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The Royal Oldham Hospital

Provider The Pennine Acute Hospitals NHS Trust Type NHS Healthcare Organisation Region North West Last inspected 3 Dec 2020

Overall rating: Requires Improvement  View full CQC report

Domain ratings

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

Earlier inspection findings

pre-2024 framework · 9 must-do 3 should-do

Must-do actions (9)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 9
Must do
Safe
The trust must ensure that staff in the service prevent and control the spread of infection by adhering to the trust infection prevention and control policy in relation to hand hygiene.
Regulation: Regulation 12(1)
⚠ On multiple occasions we saw that staff did not adhere to hand hygiene protocols; alcohol gel was used but this was not consistent.
Must-do action 2 of 9
Must do
Safe
The trust must ensure that staff in the service prevent and control the spread of infection by adhering to the trust infection prevention and control policy in the use of personal protective equipment at all times and in all areas.
Regulation: Regulation 12(1)
⚠ We noted a staff member taking a patient’s history on the respiratory corridor without eye protection. Another staff member interacted closely with patients and the immediate physical environment, without using gloves and without washing hands or changing PPE between patients. Staff did not always change personal protective equipment (PPE) when …
Must-do action 3 of 9
Must do
Safe
The trust must ensure that staff in the service prevent and control the spread of infection by adhering to trust infection prevention and control policy in maintaining patient and staff safety through social distancing.
Regulation: Regulation 12(1)
⚠ Staff did not always maintain social distancing between patients or themselves. We saw six staff members not maintaining social distance in an office next to the green (non-COVID) resuscitation area. Staff workstations within the department were close together which limited staff ability to socially distance when updating patient records. Staff, …
Must-do action 4 of 9
Must do
Safe
The trust must ensure that staff in the service prevent and control the spread of infection by adhering to trust infection prevention and control policy and cleaning protocols when cleaning cubicle spaces between patients.
Regulation: Regulation 12(1)
⚠ Although staff cleaned cubicles and equipment between patients, cleaning of the floor area was not consistent. We also saw that the department’s patient assisted transfer board was not always decontaminated after use by external partner staff. This increased the risk of cross contamination or cross infection of patients and staff.
Must-do action 5 of 9
Must do
Safe
The trust must improve the flow of patients through the emergency department and the hospital so that patients are assessed, treated, admitted and discharged in a safe, timely manner.
Regulation: Regulation 12(1)
⚠ However, during periods of high demand, long waits to be seen, treated, discharged or admitted meant that patients could be exposed to an increased risk of harm.
Must-do action 6 of 9
Must do
Safe
The service must ensure that care is provided in line with national performance standards.
Regulation: Regulation 12(1)
⚠ Key performance metrics including ambulance handover times, waiting times from referral to treatment and arrangements to admit, treat and discharge patients, 12-hour trolley waits, and total time in the department were not in line with national standards or trust internal targets.
Must-do action 7 of 9
Must do
Caring
The trust must ensure the service maintains patients’ privacy and dignity at all times on the corridors when undertaking confidential conversations, assessments and providing treatment.
Regulation: Regulation 10(1)
⚠ Although staff treated patients with compassion and kindness patients’ privacy and dignity was not always maintained in the corridors during period of high demand, particularly when physical examination was required, and the allocated cubicle was already in use. Privacy screens were available, but staff told us there were insufficient screens …
Must-do action 8 of 9
Must do
Safe
The trust must ensure that staff in the service have the appropriate qualifications, competence and skill through completion and are compliance with all levels of life support training appropriate to their role.
Regulation: Regulation 12(1)
⚠ Training compliance rates for advanced life support and paediatric advanced life support were low across all staff groups. Adult basic life support training rates were over 80% for eligible nurses and healthcare support workers. Training compliance rates for advanced life support was lower at 49% and 48%, and advanced paediatric …
Must-do action 9 of 9
Must do
Safe
The trust must ensure that, where the service continues to use the temporary mental health assessment room, the room is compliant with the standards set out in the Psychiatric Liaison Accreditation Network’s Quality Standards for Liaison Psychiatry Services
Regulation: Regulation 15(1)
⚠ The service had repurposed the plaster room into a temporary mental health assessment room. The room was not fully suitable for this purpose. There was only one entrance and exit door and this did not have an observation window. Though some fittings had been boxed in there were sharp edges …

Should-do actions (3)

Recommended improvements to enhance service quality.

Should-do action 1 of 3
Should do
Safe
The trust should continue to monitor staff compliance with recording fridge temperatures and consider reminding staff of the need to check with pharmacy when the fridges are not noted to have gone out of range.
Should-do action 2 of 3
Should do
Safe
The trust should consider reviewing the service’s healthcare support worker fill rates once the newly recruited staff are in post to determine if this has had a positive impact on the fill rates.
Should-do action 3 of 3
Should do
Safe
The trust should consider what actions the service can take to improve safeguarding adults and safeguarding children level three training rates for doctors.

Location details

CQC ID: RW603
Local authority: Oldham
Region: North West

Inspection report

Type: Focused inspection
Date: 3 December 2020
Rating: Requires improvement
Actions: 9 must-do 3 should-do
AI-extracted 3 Jun 2026