Source · CQC inspection
Rochdale Infirmary
Provider Northern Care Alliance NHS Foundation Trust
Type NHS Healthcare Organisation
Region North West
Overall rating: Not Yet Rated View full CQC report
Domain ratings
Safe
Not Yet Rated
Effective
Not Yet Rated
Caring
Not Yet Rated
Responsive
Not Yet Rated
Well-led
Not Yet Rated
Current CQC assessment
Ratings by service
Medical care (Including older people's care)
Good
Earlier inspection findings
Must-do actions (77)
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 maker to ensure they have effective oversight.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Must-do action 13 of 77
Must do
Safe
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.
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.
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.
Must-do action 16 of 77
Must do
Safe
The service must ensure that staff comply with all aspects of the surgical safety checklist.
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.
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.
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.
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.
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.
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.
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.
Must-do action 24 of 77
Must do
Safe
The service must ensure that staff receive 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.
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.
Must-do action 27 of 77
Must do
Safe
The service must ensure mandatory training compliance is improved to support patient safety.
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.
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.
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.
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.
Must-do action 32 of 77
Must do
Safe
The service must ensure that all medicines are kept securely on the wards.
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.
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.
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).
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Must-do action 50 of 77
Must do
Safe
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 to the service when they need it.
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.
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.
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.
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.
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.
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.
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.
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.
Must-do action 59 of 77
Must do
Safe
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 to the service when they need it.
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.
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.
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.
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.
Must-do action 64 of 77
Must do
Safe
The trust must ensure that daily safety checks of equipment are 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.
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.
Must-do action 67 of 77
Must do
Safe
The trust must ensure that there are robust processes for medicines management.
Must-do action 68 of 77
Must do
Safe
The trust must ensure that records are completed contemporaneously and all are accessible to staff providing care.
Must-do action 69 of 77
Must do
Safe
The trust must ensure that staff complete an annual appraisal and are supported to develop their skills.
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.
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.
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.
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.
Must-do action 74 of 77
Must do
Safe
The trust must ensure that there are robust processes for medicines management.
Must-do action 75 of 77
Must do
Safe
The trust must ensure that records are completed contemporaneously and all are accessible to staff providing care.
Must-do action 76 of 77
Must do
Safe
The trust must ensure that staff complete an annual appraisal and are supported to develop their skills.
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.
Should-do actions (43)
Should-do action 1 of 43
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.
Should-do action 2 of 43
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.
Should-do action 3 of 43
Should do
Well-led
The trust should ensure staff understand relevant strategies and can comment and contribute where appropriate.
Should-do action 4 of 43
Should do
Well-led
The trust should ensure it continues to improve culture and support staff to speak up.
Should-do action 5 of 43
Should do
Well-led
The trust should ensure it effectively manages the administration of the fit and proper persons checks.
Should-do action 6 of 43
Should do
Responsive
The trust should ensure complaints are investigated and responded to in accordance with the relevant policy and best practice.
Should-do action 7 of 43
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.
Should-do action 8 of 43
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.
Should-do action 9 of 43
Should do
Caring
The service should ensure it takes action to implement a more dementia-friendly environment across the surgical wards and theatre area.
Should-do action 10 of 43
Should do
Caring
The service should ensure it takes action to encourage and improve the utilisation of ‘this is me’ documents or ‘hospital passports’.
Should-do action 11 of 43
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.
Should-do action 12 of 43
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.
Should-do action 13 of 43
Should do
Safe
The trust should ensure emergency medicines checks are completed.
Should-do action 14 of 43
Should do
Safe
The trust should ensure that patient observations are carried out in a timely manner.
Should-do action 15 of 43
Should do
Safe
The service should ensure that cleaning schedules are completed appropriately.
Should-do action 16 of 43
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.
Should-do action 17 of 43
Should do
Caring
The service should ensure that mixed sex breaches are avoided on medical wards.
Should-do action 18 of 43
Should do
Caring
The service should ensure that ward moves are not completed after 8pm, unless clinically required, to avoid disturbing rest and disorientating patients.
Should-do action 19 of 43
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 43
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.
Should-do action 21 of 43
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.
Should-do action 22 of 43
Should do
Safe
The service should ensure that all staff use, and wear, required personal protective equipment, including the correct use of surgical facemasks.
Should-do action 23 of 43
Should do
Safe
The service should ensure staff store patient records and information securely.
Should-do action 24 of 43
Should do
Effective
The service should ensure they meet the nutritional and hydration needs of patients.
Should-do action 25 of 43
Should do
Effective
The service should ensure patients receive timely pain relief to ensure that care and treatment meets their needs.
Should-do action 26 of 43
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.
Should-do action 27 of 43
Should do
Safe
The service should ensure staff store patient records and information securely.
Should-do action 28 of 43
Should do
Effective
The service should ensure patients receive timely pain relief to ensure that care and treatment meets their needs.
Should-do action 29 of 43
Should do
Safe
The service should ensure that all staff use, and wear, required personal protective equipment, including the correct use of surgical facemasks.
Should-do action 30 of 43
Should do
Safe
The service should ensure staff store patient records and information securely.
Should-do action 31 of 43
Should do
Effective
The service should ensure they meet the nutritional and hydration needs of patients.
Should-do action 32 of 43
Should do
Effective
The service should ensure patients receive timely pain relief to ensure that care and treatment meets their needs.
Should-do action 33 of 43
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.
Should-do action 34 of 43
Should do
Safe
The trust should ensure that consumables are stored securely in clinic rooms.
Should-do action 35 of 43
Should do
Responsive
The trust should ensure that all minority groups are included in service planning.
Should-do action 36 of 43
Should do
Well-led
The trust should ensure that leaders communicate the vision and strategy to all staff.
Should-do action 37 of 43
Should do
Safe
The trust should ensure that lone worker arrangements are robust to keep community staff safe.
Should-do action 38 of 43
Should do
Responsive
The trust should ensure that information to provide feedback, including how to complain, is clearly displayed in all areas.
Should-do action 39 of 43
Should do
Safe
The trust should consider the use of Situation, Background, Assessment, Recommendation (SBAR) for handover processes.
Should-do action 40 of 43
Should do
Effective
The trust should consider applying for reaccreditation with the UNICEF baby friendly initiative.
Should-do action 41 of 43
Should do
Effective
The trust should consider readmitting babies for phototherapy to paediatric wards rather than maternity.
Should-do action 42 of 43
Should do
Well-led
The trust should ensure that leaders communicate the vision and strategy to all staff.
Should-do action 43 of 43
Should do
Safe
The trust should ensure that lone worker arrangements are robust to keep community staff safe.