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Provider: Bolton NHS Foundation Trust Good

On 11 April 2019, we published a report on how well Bolton NHS Foundation Trust uses its resources. The ratings from this report are:

  • Use of resources: Good  
  • Combined rating: Good  

Read more about use of resources ratings


Inspection carried out on 04 Dec 2018 to 10 Jan 2019

During a routine inspection

Our rating of the trust stayed the same. We rated it as good because:

  • We rated safe, effective, caring and responsive as good.
  • We rated all of the trust’s eight acute services as good. In rating the trust, we took into account the current ratings of the five acute, Bolton One and community services not inspected this time.
  • We rated well-led for the trust as outstanding.
  • The trust had taken the appropriate actions relating to the requirements of the previous inspection.
  • The trust was inspected for its use of resources and rated good which gives a combined rating of good.

At the Royal Bolton Hospital;

  • We inspected urgent and emergency care services during this inspection to check if improvement had been made since our last inspection in 2016. The ratings for safe, effective and responsive improved from requires improvement to good. This improved the overall rating for this service to good.
  • We inspected medical care (including older people’s care) and found that there had been improvement since our last inspection in 2016. The rating for safe improved from requires improvement to good and caring improved to outstanding.
  • We inspected maternity services and rated the service as good across all domains.

Our full Inspection report summarising what we found and the supporting Evidence appendix containing detailed evidence and data about the trust is available on our website –

CQC inspections of services

Service reports published 10 August 2016
Inspection carried out on March 2016 During an inspection of Community health services for adults Download report PDF (opens in a new tab)
Inspection carried out on March 2016 During an inspection of Community health services for children, young people and families Download report PDF (opens in a new tab)
Inspection carried out on 21 March 2016 During an inspection of Community health inpatient services Download report PDF (opens in a new tab)
See more service reports published 10 August 2016
Inspection carried out on March 2016

During a routine inspection

Bolton NHS Foundation Trust provides a range of hospital and community health services in the North West sector of Greater Manchester, delivering services from the Royal Bolton Hospital (RBH) site in Farnworth, in the South West of Bolton, close to the boundaries of Salford, Wigan and Bury; as well as providing a wide range of community services from locations within Bolton.

The Royal Bolton hospital site is situated in the town of Farnworth, near Bolton. For services, in particular patients requiring non elective treatment, it is estimated to have a catchment population of 310-320,000, compared with a resident Bolton population of 270,000.

The Royal Bolton hospital provides a full range of acute and a number of specialist services including urgent and emergency care, general and specialist medicine, general and specialist surgery and full consultant led obstetric and paediatric service for women, children and babies, including level three neonatal care and 24-hour paediatric and consultant-led obstetric services


At Bolton NHS Foundation Trust, the Integrated Community Services Division consists of domiciliary, clinic and bed based services across the Bolton footprint to GP registered population. Most services are commissioned via Bolton Clinical Commissioning Group. The trust worked in partnership with Bolton Council, Greater Manchester West, North West Ambulance Service and with the voluntary sector such as Age Concern and Urban Outreach. The Division had approximately 420 Staff (380.46 whole time equivalent) and had a budget of £16.8 million.

Approximately 110,000 people

attend the trust for emergency treatment every year and 72,000 patients are admitted. Approximately 310,000 attend the outpatient departments for consultations. The Royal Bolton Hospital has approximately


beds and employs 5200 staff.

We visited the hospital on 21- 24 March 2016. We also carried out an out-of-hours unannounced visit on 6 April 2016. During this inspection, the team inspected the following core services:

  • Urgent and emergency services

  • Medical care services

  • Surgery

  • Critical care

  • Maternity and gynaecology

  • Children and young people

  • End of life

  • Outpatients and diagnostic services

  • Community Adults

  • Community adult inpatient services

  • Community children and young people

  • Child Adolescence mental health services

Overall, we rated Bolton NHS Foundation Trust as good for services it was providing.

We rated Royal Bolton Hospital as good over-all. We have judged the service as ‘good’ for effective, caring, responsive and well led. We found that services were provided by compassionate, caring staff and patients were treated with dignity and respect. However, improvements were needed to ensure that services were safe.

We rated Bolton One as good for all key questions safe, effective, caring, responsive and well-led.

We rated community inpatients, community adults and children and young people as good in all 5 domains.

