Home / Sources / CQC / Fairfield General Hospital
Index live
Source · CQC inspection

Fairfield General Hospital

Provider Northern Care Alliance NHS Foundation Trust Type NHS Healthcare Organisation Region North West Last inspected 7 Feb 2020

Overall rating: Outstanding  View full CQC report

Domain ratings

Five CQC key questions
Safe
Good
Effective
Good
Caring
Outstanding
Responsive
Outstanding
Well-led
Good

Earlier inspection findings

pre-2024 framework · 77 must-do 36 should-do

Must-do actions (77)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 77
Must do
Well-led
The trust must ensure there is consistent assessment, monitoring and improvement of the quality and safety of the services provided and that this is presented uniformly to decision makers to ensure they have effective oversight.
Regulation: Regulation 17(2)(a)
⚠ Leaders did not operate consistent, effective governance processes throughout the service. There were differences in policies and clinical practice which did not reflect best-practice guidelines. Leaders and teams did not consistently use systems to manage performance effectively.
Must-do action 2 of 77
Must do
Well-led
The trust must ensure that effective structures and processes are in place to assess, monitor and mitigate the risks relating to the health, safety and welfare of patients which arise from the carrying on of the regulated activity; including an effective audit programme and good quality data that monitors actions to improve patient care.
Regulation: Regulation 17(2)(b)
⚠ Leaders and teams did not consistently use systems to manage performance effectively. They identified and escalated relevant risks and issues but did not always take actions to reduce their impact. The service collected data and analysed it, but not all staff were assured that the data was always accurate, and …
Must-do action 3 of 77
Must do
Safe
The trust must ensure that services are always safely staffed by people with the necessary skills, knowledge and experience.
Regulation: Regulation 18(1)
⚠ Services were not always safely staffed by people with the necessary skills, knowledge and experience. Staffing levels were below required levels in several areas.
Must-do action 4 of 77
Must do
Safe
The trust must ensure staff complete mandatory training in accordance with the relevant schedule and receive sufficient training, supervision and appraisal to perform their duties competently.
Regulation: Regulation 18(2)(a)
⚠ Staff did not always complete mandatory training in accordance with the relevant schedule and receive sufficient training, supervision and appraisal to perform their duties competently. Compliance with mandatory training was below the trust target in several areas.
Must-do action 5 of 77
Must do
Safe
The trust must ensure they are effectively assessing and managing the risks to the health and safety of patients receiving care and treatment. The trust must ensure they are doing all that is reasonably practicable to mitigate any such risk.
Regulation: Regulation 12(a)(b)
⚠ The trust was not effectively assessing and managing the risks to the health and safety of patients receiving care and treatment, and not doing all that was reasonably practicable to mitigate such risk. Leaders and teams did not always take actions to reduce the impact of identified risks.
Must-do action 6 of 77
Must do
Safe
The trust must ensure it is effectively and appropriately assessing and managing the risks to service users who are waiting to receive care and treatment by ensuring clinical need and priorities are regularly reviewed.
Regulation: Regulation 12(2)(a)(b)
⚠ The trust was not effectively and appropriately assessing and managing the risks to service users who are waiting to receive care and treatment. The trust was experiencing significant issues with access and flow, with high volumes of delayed admissions and patients waiting.
Must-do action 7 of 77
Must do
Well-led
The trust must ensure it aligns relevant policies and procedures to reduce unwarranted variation in clinical practice, and that policies are up to date.
Regulation: Regulation 17(1)
⚠ The trust did not align relevant policies and procedures to reduce unwarranted variation in clinical practice, and policies were not always up to date. There were differences in policies and clinical practice which did not reflect best-practice guidelines.
Must-do action 8 of 77
Must do
Safe
The trust must take action to improve performance and reduce variation in medicines reconciliation rates across the organisation.
Regulation: Regulation 12(2)(a)(b)
⚠ There was recognised inequity in pharmacy service across the trust in terms of service provision. Performance in medicines reconciliation at The Royal Oldham Hospital at both 24 and 72 hours was consistently below trust target.
Must-do action 9 of 77
Must do
Safe
The service must ensure that staff receive appropriate training, supervision and appraisals. This should include, but not be limited to, training in life support training, as is necessary to enable them to carry out the duties they are employed to perform.
Regulation: Regulation 18(1)(2)(a)
⚠ The service did not always ensure that staff received appropriate training, supervision and appraisals. Staff did not always complete mandatory training in key skills, particularly life support, with adult basic life support (BLS) compliance at 64% for nursing staff and 43% for medical staff.
Must-do action 10 of 77
Must do
Safe
The service must take action to monitor staff compliance for sepsis training and develop a more comprehensive mandatory training package to enable staff to support complex patients such as those living with dementia, autism, or a learning disability.
Regulation: Regulation 18(1)(2)(a)
⚠ The service did not monitor staff compliance for sepsis training, and a comprehensive mandatory training package to support complex patients (dementia, autism, learning disability) was not in place or mandatory.
