CQC Improvements


Pennine Acute’s CQC Improvement Plan

The Care Quality Commission (CQC) inspection report of our services run by The Pennine Acute Hospitals NHS Trust (PAT) published in August 2016 gave the Trust an overall ‘Inadequate’ rating. The CQC inspected all of PAT’s hospitals and community services:

  • Rochdale Infirmary rated ‘Good’
  • Fairfield General Hospital in Bury rated ‘Requires Improvement’
  • North Manchester General & The Royal Oldham Hospitals rated ‘Inadequate’
  • All community services rated ‘Good’ across all CQC domains
  • ‘Outstanding’ rating given for Caring in the Community End of Life Service
  • Outpatients, x-ray & diagnostic services rated ‘Good’ across all hospital sites

Since April 2016, the Trust has benefitted from joint working and support from Salford Royal NHS Foundation Trust under the leadership of Mr Jim Potter, Chairman, and Sir David Dalton, Chief Executive.

The CQC conducted unannounced visits in Oct/Nov 2017 - the results of the new inspections can be found here.

Improvement Plan

A comprehensive improvement action plan was delivered in response to both the CQC report and Salford Royal’s own diagnostic review and assessment.

This Improvement Plan was approved by the CQC and endorsed by the Pennine Improvement Board and PAT’s Board of Directors in October 2016. The delivery of the Improvement Plan is monitored by the Improvement Board. The Improvement Board is chaired by Jon Rouse, GM HSCP, and is made up of healthcare partners; four local CCGs, Local Authorities, GM HSCP, CQC, NHS Improvement.

The CQC’s 77 ‘Must Dos’ and 144 ‘Should Dos’ in its report have been mapped to the themes contained within the Improvement Plan. The Improvement Plan and updates are publicly available on our website here.

Improvement Themes

All actions in the PAT Improvement Plan are integrated into six main improvement themes:

  • Improving Fragile Services: stabilise Urgent Care, Maternity, Paediatric, Critical Care;
  • Improving Quality; Improving Safety, Effectiveness, Patient Experience;
  • Improving Risk & Governance: implement new risk & governance arrangements;
  • Improving Operations & Performance: focus on improving data quality, patient flow systems, pathway management, models of care
  • Improving Workforce and Safe Staffing: focus on staff recruitment and retention;
  • Improving Leadership & Strategic Relations: clinical leadership development and strengthening local hospital operational management with new structure for each site.

Improvement Plan Progress

Since August 2016, the Trust has focused on stabilising services, addressing and strengthening areas that needed attention and in supporting staff in these areas. Month on month progress on the improvement plan continues to be made and a number of improvements sustained. Key risks continue to be around workforce availability.