You are here

We are carrying out checks at Leigh Infirmary using our new way of inspecting services. We will publish a report when our check is complete.

Inspection Summary

Overall summary & rating


Updated 9 March 2018

A summary of our findings about this location appears in the overall summary

Inspection areas



Updated 9 March 2018



Updated 9 March 2018



Updated 9 March 2018



Updated 9 March 2018



Updated 9 March 2018

Checks on specific services

Maternity and gynaecology


Updated 22 June 2016

The maternity and gynaecology services at Leigh Infirmary required improvement in the effective domain but were good in the other domains.

Policies were not always clear or followed current guidelines. Staff knew how to report incidents. Lessons were shared and, however; there was no integrated trust wide learning system. All areas were visibly clean and tidy and staff followed hygiene procedures.

Daily checks of equipment were completed, but systems for monitoring the maintenance of equipment were not robust. Safeguarding processes were in place and under review. Medicines were stored in secure cupboards and daily checks completed. Records for patients receiving surgical care and termination of pregnancy were reviewed and completed appropriately.

Staff had received mandatory training relevant for their role however there was room for improvement in the uptake of Breastfeeding for midwives, basic life support training by medical staff and delirium training by all staff. Medical staffing numbers were adequate for the patient’s needs. Any shortfall in staffing levels was supported by bank nurses.

Trust guidelines were in place; however these were not always clear or adhered to. Two guidance documents for the management of termination of pregnancy gave differing guidance. Guideline reviews were not robust in that they did not always include reviewing the references on the document. The trust participated in a number of local and national audits.

Women were assessed for pain relief and supported individually postoperatively. Patients breast feeding was supported in the community, however; the numbers decreased after discharge from postnatal care.

Midwives were annually assessed by their supervisors and other staff had been appraised to be competent although midwives did not rotate.

Services were available on weekdays only. Ward two carried out elective day-case surgery and clinics were at Leigh for routine antenatal and gynaecology appointments. Community staff had limited access to records due to a lack of computers.

We observed positive interactions between patients and staff. We observed staff actively engaging with patients in a kind and compassionate way. Patients were accommodated sensitively, where possible, if a side room was appropriate. Emotional support was available if needed.

The service had been planned across the geographical location. Gynaecology clinic services were based in the women’s centre at Leigh Infirmary. The antenatal clinics were being supported by main outpatients as they are in the process of relocating to refurbished premises in the former ward one. Each maternity patient was allocated a named midwife, in the community. Antenatal clinics were available across the Wigan and Leigh areas in GP surgeries.

There were specialist midwives including public health, safeguarding and a mental health nurse. Also diversity and dementia champions were available. Any patient identified with a learning disability or mental health issue were supported on an individual basis as needed.

Midwives were not clear about the trust vision and strategy. There were regular senior meetings that were cascaded to staff but staff felt that meetings with them needed to be more formal. Staff felt that they were supported by their managers; however hospital midwives felt there were fewer opportunities for them to develop than in the community.

A trust ‘pioneering staff engagement’ programme was in place across a multi-disciplinary team with a number of innovating programmes in progress. The service had received several awards over the past two years. Policies were not always clear or followed current guidelines.

Medical care (including older people’s care)


Updated 9 March 2018

Our overall rating of this service stayed the same. We rated it as good because:

  • Staffing levels were planned and meet the needs of the service and nurse staffing levels on Taylor Ward had improved. The service had enough staff with the right skills, qualifications and experience. Staff knew who their managers were and received regular feedback on their work.
  • Staff knew what incidents to report and how to report them. Managers investigated incidents and shared lessons learned. They identified any themes and monitored near misses
  • The service was meeting the trust’s target for staff completing mandatory training and staff were supported through individual competencies specific to their role.
  • Staff understood and followed procedures to protect vulnerable adults or children.
  • Staff always had access to up-to-date, accurate and comprehensive information on patients’ care and treatment.
  • The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.
  • The service planned and provided services in a way that met the needs of local people and care and treatment provided was based on national guidance.
  • There was a cohesive and thorough multidisciplinary approach to assessing the range of people’s needs, setting individual goals and providing patient centred care.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
  • Staff treated patients with compassion, dignity and respect. Staff involved patients and those close to them in decisions about their care and treatment. They made sure patients were aware of their goals and plan of care.
  • Staff described the culture within the service as open and transparent. Staff could raise concerns and the majority felt listened to.