Must-do action 11 of 77
Must do
Safe
The service must ensure that there are sufficient numbers and skill mix of nursing staff that can meet peoples care and treatment needs and keep them safe from avoidable harm.
Regulation: Regulation 18(1)
⚠ The service did not always have enough nursing staff to keep patients safe from avoidable harm and to provide the right care and treatment. Dayshift fill rates for registered nursing staff ranged from 74% to 83%.
Must-do action 12 of 77
Must do
Well-led
The trust must ensure it aligns relevant policies and procedures to reduce unwarranted variation in clinical practice, and that policies are up to date.
Regulation: Regulation 17(1)
⚠ The trust did not align relevant policies and procedures to reduce unwarranted variation in clinical practice, and policies were not always up to date. Some services were using legacy policies from previous trusts or accessing separate suites of policies.
Must-do action 13 of 77
Must do
Responsive
The service must continue to monitor and take appropriate actions to improve average length of patient stay, readmission rates and referral to treatment waiting time performance in line with national standards.
Regulation: Regulation 12(1)
⚠ People could not always access the service when they needed it or received the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not in line with national standards. The average length of patient stay was worse than the England average.
Must-do action 14 of 77
Must do
Responsive
The service must implement clear plans, with set timescales and actions, to improve patient's access to care and to achieve their timely discharge from hospital.
Regulation: Regulation 17(2)(a)(f)
⚠ The service did not implement clear plans, with set timescales and actions, to improve patient's access to care and to achieve their timely discharge from hospital. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not in line with national standards.
Must-do action 15 of 77
Must do
Well-led
The service must ensure there are suitable systems in place to assess, monitor and improve quality and performance of key processes effectively.
Regulation: Regulation 17(2)(a)(f)
⚠ The service did not ensure there were suitable systems in place to assess, monitor and improve quality and performance of key processes effectively. Whilst staff monitored the effectiveness of care and treatment, they did not consistently use the findings to make improvements.
Must-do action 16 of 77
Must do
Safe
The service must ensure that staff comply with all aspects of the surgical safety checklist.
Regulation: Regulation 12(1)
⚠ Theatre staff did not always comply with all aspects of the surgical safety checklist, with the debrief step showing 70% compliance in March 2022 and 66% in June 2022.
Must-do action 17 of 77
Must do
Safe
The trust must ensure that there are sufficient numbers and skill mix of nursing staff that can meet peoples care and treatment needs and keep them safe from avoidable harm.
Regulation: Regulation 18(1)
⚠ Services were not always safely staffed by people with the necessary skills, knowledge and experience. Staffing levels were below required levels in several areas across the trust.
Must-do action 18 of 77
Must do
Safe
The trust must ensure that staff receive training in key skills including mandatory training including resuscitation and safeguarding appropriate to their role.
Regulation: Regulation 18(1)(2)(a)
⚠ Staff did not always complete mandatory training in accordance with the relevant schedule and receive sufficient training, supervision and appraisal to perform their duties competently. Compliance with mandatory training was below the trust target in several areas.
Must-do action 19 of 77
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)
⚠ The trust was not effectively assessing and managing the risks to the health and safety of patients receiving care and treatment. Leaders and teams did not consistently use systems to manage performance effectively and did not always take actions to reduce their impact.
Must-do action 20 of 77
Must do
Safe
The trust must ensure that action is taken to improve timeliness of medicines reconciliation and of the administration of time sensitive medicines to support safer medicines prescribing and administration.
Regulation: Regulation 12(2)(g)
⚠ Performance in medicines reconciliation at The Royal Oldham Hospital at both 24 and 72 hours was consistently below trust target.
Must-do action 21 of 77
Must do
Well-led
The trust must ensure that all staff are using the most up to date version of the intranet policy store.
Regulation: Regulation 17(1)
⚠ Policy governance within the trust required significant improvement. Some services were using legacy policies from previous trusts or accessing a suite of policies separate to the central Northern Care Alliance hub.
Must-do action 22 of 77
Must do
Safe
The trust must take action to develop a more comprehensive mandatory training package to enable staff to support complex patients such as those living with dementia, autism, or a learning disability and monitor staff compliance.
Regulation: Regulation 18(1)(2)(a)
⚠ The NCA had not made completion of training in learning disability and autism mandatory, and staff had not completed the necessary programme of learning as required.
Must-do action 23 of 77
Must do
Safe
The trust must ensure that processes are followed to reduce the risk that medicines will be used outside their expiry date.
Regulation: Regulation 12(2)(g)
⚠ The trust did not ensure that processes were followed to reduce the risk that medicines would be used outside their expiry date.
Must-do action 24 of 77
Must do
Effective
The service must ensure that staff receive appropriate support, training, professional development, supervision and appraisals.
Regulation: Regulation 18(1)(2)(a)
