We carried out an unannounced inspection at Rochdale Infirmary because we had received information of concern. We had been told that staffing levels during the night were insufficient to care for patients’ needs.

We arrived at the inspection at 5.15am and inspected the Urgent Care Centre (UCC) and the Clinical Assessment Unit (CAU). We saw evidence that there were sometimes less staff on duty than on the night of our inspection. Staff described the problems this caused.

All the staff we spoke with told us that the locum doctor working at the UCC frequently spent several hours seeing patients on the CAU, and this put pressure on the staff at the UCC.

The staff we spoke with on the CAU gave us examples of when all the staff were required to give one to one care to patients. They said that on these occasions they were unable to care for other patients on the ward, and it was impossible to access extra staff in these situations.

The trust supplied us with evidence that was contradictory to the information given to us by staff. We saw evidence that during a 16 day period the doctor from the UCC attended the CAU on five nights, spending an average of 28 minutes on the CAU. We also saw evidence that over a ten month period patient watch had been requested on ten occasions. Additional staff were either provided or were not required due to the number of staff already on duty.

We found there were enough staff on duty during the night to meet the needs of the patients.

Patients who were able told us they were involved in discussions with staff about their care. They said they were pleased they were being cared for in a hospital close to their home.

When asked about the staff patients said “There’s no problems here” and “They’ve been all right, it’s grand here”. Patients told us “They are very good here, better than [another hospital in the area]” and “Staff are very good”. One patient said “It seems to be very relaxed here with it being a small hospital”.

We saw the results of the urgent care centre patient satisfaction survey for 11 April 2012. When asked to rate their overall experience of the urgent care centre 95% of respondents rated it as eight or above out of 10.

The patients we spoke with said that staff had spoken with them about their discharge, and other professionals, such as social workers, had asked about help they might need at home.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that improvements had been made and no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

We did not receive feedback from people who use the service as part of this review as no one was available to talk to us at the time of our visit.

During our visit on 19 January 2011 we interviewed 11 patients. We were told that care was good and patients were kept up to date with information about their care and treatment. Staff explained everything in a way that patients could understand. We heard very positive comments about the food.

The Pennine Acute Hospitals NHS Trust provides general and specialist hospital services to around 820,000 residents across the north east of Greater Manchester in Bury, Prestwich, North Manchester, Middleton, Heywood, Oldham, Rochdale and parts of East Lancashire.

Rochdale Infirmary is part of The Pennine Acute Trust and the trust has three other acute hospital sites, which are: North Manchester General Hospital, Oldham General Hospital and Fairfield Hospital (Bury), and also provides a large community service.

We were told that 13,100 patients had attended the day surgery unit from July 2014 to June 2015.

During our inspection, we visited five theatres, two recovery wards and the ophthalmic ward

The Care Quality Commission (CQC) carried out a comprehensive planned inspection at Rochdale Infirmary between 23 February and 3 March 2016; we inspected urgent care, medical, surgical and outpatient and diagnostic services. There are 21 inpatient beds at the hospital.

The urgent care centre provides non-emergency services to around 240,000 residents that live in the communities of Heywood, Middleton and Rochdale. The department is open 24 hours a day, seven days a week.

Medical services at Rochdale Infirmary are provided from two wards and an endoscopy department. The clinical assessment unit (CAU) accepts patients via GP referral, or patients may be admitted via transfer from other trust sites or the urgent care centre. Rochdale Infirmary also hosts the oasis unit, which is a five bedded specialist dementia ward, offering medical treatment to patients with a diagnosis of dementia or delirium.

The surgical services at Rochdale Infirmary carry out a range of surgical procedures such as ophthalmology, colorectal surgery and general surgery (such as gastro-intestinal surgery. 13,100 patients attended the day surgery unit from July 2014 to June 2015.

The outpatient department (OPD) provides a number of clinics, including orthopaedic, urology, rheumatology, pain, respiratory and infectious diseases. The radiology department provides digital radiography services, computed tomography (CT) and magnetic resonance (MR) imaging.