We rated the child adolescent mental health service as requires improvement in safe, effective, responsive and well-led domains, and good in the caring domain.

Our key findings were as follows:

Leadership and Management

  • There was a positive culture and a sense of pride throughout teams across the trust, and staff were committed to being part of the trusts vision and strategy going forward.

  • There was effective teamwork and clear leadership and communication in services at a local level. Managers and leaders were visible and approachable. Staff we spoke to felt supported by their managers and supported and encourage to raise concerns and ideas.

  • The trust was led and managed by an executive team that were approachable and visible. All staff we spoke to knew the team and felt that they were listened to and concerns were acted upon. All staff spoke with the highest regard for board members, and gave examples of positive interactions and collaborative working between the board and staff in order to improve safe care and treatment and outcomes for patients.


  • There was a very positive culture throughout the trust. Staff of all grades were committed to continually making improvements to the quality of care delivered.

  • There was a supportive culture across divisions, and staff worked collectively to identify quality improvements and help deliver services safely on a day-to-day basis.

  • Staff were proud of the services they delivered and proud of the trust.

  • There was a range of reward and recognition schemes that were valued by staff. Staff were encouraged to be proud of their service and celebrate their achievements.

Equality and Diversity

  • The Director of Nursing was executive lead for equality and diversity. There was a strategy in place  which was monitored though the equality and diversity inclusion steering group and the patient experience, inclusion and partnership committee.

  • We found that the trust had a positive and inclusive approach to equality and diversity. We found that staff were committed and proactive in relation to providing an inclusive workplace.

  • There were a range of staff groups and patient groups that contributed to the trust equality, diversity and inclusion agenda, which included learning disability patient groups, people living with dementia and young people accessing adolescent mental health services (CAMHS).

  • The trust had key objectives aligned to the public sector equality duty and equality delivery system (EDS2), and had audit and monitoring systems in place against key metrics, for example diversity of patients, complaints and patient feedback in order to understand the quality of care and service being provided. We saw that good progress had been made against the EDS2 standards.

  • As part of the new Workforce Race Equality Standard (WRES) programme, we have added a review of the trusts approach to equality and diversity to our well led methodology. The WRES has nine very specific indicators by which organisations are expected to publish and report as well as put action plans into place to improve the experiences of it Black and Minority Ethnic (BME) staff. As part of this inspection, we looked into what the trust was doing to embed the WRES and race equality into the organisation as well as its work to include other staff and patient groups with protected characteristics.

  • We analysed data from the NHS Staff survey regarding questions relating to the Workforce Race Equality Standard (WRES). The results for the trust were positive for the trust in most areas.

  • However,

    there had been an increase in all staff experiencing harassment, bullying or abuse from patients, relatives or the public in the last 12 months. There had been a notable increase in reports from staff from a BME background from 25% in 2014 to 39% in 2015. Similarly, the percentage of staff experiencing harassment, bullying or abuse from staff in last 12 months had shown a small increase for all staff, however BME staff reporting bullying had gone up from 26% to 36%.

  • The trust had acted upon findings from the national staff survey as part on ongoing range of actions in place to support staff engagement. Examples included a non-executive director responsible leading whistleblowing concerns and

    a new appointment of a “speak up guardian” would further support staff in being able to raise concerns.

  • All staff we spoke to felt well supported, able to raise concerns and develop professionally.

Governance and risk management

  • Governance and risk management structures were embedded in the trust.

  • There was a robust committee structure in place that supported challenge and review of performance, risk and quality. Mechanisms were in place to ensure that committees were led and represented appropriately, to ensure that performance was challenged and understood.

  • The trust had a pro-active approach to risk management with clear roles and responsibilities and monitoring arrangements in place. We observed a particular area of good practice, in which all new incidents and risks were reported to board members daily. Within this, a second report was circulated within the day reporting key actions that had been taken. This pro-active approach meant that board members were clear on strategic and operational risks at the earliest opportunity.

  • The Board Assurance Framework (BAF)

    was aligned to strategic objectives and we saw evidence that it was linked appropriately to divisional risk registers that were regularly reviewed. We observed that the trust did not have an over-all trust risk register, however processes were in place to ensure that both operational and strategic risk and performance issues were reported and acted upon though monthly management meetings chaired by the chief executive.