⚠ The service did not always ensure that staff received appropriate support, training, professional development, supervision and appraisals.
Must-do action 25 of 77
Must do
Safe
The service must ensure that staff receive the appropriate training relevant to their role to enable them to carry out their duties and maintain the necessary skills to keep patients safe.
Regulation: Regulation 18(1)
⚠ The service did not always have training in key skills. The service was not meeting its mandatory training compliance target.
Must-do action 26 of 77
Must do
Safe
The service must ensure that there are sufficient numbers of both medical and nursing staff that can meet people's care and treatment needs and keep them safe from avoidable harm.
Regulation: Regulation 18(1)
⚠ The service did not have enough staff to care for patients and keep them safe.
Must-do action 27 of 77
Must do
Safe
The service must ensure mandatory training compliance is improved to support patient safety.
Regulation: Regulation 18(1)
⚠ The service was not meeting its mandatory training compliance target.
Must-do action 28 of 77
Must do
Responsive
The service must take actions to improve referral to treatment waiting time performance in line with national standards.
Regulation: Regulation 17(2)(b)
⚠ People could not always access the service when they needed it or received the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not in line with national standards.
Must-do action 29 of 77
Must do
Safe
The service must effectively and appropriately assess and manage the risks to service users who are waiting to receive care and treatment.
Regulation: Regulation 12(1)
⚠ The service did not effectively and appropriately assess and manage the risks to service users who are waiting to receive care and treatment. People could not always access the service when they needed it or received the right care promptly.
Must-do action 30 of 77
Must do
Safe
The service must ensure that they have enough medical or nursing staff to keep patients safe and that patients requiring one to one observations receive this level of care.
Regulation: Regulation 18(1)
⚠ Services were not always safely staffed by people with the necessary skills, knowledge and experience. Staffing levels were below required levels in several areas across the trust.
Must-do action 31 of 77
Must do
Safe
The service must ensure that all emergency trolleys are sealed, with a record of checks to show they are ready for use.
Regulation: Regulation 12(2)(e)
⚠ The design, maintenance and use of facilities, premises and equipment did not always keep people safe. Emergency trolleys were not always sealed or had a record of checks.
Must-do action 32 of 77
Must do
Safe
The service must ensure that all medicines are kept securely on the wards.
Regulation: Regulation 12(2)(g)
⚠ The service did not ensure that all medicines were kept securely on the wards. The service used systems and processes to safely prescribe, administer, record and store medicines, but issues were identified.
Must-do action 33 of 77
Must do
Safe
The service must ensure that levels of medical and nursing staff training in safeguarding, resuscitation techniques and other mandatory training courses meet trust targets.
Regulation: Regulation 18(2)(a)
⚠ Staff did not always complete mandatory training in accordance with the relevant schedule and receive sufficient training, supervision and appraisal to perform their duties competently. Compliance with mandatory training was below the trust target in several areas.
Must-do action 34 of 77
Must do
Safe
The service must ensure that substances that are hazardous to health are properly controlled and kept securely.
Regulation: Regulation 15(1)(a)
⚠ The design, maintenance and use of facilities, premises and equipment did not always keep people safe. Substances that are hazardous to health were not always properly controlled and kept securely.
Must-do action 35 of 77
Must do
Safe
The service must ensure that all staff follow infection control principles, including the use of personal protective equipment (PPE).
Regulation: Regulation 12(2)(h)
⚠ The service did not always control infection risk well. Staff did not consistently use equipment and control measures to protect patients, themselves, and others from infection.
Must-do action 36 of 77
Must do
Safe
The service must ensure that guidance and training on treating patients with eating disorders is adequately rolled out and delivered to all relevant staff.
Regulation: Regulation 18(2)(a)
⚠ Staff did not always complete mandatory training in accordance with the relevant schedule and receive sufficient training, supervision and appraisal to perform their duties competently. Guidance and training on treating patients with eating disorders was not adequately rolled out.
Must-do action 37 of 77
Must do
Responsive
The service must ensure that referral to treatment times for patients and national standards for treatment of patients with suspected cancer are met.
Regulation: Regulation 17(1)
⚠ The trust was experiencing significant issues with access and flow. Referral to treatment times for patients and national standards for treatment of patients with suspected cancer were not met.
Must-do action 38 of 77
Must do
Well-led
The service must ensure that all staff are using the most up to date version of the intranet policy store.
Regulation: Regulation 17(1)
⚠ Policy governance within the trust required significant improvement. Some services were using legacy policies from previous trusts or accessing a suite of policies separate to the central Northern Care Alliance hub.
Must-do action 39 of 77
Must do
Safe
The trust must ensure that staff receive appropriate training, supervision and appraisals. This should include, but not be limited to, training in life support as is necessary to enable them to carry out the duties they are employed to perform.
Regulation: Regulation 18(1)(2)(a)
