of the nursing establishment and endoscopy funded lists was being undertaken in response to feedback from nursing staff.

However, the decline in staff survey results had not been addressed in a timely manner, and at the time of our assessment, no action plan had been established. We were told that staff well-being was an area of priority. Focus groups and drop-in sessions had been planned with the assistant director of nursing (ADNS) with an action plan to follow. At the time of assessment, no planned implementation dates had been shared.

Some staff we spoke with told us that the workplace culture had improved since our previous assessment.

The medical division leadership team had experienced several staff changes over the past 12 months. Senior leaders told us there had been a 6-month period without a full leadership team. Since our last assessment, there has been a change in leadership within the division, with a new divisional nurse director and a new divisional managing director appointed. The divisional clinical director remained in post, having held the role for the past three years. At the time of the assessment there were no senior leadership vacancies.

Senior leaders acknowledged that the directorate had undergone considerable change and recognised that further improvement was still required. They expressed a commitment to enhancing staff engagement and creating opportunities to listen to staff ideas.

Senior leaders reported higher compliance with well-led and people management metrics in recent nursing assessment and accreditation audits. We looked at audit data that showed that most wards had been rag rated green for both of these metrics.

We looked at results from the 2024 staff survey for the metric ‘compassionate leadership’. Data showed that for most of the medical wards, scores had declined compared to the previous year and only 2 medical wards were better than the trust average.

However, staff told us they felt well supported by both managers and senior leaders. They spoke positively about their working environment and reported feeling motivated. Nurse associates and healthcare assistants (HCA’s) said they received good support from nurses in higher bands.

Staff we spoke with told us that senior leaders were visible in clinical areas on a regular basis. Clinical leaders were consultants who worked within their specialities and were reported to be visible and approachable.

Leaders and senior clinical staff were encouraged to complete an accelerated leadership course, and staff we spoke with gave positive feedback.

Staff told us that consultants were supportive. Medical staff said they received good support from medical directors and described senior leaders as approachable and responsive.

Partners and stakeholders spoke positively about the skills, knowledge, experience and credibility of the leadership team. They described leaders as being open and transparent in how they made decisions. Where areas for improvement were identified, leaders responded with appropriate improvement plans, which were shared via system boards.

There were processes and systems in place so that staff were supported to raise concerns. There had been an external review in 2024 to assess the effectiveness of freedom to speak up (FTSU) arrangements in place at the trust. The review had concluded there was substantial assurance that there was an effective system in place. Areas of improvement were recommended such as more allocated time for FTSU guardians to undertake the role.

There was a freedom to speak up policy which was in date and had been reviewed in June 2025. It included links to resources and contact details, along with guidance on how to raise a concern, should staff need to do so.

Most staff we spoke with were aware of the FTSU process, who the guardian was for the trust and who the champions were in the division. However, not all staff said they felt confident to speak up or use the process.

The most recent NHS staff survey collected feedback from staff between September and November 2024. We looked at results from 10 medical wards and looked at the question “I feel safe to speak up about anything that concerns me in this organisation”. The average score for this metric was 51% and most wards (7 out of 10) scored worse than the trust average (60%). Half of the wards performed worse compared to the previous year (56%) and 3 wards had performed better.

Partner and stakeholder feedback included concerns that some staff might not feel confident to speak up, as they were working under pressure and worried about the future of their jobs.

FTSU meetings took place monthly. Leaders told us there were no specific FTSU trends or concerns within the division and reported that the process was working well.

The division had 3 FTSU cases in the previous 12 months and most had been resolved and closed in a timely manner.

There were systems in place to address concerns about bullying and harassment, including a newly revised policy on tackling workplace bullying and harassment.

Staff could report concerns within their own directorate or to other directorates. Trainee doctors had access to a nominated clinical supervisor, undergraduate and postgraduate workforce teams, and the deanery to raise concerns. Issues could also be raised at doctor’s forums.

Senior leaders told us they worked closely with the HR advisor who attended weekly directorate meetings so that concerns and issues could be managed quickly.

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

My Next Patient Model

At our previous assessment, the division did not have effective systems or processes in place to monitor and improve the safety of the use of temporary escalation spaces (TES) under the trust’s continuous flow model (CFM). The trust paused the use of this model following our last assessment and relaunched the use of TES spaces within the medical division in April 2025 with a new process called My Next Patient (MNP). We found MNP demonstrated improvements in patient safety and risk management. The process now included environmental risk assessments, patient safety checklists and an exclusion criteria. Decisions about MNP patient transfers were more clinically led.

Despite the improvements, there were occasions when staff had not always followed the MNP policy and audits showed that not all MNP patients had risk assessments completed. Compliance with risk assessments ranged from 78% and 89% between April and June 2025. Staff reported instances during night shifts where MNP patient transfers proceeded despite concerns raised regarding the lack of additional staffing.

Although an initial evaluation of MNP was not scheduled for completion until October 2025, senior leaders did not highlight any of the gaps that we identified during our assessment when we asked them about MNP progress. It was unclear what actions were being implemented to address the issues highlighted by audits.

The evaluation process for MNP lacked patient feedback since it had been relaunched. The division had an action plan in place to support the delivery of the MNP model. The action plan stated that a formal evaluation report would be completed 6 months after the launch of the MNP model. However, the division had not collected feedback from patients who had been transferred into temporary escalation spaces under the new MNP model. Although a survey had been developed, it had not been implemented 3 months after the model’s introduction. There was no patient feedback or thematic data to help identify early issues or areas for improvement. This meant there had been missed opportunities to gain critical insights into how the model affected patient experience, dignity, and safety.

As part of the launch of MNP the trust had developed a letter for MNP patients which explained the process to help their understanding and expectations. Data for June 2025 showed 89% of MNP patients had received the letter. This showed an increase in compliance from April (60%). In May 2025 only 22% of patients had received the letter and 77% had received a verbal explanation instead.

