Source · CQC inspection

The Christie Main Site

Type NHS Healthcare Organisation Region North West Last inspected 12 May 2023

Overall rating: Good View full CQC report

Domain ratings

Five CQC key questions

Safe

Requires Improvement

Effective

Outstanding

Caring

Outstanding

Responsive

Outstanding

Well-led

Outstanding

Earlier inspection findings

pre-2024 framework · 8 must-do 4 should-do

Must-do actions (8)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 8

Must do

Safe

The trust must ensure staff complete mandatory training in accordance with the relevant schedule and receive relevant training, supervision and appraisal to perform their duties competently.

Regulation: Regulation 18(2)(a)

⚠ The service provided mandatory training in key skills to all staff but did not always make sure everyone completed it. Staff received but did not keep up to date with their mandatory training. For example, in October 2022, nursing staff compliance for Equality, diversity and human rights was 72%, Fire …

Must-do action 2 of 8

Must do

Well-led

The trust must ensure that policies are reviewed and ratified in a more timely manner.

Regulation: Regulation 17(1)

⚠ Some essential policies had passed their review date. For example, the national early warning score (NEWS2) policy and the consent policy. Eight policies had been due for review in 2020. This meant staff did not always have the most up to date policy or guidance to follow.

Must-do action 3 of 8

Must do

Safe

The trust must ensure that serious incidents and mortality reviews are investigated in a timely manner and learning is shared across the organisation as required.

Regulation: Regulation 12(2)(b)

⚠ The trust reported and investigated complaints, incidents and mortality but these were not always completed in a timely manner. Learning was not always shared with relevant staff across the trust. For serious incidents, only 48% of incidents were closed off within the required timescales and outcomes were not always shared …

Must-do action 4 of 8

Must do

Responsive

The trust must ensure there is an effective process to manage complaints, in particular, ensuring the timeliness of responses.

Regulation: Regulation 16(2)

⚠ The trust reported and investigated complaints, incidents and mortality but these were not always completed in a timely manner. Trust data showed that only 57 (43%) of the complaints were responded to within their timescales. Some complaint investigations and responses took 6 or 7 months to be concluded.

Must-do action 5 of 8

Must do

Well-led

The trust must ensure there is an effective process to manage the administration of the fit and proper persons checks.

Regulation: Regulation 5

⚠ There were gaps in assurance for requirements of the Fit and Proper Persons Requirement (FPPR). We reviewed 10 FPPR files for board members and found a lack of a robust process; evidence of competency-based interviews were not consistently recorded in files, one non-executive director file had no evidence of a …

Must-do action 6 of 8

Must do

Safe

The service must ensure staff complete mandatory training, including safeguarding training in accordance with the relevant schedule and receive relevant training to perform their duties competently.

Regulation: Regulation 18(1)(2)(a)

⚠ The service provided mandatory training but not all staff completed it on time including mandated annual updates. Medical staff did not always complete life support and safeguarding training in a timely manner. For example, in October 2022, nursing staff compliance for Safeguarding adults level 2 was 76%, Safeguarding children level …

Must-do action 7 of 8

Must do

Safe

The trust must ensure that patient risk assessments are consistently completed and reviewed in a timely manner for all patients.

Regulation: Regulation 12(1)(2)(a)(b)

⚠ Staff did not always complete and review risk assessments for patients in a timely manner. Of the 23 patient records we reviewed, 12 risk assessments were either not completed or had not been reviewed in a timely manner in line with the trust’s own policy.

Must-do action 8 of 8

Must do

Safe

The service must ensure the proper and safe management of medicines, to include the completion of antimicrobial documentation for safe prescribing in line with trust policies.

Regulation: Regulation 12(1)(2)(g)

⚠ The service did not always manage medicines well. Documentation of antimicrobial prescribing was the weakest area on all medical wards. Antimicrobial prescribing audits showed that only 34% of prescriptions had a duration recorded on the drug chart and only 61% had an indication (a reason for the prescription) recorded on …

Should-do actions (4)

Recommended improvements to enhance service quality.

Should-do action 1 of 4

Should do

Well-led

The trust should continue to make improvements in culture across the organisation, support staff when raising concerns and act on them in a timely way.

Should-do action 2 of 4

Should do

Well-led

The trust should continue to develop and promote fundamental strategies such as the equality, diversity and inclusion strategy and take appropriate actions to improve staff engagement, especially those with particular equality characteristics.

Should-do action 3 of 4

Should do

Responsive

The trust should consider monitoring delayed discharges or transfers of care in regard to patient experience.

Should-do action 4 of 4

Should do

Responsive

The trust should ensure there is an effective process to provide information in an accessible format for service users with information or communication needs.

Location details

CQC ID: RBV01

Local authority: Manchester

Region: North West

Inspection report

Type: Location

Date: 12 May 2023

Rating: Good

Actions: 8 must-do 4 should-do

AI-extracted 3 Jun 2026