⚠ The service provided mandatory training in key skills but not all staff completed it, this was particularly evident for resuscitation training. Mandatory training compliance for staff was 86% for nursing staff and 76% for medical staff, below the trust target of 90%.
Must-do action 40 of 77
Must do
Safe
The trust must ensure that there are sufficient numbers of nursing and medical staff that can meet people's care and treatment needs and keep them safe from avoidable harm.
Regulation: Regulation 18(1)
⚠ The service did not always have enough nursing and medical staff to keep patients safe from avoidable harm and to provide the right care and treatment.
Must-do action 41 of 77
Must do
Effective
The service must ensure they participate in clinical audit to demonstrate the effectiveness of care and treatment.
Regulation: Regulation 17(1)(2)(a)
⚠ There was limited evidence that the medical division monitored the effectiveness of care and treatment and used the findings to make improvements and achieved good outcomes for patients. The service did not participate in several national clinical audits.
Must-do action 42 of 77
Must do
Responsive
The trust must ensure that effective and timely care is provided to improve patient access and flow through the hospital to safe discharge or transfer to inpatients services.
Regulation: Regulation 12(1)(2)(i)
⚠ People could not always access the service when they needed it or received the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not in line with national standards.
Must-do action 43 of 77
Must do
Responsive
The trust must take actions to improve referral to treatment waiting time performance in line with national standards.
Regulation: Regulation 17(2)(b)
⚠ People could not always access the service when they needed it or received the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not in line with national standards.
Must-do action 44 of 77
Must do
Responsive
The trust must take actions to improve the timeliness of patient complaint responses to within the timescales specified in the trust complaints policy.
Regulation: Regulation 16(2)
⚠ Complaints were not always responded to within the timescales specified in the trust complaints policy. The division's compliance for responding to complaints within the agreed timeframe was 46%.
Must-do action 45 of 77
Must do
Safe
The service must ensure staff receive the required training to enable them to carry out the duties they are employed to perform. This includes but is not limited to life support, training on learning disabilities and autism and safeguarding training.
Regulation: Regulation 18(1)(2)(a)
⚠ The service did not always have training in key skills and did not always manage safety well. The service had low levels of compliance with life support training. Clinical staff did not complete specific training on recognising and responding to patients with mental health needs, learning disabilities, autism and dementia.
Must-do action 46 of 77
Must do
Safe
The service must deploy sufficient numbers of suitably qualified nursing and support staff to keep patients safe.
Regulation: Regulation 18(1)
⚠ The service did not have enough staff to care for patients and keep them safe. The service did not always deploy sufficient numbers of suitably qualified nursing and support staff to keep patients safe.
Must-do action 47 of 77
Must do
Safe
The service must ensure all areas of the department are clean and staff have access to enough equipment that is secure, suitable and properly maintained. This includes but is not limited to checks of specialist equipment and rooms used for assessing a patient’s mental health.
Regulation: Regulation 15(1)(a)(b)(c)(e)
⚠ Not all areas of the department were clean nor had suitable furnishings which were clean and well-maintained. The design, maintenance and use of facilities, premises and equipment did not always keep people safe, including the mental health assessment room which was unsafe.
Must-do action 48 of 77
Must do
Safe
The service must ensure they effectively assess risks to patients and do all that is possible to mitigate such risks. This includes but is not limited to risk relating to patients placed on corridors, patients with suspected sepsis and other specific risk issues.
Regulation: Regulation 12(1)(2)(a)(b)
⚠ Patients with suspected sepsis were not always escalated appropriately or treated in a timely manner. Staff did not consistently assess risks to patients, nor act on them. The service did not always identify nor quickly act upon patients at risk of deterioration.
Must-do action 49 of 77
Must do
Caring
The service must ensure patients are treated with dignity and respect and ensure the privacy for patients is maintained, particularly for those cared for on the corridor.
Regulation: Regulation 10(1)(2)(a)
⚠ Due to staff shortages and overcrowding in the department, staff were not able to respect the privacy and dignity of patients. They were not able to take account of their individual needs, nor help them understand their conditions.
Must-do action 50 of 77
Must do
Responsive
The service must ensure it acts to mitigate the risks to patients waiting in the department including those waiting for triage, treatment, admission or on a trolley. It must ensure patients can access the service when they need it.
Regulation: Regulation 12(1)(2)(b)
⚠ People could not access the service when they needed it and had to wait too long for treatment. The service did not act to mitigate the risks to patients waiting in the department.
Must-do action 51 of 77
Must do
Well-led
The service must ensure it operates effective systems and processes to assess, monitor and improve the quality and safety of services.
Regulation: Regulation 17(1)(2)(a)
⚠ Leaders did not consistently run services well and did not always use reliable information systems. The service did not operate effective systems and processes to assess, monitor and improve the quality and safety of services.
