CountessofChesterHospitalNHSFoundationTrust ......Hospital QualityReport CountessofChesterHealthPark LiverpoolRoad Chester CH21UL Tel:01244365000 Website: Dateofinspectionvisit:February2016

This report describes our judgement of the quality of care at this hospital. It is based on a combination of what we foundwhen we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from patients, thepublic and other organisations.

Ratings

Overall rating for this hospital Requires improvement –––

Urgent and emergency services Good –––

Medical care (including older people’s care) Good –––

Surgery Good –––

Critical care Good –––

Maternity and gynaecology Good –––

Services for children and young people Good –––

End of life care Requires improvement –––

Outpatients and diagnostic imaging Good –––

Countess of Chester Hospital NHS Foundation Trust

TheThe CountCountessess ofof ChestChestererHospitHospitalalQuality Report

Countess of Chester Health ParkLiverpool RoadChesterCH2 1ULTel:01244365000Website: www.coch.nhs.uk

Date of inspection visit: February 2016Date of publication: 29/06/2016

1 The Countess of Chester Hospital Quality Report 29/06/2016

Letter from the Chief Inspector of Hospitals

The Countess of Chester Hospital is part of The Countess of Chester Hospital NHS Foundation Trust which provides a fullrange of acute and a number of specialist services including an urgent and emergency care, general and specialistmedicine, general and specialist vascular surgery and full consultant led obstetric and paediatric hospital service forwomen, children and babies.

The Countess of Chester Hospital is situated within the Countess of Chester health park in Cheshire, and providesservices to a population of approximately 412,000 residents mainly in Chester and surrounding rural areas, EllesmerePort, Neston and the Flintshire area.

Over 425,000 patients attend the Trust for treatment every year. The Countess of Chester Hospital has approximately 680beds.

We carried out this inspection as part of our scheduled program of announced inspections.

We visited the hospital on the 16, 17, 18, 19 February 2016. We also carried out an out-of-hours unannounced visit on 26February 2016. During this inspection, the team inspected the following core services:

• Urgent and emergency services

• Medical care services (including older people’s care)

• Surgery

• Critical care

• Maternity and gynaecology

• Children and young people

• End of life

• Outpatients and diagnostic services

Overall, we rated Countess of Chester hospital as ‘requires improvement’. We have judged the service as ‘good’ foreffective, caring and well led. We found that services were provided by compassionate, caring staff and patients wererespected and treated with dignity. However, improvements were needed to ensure that services were safe andresponsive to people’s needs.

Our key findings were as follows:

Leadership and Management

• The hospital was led and managed by an accessible and visible executive team. This team were well known to staff,visited most wards and departments regularly, and responded to issues that staff raised, however some staff onsurgical wards did not feel they were as engaged with board members.

• We saw that the board had taken some steps to improve communication within all staff using a variety of methodsof communication including department visits, drop in sessions, newsletters and social media.

• There was clear leadership and communication in services at a local level, senior managers were visible,approachable, and staff were supported in the workplace. Staff achievements were recognised both informally andthough staff recognition awards.

Summary of findings


• There was a positive culture throughout teams in the hospital and staff were committed to being part of the trustsvision and strategy going forward.

Access and Flow

• The trust had established policies and both internal and external escalation procedures in place to support accessand flow across the trust which were co-ordinated though meetings held at various points though the day to assessand prioritise patient movements in the trust. This included a designated hospital team who were responsible forpatient flow, and provided senior nurse presence and clinical leadership across the trust out of hours.

• Access and flow remained a challenge in the emergency department, The trust achieved the 95% four hour targeton two occasions between November 2014 and October 2015,

• There were issues with access and flow across the medical and surgical wards with high bed occupancy rates anddelayed discharges due to the complexity of patient’s needs. Some medical patients were being nursed innon-speciality beds. Trust data showed In August 2015 data showed that there were 34 patients in total, which roseto 120 in September and further increased to 130 in October 2015. We observed that this data included thosepatients who were supported in escalation beds within urgent care.

• A number of extra beds had been opened to help support flow though the hospital at both Countess of ChesterHospital and Ellesmere Port Hospital, which were focused on intermediate care delivery.

• At the time of our inspection, there were approximately 100 patients who remained in hospital due to delays intransfers of care. These were due to a variety of reasons including packages of care and decisions about communityliving arrangements.

• The trust was working closely with other strategic leaders to plan system delivery, strategy and plans in order tosupport elective and emergency admissions, attendances and discharges to the hospital. As part of this, the trusthad introduced a number of initiatives including a general practitioner admissions unit (GPAU) which opened at theend of the announced aspect of this inspection. During the unannounced inspection, we observed that the generalpractitioner admissions unit (GPAU) was having a positive impact on flow though the hospital and there had been areduction in patients who were delayed in being transferred from the hospital.

• Medical services met the national 18-week referral to treatment time targets in all specialities from September 2014to September 2015.

• The maternity service had closed six times during 2015 due to staff activity. This had been managed safely throughthe escalation policy, which involved working with other local maternity services and emergency ambulanceservices.

• In January 2016, the trust achieved the referral to treatment (RTT) targets, of 95%, in all areas and specialities withthe exception of ear, nose and throat at 94%.

• All three cancer wait measures (patients seen within two weeks, 31 day wait and 62 day wait) were generally betterthan the England average from 2013/14 to 2015/16, although October and November 2015 were below the target of85% for 62-day wait at 77% and 79.8% for the planned care division.

Cleanliness and Infection control

• Clinical areas at the point of care were visibly clean; however, we did identify some cleanliness issues in urgent andemergency services, outpatients and in non clinical areas specifically related to an area within maternity services.

• The trust had infection prevention and control policies in place, which were accessible to staff and staff wereknowledgeable on preventing infection.

Summary of findings


• There was enough personal protective equipment available, which was accessible for staff and staff used thisappropriately.

• Staff generally followed good practice guidance in relation to the control and prevention of infection in line withtrust policies and procedures.

• Between April 2015 to December 2015, there were two cases of MRSA bacteraemia reported across the trust.Lessons from all cases were disseminated to staff for learning across directorates.

• The hospital undertook early screening for infections including MRSA during patient admissions and preoperativeassessments. This meant that staff could identify and isolate patients early to help prevent the spread of infection.

Nurse Staffing

• The trust had established process in place to assess nurse staffing levels, which included using an evidence basedtool. The trust was also in the early stages of using a workload management tool (NHPPD) from the recentlypublished Lord Carter model hospital review. The hospital was also piloting an national activity monitoring tool, togain robust data on required nurse staffing levels going forward.

• The trust undertook biannual nurse staffing establishment reviews as part of mandatory requirements. As part ofthis, key objectives were set though this work to support safer staffing. Data provided as part of this review inJanuary 2016 identified that over-all the trust had maintained over 95% of staffing levels planned against actuallevels for nine months, however there was the recognition that additional nurse recruitment was required.

• There were a number of initiatives in place to support recruitment, notably the trust had recently appointed 20 – 30registered nurses from Spain.

• The trust had systems in place to review midwifery staffing levels using national guidance (National Institute ofClinical Excellence : Safe Midwifery staffing for Maternity units 2015 NG4) and were in the process of employingadditional midwives following the most recent review in January 2016.

• However, nurse-staffing levels, although improved, remained a challenge across most areas. Staffing levels weremaintained by staff regularly working extra shifts and with the use of bank or agency staff. Inductions were in placefor new staff in order to mitigate the risk of using staff that were not familiar with the hospital.

Medical Staffing

• Medical treatment was delivered by skilled and committed medical staff.

• The information we reviewed showed that medical staffing was generally sufficient at the time of the inspection.

• Data from January 2016 showed minimal use of locum cover.

• Trust data at the time of inspection showed a turnover rate of 17.7% and a sickness rate of 0.41% for medical staff.

• A shortage of a paediatric consultant was recorded on the divisional risk register on 21/10/15 however; approvalhad been obtained to increase medical staffing in this area.

• The number of palliative care consultants was below the recommended staffing levels outlined by the Associationfor Palliative Medicine of Great Britain and Ireland, and the National Council for Palliative Care guidance, whichstates there should be a minimum of one WTE consultant per 250 beds.

• The trusts medical staffing information confirmed 60 hours consultant cover for the delivery suite. This meant theservice met the recommendation in the safer childbirth best practice guidelines.

• Interventional radiologists worked on a rota system. There were seven consultants covering 24 hours per day, sevendays a week. The trust had recently recruited three interventional radiologists to manage the increasing workload.

Summary of findings


Mortality Rates

• Mortality and morbidity reviews were held in accordance with trust policies and were underpinned by policies andprocedures. All cases were reviewed and appropriate changes made to help to promote the safety of patients. Keylearning Information was cascaded to staff appropriately.

• The Summary Hospital-level Mortality Indicator (SHMI) is a set of data indicators, which is used to measuremortality outcomes at trust level across the NHS in England using a standard and transparent methodology. TheSHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and thenumber that would be expected to die based on average England figures, given the characteristics of the patientstreated at the hospital. Between August 2014 and July 2015 the trust score was 103, which was slightly higher thanthe national average.

• Notably the hospital had achieved a ‘A’ rating for the Senital Stroke National Audit Programme (SSNAP) in 2014,which was a significant improvement from an “E” rating in 2013. The stroke service had been recognised regionallyfor using innovation to improve outcomes for patients.

Nutrition and Hydration

• Patients had access to food and drink whilst in emergency assessment unit (EAU) and staff offered refreshmentsthroughout the department.

• We found that there were policies and procedures in place to support patients nutritional and hydration needs.Patients nutritional needs were risk assessed and results were acted upon appropriately.

• Most patients were supported with hydration; however, we observed that within surgical wards, there was no clearsystem in place to identify patient in need of assistance with eating and drinking. We found that most patientsreceived assistance with eating and drinking as needed.

• Patients we spoke with said they were happy with the standard and choice of food available. The menus werecomprehensive and there was a wide variety for patients to choose from.

• Staff and patients had access to specialist nutritional advice from the dietician team who responded promptly topatient referrals.

• There was an infant feeding team and ‘Bosom buddy’ volunteers to provide breast-feeding support. Mothers withbabies on the neonatal unit were encouraged and supported to express milk for their babies.

• Women on the maternity and gynaecology units were provided with snacks, meals and drinks while on the unit, fluidbalance charts were completed so that oral intake could be monitored when required and when intravenous fluidswere administered.

• The trust were rolling out care and comfort worker roles to work across the wards to assist patients with nutrition andhydration.

We saw several areas of outstanding practice including:

• The sentinel stroke national audit programme (SSNAP) latest audit results rated the trust overall as a grade ‘B’ whichwas an improvement from the previous audit results when the trust was rated as a grade ‘E’.

• The trust were rolling out care and comfort worker roles to work across the wards to assist patients with nutrition andhydration.

• We observed a theatre morning briefing which included all staff within the theatre areas. This briefing ensured that allstaff were aware of theatre wide issues and safety concerns and also ensured that staff felt they were part of the widertheatre team.

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

Importantly, the trust must:

Summary of findings


• Ensure that adequate numbers of suitably qualified staff are deployed to all areas within the surgical services toensure safe patient care.

• Ensure that patients placed in areas outside their speciality meet the trusts criteria and ensure that there is suitablyqualified staff to meet their needs.

• Ensure that patients nutritional and hydration needs are met at all times.• Ensure that all staff are able to understand and apply the Mental Capacity Act 2005 and the Deprivation of Liberty

Safeguards.• Ensure that there are sufficient staff trained in adult and children’s safeguarding procedures in the accident and

emergency department.• Ensure there are sufficient numbers of suitably qualified and skilled staff on medical wards.• Ensure that all medications are stored in a secure environment at all times.• Ensure staffing levels are maintained in accordance with national professional standards on the neonatal unit and

paediatric ward.• Ensure that there is one nurse on duty on the children’s ward trained in Advanced Paediatric Life Support on each

shift.• Improve the waiting times for reporting of radiology investigations.