The overall rating for this hospital was good for medical care, surgery and outpatients and diagnostic services, however, urgent care services required improvement.

Our key findings were as follows:

Incident Reporting

• Staff were encouraged to report incidents, which included near misses. Feedback was optional but staff reported that feedback was given when asked for.
• We saw evidence of incidents being reviewed by the clinical lead in the department and actions being taken so that lessons were learnt. If a serious incident occurred, the trust policy was for it to be escalated to the risk management team who would then assign it to an appropriate member of staff for investigation.

• Patients were given information about how to make a complaint. There had been four complaints about medical services at the hospital between 1 December 2014 and 31 December 2015. Complaints were discussed at clinical governance meetings and a quarterly learning from experience was sent to the trust board.

• However, complaints and concerns were not responded to in a timely manner to help improve services within the urgent care department.

Cleanliness and infection control

• Medical services were clean and tidy. Infection prevention audits were completed and showed that the areas we visited were compliant with trust policies. We saw staff using personal protective equipment, such as aprons and gloves and observed them washing their hands appropriately.
• In surgical services we observed good infection prevention practices by staff and noted good compliance in this area.

Caring

• Staff were kind, caring and compassionate. They maintained the privacy and dignity of patients in their care.
• Patients were cared for in an individualised way of the oasis unit and their carers and families were encouraged to be involved in their care.
• Friends and family test results showed that 97.5% of patients would recommend medical services at Rochdale Infirmary. Open visiting was in place and there was access to specialist mental health services.

Leadership, vision and clinical governance

• Overall the hospital leadership was strong and cohesive, with a clear vision and strategy.
• Care and treatment was delivered in line with evidence based practice and national guidance, such as those from the National Institute for Health and Care Excellence (NICE) and Royal College of Emergency Medicine (CEM).
• Local audits were completed and the endoscopy unit was accredited by the Joint Advisory Group on Gastrointestinal Endoscopy (JAG).
• Staff described the culture as friendly and supportive and they were proud of the services they provided; staff were positive about working in the service and described a culture of flexibility and commitment.
• Staff had been involved in the development of the trust vision and values and the “healthy, happy, here” programme of work.
• However, Patient risk was not always monitored and documented appropriately through the use of the early warning scores (EWS) and the Manchester early warning score (MANCHEWS) for children in the urgent care department.
• The effectiveness of treatment was not measured on a regular basis so that there was the opportunity to improve services within the urgent care department.
• Patient records were not consistently recorded in line with GMC guidelines within the medical department and not always kept securely in the surgical department.

Staffing

• Medical and nursing staffing levels and skill mix in surgical services was recognised as being appropriate to meet patient need and reflected current guidance. Operating theatres were established against the ‘Association for Perioperative Practice (AfPP) staffing recommendations.
• In medical services, nursing staffing had been calculated using a recognised acuity tool and shift fill rates were very high. Medical cover was provided 24 hours a day and senior advice was available from Fairfield General Hospital.
• However, there were not always sufficient numbers of staff with the appropriate skills available in the urgent care department at all times.

Providing responsive services

• The hospital was generally responsive to people’s needs and the oasis unit within the medicine department is was an example of outstanding innovation and service planning and met meets both the needs of the local population and individual needs; the oasis unit was designed to be dementia friendly. The unit reflected the needs of patients living with dementia and staff delivered patient-centred care. There was a trust wide dementia strategy and a nurse consultant in dementia care.
• Ambulatory care was available seven days a week, reducing the need for patients to be admitted to hospital.
• Patients with a learning disability were identified and there was a learning disability specialist nurse.
• Pain was assessed and patients received timely pain relief. Patients had their nutritional needs assessed.
• Feedback from staff and patients had resulted in changes to aspects within the service.