Must-do action 52 of 77
Must do
Safe
The service must ensure staff receive the required training to enable them to carry out the duties they are employed to perform. This includes but is not limited to safeguarding and training on learning disability and autism.
Regulation: Regulation 18(1)(2)(a)
⚠ Staff did not always complete mandatory training in accordance with the relevant schedule and receive sufficient training, supervision and appraisal to perform their duties competently. Compliance with mandatory training was below the trust target in several areas.
Must-do action 53 of 77
Must do
Safe
The service must deploy sufficient numbers of suitably qualified nursing and support staff to keep patients safe.
Regulation: Regulation 18(1)
⚠ Services were not always safely staffed by people with the necessary skills, knowledge and experience. Staffing levels were below required levels in several areas across the trust.
Must-do action 54 of 77
Must do
Safe
The service must ensure all areas of the department are clean and staff have access to enough equipment that is secure, suitable and properly maintained. This includes but is not limited to checks of specialist equipment and rooms used for assessing a patient’s mental health.
Regulation: Regulation 15(1)(a)(b)(c)(e)
⚠ The design, maintenance and use of facilities, premises and equipment did not always keep people safe. All areas of the department were not clean and staff did not have access to enough equipment that was secure, suitable and properly maintained.
Must-do action 55 of 77
Must do
Safe
The service must ensure they effectively assess risks to patients and do all that is possible to mitigate such risks. This includes but is not limited to risk relating to patients placed on corridors, patients awaiting triage and treatment, patients with suspected sepsis and other specific risk issues.
Regulation: Regulation 12(1)(2)(a)(b)
⚠ The trust was not effectively assessing and managing the risks to the health and safety of patients receiving care and treatment. Leaders and teams did not consistently use systems to manage performance effectively and did not always take actions to reduce their impact.
Must-do action 56 of 77
Must do
Well-led
The service must ensure it operates effective systems and processes to assess, monitor and improve the quality and safety of services.
Regulation: Regulation 17(1)(2)(a)
⚠ Leaders did not operate consistent, effective governance processes throughout the service. The service did not operate effective systems and processes to assess, monitor and improve the quality and safety of services.
Must-do action 57 of 77
Must do
Safe
The service must ensure staff receive the required training to enable them to carry out the duties they are employed to perform. This includes but is not limited to life support, learning disabilities and autism and safeguarding training.
Regulation: Regulation 18(1)(2)(a)
⚠ The service did not always have enough nursing staff and support staff with the right qualifications, skills, training, and experience to keep patients safe. Staff were experienced and qualified but did not always have right skills and knowledge to meet the needs of patients because not all staff completed the …
Must-do action 58 of 77
Must do
Safe
The service must deploy sufficient numbers of suitably qualified nursing and support staff to keep patients safe.
Regulation: Regulation 18(1)
⚠ The service did not always have enough nursing staff and support staff with the right qualifications, skills, training, and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
Must-do action 59 of 77
Must do
Responsive
The service must ensure it acts to mitigate the risks to patients waiting in the department including those waiting for triage, treatment, admission or on a trolley. It must ensure patients can access the service when they need it.
Regulation: Regulation 12(1)(2)(b)
⚠ People could not access the service when they needed it and had to wait too long for treatment. The service did not act to mitigate the risks to patients waiting in the department.
Must-do action 60 of 77
Must do
Safe
The service must ensure all areas of the department are suitable and properly maintained. This includes but is not limited to the size and design of the department and rooms used for assessing a patient’s mental health.
Regulation: Regulation 15(1)(b)(c)(d)
⚠ The design, maintenance and use of facilities, premises and equipment did not always keep people safe. The service did not ensure all areas of the department were suitable and properly maintained.
Must-do action 61 of 77
Must do
Well-led
The service must ensure it operates effective systems and processes to assess, monitor and improve the quality and safety of services.
Regulation: Regulation 17(1)(2)(a)
⚠ Staff did not always monitor the effectiveness of care and treatment. Findings were not used to make improvements and achieve good outcomes for patients. The service did not operate effective systems and processes to assess, monitor and improve the quality and safety of services.
Must-do action 62 of 77
Must do
Safe
The trust must ensure that staff receive training in key skills including mandatory training including resuscitation, safeguarding and Practical Obstetric Multi-Professional Training (PROMPT) appropriate to their role.
Regulation: Regulation 18(1)(2)(a)
⚠ Staff did not always complete mandatory training in accordance with the relevant schedule and receive sufficient training, supervision and appraisal to perform their duties competently. Compliance with mandatory training was below the trust target in several areas.
Must-do action 63 of 77
Must do
Safe
The trust must ensure that equipment is maintained in a timely manner and staff have assurance that it safe to use.
Regulation: Regulation 12(1)(2)(e)