In addition the trust should:

In urgent and emergency care services :

• The trust should review medical record storage to ensure that records are accessible for staff easily, but mitigate therisks of the public being able to access records.

• The trust should ensure all premises and equipment used by the service provider are clean.

• The trust should review processes to improve access and flow through the accident and emergency department.

• The trust should review processes of managing patients own medications in accident and emergency areas.

In medical care services :

• The trust should ensure the electronic paper records system is robust and staff are sufficiently trained andcompetent in using and understanding the system.

• The trust should ensure all patients’ records are secure.

• The trust should ensure at all patients and staff across the trust have access to dementia services.

• The trust should ensure that all staff receive mandatory training including mental capacity act training.

• The trust should consider that basic monitoring equipment (blood pressure machine) is available in the dischargelounge.

In surgery :

• The trust should ensure that all staff receive the adequate level of safeguarding training.• The trust should ensure that all staff are treated with dignity and respect during their course of employment.• The trust should ensure that staff are able and feel comfortable to raise concerns.• Staffing levels on some wards were below 95% of the planned target with levels less 90% on some occasions. Staff

worked extra shifts and agency staff were used on a regular basis to ensure patient safety. At night the staff skill mixon the wards was not always sufficient to meet the needs of the patients as staff with specialised competencies fortheir area of work would be moved to support ward areas that required additional staff.

In critical care:

Summary of findings


• Ensure that all critical care staff are aware of Duty of Candour regulations and their responsibilities within this.

• Ensure that there are robust procedures in place to monitor impact and reduce the numbers of patients that aredelayed in being discharged from the critical care unit.

• Ensure that there are robust procedures in place to monitor impact and reduce delays of patients waiting to beadmitted to the critical care unit.

• Consider supporting critical care patients who have been discharged from hospital to identify any psychologicalsupport that may be needed.

• Ensure that the critical care unit achieves 50% of nursing staff have a specialist critical care qualification.

In maternity and gynaecology :

• The trust should ensure that all areas, all fridges and equipment are clean and checked as required.• The trust should ensure robust systems are in place to evaluate and improve their practice in respect of incidents and

all investigations relating to the safety of the service.• The service should review procedures for evacuation from the birth pool and consider regular drills including

practising removing women from the pool.• Undertake robust risk assessment for the women and children’s building so that the risks associated with baby safety

are maximised.• The provider should provide staff with opportunity to and need for staff to receive yearly individual appraisals.• The provider should consider producing regular updates specifically about the stages maternity and gynaecology

audits have reached.• The provider should consider ways of supporting women to feel confident in choosing a birth plan which does not

require intervention unless necessary.

Children and young people’s services:

• The trust should take steps to ensure that resuscitation equipment is checked in line with trust policy.• The trust should ensure that the door to the kitchen on the children’s ward is locked and access restricted as

appropriate.• Consideration should be given in relation to safe storage of records on the children’s ward. The notes trolley and

storage cupboard should be kept locked to ensure safe storage.• The trust should ensure controlled medicines are checked daily in line with trust policy.• Consideration should be given to the introduction of a routine nutritional assessment tool for all patients on the

children’s ward.• The trust should ensure staff attend mandatory and safeguarding training as required for their role.• Consideration should be given for the development of a winter management plan.

End of Life:

• Ensure the roll out of the Care and Communication documentation across the trust.

• Ensure all staff have appropriate End of Life training and support.

• Evaluate and improve their practice in respect of the quality of people’s experience.

• Ensure all staff are aware of the vision and strategy for end of life services.

In outpatients and diagnostic imaging services:

• The trust should improve the waiting times for reporting of radiology investigations.

• The trust should ensure staff are assured that equipment has been maintained safely.

Summary of findings


• The trust should consider the layout of the waiting area to provide privacy for patients when confirmingconfidential details.

• The trust should consider improving the environment for children in the outpatients department as it is notchild-friendly.

• The trust should ensure that all resuscitation equipment is checked and positioned appropriately in order that it isavailable in an emergency.

• The trust should ensure all equipment and clinical areas are free from dust.

• The trust should ensure that all guidelines are clear and followed using national guidance for best practice.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Summary of findings


Our judgements about each of the main services

Service Rating Why have we given this rating?Urgent andemergencyservices

Good ––– We rated emergency and urgent services as goodbecause:

• Staff were committed and proud of the servicethey provided.

• There were staff vacancies and bank andagency staff were successfully used to fill gaps.

• Medical cover was sufficient and staff workedwell together.

• Staff treated patients and their relatives withrespect and dignity and communicated withthem well.

• Patients were involved in care planning and feltinformed.

• Incidents were reported via an electronicsystem and staff could access the system.

• Staff reported receiving feedback and learningfrom incidents.

• Risk assessments were completed and staffimplemented measures to reduce risks.

• Equipment was available and serviced.• Medicines were stored safely.• Risk registers were in place.• Staff were aware of the trusts values and

vision.• Staff felt well supported by the

multi-disciplinary team and workedcollaboratively to ensure patients were caredfor.

However,

• Access and flow was a challenge due to bedcapacity, and some patients were in theemergency department for long periods.

• Four hour targets were not being met, howeverpatients were cared for and their needs met.

• Clinical areas at the point of care were visiblyclean, however, we observed some noneclinical storage areas that were dusty.

• We observed a storeroom with a ladder to anunlocked hatch to the roof space near theresuscitation room, action was taken duringthe inspection.

Summaryoffindings

Summary of findings


• Two storerooms were found to have doorspropped open; the door to the dirty utility wasalso propped open and the lock was sealedwith tape to ensure the door did not lock.

• There were three tubs of chlorine tablets on theshelf in the dirty utility and access to cleaningmaterials.

Medical care(includingolderpeople’scare)

Good ––– We rated medical care as good because:

• Incidents and complaints were reported via anelectronic system and staff could access thesystem.

• Most staff reported receiving feedback andlearning from incidents and complaints.

• Risk registers were in place; however, actionplans with timelines were not documented,however risks identified in this division werereflected in trust wide initiatives in place tomitigate risks.

• Wards were visibly clean, staff followed goodhygiene practices.

• There were good systems for handling anddisposing of medicines.

• Equipment was available and serviced asrequired.

• Staffing across medical services was on the riskregister and actions had been taken includingrecruitment overseas and regular monitoringof staffing levels during the day to helpmitigate the risk. The trust biannual reviewstated that overall the trust had maintainedover 95% of the planned staffing levels.

• The trust had identified this as an area forimprovement and a pilot of a new roster wascommencing in April 2016. The trust were alsoundertaking a number of initiatives relating tomeasuring patient acuity to help plan staffing.

• Patients risk assessments were completed andstaff implemented measures to reduce risks.

• Staff were aware of the trusts values andvision. Staff enjoyed working at the hospital,felt well supported by their managers andworked collaboratively together to ensurepatient were cared for.

Summaryoffindings

Summary of findings


• Staff treated patients and their relatives withrespect and dignity and communicated withthem effectively. Patients were happy withtheir care, felt informed, and were involved incare planning.

However,

• Data provided showed there were occasionswhen the nurse staffing levels were less than 90%.

• There were issues with access and flow acrossthe medical wards with high bed occupancyrates and delayed discharges due to thecomplexity of patient’s needs. Some patientswere being nursed in non-speciality beds andon occasions in mixed sex wards, although thiswas based on clinical need.

• There was a risk that personal information wasaccessible to members of the public aspatient’s records were not always storedsecurely.

• Monitoring documentation for input andoutput, bowel charts and cannulation checkswere not always consistently completed.

• On one ward, a large quantity of medicationwas found in an accessible unlocked cupboard,which was a risk to patients and members ofthe public.

• Compliance with mandatory training for themajority of staff was below trust target. Thetrust target was 95%.

Surgery Good ––– We rated surgery as good because:

• We found that staff were aware of how toreport incidents and we saw evidence that theservice undertook robust and appropriateincident investigations.

• The uptake levels of mandatory training werehigh for both nursing and medical staff.

• Staff were fully aware of how to raise andmanage safeguarding issues appropriately.

• Staff managed medicines well and nursestaffing levels in the theatre areas weresufficient.

• Patients received surgical care which wasevidence based and met national guidelines.

Summaryoffindings

Summary of findings


• Clinical audits were routinely undertaken andaction as a result of these was evident.

• Patients were assessed and provided withappropriate pain relief.

• Knowledge of the Mental Capacity Act 2005 andDeprivation of Liberty Safeguards was good inmost areas however, most staff did not receivetraining in these areas.

• Staff treated patients with kindness, dignityand respect and patients told us that they werehappy with the care they received.

• The surgical services were responsive to theneeds of patients.

• Information was readily available for patientsin a variety of formats, which could be adaptedto individual needs.

• The access and flow within the surgical serviceswas challenging at times, however staffmanaged this effectively.

• Patients had timely access to consultant ledcare. The service was well led and staffrespected their local leaders.

• Staff could not articulate the trusts vision andvalues; however they were aware of significantwork programmes taking place

• There were robust governance frameworks andmanagers were clear about their roles andresponsibilities.

• There was clear leadership in the service andsenior managers were visible andapproachable.

• We found the culture within the service wasopen and managers made efforts to engagewith staff and the public.

• We found evidence that the trusts board madeattempts to engage with staff through differentmediums and had implemented a speak outsafely campaign.

However,

• In some areas we found that the learning fromthese investigations was not disseminatedfully.

• We found that Nurse staffing levels on thesurgical wards were not always sufficient tomeet patients needs.

Summaryoffindings

Summary of findings


• Some staff raised concerns about leaders attrust board level, and these concerns includedlack of visibility and support and fear of raisingconcerns.

Critical care Good ––– We have rated critical care services as goodbecause:

• Incidents were reported and acted upon andused continuously as a service improvementtool

• Safety thermometer data was collected anddisplayed in public areas for patients andrelatives to view.

• Performance results were also shared with staffin critical care in a monthly unit newsletter,together with results from relative’s surveys.

• There were sufficient numbers of suitablyskilled nursing and medical staff to care for thepatients.

• The service took part in the intensive carenational audit and research (ICNARC) data sowe were able to bench mark its performanceand effectiveness alongside other similarspecialist trusts.

• The trust performed well, however dataindicated some concerns regarding delayeddischarges.

• The trust had an outreach team with fivecritical care trained, dedicated members ofstaff who supported wards in the earlydetection and treatment of acutely unwellpatients.

• There was evidence if a multidisciplinaryapproach to caring for the patients. Wardrounds included consultants, aphysiotherapist, a pharmacist, a junior doctor,a nurse, SHO and a member of the outreachteam.

• There was adequate number of nursing andmedical staff to provide a seven-day service.

• Staff were aware of the vision for the serviceand had strategies in place for innovation andimprovement.

However,

Summaryoffindings

Summary of findings


• We did find that that the unit fell below theintensive care society’s recommended level ofstaff who held a post registration award incritical care nursing.

Maternityandgynaecology

Good ––– We rated Maternity and gynaecology as goodbecause:

• The trust had systems in place to reviewmidwifery staffing levels using latest nationalguidance (National Institute of ClinicalExcellence : Safe Midwifery staffing forMaternity units 2015 NG4) and were in theprocess of employing addition midwivesfollowing the most recent review in January2016.

• Clinical areas at the point of care were clean.• The trust provided clear procedures for

reporting incidents and the electronicreporting system was accessible to the majorityof staff.The trust treated incidents seriouslyand ensured completed investigations.

• Multiagency and disciplinary working wasestablished and promoted the best outcomefor mothers and their babies.

• The record keeping systems were effectiveensured accurate and up-to-date informationabout patients was readily available.