Governance and quality assurance

The division maintained a structured schedule for both internal and external audits. The schedule clearly outlined the frequency and scope for each audit. However, we found that action plans from national and local audits were not always fully completed or timely. Existing action plans had not always driven improvement in audit performance. NICE guidance baseline assessments were not always timely and leaders acknowledged an urgent review was needed for several assessments that were outstanding. The trust acknowledged that further work was required to ensure audits, such as pain audits, were standardised across the division.

During our previous assessment, some wards had not showed improvement over time on the nursing assessment and accreditation audits. Managers had said they were concentrating on bringing improvements to the scores. However, at this assessment, leaders reported a decline in the results for the audits, with only 27% of wards for Oldham Care Organisation achieving green and 41% scoring red.

Reassessments across the wards were still not being carried out in a timely manner. For example, wards flagged as red had reassessment intervals ranging from 7 to 11 months. We reviewed minutes from the quality and clinical effectiveness group meeting in June 2025. Leaders reported that the reassessment schedule was unachievable due to the increasing number of areas that needed assessments as well as the significant number of red wards. The Assessment and Accreditation team had reviewed and implemented a new reassessment schedule of 3-5 months for red wards, 6-8 months for amber and 9-12 months for green.

Leaders said that the Assessment and Accreditation team had provided targeted support for teams that were experiencing challenges. They told us there needed to be a different approach to assessing fundamental standards and how best to improve these outcomes.

There was a trust wide work stream to update and harmonise policies. However, we found examples of some key policies that had not yet been updated. For example, the adult patient observation policy was out of date by 5 years. At our previous assessment in August 2024 the draft policy had been at version 2 and, at the time of this assessment the policy had still not been ratified and implemented for staff to use. The policy had been approved at the clinical effectiveness committee in July 2025 and was subject to minor changes.

Senior leaders told us that trust wide implementation of the policy had been complex due to a number of factors. For example, multiple digital systems needed to be updated to reflect the policy changes and linked clinical policies (including the oxygen policy) needed to be reviewed to ensure that they align.

Leaders participated in weekly governance meetings to review performance dashboards, including data on incidents, complaints and compliments, risks, and audits.

Each directorate had a dedicated governance lead, alongside a mortality lead who contributed to the monthly morbidity and mortality meetings. Both roles were part of the clinical governance structure and provided input as required.

Risks were aligned to the appropriate committees, including those for quality, operations, and performance. Leaders told us that monthly care organisation risk meetings ensured they remained aware of both emerging and longstanding risks on the risk register. They were actively working to distinguish between what constitutes a 'true risk' and what should be considered routine business as usual.

The senior leadership team demonstrated awareness of the key challenges and risks facing the service. The top risks included ‘electronic chemotherapy prescribing’ and a business case was in progress to provide a trust wide chemotherapy prescribing system. Leaders also noted that a broader organisational risk was patient flow across the hospital.

Some partners and stakeholders told us that there were clear governance, roles, and responsibilities in place. However, some felt that the frequent changes to roles and structures had made it more difficult to maintain clarity and consistency in governance.

The division had a comprehensive information governance policy. The division had no information governance breaches in the previous 6 months.

Records

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

We found that the use of multiple IT and paper-based systems was burdensome and inefficient, making it difficult to locate essential information. For example, identifying a patient's admission date from A&E records was often challenging.

We observed monthly newsletters from various medical wards that shared important information including lessons learnt, training, social events and policy updates. Newsletters also promoted the trusts support programme for staff called ‘SCARF’ (Support, Care, Assist, Recognise, Family). This helped staff look after their physical, emotional, and psychological wellbeing and to make it easier for staff to find access to practical resources and information. Staff we spoke with had heard of the SCARF programme and knew how to access it if they needed to.

A well-being day was held on AMU, offering therapeutic activities for staff and support from a mental health practitioner.

Leaders told us that patient experience meetings took place monthly where staff shared examples of how they had improved care for patients and families. Divisional updates and feedback from both national and local surveys were discussed, alongside patient stories that gave insight into real experiences. We saw examples of patient stories in the divisional operations and quality assurance meetings.

Patient feedback was gathered through an initiative called ‘observe, listen and act’ (OLA) with a focus on listening and acting on patient experiences. Improvements were shared through bimonthly OLA presentations, which highlighted the actions taken in response to feedback. The meetings alternated monthly between divisional updates and OLA feedback. These meetings also involved staff training events and guest speakers to promote engagement.

Staff at care homes told us they had met with senior leaders after raising concerns about unsafe discharges, and that improvements had since been made. The divisional nurse director had worked with local care homes to strengthen relationships and to improve patient experience and expectations at discharge.

We spoke with partners and stakeholders who believed that the service provided a model of care that took a population health management approach, with a strong focus on prevention. This approach aimed to reduce health inequalities and support individuals to maintain their well-being at home.

Partners and stakeholders reported that the trust was an active member of the Oldham Integrated Care Partnership and participated in both formal governance meetings and informal development workshops. Trust representatives regularly collaborated with local and regional partners on delegated decision-making, transformation initiatives, and service improvement programmes.

The service worked effectively with external partners, including the Oldham Health and Social Care Senate, third sector organisations, out-of-hours providers, and Greater Manchester locality leads. Leaders told us that there were well-established links and meetings with primary care network leads, including GPs. For example, they had discussed the challenges and barriers from GP’s with a clinical focus on what each team needed.

Leaders told us that since the implementation of the Patient Safety Incident Response Framework (PSIRF) model, service user engagement had increased. Patients were more frequently invited to share their experiences directly with teams and feedback had been largely positive and motivating for staff.

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