⚠ The design, maintenance and use of facilities, premises and equipment did not always keep people safe. Equipment was not maintained in a timely manner and staff did not have assurance that it was safe to use.
Must-do action 64 of 77
Must do
Safe
The trust must ensure that daily safety checks of equipment are fully completed.
Regulation: Regulation 12(1)(2)(e)
⚠ The design, maintenance and use of facilities, premises and equipment did not always keep people safe. Daily safety checks of equipment were not fully completed.
Must-do action 65 of 77
Must do
Safe
The service must ensure that trust processes are followed to reduce the risk that medicines will be used outside their expiry date including for medicines with a shortened expiry once opened.
Regulation: Regulation 12(1)(2)(g)
⚠ The trust did not ensure that processes were followed to reduce the risk that medicines would be used outside their expiry date including for medicines with a shortened expiry once opened.
Must-do action 66 of 77
Must do
Safe
The trust must ensure that any shortfalls in midwifery staffing have mitigations in place to ensure safe levels.
Regulation: Regulation 18(1)
⚠ Services were not always safely staffed by people with the necessary skills, knowledge and experience. Staffing levels were below required levels in several areas across the trust.
Must-do action 67 of 77
Must do
Safe
The trust must ensure that there are robust processes for medicines management.
Regulation: Regulation 12(1)(2)(g)
⚠ The trust did not ensure that there were robust processes for medicines management. The service used systems and processes to safely prescribe, administer, record and store medicines, but issues were identified.
Must-do action 68 of 77
Must do
Effective
The trust must ensure that records are completed contemporaneously and all are accessible to staff providing care.
Regulation: Regulation 17(1)(2)(c)
⚠ The service collected data and analysed it. However, not all staff were assured that the data was always accurate. Data was not recorded or presented uniformly across the trust and some important data was not captured. Records were not completed contemporaneously and were not always accessible.
Must-do action 69 of 77
Must do
Effective
The trust must ensure that staff complete an annual appraisal and are supported to develop their skills.
Regulation: Regulation 18(1)(2)(a)
⚠ Staff did not always complete an annual appraisal and were not supported to develop their skills. Compliance with appraisals was below trust targets.
Must-do action 70 of 77
Must do
Well-led
The trust must ensure that all action plans continue to be monitored and are embedded to help drive improvement and outcomes for women.
Regulation: Regulation 17(1)(2)(a)(b)
⚠ Leaders did not operate consistent, effective governance processes throughout the service. All action plans were not continuously monitored and embedded to help drive improvement and outcomes.
Must-do action 71 of 77
Must do
Safe
The trust must ensure that staff receive training in key skills including mandatory training including resuscitation, safeguarding and Practical Obstetric Multi-Professional Training (PROMPT) appropriate to their role.
Regulation: Regulation 18(1)(2)(a)
⚠ Staff did not always complete mandatory training in accordance with the relevant schedule and receive sufficient training, supervision and appraisal to perform their duties competently. Compliance with mandatory training was below the trust target in several areas.
Must-do action 72 of 77
Must do
Safe
The trust must ensure that equipment is maintained in a timely manner and daily checks are completed so that staff have assurance that equipment is safe to use.
Regulation: Regulation 12(1)(2)(e)
⚠ The design, maintenance and use of facilities, premises and equipment did not always keep people safe. Equipment was not maintained in a timely manner and daily checks were not completed so that staff had assurance that equipment was safe to use.
Must-do action 73 of 77
Must do
Safe
The trust must ensure that any shortfalls in midwifery staffing have mitigations in place to ensure safe levels.
Regulation: Regulation 18(1)
⚠ Services were not always safely staffed by people with the necessary skills, knowledge and experience. Staffing levels were below required levels in several areas across the trust.
Must-do action 74 of 77
Must do
Safe
The trust must ensure that there are robust processes for medicines management.
Regulation: Regulation 12(1)(2)(g)
⚠ The trust did not ensure that there were robust processes for medicines management. The service used systems and processes to safely prescribe, administer, record and store medicines, but issues were identified.
Must-do action 75 of 77
Must do
Effective
The trust must ensure that records are completed contemporaneously and all are accessible to staff providing care.
Regulation: Regulation 17(1)(2)(c)
⚠ The service collected data and analysed it. However, not all staff were assured that the data was always accurate. Data was not recorded or presented uniformly across the trust and some important data was not captured. Records were not completed contemporaneously and were not always accessible.
Must-do action 76 of 77
Must do
Effective
The trust must ensure that staff complete an annual appraisal and are supported to develop their skills.
Regulation: Regulation 18(1)(2)(a)
⚠ Staff did not always complete an annual appraisal and were not supported to develop their skills. Compliance with appraisals was below trust targets.
Must-do action 77 of 77
Must do
Well-led
The trust must ensure that all action plans continue to be monitored and are embedded to help drive improvement and outcomes for women.
Regulation: Regulation 17(1)(2)(a)(b)
⚠ Leaders did not operate consistent, effective governance processes throughout the service. All action plans were not continuously monitored and embedded to help drive improvement and outcomes.