• Women were cared for with kindness andcompassion and were positive about thestandard of care and treatment provided bythe maternity and gynaecology services.

• The service encouraged and supportedlearning and development. The ratio ofsupervisors of midwives to midwives was 1:14which better than the recommended 1:15.

• The trust ensured staff followed best practiceguidance and participated in national and localaudits in relation to care and treatment.

• The majority of staff felt communicationbetween ward staff and senior managers waseffective.

• Midwives subscribed to the philosophy of thenursing and midwifery council six ofcompassionate care and we saw this inpractice.

Summaryoffindings

Summary of findings


• There was an active local maternity networkwhich involved stakeholders and service usersin place to help inform maternity services goingforward.

• The gynaecology ward and clinics were wellrun by the gynaecology service and wardmanagers.

However,

• The number of midwives employed did notmeet best practice Birthrate Plusrecommendations. This resulted on the closureof the unit and delays in procedures for womenusing the service on rare occasions.

• The layout and security detectionarrangements meant mothers and babiesweren’t always monitored, however access tothe unit was monitored by close circuittelevision at key points across the unit, andaccess was restricted either by a staffedreception or swipe access door.

• General cleanliness in non clinical areas on thecentral labour suite and Cestrian ward neededto improve.

• During inspection we did not find evidence ofemergency response training did not includeddrills for dealing with common obstetricemergencies. However, the trust informed usthat this was covered on induction andalso using innovative methods of teaching.

• The trust did not provide midwives, health careassistants and midwife assistants withindividualised appraisals.

• The trust did not employ a specialistbereavement midwife; however, there weretwo link bereavement midwives.

• The management system for audits needed tobe improved and sharing the lessons learntfrom incidents, audits and complaints was notwell established.

• There were not enough opportunities formidwives to meet and review the safety of theward or unit during each shift.

Summaryoffindings

Summary of findings


Services forchildren andyoungpeople

Good ––– We rated services for children and young people asgood because:

• We saw evidence that incidents were beingreported and that information followingclinical incidents was fed back to staff in dailysafety briefings.

• Cleanliness and hygiene was of a high standardin areas we visited and staff followed goodpractice guidance in relation to the control andprevention of infection.

• Care was delivered by caring andcompassionate staff and the differing needs ofchildren and young people were consideredwhen delivering care.

• Facilities were available for parents to stay withtheir children.

• 97.6% of children and young people were seenwithin the 18 week target time andcorrespondence with GPs following admissionor treatment was sent in a timely fashion.

• The hospital at home service enabled childrento be treated in their own home or reducedtheir stay in hospital.

• Managers had a good knowledge ofperformance and were aware of the risks andchallenges to their service.

However,

• Nurse staffing levels on the children’s unit didnot reflect Royal College of Nursing (RCN)standards (August 2013) and nurse staffinglevels on the neonatal unit did not meetstandards recommended by the BritishAssociation of Perinatal Medicine (BAPM).

• The neonatal unit lacked storage space andresources for barrier nursing.

• There was not always a member of nursingstaff on duty with Advanced Paediatric LifeSupport (APLS) on the children’s unit.

End of lifecare

Requires improvement ––– We rated end of life services as requiresimprovement over-all because :

• There was an insufficient number of generalnursing staff who had received appropriate

Summaryoffindings

Summary of findings


training regarding end of life care and thereplacement for the withdrawn Liverpool CarePathway [LCP] the care and communicationrecord [CCR].

• The trust performed worse than the Englandaverage in five of the seven organisational keyperformance indicators for the National Care ofthe Dying Audit 2014. However an action plan iscurrently in place to address the issuesidentified in the 2014 audit.

However,

• There was a three-year vision developed by thetrust's end of life committee. We found this hadbeen communicated to most general wardteams. We found evidence of an overarchingmonitoring of the quality of the service acrossthe trust. Complaints were responded toappropriately.

• Specialist palliative care nurses we spoke withwere able to describe safeguarding proceduresand provided us with examples of how thesewould be used.

• All of the general nursing staff we spoke withwere aware of how to report an incident orraise a concern.

• Appropriate equipment was available topatients at the end of their life; the equipmentat the hospital was adequately maintained.

• Medicines were managed appropriately.• Patients were involved in care planning and

decision making. Staff were respectful andtreated patients with compassion.

• Specialist nurses were visible, competent, andknowledgeable.

• The trust had a dedicated specialist palliativecare team [SPCT] who provided good supportto patients at the end of life. Care and supportwas given in a sensitive and compassionateway.

• On the wards staff worked hard to meet andplan for patient’s individual needs and wishes.

Summaryoffindings

Summary of findings


• Staff within the [SPCT] team were verymotivated and committed to meeting patients’different needs at the end of life and wereactively developing their own systems andprojects to help achieve this.

Outpatientsanddiagnosticimaging

Good ––– Overall we found the outpatient and diagnosticservice as good because:

• There was strong reporting culture with staffreporting incidents via the trusts electronicsystem. There was some learning fromincidents, although similar incidents continuedto be reported in radiology areas.

• Systems were in place for the maintenance ofequipment. Processes were in place for dailychecking of resuscitation equipment.

• Any prescribed medications were stored inlocked cupboards and there was no controlleddrugs or intravenous fluids stored inoutpatients at COCH. Patients’ records weremaintained on paper and via electronicsystems, although; plans for changes inelectronic systems were in place.

• Staff had received mandatory training,although some groups were not up-to-datewith safeguarding requirements. There wassome staff shortages identified, althoughrecruitment processes were in progress.

• There was a caring culture embedded in allareas visited and from all members of staff wemet. We observed good, compassionate carebeing delivered.

• Reception staff were polite and helpful.Patients and their relatives were very positiveabout the staff in outpatients and radiology.They said they were supportive andcommunicated well. We observed respectfulinteractions between staff and patients.

• Staff actively involved those close to patientswith initiatives in place to support relatives ofpatients who attended regularly.

• There was specialist staff in clinics with goodmultidisciplinary working, although not all hadbeen appraised annually.

• Services were available seven days a week.

Summaryoffindings

Summary of findings


• Consent for procedures was obtained althoughby different clinicians.

• There were audit plans in place and good useof the WHO safety checklist, for radiologicalinterventions, was observed.

• The outpatient and diagnostic services wereavailable at both Countess of Chester Hospital(COCH) and Ellesmere Port Hospital (EPH). Themain activity was at COCH with a smalldepartment at EPH for routine care of patientsin the local area.

• Targets of referral to treatment targets werewithin national guidelines, however; there wasa wide variation in waiting times for individualconsultants. Extra clinics were arranged, out ofhours and at weekends to manage thedemands of the local population.

• There was support for patients with individualneeds including visually impaired, hearingimpaired, learning disability or dementia.

• There was evidence of learning fromcomplaints and how changes had beenimplemented.

• There was a clear vision and strategy for thefuture.

• The management teams were stable andcommitted to patient well-being in both outpatients and diagnostics despite challenges.

• There were governance processes embeddedwith action plans in progress to improveservices. Waiting list initiatives took place tomeet demands of the local population.

• There were regular meetings, at all levels. Stafffelt supported by their line managers and therewas good team working in the departments.

• There were several innovations taking placewith plans to increase services.

• Radiology trust guidelines and standardoperating procedures were in place althoughnot always clear and robust. There had beenrecent reviews of procedures.

• There were delays in reporting in radiology,which meant there could be delays intreatment. The trust had responded toincreased demand by outsourcing x-rayreporting.

Summaryoffindings

Summary of findings


However,

• There was dust found on some medicalequipment.

• In the nuclear medicine department ofradiology, we observed that a prescribedmedication was not always signed asadministered.

• There were delays in reporting in radiology,which meant there could be delays intreatment. The trust had responded toincreased demand by outsourcing x-rayreporting.

Summaryoffindings

Summary of findings


TheThe CountCountessess ofof ChestChestererHospitHospitalal

Detailed findings

Services we looked atUrgent and emergency services; Maternity (community services); Surgery (gynaecology); Medical care(including older people’s care); Surgery; Critical care; Maternity and gynaecology; Services for children andyoung people; End of life care; Outpatients and diagnostic imaging.


Contents

PageDetailed findings from this inspectionBackground to The Countess of Chester Hospital 22

Our inspection team 22

How we carried out this inspection 23

Facts and data about The Countess of Chester Hospital 23

Our ratings for this hospital 24

Findings by main service 25

Action we have told the provider to take 154

Background to The Countess of Chester Hospital

The Countess of Chester Hospital is one of two hospitalsites managed by The Countess of Chester NHSFoundation Trust. The hospital is the main site andprovides a full range of hospital services includingemergency care, critical care, a comprehensive range ofelective and non-elective general medicine (includingelderly care) and surgery, a neonatal unit, children andyoung people’s services, maternity and gynaecologyservices and a range of outpatient and diagnosticimaging services.

The Countess of Chester Hospital is situated within theCountess of Chester health park in Cheshire, and providesservices to a population of approximately 412,000residents mainly in Chester and surrounding rural areas,Ellesmere Port, Neston and the Flintshire area. Over425,000 patients attend the Trust for treatment everyyear. The Countess of Chester Hospital has approximately680 beds.

Our inspection team

Our inspection team was led by:

Chair: Elizabeth Childs

Head of Hospital Inspections: Ann Ford, Care QualityCommission

The team included an inspection manager, 9 CQCinspectors, an inspection planner, an assistant planner, asenior analyst and a variety of specialists including : adirector of nursing, a safeguarding nurse, a nurseconsultant, an accident and emergency nurse, a nurse

consultant in accident and emergency, an intensive careconsultant, an intensive care advanced nursepractitioner, a consultant obstetrician and gynaecologist,a senior neonatal midwife, a clinical nurse specialist inmedicine, an associate medical director in radiology, anurse consultant in acute medicine, a consultantpaediatrician and neonatologist, a paediatric nurse, aconsultant in vascular surgery, a theatre manager and astudent nurse.

Detailed findings


How we carried out this inspection

To get to the heart of patients’ experiences of care, wealways ask the following five questions of every serviceand provider:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

Before visiting the hospital, we reviewed a range ofinformation we held about Countess of Chester Hospitaland asked other organisations to share what they knewabout it. These included the Clinical CommissioningGroups, NHS England, Health Education England, theGeneral Medical Council, the Nursing and MidwiferyCouncil, the Royal Colleges and the local Health watch.

We held a listening event for people who hadexperienced care at either Countess of Chester Hospitalor Ellesmere Port Hospital on 9 February 2016 inCountess of Chester Hospital. The event was designed totake into account people’s views about care andtreatment received at the hospital. Some people alsoshared their experiences by email and telephone. Theannounced inspection of Countess of Chester Hospitaltook place on 16 – 19 February 2016.

The inspection team inspected the following coreservices:

• Urgent and Emergency Services

• Medical care (including older people’s care)

• Surgery

• Intensive/critical care

• Maternity and gynaecology

• Children and young people’s services

• Outpatients and Diagnostic Imaging

• End of life care

As part of the inspection, we held focus groups anddrop-in sessions with a range of staff in the hospital,including nurses, trainee doctors, consultants, midwives,student nurses, administrative and clerical staff,physiotherapists, occupational therapists, pharmacists,domestic staff and porters.

We also spoke with staff individually as requested. Wetalked with patients and staff from all the ward areas andoutpatients services. We observed how people werebeing cared for, talked with carers and/or familymembers, and reviewed patients’ records of personalcare and treatment.

We undertook an unannounced inspection between 3pmand 8pm on 4 March 2016 at Countess of ChesterHospital. As part of the unannounced inspection, welooked at the emergency department, outpatients andradiology, and medical care wards. We would like tothank all staff, patients, carers and other stakeholders forsharing their balanced views and experiences of thequality of care and treatment at Countess of ChesterHospital.