Access and flow

• The urgent care & emergency services department had performed consistently well in achieving the Department of Health target for 95% of patients to be seen, treated, discharged or admitted within 4 hours.
• Referral to treatment times (RTT) and cancer waiting times were better than the England average, clinicians engaged with appointment booking staff to meet targets around RTT.
• There were clear admission and discharge processes in place and a transfer of care team was available to support with more complex discharges.
• In medical services, the average length of stay was lower (better) than the England average and the overall risk of readmission was also lower.
• In surgical services, service developments had improved patient access to treatment through the introduction of new elective lists.
• However, the did not attend (DNA) for appointment rates in the outpatient department (OPD) were higher than the England average and DNA rates were also high in the radiology department.

We saw several areas of outstanding practice including:

• The oasis unit was an example of outstanding innovation and service planning to meet both the needs of the local population and individual needs. The unit opened in 2014 and was thought to be the first of its kind in a hospital in England at this time. This unit offered specialist care for patients with delirium or living with dementia during periods of acute illness. The unit was designed to be dementia friendly and offered patient-centred care. The positive impact of the unit had been recognised and was doubling in size as a result of this.
• The Outpatient and Diagnostics department had a patient tracking list that was clinically led.
• The radiology department had no backlog in reporting in any modalities; this had been recognised nationally as extremely good practice.

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

Action the hospital MUST take to improve:

Urgent care

• The department must ensure that there are sufficient numbers of staff with the appropriate skills available at all times. This includes ensuring that there are sufficient numbers of staff available to resuscitate adults and children.
• The department must ensure that staff have Advanced Life Support training.
• The department must ensure that patient risk is monitored and documented appropriately through the use of the early warning scores (EWS) and the Manchester early warning score (MANCHEWS) for children.
• The department must ensure that the effectiveness of treatment is measured on a regular basis so that there is the opportunity to improve services when required.

Action the hospital SHOULD take to improve

Urgent Care

• The department should improve performance in relation to triage times.
• The department should ensure that they provide appropriate documentation and training to support staff when providing care to patients whose circumstances make them vulnerable, such as those living with dementia or a learning disability.
• The department should ensure that all equipment is checked on a regular basis and that it is safe for use.
• The department should ensure that fridge thermometers are working in a way that ensures that medication is kept in an appropriate environment and these should be recorded daily.
• The department should continuously monitor the service that they provide through local audits and audits that are recommended by the royal college of emergency medicine (RCEM). This should include developing action plans to facilitate improvement.
• The department should facilitate all planned training days so that staff can maintain and develop their skills.
• The department should ensure that complaints and concerns are responded to in a timely manner.

Medicine

• The department should ensure that records are completed and maintained in line with General Medical Council (GMC) guidance on keeping records and CG2 - record keeping guidelines.
• The department should carry out a risk assessment of the environment manometry room with specific consideration of infection control, accessibility, storage of equipment and supplies and privacy and dignity.
• The department should ensure that there is a system in place to deploy sufficient numbers of suitably qualified, competent and skilled staff on the oasis unit to maintain the safety of all patients, regardless of the presence of staff employed by other trusts.
• The department should ensure that staff receive a regular and effective appraisal to enable staff to carry out the duties they are employed to perform.
• The department should consider undertaking local patient surveys to gain feedback from the public about services provided.

Surgery

• The department should consider the provision of additional training for staff in relation to the legal requirements of the Mental Capacity Act 2005 and Deprivation of Liberties Safeguards.
• The department should develop surgical strategies as part of the ‘Healthier Together’ strategy.
• The department should ensure that access to clinical waste is restricted to designated staff groups.
• The department should ensure that patient records are secure at all times.

Outpatients and diagnostics

• The department should continue to reduce the waiting times for the diagnostic procedures of colonoscopy, gastroscopy and sigmoidoscopy.
• The department should consider the replacement of the allied health professional senior manager for the trust.
• The department should reduce their did not attend rates in the outpatient department (OPD) and in radiology.

Professor Sir Mike Richards

Chief Inspector of Hospitals