Should-do actions (36)

Recommended improvements to enhance service quality.

Should-do action 1 of 36
Should do
Well-led
The trust should ensure there is clarity in the roles and responsibilities of executive leads and that roles allow equitable capacity for the executive directors.
Regulation: Regulation 17(1)
Should-do action 2 of 36
Should do
Well-led
The trust should ensure serious incidents are investigated in a timely manner and learning is shared across the organisation as required.
Regulation: Regulation 17(2)(a)(b)
Should-do action 3 of 36
Should do
Well-led
The trust should ensure staff understand relevant strategies and can comment and contribute where appropriate.
Regulation: Regulation 17(2)(e)(f)
Should-do action 4 of 36
Should do
Well-led
The trust should ensure it continues to improve culture and support staff to speak up.
Regulation: Regulation 17(2)(e)(f)
Should-do action 5 of 36
Should do
Well-led
The trust should ensure it effectively manages the administration of the fit and proper persons checks.
Regulation: Regulation 19(2)
Should-do action 6 of 36
Should do
Responsive
The trust should ensure complaints are investigated and responded to in accordance with the relevant policy and best practice.
Regulation: Regulation 16(1)(2)
Should-do action 7 of 36
Should do
Safe
The service should ensure it takes appropriate actions to improve timeliness and compliance for completing risk assessments and intentional rounding observations in line with trust targets.
Regulation: Regulation 12(1)(2)(a)(b)
Should-do action 8 of 36
Should do
Effective
The service should ensure it takes action to improve clinical audit outcomes and take appropriate actions to reduce the number of outstanding reports and overdue action plans.
Regulation: Regulation 17(1)
Should-do action 9 of 36
Should do
Caring
The service should ensure it takes action to implement a more dementia-friendly environment across the surgical wards and theatre area.
Regulation: Regulation 9(3)(b)
Should-do action 10 of 36
Should do
Caring
The service should ensure it takes action to encourage and improve the utilisation of ‘this is me’ documents or ‘hospital passports’.
Regulation: Regulation 9(3)(b)
Should-do action 11 of 36
Should do
Responsive
The service should ensure it takes action to improve the timeliness of patient complaint responses to within the timescales specified in the trust complaints policy.
Regulation: Regulation 16(1)(2)
Should-do action 12 of 36
Should do
Well-led
The service should continue to take action to enlist a clinical director of general and oral surgery and ensure that all required staff have job plans in place.
Regulation: Regulation 18(1)
Should-do action 13 of 36
Should do
Safe
The trust should ensure emergency medicines checks are completed.
Regulation: Regulation 12(1)(2)(g)
Should-do action 14 of 36
Should do
Safe
The trust should ensure that patient observations are carried out in a timely manner.
Regulation: Regulation 12(1)(2)(a)(b)
Should-do action 15 of 36
Should do
Safe
The service should ensure that cleaning schedules are completed appropriately.
Regulation: Regulation 12(1)(2)(h)
Should-do action 16 of 36
Should do
Safe
The service should consider developing a more comprehensive mandatory training package to enable staff to support complex patients such as those living with dementia, autism or a learning disability.
Regulation: Regulation 18(2)(a)
Should-do action 17 of 36
Should do
Caring
The service should ensure that mixed sex breaches are avoided on medical wards.
Regulation: Regulation 10(2)(a)
Should-do action 18 of 36
Should do
Responsive
The service should ensure that ward moves are not completed after 8pm, unless clinically required, to avoid disturbing rest and disorientating patients.
Regulation: Regulation 12(1)(2)(b)(i)