  • Divisional risk registers did not always demonstrate that actions were taken to mitigate and manage all risks effectively.
  • Some staff reported the executive team and senior managers were not visible at this site. Some staff reported low morale on Taylor Ward which would be closing in 2018.



Updated 22 June 2016

Staff were enthusiastic and proud of the services they provided. Staffing levels were sufficient and a safer nursing care staffing tool was utilised to ensure staffing levels were adequate. Medical staff rotas were in place and locum agency staff filled any gaps when the service was short staffed. Staff morale was good and staff felt well supported.

Incidents were reported and lessons learnt shared. Staff knew how to access the incident reporting system and could tell us about incidents they had reported. There were low incidents of pressure ulcers and infections. Risk assessments were completed and staff implemented measures to reduce risks.

The environment was clean and tidy and staff had access to the equipment they required to do their jobs. Medicines were managed safely and stored securely.

Referral and discharges worked well and staff shared relevant information. Services were coordinated and patients were appropriately referred to specialist services. Staff treated patients with respect and dignity, offered support and included them in their care planning. Patients received a caring service and staff discussed treatment plans with patients to ensure a person-centred approach. Referral to treatment times for the hospital were similar to or above the national average.

Risk registers were in place and discussed at team meetings. Staff were aware of the trust’s values and vison. Staff felt well-supported by managers and colleagues.



Updated 22 June 2016

Whilst low numbers of incidents were recorded by the departments those that were reported were graded according to risk and shared to promote learning. There was an open and honest culture amongst staff. The environment differed depending upon location. Whilst the outpatient department was dated with little natural light, the Hanover Centre was light and spacious following refurbishment in 2013. The areas we inspected were visibly clean and tidy.

Safeguarding was managed by a central team who advised and supported staff who had been trained according to the level of contact with patients and those close to them. Patient risks were managed with resuscitation trolleys in departments.

Staffing was adequate with few vacancies and little or no use of agency staff. Staff used guidelines, procedures and policies to provide care for patients. Departments undertook audits and presented findings to colleagues to promote learning and improve services.

Staff received appraisals and were given opportunities to enhance learning. Radiology services were provided seven days a week. Outpatient clinics were not routinely provided on a seven day basis but clinics were held in the evenings and occasionally on a Saturday morning to manage waiting lists.

Patient records contained the necessary information. However medical signatures were not always legible and registration numbers and printed names were not always included. Approximately ten patient records per month were unavailable for clinic appointments. Staff accessed the electronic systems or contacted GPs if information was not available.

Staff understood consent and we saw evidence that written or verbal consent was obtained when required.

Outpatient services documented standards to maintain high levels of service and these were displayed for patients and visitors.

Patients were happy with the care they received and said staff had a polite and compassionate manner. Patients felt supported by staff during appointments.

A range of initiatives were in place to meet people’s needs.

The hospital met the department of health target of providing appointments for patients within 18 weeks. Ninety seven percent of patients referred for an urgent appointment for suspected cancer were seen within the department of health target time of two weeks. On average patients received appointments within 19 days for non-obstetric ultrasound scans, and two days for x-ray.

Waiting times following arrival in clinic varied depending on the type of appointment. At the time of our inspection there were no visible delays for patients waiting to be seen. Reporting time for scan results was one to two days. However, in September 2015, 1,367 x-rays were waiting for reports to be completed across all sites. Further staff were being recruited to manage this.

Verbal complaints were dealt with at the time through communication if possible, but verbal complaints were not always recorded by staff. Those that were recorded were monitored with results shared monthly to promote learning.

Staff had ideas about how to improve services. Trust values were evident in the areas we inspected. Governance meetings were held monthly. Risk was managed through a local risk register which documented the issue, mitigation, risk score and review date of each risk.

Staff felt supported by managers and services engaged with the public, through forums and questionnaires.

Urology staff offered ‘one-stop’ appointments for haematuria patients which enabled patients to undergo biopsies during initial appointments rather than having to re-attend on another day.