Facts and data about The Countess of Chester Hospital

The Countess of Chester NHS Foundation Trust serves apopulation of approximately 445,000 people in andaround Western Cheshire, Ellesmere Port, Neston andNorth Wales. The Trust was one of the first 10 in thecountry to gain foundation status in 2004. In 2010,Ellesmere Port Hospital came under the management of

the Countess of Chester Hospital NHS Foundation Trust.Ellesmere Port Hospital is a rehabilitation unit providingPhysiotherapy, Radiology, Mental Health and COCHConsultant clinics.

The Countess of Chester Foundation Trust hasapproximately 683 beds and employs 4105 staff.

Detailed findings


The health of people in Cheshire West and Chester isvaried compared with the England average. Deprivation islower than average, however about 15.4% (9,000)children live in poverty. Life expectancy for both men andwomen is similar to the England average.

In 2014/15 there were 74,404 emergency departmentattendances and 444,045 outpatient attendances.

Our ratings for this hospital

Our ratings for this hospital are:

Safe Effective Caring Responsive Well-led Overall

Urgent and emergencyservices Good Good Good Requires

improvement Good Good

Medical care Good Good Good Requiresimprovement Good Good

Surgery Requiresimprovement Good Good Good Good Good

Critical care Good Good Good Requiresimprovement Good Good

Maternity andgynaecology Good Good Good Good Good Good

Services for childrenand young people

Requiresimprovement Good Good Good Good Good

End of life care Good Requiresimprovement Good Requires

improvementRequires

improvementRequires

improvement

Outpatients anddiagnostic imaging Good Good Good Good Good Good

Overall Requiresimprovement Good Good Requires

improvement Good Requiresimprovement

NotesWe are currently not confident that we are collectingsufficient evidence to rate effectiveness for Outpatients &Diagnostic Imaging.

Detailed findings


Safe Good –––

Effective Good –––

Caring Good –––

Responsive Requires improvement –––

Well-led Good –––

Overall Good –––

Information about the serviceThe Emergency Department (ED) at the Countess ofChester Hospital treats 72,000 patients serving apopulation of over 250,000. The department includes ateam of eight consultants and a matron, supported by ateam of middle grade doctors, junior doctors, emergencynurse practitioners (ENP) and advanced nursepractitioners (ANP).

The department is a designated trauma unit and receivesacute stroke patients, facilitating thrombolysis whereappropriate. ED also acts as the receiving point for theSouth Mersey Arterial Centre (SMArt), all surgical GPreferrals and acutely unwell medical admissions. Thedepartment is also a designated place of safety forpatients on Section 136 of the Mental Health Act.

The department consists of a three bedded resuscitationroom, 14 ‘major’s’ cubicles, an ENP led ‘minor’s’ area, a 22bedded emergency assessment unit (EAU) and a separatechildren’s waiting area. Patients have a clinicalassessment prior to registration providing earlyassessment and appropriate streaming of patients.

A Primary Care Unit is co-located within the departmentwhich is ANP led.

ED attendances were 56, 756 of patients aged 17 yearsand over, and 12, 330 under 16’s between April 2013 andMarch 2014. The ED department was originally built for30,000 attendances but is currently seeing in excess of70,000 patients per year and on average treatsapproximately 190 patients per day.

During our inspection, we visited ED, ambulatory careand the GPAU, spoke to 22 staff including doctors, nursesand allied health professionals, five patients andrelatives, reviewed 10 patient records and reviewedinformation provided by the trust and the public.

Urgentandemergencyservices

Urgent and emergency services


Summary of findingsWe rated emergency and urgent services as goodbecause:

• Staff were committed and proud of the service theyprovided.

• There were staff vacancies and bank and agency staffwere successfully used to fill gaps.

• Medical cover was sufficient and staff worked welltogether.

• Staff treated patients and their relatives with respectand dignity and communicated with them well.

• Patients were involved in care planning and feltinformed.

• Incidents were reported via an electronic system andstaff could access the system.

• Staff reported receiving feedback and learning fromincidents.

• Risk assessments were completed and staffimplemented measures to reduce risks.

• Equipment was available and serviced.

• Medicines were stored safely.

• Risk registers were in place.

• Staff were aware of the trusts values and vision. Stafffelt well supported by the multi-disciplinary teamand worked collaboratively to ensure patients werecared for.

However,

• Access and flow was a challenge due to bed capacity,and some patients were in the emergencydepartment for long periods.

• Four hour targets were not being met, howeverpatients were cared for and their needs met.

• Clinical areas at the point of care were visibly clean,however, we observed some none clinical storageareas that were dusty.

• We observed a storeroom with a ladder to anunlocked hatch to the roof space near theresuscitation room, action was taken during theinspection.

• Two storerooms were found to have doors proppedopen; the door to the dirty utility was also proppedopen and the lock was sealed with tape to ensure thedoor did not lock.

• There were three tubs of chlorine tablets on the shelfin the dirty utility and access to cleaning materials.




Are urgent and emergency services safe?

Good –––

We rated safe as good because:

• Staff knew how to report incidents and receivedfeedback and lessons learned information.

• Staff understood ‘Duty of Candour’ (the regulationintroduced for all NHS bodies in November 2014,meaning they should act in an open and transparentway in relation to care and treatment provided) andfelt confident to practice it.

• Staff had access to safeguarding training and couldaccess support as required, however 27 out of 71 staffstill required level three safeguarding children’straining.

• Records were electronic and paper based. Recordswere generally of a good standard.

• The department had a copy of the trust major incidentplan and felt clear about their role within it.

• Clinical areas at the point of care were visibly clean.

• We observed appropriate use of personal protectiveequipment (PPE) and hand washing. Infection controlaudits were completed.

However,

• There were staffing vacancies within the department,however staff did extra shifts to provide cover andagency was used to fill any gaps.

• Medicines were stored securely; however, the processwas unclear with storage of patients’ own controlleddrugs.

• Clinical areas at the point of care were visibly clean,however some non clinical storage areas were dusty.The staff did not have cleaning rota’s within thedepartment but there was designated domesticsupport who had cleaning schedules displayed onnotice boards.

Incidents

• There had been no never events reported for urgentand emergency care between February 2015 andJanuary 2016.

• Urgent and emergency care reported 432 incidentsbetween February 2015 and January 2016, 227 ofthese were reported as no or low harm. Five incidentsrequired further investigation. We reviewed incidentinvestigations which included appropriate actionplanning and shared learning cascaded to all staff.

• There were policies and procedure in place forreporting incidents..

• Staff knew how to report incidents using the electronicreporting system.

• Learning was shared via a departmental newsletterand communication board.

• Staff understood ‘Duty of Candour’ and theirresponsibilities related to this.

• Duty of Candour was included within trust inductionand all mandatory training programmes. There was astaff information leaflet about Duty of Candour, whichwas included within the welcome event informationpack and was also available on the intranet.

Cleanliness, infection control and hygiene

• The trust had introduced MRSA screening to test allpatients for MRSA skin carriage prior to admission.Results showed that 18% of positive results originatedfrom initial screening in ED between July andSeptember 2015. Therefore, the screening programmesupported early identification of MRSA colonisedpatients.

• The trust completed a Patient Led Assessment of theCare Environment (PLACE) in November 2015 and thereport highlighted 11 actions. The audit identified thatthere was no cleaning schedule in place, whichreflected initially what we saw. Senior staff told us thiswas being developed and it was put in place duringthis inspection.

• The PLACE audit identified 11 areas for action in thedepartment, which were being monitored by the trustboard. At the time of the visit, there were eight actionsoutstanding, however some of these required accessto patient areas for maintenance work.




• Hand hygiene results were displayed on an infectioncontrol notice board. Results from hand hygieneaudits between January 2015 and January 2016showed that the department scored between 61-100%compliant. It was unclear if any action plans had beenformulated to target hand hygiene compliance.

• Hand hygiene audits for ambulatory care showedoverall compliance at 96% between June andNovember 2015.

• There was good availability of personal protectiveequipment (PPE), hand gel and sufficient handwashing facilities and we observed staff followinginfection prevention policies and procedures.

• There was good availability of personal protectiveequipment (PPE), hand gel and sufficient handwashing facilities and we observed staff followinginfection prevention policies and procedures.

• An audit was completed in September 2015,undertaken by the supplier of the sharps containers.The results showed compliance with use of thetemporary closure mechanism had improvedsignificantly with 89% noted to be in use from the 2015audit compared to 64% from 2014. As part of ourinspection we observed, all sharps bins were signedand dated, however none were partially closed whennot in use (in line with best practice).

• Two cubicles in the major’s area and two in the minorscould be used for isolation of patients when required.

• Clinical areas at the point of care were visibly clean.We observed dirty floors in store cupboards and duston stored items. There were also issues with dusting ofhigh and low surfaces and some areas were visiblydirty. Senior staff were alerted to this and action wastaken to address our concerns.

Environment and equipment:

• Staff had access to the equipment they required to dotheir jobs and equipment was serviced regularly. Wefound one thermometer that was overdue for service.

• A mattress on a trolley in the resuscitation area had asensor pad and tape on the underside and a slit in thecover. This was highlighted to staff, however thismattress was still in use the next day. Staff werealerted again and the mattress was replaced.

• Resuscitation equipment was being checked daily asper trust guidance however the equipment and trolleywere visibly dusty despite the checklist asking for dailydamp dusting. This was highlighted to senior staff.

• There was a designated separate children’s waitingarea accessed from the main waiting area. Access wasvia a buzzer system from reception.

• Fridge temperatures were not recorded daily, therewere five days missing out of the two weeks prior toinspection.

• Five stock boxes in a cupboard for use in majorincidents were out of date. We alerted senior staff whoactioned this immediately.

• The department had a psychiatric assessment roomavailable, however there were chairs available thatcould be used as weapons and a possible ligature riskfrom the ceiling/ lighting. We highlighted this to seniorstaff and the chairs were removed immediately andadvice from health and safety regarding the ceilingwas sought. Senior staff told us that they had securedagreement with the estates department to replace theceiling.

• There was good access to the diagnostic imagingservices which was next to the department.

• Equipment we observed within the department werevisibly clean and had ‘I am clean’ stickers attached.

Medicines

• The department used secure systems for storage ofmedicines. This incorporated keypad or fingerprintaccess.

• Allergies were clearly recorded in patients’ records.

• Medicine systems were reviewed during the inspectionby our pharmacy advisor. Our advisor found that therewere no patient group directives (PGD) used within thedepartment however staff could administer up tothree doses of simple remedies such as paracetamol.This was as per trust policy, which described whichdrugs could be given, how and when.

• The matron received a daily report on access to thedrug storage systems to ensure the system was usedefficiently and staff followed processes.




• Intravenous (IV) fluids were stored in a locked clinicalroom and random checks of expiry dates showed theywere within date.

• Pharmacy re-stocked stores. The pharmacydepartment operated a full pharmacy service Mondayto Friday 9-5pm and provided a dispensary service onSaturday and Sunday mornings.

• Medication was prescribed on the emergencydepartment treatment cards for administration. Therewas a separate emergency department system fromthe main acute electronic system. We reviewed theseand found there was some communication betweenthe two systems but that medicines did notautomatically transfer between the two. This couldpotentially mean missed or double doses ofmedicines.

• We reviewed current IV fluid prescription charts on theemergency assessment unit and these were fullycompleted and signed.

Records

• Paper and electronic records were used within thedepartment.

• The paper record used was an emergency departmentcard printed off in the area designated followingstreaming.

• The medical staff recorded interventions via theelectronic record system. This was visible to staff onthe wards, however other speciality medical staff usedpaper records, this meant not all treatment plans wererecorded in the same way.

• We observed ten completed observation charts in usefor early warning scores (EWS), comfort and care, Fluidintake and output, which were legible, signed anddated.