Should-do action 19 of 36
Should do
Well-led
The service should consider developing a vision and strategy that is specific to the medicine division.
Should-do action 20 of 36
Should do
Safe
This service should ensure tools to identify patients at risk of deterioration are used in an accurate and timely manner by staff.
Regulation: Regulation 12(1)(2)(a)(b)
Should-do action 21 of 36
Should do
Safe
The service should ensure that the premises are safe to use for their intended purpose and are used in a safe way.
Regulation: Regulation 12(1)(2)(d)
Should-do action 22 of 36
Should do
Safe
The service should ensure that all staff use, and wear, required personal protective equipment, including the correct use of surgical facemasks.
Regulation: Regulation 12(1)(2)(h)
Should-do action 23 of 36
Should do
Safe
The service should ensure staff store patient records and information securely.
Regulation: Regulation 17(1)(2)(c)
Should-do action 24 of 36
Should do
Effective
The service should ensure they meet the nutritional and hydration needs of patients.
Regulation: Regulation 14(1)(2)(b)
Should-do action 25 of 36
Should do
Effective
The service should ensure patients receive timely pain relief to ensure that care and treatment meets their needs.
Regulation: Regulation 9(1)(2)(3)(b)
Should-do action 26 of 36
Should do
Effective
The service should ensure care and treatment is carried out with the informed consent of the patient and such consent is clearly recorded.
Regulation: Regulation 11(1)
Should-do action 27 of 36
Should do
Safe
The trust should ensure that consumables are stored securely in clinic rooms.
Regulation: Regulation 12(1)(2)(e)
Should-do action 28 of 36
Should do
Responsive
The trust should ensure that all minority groups are included in service planning.
Regulation: Regulation 17(1)(2)(e)
Should-do action 29 of 36
Should do
Well-led
The trust should ensure that leaders communicate the vision and strategy to all staff.
Regulation: Regulation 17(1)(2)(e)(f)
Should-do action 30 of 36
Should do
Safe
The trust should ensure that lone worker arrangements are robust to keep community staff safe.
Regulation: Regulation 17(1)(2)(b)
Should-do action 31 of 36
Should do
Responsive
The trust should ensure that information to provide feedback, including how to complain, is clearly displayed in all areas.
Regulation: Regulation 16(1)(2)
Should-do action 32 of 36
Should do
Safe
The trust should consider the use of Situation, Background, Assessment, Recommendation (SBAR) for handover processes.
Should-do action 33 of 36
Should do
Effective
The trust should consider applying for reaccreditation with the UNICEF baby friendly initiative.
Should-do action 34 of 36
Should do
Responsive
The trust should consider readmitting babies for phototherapy to paediatric wards rather than maternity.
Should-do action 35 of 36
Should do
Well-led
The trust should ensure that leaders communicate the vision and strategy to all staff.
Regulation: Regulation 17(1)(2)(e)(f)
Should-do action 36 of 36
Should do
Safe
The trust should ensure that lone worker arrangements are robust to keep community staff safe.
Regulation: Regulation 17(1)(2)(b)

Location details

CQC ID: RM315
Local authority: Bury
Region: North West

Inspection report

Type: Location
Date: 22 December 2022
Rating: Requires improvement
Actions: 77 must-do 36 should-do
AI-extracted 3 Jun 2026

Related PFD reports

2025-0268 — Michelle Mason (Jun 2025)
2025-0147 — Mark Fernandez (Mar 2025)
2024-0614 — Anne Taylor (Nov 2024)
2024-0437 — Mary Horgan (Aug 2024)
2023-0493 — Donna Donnellan (Nov 2023)
2021-0433 — Nichola Lomax (Dec 2021)
2021-0348 — Mohammed Salam (Oct 2021)
2021-0215 — Leslie Horsfield (Jun 2021)
2021-0028 — Monica McCormick (Feb 2021)
2019-0436 — Constance Robinson (Dec 2019)