  • Board assurance related to the BAF and strategic and operational objectives were tested in practice by board members and governors. This was done though a formal programme of work which was aligned to current themes and risks. Staff said they found this supportive and felt that the board understood operational issues and this approach created a collective approach to decision making.

  • There were divisional governance meetings where performance, risks and learning was discussed and shared. Staff had access to robust data to support good performance which included thematic reviews and correlation of data to promote early identification of poor performance. We observed that whilst this was being used well operationally, there may be a missed opportunity to prospectively use data to further to support trust wide initiatives, however the trust’s current information technology systems limited real-time information across the trust.

Mortality rates

  • Mortality and morbidity reviews were held in accordance with trust policies and were underpinned by robust and well understood procedures. All cases were reviewed and appropriate changes made to help to promote the safety of patients and prevent avoidable deaths. Key learning Information was cascaded to staff appropriately. Monitoring arrangements were in place at board level to ensure that any findings were acted upon.

  • The Summary Hospital-level Mortality Indicator (SHMI) is a set of data indicators, which is used to measure mortality outcomes at trust level across the NHS in England using a standard and transparent methodology. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die based on average England figures, given the characteristics of the patients treated at the hospital. The risk score is the ratio between the actual and expected number of adverse outcomes. A score of 100 would mean that the number of adverse outcomes is as expected compared to England. A score of over 100 means more adverse (worse) outcomes than expected and a score of less than 100 means less adverse (better) outcomes than expected. In November 2015, the trust score was 104.

Nursing and midwifery staffing

  • The trust undertook biannual nurse staffing establishment reviews using a recognised evidence based tool as part of mandatory requirements. Key objectives were set though this work to support safer staffing and address and mitigate identified shortfalls and support recruitment.

  • The trust was in the process of implementing a daily acuity tool to further support safer staffing levels based on patients acuity and needs.

  • There were processes in place to ensure ward staffing levels were monitored on a daily basis. Senior nurses and matrons met each week to discuss nurse staffing levels across services to ensure that that there were sufficient numbers of staff.

  • Staffing on a day to day basis was reviewed as part of the trust bed management meetings. Shortfalls were subject to management action and risk mitigation.

  • However, nurse staffing levels remained a challenge, particularly in emergency, medical and the paediatric department. Nursing staffing was identified on both operational and corporate risk registers. At the time of this inspection there were 50 nursing staff vacancies across the trust and additional posts had been made available in order to support the increased requirements across the across the acute hospital.

  • Staffing levels were maintained by staff regularly working extra shifts and with the use of bank or agency staff. Inductions were in place for new staff in order to mitigate the risk of using staff that were not familiar with the trust’s policies and procedures.

Medical staffing

  • Whilst most areas had sufficient numbers of medical staff to meet patients needs, which included the use of agency staff, there were pressures within the emergency department due to increased demand.

  • Increased activity in the emergency department had meant that emergency department consultants were regularly working in place of middle grade staff to ensure the department continued to function with appropriate medical staffing levels. We observed that medical staff were committed to maintaining patient safety and worked well together as a team to ensure that rotas were covered.

  • A recent review by the Royal College of Emergency Medicine had recommended an increase in establishment of consultants of 6.5 WTE, which was being considered at the time of this inspection. In addition, it had been recommended to increase medical middle grade staffing by five WTE. Whilst the shifts we reviewed showed that staffing levels were sufficient. We were concerned that the current use of consultants to fill middle grade shifts may not be sustainable in the long term.

  • The trust board had recently authorised recruitment for two middle grade doctors and relaxed the cap on locum use to assist with staffing. However, managers described difficulties recruiting due to the high volume of patients attending the ED compared with other EDs.

Access and flow

  • The trust had established policies and both internal and external escalation procedures in place to support patient flow and movement across the trust. This included established escalation meetings and a designated site manager co-ordinating patient flow.

  • Access and flow remained a challenge, and the emergency department did not, at times see, treat, admit or discharge patients within the national target of four hours.

  • Plans were in place to expand the emergency department in order to accommodate the increase in patient attendances, including the increase in patients attending from outside of Bolton.

  • There were some pressures with access and flow across the medical and surgical wards, including patients who were medically optimised and ready for discharged. Access and flow issues resulted in a number of patients being cared for on a ward outside of their speciality. There were policies and procedures in place outlining the management of these patients to ensure that the appropriate medical teams saw patients regularly and appropriately.