Safeguarding

• Staff accessed training for safeguarding children andadults. The trust had designated leads for both. 89%of nursing staff and 59% of medical staff hadcompleted safeguarding adult’s level 2 training againstthe trust target of 80%.

• Senior staff told us that 27 out of 71 staff required level3 children training. 100% of nursing staff and 80% ofmedical staff had completed safeguarding childrenlevel 2 training against the trust target of 80%.

• The trust had safeguarding policies in place and staffknew how to access it via the trust intranet.

• There was no electronic flagging system for childrenwho presented with child protection plans or previoussafeguarding concerns. This would be picked up whenreviewed by the clinician. There was a lead consultantand nurse for safeguarding in ED departments.

• Staff were able to access the trust safeguarding teamsfor specialist advice via telephone and staff from thetrust children’s safeguarding team attended ED dailyto collect notifications and ensure appropriatereferrals had been made.

Mandatory training

• Staff received mandatory training on a range ofsubjects including infection control, risk andgovernance, medicine management, safeguardingand resuscitation.

• The department mandatory training completion figurewas 69% for nursing staff and 100% for medical staffagainst the trust target of 95%.

• The matron told us that department staff attendedadvanced life support training and paediatric lifesupport training each month,however we did not seecurrent completion rates.

Assessing and responding to patient risk

• Initial assessment and management of patientscommenced via a triage system, which commenced at9am until 9pm seven days a week and could beallocated to be Band 5, 6 or 7. Patients took a numberon arrival and then were called to be triaged by anurse. Patients were assessment by a registered nursewithin 15 minutes of arrival and this included anassessment of pain. The nurse determined which areaof the department the patient needed to access:majors, minors or primary care. Observations and abasic history were taken at this point.

• Outside of these hours, reception reviewed attendeesand liaised with staff to direct patients to the correctarea.




• Early warning scores were introduced in November2015 and should be completed as a minimum everyfour hours. The escalation process was noted on thechart. Early warning scores (EWS) was usedthroughout the trust to alert staff if a patient’scondition was deteriorating. This was a basic set ofobservations such as respiratory rate, temperature,blood pressure and pain score used to alert staff toany changes in a patient’s condition. The recordsreviewed showed completion of EWS on EAU andappropriate escalation as per guidance.Documentation of these scores was discussed at teammeetings and noted in minutes.

• There was a rapid assessment and treat (RAT) teamavailable from 10am-5pm.

Nursing staffing

• The trust did not use an acuity tool to determinestaffing within accident and emergency. Best practicerecommendations were followed for staffing for leveltwo and major trauma patients.

• Staffing levels agreed were 11 trained nurses on anearly shift, 13 in the afternoon and nine overnight.There was also two additional staff to cover untilmidnight.

• The staff held handovers at 8am and 8pm. Senior staffheld a ‘huddle’ at 5pm to determine access and flow inthe department. There were two consultants withpaediatric experience and one ANP in primary carewho was paediatric trained.

• At the time of inspection, there were two staff on sickleave, five on maternity leave and four more due tostart maternity leave. Senior staff told us thatmaternity leave was back filled and they did this byoffering a six month temporary contract to new staff ora permanent contract if staff were experienced.

• There were three nursing vacancies and thedepartment had a turnover rate of 18.6% in November2015. Figures to January 2016 showed staff budgetsfor 89.8 wte and an actual staffing of 90.9.

• The sickness rate in November 2015 was 3.08%.

• There was good skill mix within the department withemergency nurse practitioners, advanced nursepractitioners, nurses, physiotherapist, and doctors.

• There was use of agency and bank nurses. Rotasshowed use of their own staff doing extra shifts andregular agency staff. For the week inspected therewere seven shifts uncovered and the week after therewere ten trained nurse bank shifts uncovered and fouruntrained shifts.

Medical staffing

• The staff skill mix showed there were fewerconsultants than the England average.

• Data from January 2016 showed a budget for medicalstaff of 31.4 wte and actual staffing levels of 31.7 wte.This meant there was very low use of locum cover.

• Trust data showed a turnover rate of 17.7% and asickness rate of 0.41%

• Staff conducted handovers at 8am and 8pm and thematron, team lead and consultant had a ‘huddle’ at5pm to review current activity and flow. We did notobserve a handover during our inspection.

• Consultant cover was available 9am to midnight sevendays per week and then on call overnight. There weretwo consultants with paediatric experience.

Major incident awareness and training

• The department had a copy of the major incidentplan. Senior staff told us that a desktop exercise hadtaken place and from that, the plan was beingreviewed, responsibilities, and action cards beingupdated.

• The business continuity plan was easily accessible tostaff and could show us where it was kept.

• A security office was based on the corridor by thedepartment and the cameras in operation at thenurses’ station were operated from there.

• The hospital had hazardous materials and items(HAZMAT) arrangements in place and had identified anarea away from the main entrance for initialdecontamination. Trust data showed that 30 staff hadreceived decontamination training and four hadattended emergency preparedness, resilience andresponse (EPPR) training.




Are urgent and emergency serviceseffective?(for example, treatment is effective)

Good –––

We rated effective as good because:

• Staff followed national and local guidelines andpolicies.

• The division participated in local and national audits,such as the Royal College of Emergency Medicine(RCEM) audits. Action plans were formulated andshared.

• Patients were assessed for pain relief and were offeredanalgesia. Patients’ nutrition and hydration needswere assessed.

• Staff had appraisals and access to training anddevelopment. Multi-disciplinary team working workedwell, working collaboratively to plan and provide care.

• Staff obtained consent to treatment and discussedcare planning.

• Trust policies for mental capacity and deprivation ofliberty safeguards were in place.

Evidence-based care and treatment

• Policies in place based on national guidelines such asNational Institute for health and Care Excellence(NICE). For example; Pressure ulcer prevention andfalls.

• Staff had training on the mental capacity act andunderstand the requirements of the mental health act.

• Care and treatment was provided in line with evidencebased, best practice guidance such as the ‘ClinicalStandards for Emergency Departments’ guidelines.

• Guidelines followed included those for managementof sepsis, stroke and fractured neck of femur. Thedepartment had updated their pathways following thenational auditing progress and r-audited internallyfollowing changes to monitor progress.

• We observed the updated fracture neck of femurpathway and this worked well. This was updatedfollowing results from the previous national auditresults.

• Staff adhered to local policies and procedures andcould access them via the intranet.

Pain relief

• Patients we spoke with told us they received pain reliefin a timely way.

• Patients were asked at streaming if pain relief wasrequired. This was assessed by the nursing staff andappropriate action taken, however only paracetamolwas given in streaming.

• Drug rounds were undertaken on the emergencyadmissions unit and staff asked patients if pain reliefwas required.

• During the inspection we observed staff discussingpain relief with patients and administering as required.

Nutrition and hydration

• Patients had access to drinks whilst in emergencyassessment unit (EAU) and staff offered refreshmentsthroughout the department.

• There was a stock of sandwiches available for patientswho were in the department for extended periods..

• Meal trolleys were used for patients in beds withinEAU.

• We observed water jugs on tables for patients in beds,on EAU and also within majors.

• The EAU had access to hot drinks outside the dayroom and were offered to patients in bed.

• Staff told us they had volunteers who would help withproviding drinks.

• We observed seven intravenous charts and fluidcharts. These were fully completed and up to date.

Patient outcomes

• Unplanned re-attendance rates to ED within 7 dayswere better than the England average betweenOctober 2013 and September 2015.




• The Royal College of Emergency Medicine (RCEM)consultant sign-off audit shows three indicators wereabout the same as other trusts and one was below theEngland average. New electronic records hadimproved compliance and are were audited.

• Audit results for the severe sepsis audit showed amixed performance with five indicators around thesame as other trusts in middle England. Following thisaudit, the trust reviewed their pathways. We observedthe pathway in practice and found staff followed itappropriately. The pathway was easy to follow and onone sheet and improvements included havingpre-mixed antibiotics available from pharmacy.

• The fitting child audit showed three indicators in themiddle England quartile and two in the lower Englandquartile.

• The mental health audit showed six indicators in themiddle England quartile and two indicators in thelower England quartile.

• The older people audit showed three indicators in themiddle England quartile and two in the lower Englandquartile. All audit results and recommendations weremonitored and actioned though departmentalgovernance arrangements.

Competent staff

• Records showed 95% of appraisals in the departmenthad been completed.

• Staff received corporate and local inductions and hadaccess to a named mentor.

• Local induction included staff being supernumeraryand shadowing all areas including specialities such assafeguarding and surgery.

• Newly qualified staff had a local induction and a sixmonth preceptorship with a mentor. Staff we spokewith found this induction very comprehensive andsupportive.

• Staff reported having access to training relevant totheir job role, including venepuncture andcannulation.

• Medical staff had training sessions weekly in thedepartment.

• There were link nurses for various areas, such assafeguarding and infection control, identified whowould cascade information and training.

Multidisciplinary working

• Handover took place at 8am each morning and againat 8pm. The matron held a huddle with the consultantand team lead at 5pm to review the current access,flow though the department, and identify any issues.

• There was evidence of good multidisciplinary teamworking throughout the department involving doctors,nurses, occupational therapists and physiotherapists.Senior staff and medical staff reported good liaisonwith other departments.

• We observed team working within EAU and therapystaff liaising with staff, patients and relatives.

Seven-day services

• Medical cover was provided consistently over sevendays.

• There was access to the multidisciplinary team anddiagnostics over seven days and discharges wereplanned over the weekend.

• Pharmacy provided a dispensary service on Saturdayand Sunday mornings.

Access to information

• Information boards were visible in staff areas andthese displayed audit information, link nurse detailsand trust wide correspondence.

• Staff had access to the information they needed toprovide appropriate care and treatment including careplans and risk assessments

• White boards behind the nurse’s station identified bedcapacity within EAU.

• A department newsletter included updated trust wideinformation as well as any issues raised. This includednew policies, any new incidents and trust updates.

• Staff had access to the trust intranet and accessedpolicies and procedures when required.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards




• Staff sought consent from patients prior toundertaking any treatment or procedures anddocumented this clearly in patient records whereappropriate.

• Staff had the appropriate skills and knowledge to seekconsent from patients. Staff were able to clearlyarticulate how they sought informed verbal andwritten consent before providing care or treatment.

• Staff had a good understanding of the legalrequirements of the Mental Capacity Act 2005 andDeprivation of Liberty Safeguards.

• Staff gave us examples of when patients lacked thecapacity to make their own decisions and how thiswould be managed.

• A trust-wide safeguarding team provided support andguidance for staff in relation to any issues regardingmental capacity assessments and deprivation ofliberties safeguards during working hours.

Are urgent and emergency servicescaring?

Good –––

We rated caring as good because:

• Patients felt positive about the treatment and carethey received and felt supported to make informedchoices.

• Staff engaged with patients and offered kind andconsiderate care to patients and those close to them.

• We saw that privacy and dignity was maintained andtheir needs were met.

• A bereavement follow up service was offered tobereaved relatives and they were invited back to thedepartment for a one to one conversation with aconsultant to discuss the care and treatment of theirloved one.

Compassionate care

• In the ED friends and family test the trust remainedbelow the England average from November 14 to

October 15 with rates ranging from 78% to 86%recommending the service. In January 2016, theresponse rate was 16% and 84% recommended theservice.

• Curtains were used to maintain privacy and dignityduring assessment and treatment.

• All questions in the CQC A&E survey relating to thecaring domain are about the same as other trusts.

• We observed staff providing compassionate care topatients and supporting their carers and relatives.

Understanding and involvement of patients andthose close to them:

• We observed staff communicating with patients andrelatives in a way they could understand.

• Patients told us that staff kept them informed abouttheir treatment and care. They spoke positively aboutthe information staff gave to them either verbally orvia discharge information leaflets specific to theircondition.

• The department scored about the same as othertrusts in England in relation to questions about theamount of information patients received and howinvolved they were with their care in the 2014 A&Esurvey.

Emotional support

• We observed staff offering patients and relativessupport within the department.

• Rooms were available to provide privacy to supportloved ones during difficult times.

• A bereavement follow up service was offered tobereaved relatives and they were invited back to thedepartment for a one to one conversation with aconsultant to discuss the care and treatment of theirloved one.




Are urgent and emergency servicesresponsive to people’s needs?(for example, to feedback?)

Requires improvement –––

We rated responsive as requires improvement because:

• Facilities were not sufficient for the number ofattendances. This meant that there were not alwaysenough areas for patients to be seen and treated inwhich impacted upon access and flow.

• The four-hour waiting target was not met, except forJuly and August 2015.

• There were a high number of black breaches; January2015 showed the highest number of breaches with 74.Black breaches are those cases where it has takenover one hour from the time the ambulance arrives ata hospital, until the clinical and patient handovershave taken place.

However,

• Patients had their needs assessed and their needs weremet. Complaints were investigated and complimentswere displayed on staff notice boards.

Service planning and delivery to meet the needs oflocal people

• The facilities and premises were not large enough forthe services that were planned and delivered. Stafftold us that the facilities were built to accommodate30 000 attendances, however they now had over 70000 attendances. The trust had identified this andplans were agreed to update and improve facilitieswithin a two year timeframe. Discussions aroundservice provision included the trust, the clinicalcommissioning group and the local council.

• The waiting room was small and overcrowded on thefirst day of inspection, with people standing in themain waiting area. Children had access to a separatewaiting area that was not overcrowded. Bed meetingswere held every day to review capacity and staff liaisedwith colleagues on the wards to identify bedavailability.

• Engagement with other trusts in the area assisted withplanning services for the population and supportingneighbouring trusts.

Meeting people’s individual needs

• Staff worked collaboratively to meet the needs ofpatients with complex needs.

• The health of the local population varied comparedwith the England average. Deprivation was lower thanaverage, however about 15.4% (9,000) children live inpoverty. The trust worked with the local council andclinical commissioning groups to ensure services meetthe needs of the community.

• There were link nurses in the department fordementia, safeguarding and infection control. Theysupported colleagues and cascaded training.

• The trust had translation and language servicesavailable via language line, deafness support andtranslation. Staff we spoke to had not accessed theservices.

• People with a dementia diagnosis were highlighted viaan alert on the bed board. Staff had access todementia training.

• The Spiritual Care Centre at the hospital was open24hours, seven days a week and offered space forpatients, relatives and staff of all faith and no faith. Inparticular for Muslims there were washing facilities,and prayer mats available. There were Christianprayers held on Tuesday, Wednesday and Thursdaylunchtimes, and on a Sunday at 11am volunteerswould bring patients to the Holy Communion service.There were special services held at the main ChristianFestivals, together with an annual HospitalThanksgiving service. Meditation classes led by aBuddhist monk were also held in the Spiritual CareCentre.

Access and flow

• Attendances resulting in an admission between April2013 and August 2015 were consistently higher thanthe England average.

• Bed occupancy rates had been higher than the Englandaverage from April 2013 to September 2015. Occupancyrates for January – March 2014 and 2015 reached 99%.




• The unit included a 22 bedded emergency admissionsunit for patients awaiting an acute bed. During theinspection all patients were waiting a medical bed.Some patients were discharged direct from this unit andwere reviewed daily whilst on the unit by medical staff.There was access to physiotherapy and occupationaltherapy also.

• There were issues with patient flow due to medicalbed capacity. Additional bed provision was madeavailable within the minor’s area to await an in-patientbed. There were toilet facilities, however these were inthe x-ray department next to the department. Foodand drink was provided and privacy and dignitymaintained.

• Waiting times regularly breached the four hour targetbetween April 2015 and January 2016. During this timethe results were between 76-93%, except for July andAugust 2105 when the 95% target was reached.

• There were 382 black breaches from May 2014 toNovember 2015. January 2015 showed the highestnumber of breaches with 74. December 2014 to March2015 there was a high number of black breachesreported from around 30 - 74.

• The number of patients waiting four to12 hours to beadmitted was generally higher (worse) than theEngland average from November 2014 to October2015 (except in August 2015 when there was adecrease below the average by 2%). Data for October2015 showed 20% of patients waited four to 12 hoursto be admitted compared to the England average of8%

• The total time in ED performance remained higher(worse) than the England average from September2013 to September 2015 with times ranging from160-180 minutes compared to the England average of130 minutes.

• The trust had a mixed performance for the number ofpatients leaving before being seen. Over-all betweenJanuary 2015 and December 2015 this rate was 3.2%.The emergency assessment unit and primary care unitaimed to improve flow.

• Ambulance journeys with a 30-60 minute turnaroundmade up approximately 40% of all journeys betweenJune 2014 and May 2015 with January 2015 rising toapproximately 50%.

• We visited the general practitioner admissions unit(GPAU) as part of the un announced inspection. GPAUis where patients were assessed following referral byGP’s, and we observed that this new initiative hadreduced access and flow issues within the emergencydepartment. This department had opened since theconclusion of the announced inspection on 19February 2016 in order to improve access and flowacross the hospital.

Learning from complaints and concerns

• Complaints and compliments were displayed on staffnotice boards. This included anonymised complaintsfor staff to review.

• Staff had access to a department newsletter andbulletin which included information on complaints.

• Complaints were formally discussed at the divisionalgovernance board meetings on a monthly basis.

• Staff tried to resolve complaints locally wherepossible.

• Compliments and thank you cards were alsodisplayed on the staff noticeboard.

Are urgent and emergency serviceswell-led?

Good –––

We rated well-led as good because:

• Staff at all levels were enthusiastic and felt wellsupported.

• Staff were aware of the trust values and were proud ofthe services they provided.

• Governance meetings were held and incidents andrisks discussed.

• Staff felt involved in forward planning and servicedevelopment.

• The trust held an annual awards event to celebratesuccess and achievements.

• Compliments and complaints received were shared.




• Lessons were shared and discussed in team anddivisional meetings.

Vision and strategy for this service

• Staff were aware of the trust’s vision and values butnot of the Model hospital concept. This is where theNHS would have a ‘model NHS hospital’ to helpproviders aspire to best practice across all areas ofproductivity.

• Senior staff had developed strategies for improvingservices within the department, including reviewingpathways and engaging staff and staff reported beinginvolved in discussions.

Governance, risk management and qualitymeasurement

• Medical staff had weekly governance meetings andinformation was cascaded.

• Senior staff attended governance meetings and thiswas discussed at team meetings and included in thenewsletter and bulletin. The meeting minutes showeddiscussions included incidents, risks, performance andstaffing.

• Staff discussed risks that had been reported andescalated including staffing issues.

• The department had a risk register with review datesclearly documented. Risks on the register reflectedthose identified by staff and managers.

• There were regular team meetings and huddles todiscuss issues and wards displayed information onnotice boards.

• The department had a risk folder which included trustwide risk assessments as well as local riskassessments.

Leadership of service

• Staff stated that the executive team were accessibleand responsive.

• Appraisals were conducted with staff and one to onemeetings could be requested when required.

• Staff felt supported by their line managers and seniormanagement. Staff felt confident to raise issues withline managers and had access to the trust whistleblowing policy.

Culture within the service

• Staff were positive and enthusiastic and felt valued bythe organisation and the department. They felt theyworked well with colleagues and supported eachother where required.

• The trust had a performance management policywhich was implemented at departmental level.

• Staff felt encouraged to raise issues and concerns andfelt confident to do so.

Public engagement

• Patients could feedback to the trust about their careand experiences via friends and family test, inpatientexperience survey and via social media, all of whichcould be accessed via the hospital’s website.

• Feedback from patients was collated at departmentallevel.This was discussed with staff in meetings, andactions were taken to improve patient experience, forexample changing electronic signage to show patientflow in the department.

• Annual board meeting agendas and minutes wereaccessible to the public via the trust website. Theseprovided details of the upcoming meetings the publiccould attend including board meetings and annualmembers meetings.

Staff engagement

• Staff told us they received a weekly newsletter from thetrust via email which kept them up to date with currentor on going issues and information.

• The department held a range of targeted focus groupsfor all staff grades which supported staff engagementand involvement.

• Team meetings were used to give staff the opportunityto “speak out” and staff were encouraged to talk aboutmorale within the department.

• Senior staff told us that the executive team wouldcomplete a walk round and visit the department eachmonth. This meant that executives were visible to staffand they could review the work within the department.

• The trust performed within expectations for 14questions in the general medical council survey. Theyscored worse than expected for ‘Feedback’. Medical staffin the department now have weekly meetings to discussgovernance issues and to provide training.




• In 2015, the trust introduced a ‘who cares, we do’ and‘you said, we listened ' report which gave a briefsummary of the results and actions going to be taken bythe trust.

Innovation, improvement and sustainability

• The trust has recognised that changes were requiredwithin the ED Department. A ‘project build’ summarypresentation had been before the trust executive team

and they have given approval to move to the nextstage. This is a two year build plan. One of the changesis to create two cubicles in EAU (PODS) for isolationand the plan is to also increase waiting room capacity.

• During the unannounced inspection, we observed thegeneral practitioner admissions unit (GPAU) wherepatients were assessed following referral by GP’s andthis reduced access and flow issues within theemergency department.




Safe Good –––






Information about the serviceThe medical care services at the hospital provide careand treatment for a wide range of medical conditions,including general medicine, cardiology, respiratory,gastroenterology and stroke services. The stroke serviceis part of the Greater Manchester regional thrombolysisservice. There are 683 beds at the hospital and around4100 members of staff employed at the trust. The hospitalprovides medical care services to a population of 445,000.

We visited Countess of Chester as part of our announcedinspection on 16th to 19th February 2016. We alsoconducted an unannounced inspection on 4th March2016.

During the inspection we visited ward 33 (stroke), 42(cardiology), 43 (geriatric), 48(respiratory),49(gastroenterology), 51 (frailty ward), the renal unit,acute medical unit (AMU), discharge lounge, cardiaccatheterisation suite and the endoscopy unit.

We reviewed the environment and staffing levels andlooked at 18 care records and 15 medication records. Wespoke with 10 family members, 23 patients and 50members of staff of different grades, including nurses,doctors, ward managers, matrons, ward clerks, alliedhealth professions, such as physiotherapists andoccupational therapists and the senior managers whowere responsible for medical services.

We received comments from people who contacted us totell us about their experience, and we reviewedperformance information about the trust. We observedhow care and treatment was provided.

Summary of findingsWe rated medical care as good because:

• Incidents and complaints were reported via anelectronic system and staff could access the system.

• Most staff reported receiving feedback and learningfrom incidents and complaints. Risk registers were inplace; however, action plans with timelines were notdocumented, however risks identified in this divisionwere reflected in trust wide initiatives in place tomitigate risks.

• Wards were visibly clean, staff followed good hygienepractices.

• There were good systems for handling and disposingof medicines.

• Equipment was available and serviced as required.

• Staffing across medical services was on the riskregister and actions had been taken includingrecruitment overseas and regular monitoring ofstaffing levels during the day to help mitigate the risk.The trust biannual review stated that overall the trusthad maintained over 95% of the planned staffinglevels.

• The trust had identified this as an area forimprovement and a pilot of a new roster wascommencing in April 2016. The trust were alsoundertaking a number of initiatives relating tomeasuring patient acuity to help plan staffing.

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Medical care (including older people’s care)


• Patients risk assessments were completed and staffimplemented measures to reduce risks.

• Staff were aware of the trusts values and vision. Staffenjoyed working at the hospital, felt well supportedby their managers and worked collaborativelytogether to ensure patient were cared for.