  • The overall hospital-wide bed occupancy rate between

    July 2013 and December 2015

    ranged between

    80.8% and 88%, which rose to 91% on medical wards between January and March 2016.

  • In spite of pressures, we observed that the average length of stay for elective medicine at the hospital was shorter (better) than the England average at 2.9 days.

  • NHS England data showed the surgical and gynaecology services consistently performed better than the England average for 18-week referral to treatment standards for admitted (adjusted) patients between November 2014 and January 2016.

  • Most patients were admitted to the intensive care unit within four hours of making the decision to admit them and a consultant assessed 100% of patients within 12 hours of admission.

  • Diagnostic waiting times had been consistently better than the England average between January 2014 and November 2015.

  • The trust had performed consistently better than the England indicators for incomplete pathway referral to treatment times between December 2014 and November 2015.

  • Activity measures within the community services indicated that, in Bolton, the team were above the trust target for the number of GP referrals that were received (6,501 against a target of 6,187). The service indicated that these figures had been impacted on in view of the new initiative they had trialled with GPs for keeping patients out of hospital.

Cleanliness and infection control

  • Clinical areas at the point of care were visibly clean, trust had infection prevention, and control policies in place, which were accessible to staff and staff were knowledgeable on preventing infection.

  • There was enough personal protective equipment available such as aprons and gloves that were accessible for staff and was used appropriately.

  • Staff followed good practice guidance in relation to the control and prevention of infection in line with trust policies and procedures.

  • Between April 2015 and December 2015, the trust reported 19 cases of Clostridium difficile, four cases of Methicillin-resistant staphylococcus aureus (MRSA) and 18 cases of Methicillin-susceptible staphylococcus aureus (MSSA) which were in line with local and national trajectories.

  • Lessons from all cases were disseminated to staff for learning across directorates


  • There were established audit programmes in place related to the prevention of cross infection, which included

    hand hygiene, infections within a central line (a long, thin, flexible tube used to give medicines, fluids, nutrients, or blood products) and

    methicillin-resistant Staphylococcus aureus


We saw several areas of outstanding practice including:

  • The emergency department had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medicine.

  • The emergency department offered bereavement meetings were offered to those who had lost a loved one, to help them understand what had happened.

  • Emergency department Consultants were regularly working in place of middle grade staff to ensure the department continued to function with safe medical staffing levels.

  • The radiology department had a managed equipment programme in place. This meant that equipment was serviced, repaired and replaced as part of the contract in a timely way, minimising disruption to services and reducing the need for costly and time consuming business cases when equipment needed replacing. This was an innovative way of managing high cost equipment.

  • The trust were early adopters of the newborn behaviour assessment tool (NBAS).

  •  The neonatal unit were early adopters of volume ventilation.

  • The neonatal unit introduced ‘Matching Michigan’, a two-year programme designed to reduce infections in central lines, before it was rolled out as best practice. As a result ,the service was nominated for an award from the Health Service Journal (HSJ).

  • The neonatal unit introduced the ‘fresh eyes initiative’, which is where nursing staff look at other nurses’ patients at 1am and 1pm to promote things not being missed.

  • Any incidents with an initial grading of harm were circulated to all trust board members on a daily basis. Initial information was received before 9am and then follow information on what actions had been taken were received by 10.30am.

However, there were also areas where the trust needs to make improvements.

Importantly, the trust must:

  • Complete mental health assessment forms in the emergency department as soon as practicable and ensure these are distributed and used where appropriate.

  • Improve staffing levels in the emergency department with an aim to reducing agency and locum rates.

  • Improve appraisal rates in the emergency department.

  • In the emergency department, Improve the focus on audits, ensuring clear action plans are formulated and progress regularly tracked to improve outcomes.

  • Ensure that robust information is collected, analysed, and recorded to support clinical and operational practice in medical services.

  • Deploy sufficient staff with the appropriate skills on wards.

  • Ensure that records are kept secure at all times so that they are only accessed and amended by staff.

  • Ensure that staff are up to date with appraisals and mandatory training in medical wards.

  • Ensure that paper and electronic records are stored securely and are complete in outpatient’s areas.

  • Ensure that essential safety checks are completed and records of checks are maintained to provide assurance that all steps are being taken to maintain patient safety in outpatients.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.

Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.