• Staff treated patients and their relatives with respectand dignity and communicated with them effectively.Patients were happy with their care, felt informed,and were involved in care planning.

However,

• Data provided showed there were occasions whenthe nurse staffing levels were less than 90 %.

• There were issues with access and flow across themedical wards with high bed occupancy rates anddelayed discharges due to the complexity of patient’sneeds. Some patients were being nursed innon-speciality beds and on occasions in mixed sexwards, although this was based on clinical need.

• There was a risk that personal information wasaccessible to members of the public as patient’srecords were not always stored securely.

• Monitoring documentation for input and output,bowel charts and cannulation checks were notalways consistently completed.

• On one ward, a large quantity of medication wasfound in an accessible unlocked cupboard, whichwas a risk to patients and members of the public.

• Compliance with mandatory training for the majorityof staff was below trust target. The trust target was95%.

Are medical care services safe?

Good –––


• Incidents were reported by staff through effectivesystems and lessons learnt and improvements madefollowing investigations were shared at team meetings

• Most staff reported receiving feedback and learningfrom incidents and complaints.

• Wards were visibly clean, staff followed good infectioncontrol practices.

• There were good systems for handling and disposingof medicines.

• Equipment was available and serviced as required.

• Staffing across medical services was on the riskregister and actions had been taken includingrecruitment overseas and regular monitoring ofstaffing levels during the day to help mitigate the risk.The trust biannual review stated that overall the trusthad maintained over 95% of the planned staffinglevels.

• The trust was also undertaking a number of initiativesrelating to measuring patient acuity to help planstaffing.

• Staff had knowledge regarding safeguarding and wereaware of how to access the safeguarding team.

• Equipment had up to date electrical safety certificatesand the majority of equipment observed was visiblyclean.

However,

• data provided showed there were occasions when thenurse staffing levels were less than 90 %.

• In addition, staff told us they were regularly moved toother wards, which meant some wards did not havethe appropriate skill mix. The trust had identified thisas an area for improvement and a pilot of a new rosterwas commencing in April 2016.

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• There was a reliance on some wards to use agencystaff and some staff would work extra shifts as part ofthe nurse bank to support ward areas.

• Records were accessible to the public as most werekept in open trolleys that did not have the capabilityto lock. The trolleys we observed were positionedopen at the nurse’s station or on the ward corridor.

• Some staff found the electronic patient record systemin place to record and monitor patient care difficult touse and time consuming.

• Some treatment rooms did not have a door and allmedications were locked away on all wards apart fromon the frailty ward where we observed a large quantityof medications in an unlocked cupboard andtherefore accessible to patients and the public. Wefound some used sharps containers which had beenleft open in unlocked areas, which were accessible, bypatients and the public and cleaning chemicals hadbeen left out in an unlocked room on a number ofwards.

• Staff attended mandatory training courses butcompliance rates were below the trust target for themajority of staff.

Incidents.

• There were systems for reporting actual and near missincidents across medical services. Staff were familiarwith and encouraged to use the trust’s procedures forreporting incidents.

• All incidents were reviewed by the ward manager whoensured all appropriate measures had been taken, forexample when a fall had occurred, risk assessmentsand preventative measures were put in place and ifinjuries were sustained this had been managedappropriately. Any incidents with harm or near misseswere escalated to the risk and patient safety team forfull investigation.

• The executive serious incident panel met on a weeklybasis and reviewed incident trends and any individualincidents which resulted in moderate harm or greater.The level of investigation would be determined andthose that were considered a NPSA (national patientsafety agency) level one or two were reported to StEIS(Strategic Executive Information System).

• From November 2014 to October 2015 there had beenno never events reported across medical services atthe hospital. Never events are serious, whollypreventable patient safety incidents, which should notoccur if the available preventative measures areimplemented.

• From 1st December 2014 to 30th November 2015medical services across the hospital reported 2475incidents, 51 of these were escalated for furtherinvestigation.10 of the reported categories accountedfor 76% of the incidents, the most being slips, tripsand falls.

• Across the trust there were 67 serious incidentsreported from 1st February 2015 and 21st January2016. 48% (34) of those were reported in medicalservices, which included pressure ulcers, and hospitalacquired infections. All serious incidents had beeninvestigated and action had been taken to preventre-occurrence. Trust data suggests that ten of thesewere still ongoing at the time of report.

• Staff we spoke to felt they were well supported whenthey reported incidents. Incidents were disseminatedat ward staff meetings, although three members ofstaff stated they did not always get personal feedbackfor every incident reported.

• There were examples of learning and changes topractice following incidents. For example staff told usthat following an incident relating to supportingpatients who require enteral feeding, the ‘feed me up30 degrees’ was implemented. Patients who wereenterally fed were now positioned 30 degrees andabove. We observed this during our inspection.

• The trust had a duty of candour process in place toensure that people had been appropriately informedof an incident and the actions that had been taken toprevent recurrence. The duty of candour is aregulatory duty that relates to openness andtransparency and requires providers of health andsocial care services to notify patients (or other relevantpersons) of‘certain notifiable safety incidents andprovide reasonable support to that person. Seniorstaff and some junior staff understood the principlesof duty of candour and we saw evidence of the policybeing applied appropriately.

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• Duty of candour was included in mandatory trainingand a leaflet was given to staff as part of inductiontraining. Duty of candour was included in the policy forinvestigating incidents.

• Multidisciplinary mortality and morbidity reviews wereheld on a monthly basis, which was chaired by themedical director. All cases were reviewed through thisprocess to identify key learning and to identify anyactions if appropriate. Actions and learning werediscussed at key governance meetings and some stafftold us this was shared with them.

Safety thermometer

• The trust was required to submit data to the healthand social care information centre as part of the NHSSafety Thermometer (a tool designed to be used byfrontline healthcare professions to measure asnapshot of specific harms once a month). Themeasurements included pressure ulcers, falls andcatheter acquired urinary tract infections

• From January 2015 to January 2016 there were 27 newpressure ulcers, eight catheter acquired urinary tractinfections, 34 venous thromboembolism (VTE) and 10falls reported across medical services at the hospital.The data provided by the trust did not clarify whichincidents reported on the safety thermometer resultedin harm.

• Harm reviews were conducted and reports completedfor all in-patient falls and pressure ulcers reportedacross the trust from April 2015 to September 2015.Each report included a review of falls and pressureulcers including mitigating reasons and impact.Learning points were highlighted, key actionsidentified and recommendations were made includingimprovement in communication and documentation.

• Harm data was reviewed by the Director of Nursingand reported to the integrated board to monitorcompliance against local and national target.


• From April 2015 to December 2015, there were threecases of MRSA bacteraemia reported across the trust.One was reported from medical services and a casereview concluded it was unavoidable and norecommendations were identified. The other two

required a post infection review in whichrecommendations with time lines were documented.Lessons from all cases were disseminated to staff forlearningacross directorates.

• There were 17 cases of MSSA (Methicillin susceptiblestaphylococcus aureus) reported across the trust fromApril 2015 to December 2015, this was higher than theEngland average.

• From April 2015 to December 2015 there were 18 casesof Clostridium difficile (C dif) reported. A root causeanalysis investigation identified contributory factors,lessons learnt along with recommendations, whichincluded communicating to the relevant teamsregarding inappropriate prescribing of antibiotics.

• In September 2015, the trust reported a markedincrease in C-dif with eight cases reported across fivewards. A strategy meeting was held in October 2015and action plans were implemented includingcontinuing with staff awareness, staff training andsharing of any learning.

• Staff followed good practice guidance in relation tothe control and prevention of infection in line withtrust policies and procedures and we observed stafffollowing hand hygiene practice, bare below theelbow and using personal protective equipment (PPE)where appropriate. However, on one occasion, we sawpoor hand hygiene practice prior and duringadministration of intravenous therapy and at anothertime a member of staff did not use all PPE availablewhilst dealing with a contaminated area; both werehighlighted to the ward managers.

• There were sufficient number of hand washing sinksand hand gels. Hand towel and soap dispensers wereadequately stocked and personal protectiveequipment such as gloves and aprons was availablethroughout the ward areas

• Side rooms were used as isolation rooms for patientsidentified as an increased infection risk. There wasclear signage outside the rooms so staff and visitorswere aware of the increased precautions they musttake when entering and leaving the room.

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• The trust used the national colour-coding scheme forhospital cleaning materials and equipment.Thisensured that these items were not used in multipleareas, therefore reducing the risk of cross infection.Cleaning storerooms were generally clean and tidy.

• Infection, prevention and control (IPC) audits werecarried out on a regular basis in medical services.From June 2015 to December 2015 medical wardsachieved above 92% compliance. Following audits,action plans were implemented and updated whencompleted.

• In June 2015, the trust completed an audit ofcommodes across 26 areas and found that 25 % of thecommodes were soiled and a third requiredreplacement due to damage. This showed a decline incleanliness compared to the previous year. Key actionswere identified including ensuring training posterswere visible in ‘dirty’ utility areas. A further audit isplanned for 2016. During the inspection, we saw thetraining posters in some areas and all the commodeswe observed were clean and in a good state of repair.

• Hand hygiene audits across medical services from May2015 to October 2015 showed variable complianceranging from 71 % to 100%. Reasons were highlightedincluding for non-compliance with bare below elbowpolicy. The trust target was 95%. Following theseresults, action plans were put in place and were beingmonitored by the PLACE committee. Data receivedshows none of the actions had yet been completed.

• The majority of equipment was visibly clean but therewere inconsistencies across the wards in the use of the‘I am clean stickers’ which may make it unclear to newor temporary staff on the correct process foridentifying whether equipment was clean and readyfor use.

• During the inspection, we observed four stand aidsthat were stained. These were brought to the attentionof staff and acted upon immediately.

Environment and equipment

• Resuscitation equipment for each ward was readilyavailable. There were systems and records in place to

ensure that emergency equipment was checked andready for use on a daily basis. Records indicated thatthe majority daily checks of equipment had takenplace on the wards we visited.

• There were systems in place to maintain and serviceequipment. We observed portable appliance testing(PAT) had been carried out on all electrical equipmentregularly and electrical safety certificates were in date.

• Most cleaning chemicals were stored safely, howeverwe observed that some were kept in unlocked areason three wards. These should have been storedsecurely as the chemicals were potentially hazardous.This was brought to the attention of staff who tookappropriate action.

• A trust wide sharps handling and disposal audit inSeptember 2015 showed that the trust had improvedin sharps management compliance including use ofthe temporary closure mechanism of 89% comparedto 64% in 2014. However, compliance had decreasedslightly from 56 % to 52 % regarding the use of abracket/trolley in which to store sharps containers.During our inspection not all sharps containers werestored in a bracket or trolley.

• We observed that the disposal of sharps followedgood practice guidance. Most sharps containers weredated and signed upon assembling. However, on ward51 we observed that there were four sharps containersleft open which was accessible to patients and thepublic. We raised this with staff who acted upon this.

• Across medical services Patient Led Assessments ofthe Environment (PLACE) in 2015 showed a score of98.18% which was above the England average of97.57% for cleanliness. However, other areas includingfood, privacy, dignity and well-being, dementia,condition appearance and maintenance across thetrust were below the England average. The Englandaverage was 90%.

• Most wards were fit for purpose however there was anissue with lack of space on some wards, for examplethe staff office (cardiology ward) or day room (strokeward) were used to give patients and families sensitiveinformation. On ward 48, clean linen and food was

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stored in the same cupboard, this was raised to thenurse in charge who did not see it as a risk. The trustwere aware of issues with lack of storage and planswere in place to address this.

Medicines

• All wards had systems in place for the safe handlingand disposal of medicines. Ward staff told us therewas regular pharmacist presence on wards and theycould access a pharmacist as required.

• The pharmacy department operated a full pharmacyservice Monday to Friday 9-5pm, and provided adispensary service on Saturday and Sunday mornings.A pharmacist was available out of hours for urgentadvice.

• Prescriptions were via an e-prescribing system. On thesystem, VTE assessments and antibiotic stop dateswere mandatory which ensured prescribing waswithin local guidelines. Patient’s medicines to takehome on discharge (TTO) were visible and could bereviewed electronically by staff on the tracker system.

• All medicines on the wards were found to be in date,indicating that there were good stock managementsystems in place.

• We reviewed 15 patient’s prescription records whichwere fully completed, dated and had the patient’sallergy status documented. Staff told us the systemwas easy to use and they had received training.

• Suitable locked cupboards and cabinets were in placeto store medicines. All drugs we checked were withindate. We observed on one ward several strips ofmedication not in their original packaging in a lockeddrawer, which was secure; however, this may make itdifficult to identify drug expiry dates.

• All treatment rooms with doors were locked apartfrom ward 48 where a broken lock was awaiting to bereplaced. We observed no doors to the treatmentrooms on wards 51 and ward 42. All medications werelocked away on ward 42.

• On ward 51, we found two unlocked cupboards in thetreatment room containing a large quantity of oralmedication, intravenous medication and bags ofintravenous fluids

• An audit of safe and secure storage of medicines inNovember 2015 identified some wards including ward51 had medication stored inappropriately and hadunlocked cupboards. An action plan wasimplemented to address concerns with the ward andclinical area managers. A memorandum was issued inDecember 2015 following the trust audit, however dueto our findings it was unclear whether this method ofescalation was effective. There were plans to re auditin March 2016.

• There were suitable arrangements in place to storeand administer controlled drugs (medicines that arerequired to be stored and recorded separately). Stockbalances of controlled drugs and patients controlleddrugs were correct and two nurses checked the dosesand identified the patient before medicines wereadministered. We observed that not all liquidcontrolled drugs were dated upon opening andrecording errors were not recorded consistently in theCD book for example not all amendments in thecontrolled drug register were signed.

• Medicines requiring cool storage were appropriatelystored in locked fridges. Records indicated that fridgetemperatures were checked daily on most wards.

• Medication errors and risks identified were discussedat the medicines clinical quality meeting. There were489 medication errors reported between April 2015,September 2015, of those 92% resulted in no harm,7% low /minimal harm, and 1% were moderate/shortterm harm. All had been investigated and appropriateaction taken.

Records

• There were paper and electronic patient records. Theelectronic system would prompt staff to take certainactions for example when completing themultifactorial falls risk assessment if patient met thecriteria which increased risk of falling a flag would beseen to refer the patient to the physiotherapist.

• Most staff we spoke to stated inputting informationwas time consuming and that they were not madeaware of new information that would be added to thesystem for completion. We also observed a member ofstaff unable to locate care plans and another whocould not find retrospective results. Staff told us theyreceived electronic system training on induction.

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• We reviewed 18 patients care records during ourinspection. The records we reviewed had detailedinformation regarding planned care and treatment.Electronic documentation kept to record people’s vitalsigns along with risk assessments includingmalnutrition universal screening tool (MUST), and fallswere completed. However, on occasions we notedthat paper based documentation regarding bowelmovement, weight, cannulation checks and fluidbalance charts were not always completed fully.

• In most wards, records were stored in an unlockabletrolley on the corridor or at the nurse’s station andtherefore accessible to the public. This increased thepotential for patient confidentiality to be breached ifthese areas were not staffed.

Safeguarding

• Training statistics for medical services showed thatsome staff had completed safeguarding adult training.Nursing and midwifery staff were just above trusttarget with 81.3% in level two training however werebelow with 66.7% in level three training. Medical anddental staff were below trust target with 41.3% and57.1% in level two and level three training. The trusttarget was 80%.

• At the time of our inspection there was not asafeguarding adult and learning disability coordinatorin place to take the strategic and operational lead forSafeguarding Adults at the trust, however this vacancyhad been recruited too and the trust were beingsupported by the lead from the local clinicalcommissioning group. Staff had access to a nameddoctor and named nurse along with five other staffwho acted as points of contacts for advice andguidance in safeguarding.

• The trust had a safeguarding strategy board who metto discuss safeguarding issues, reports and incidents.Strategies and action plans were implemented toimprove safeguarding, this included increasingawareness and training.

• A safeguarding adults policy was in place, whichincluded standard operating procedures with keypoints and clear guidance for staff. Staff we spoke towere aware of the policy and who to access forguidance and support.

• Between February 2015 and January 2016 there hadbeen 47 safeguarding referrals made from medicalservices trust wide. Reasons for referral includedneglect, physical, financial and psychological, abuseor self-neglect.

Mandatory training

• Staff received mandatory training in areas such asmental capacity, health and safety, fire, manualhandling, infection control and medicinemanagement. Staff we spoke to said they were up todate and had completed all there mandatory training.

• Information provided by the trust at the time of ourinspection showed across medical services that allmedical, dental staff were 100% compliant withmandatory training apart from mental capacity actwhich was 35%. Compliance rates for staff was belowthe trust target of 95 %.


• Upon admission to medical wards, staff carried outrisk assessments to identify patients at risk of harm.Those patients at high risk were placed on carepathways and care plans were put in place to ensurethey received the right level of care. The riskassessments included falls, pressure ulcer andnutrition (Malnutrition Universal Screening Tool orMUST).

• We reviewed 18 patients’ records and found that allappropriate risk assessments had been completed toensure that patients were assessed and care wasmanaged safely, although some were not recordedimmediately.

• A modified early warning score system (MEWS) wasused throughout the trust to alert staff if a patient’scondition was deteriorating. This was a standard set ofclinical observations such as respiratory rate,temperature, blood pressure and pain score used forearly detection of any changes in a patient’s condition

• The trust had arrangements in place to evaluatecompliance in responding to patient risk. In October2015, a MEWS audit was conducted on 334 recordsacross 21 wards in the trust. The report highlighted

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good practice and areas for improvement includingpatients not having treatment escalated. Action planswere implemented with timescales including sharingof audit results and re auditing monthly.

• We saw effective handover meetings including the‘safety brief ‘and ‘huddles’ where staff discussedpatients and highlighted key risks. Each member ofstaff also had a paper list of patients to help ensure allrelevant information was shared with staff. Thisincluded patients with dementia, deterioratingpatients, and those at risk.

• We observed the World Health Organisation (WHO)endoscopy and surgical checklist completion in theendoscopy unit and catheterisation suite. The WHOchecklist is an international tool developed to helpprevent the risk of avoidable harm and errors duringand after surgery. These were fully completed.

• In November 2015, staff on the cardiology wardreported an incident where they were unable to gaincontact with staff on another ward with regard topatient with an arrhythmia, which is an abnormalheart rhythm. The trust has responded to this and atthe time of our inspection, mobile devices had beenordered which staff could carry and therefore becontactable at all times. This remains on the riskregister as a moderate level of risk.

• There was no observational /monitoring equipment ormedication storage in the discharge lounge. If thepatient required observations to be taken for exampleblood pressure, discharge lounge staff would go to A &E to obtain equipment and contact ward medical stafffor support. If the patient required medication, it wasadministered by ward staff attending the dischargelounge. During our inspection, we observed a sisterfrom a ward administering medication to a patient inthe discharge lounge.

Nursing staffing

• The trust had previously used a safer staffing tool,which included measuring patient acuity to identifysafe staffing levels; however, it was in the early stagesof using a workload management tool (NHPPD) fromthe recently published Lord Carter model hospitalreview and piloting an activity monitoring tool to gainrobust data going forward.

• Data provided in January 2016 by the trust shows thenumber of nurse vacancies in medical services was1.9%. The turnover rate of nursing staff was 10.69%and staff sickness was reported at 3.7%.

• The trust undertook biannual nurse staffingestablishment reviews as part of mandatoryrequirements and set key objectives though this workto support safer staffing. Data provided as part of thisreview in January 2016 identified that over-all the trusthad maintained over 95% of staffing levels plannedagainst actual levels for nine months.

• Data provided for registered nurse staffing levels forDecember 2015 and January 2016 showed that Ward42 was the only ward to achieve the plannedregistered nursing level in December 2015 andexceeded the level in January 2016. In December therewere 4 wards that were below the 95% plannedstaffing levels with the lowest being ward 51 with 86%and in January 2016 there was ward 43 with 88% andward 48 with 83% of the planned level of staff. Datawas not provided regarding untrained staffing levels.

• We reviewed nurse staffing levels for nine medicalwards in July, September and October 2015. Theaverage percentage of nursing shifts filled as plannedduring the day was variable. Concerns were identifiedeach month with staffing levels below 90 % on anumber of wards;in July ward 51 (86.8%), inSeptember ward 43 ( 84.6%), ward 48 (85.4%) andward 51(88.9%). In October 2015 nurse staffing wasbelow 90% on five wards: ward 43 (85.6%), ward 50(89.1%), ward 48 (79.9%), ward 51 (87.8%) and AMU(87.3%).

• For the same period, the average percentage ofnursing shifts filled as planned during the night wereover 90% on all wards. However in October 2015 AMUhad 93% qualified and 87.7% unqualified staff.

• Each ward had a planned nurse staffing rota andmanagers reported on a regular basis if shifts had notbeen covered. The National Institute for Health andCare Excellence (NICE) guideline ‘Safe staffing fornursing in adult inpatient ward in acute hospitals’,nurse sensitive indicators and professional judgementwere used to determine their staffing needs.

• Medical wards displayed nurse staffing information ona board at the ward entrance. This included the

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staffing levels that should be on duty and the actualstaffing levels. This meant that people who used theservice were aware of the available staff and whetherstaffing levels were in line with the plannedrequirement.

• Matrons and managers met regularly to discuss nursestaffing levels. Where there were shortfalls, staff wouldbe moved from wards to support areas with a higherpatient acuity. Some staff we spoke to were concernedthat this addressed the number of staff required butnot the skill mix, for example, staff with specialisedskills required for a specific ward were movedelsewhere and potentially replaced with a nurse whodid not have specialist skills.

• Staff told us there were nurse staffing issuesparticularly at night due to staff being moved to otherwards. This had been identified by the trust and seniorstaff told us they were currently reviewing staffing andwere planning to pilot a different way of working inApril 2016using the existing workforce to matchpatient acuity as reflected in ‘the Model Hospital’ andthis was evidenced in board papers we reviewed. Thiswill evaluate a change in shift pattern to support anextra member of staff on a nightshift as part of metricsidentified in the Department of Health efficiency workprogramme.

• Staff told us when they would complete an incidentform if they had to move to another ward due to staffshortages. We observed that 574 falls were reportedtrust wide,of those 49 (8.5%) were reported as beingimpacted upon by staffing with the highest issuereported in obtaining staff for 1-1 supervision or zonedobservation. 41 % were unwitnessed (patient found onthe floor) falls. The top three affected areas were allmedical wards.

• The trust were currently working with the Departmentof Health looking at processes and procedures relatedto patients requiring 1-1 support as part of a pilotscheme.

• On the day we inspected the majority of shifts acrossmedical services were filled as planned. We reviewedrotas and saw the majority of shifts were filledhowever, staff told us on occasions extra staff would

be needed for patients requiring 1:1 care. When staffwere moved to support other wards this was notalways updated on the rota, therefore it did not give atrue representation of staffing and skill mix per shift.

• The trust had a pool of bank staff, which they haveused along with agency staff. Trust data showed thenumber of agency staff was variable across themedical wards from May 2014 to March 2015. Thehighest use of agency staff was ward 51 with 33.6 % -48.5 % and AMU 16% - 41.6% from November 2014 -March 2015.

• Nurse staffing levels was on the risk register and ratedas a high risk. Senior managers told us following thesuccessful overseas recruitment they were looking atgoing overseas to recruit again.This was part ofmeasures identified in the biannual safe nurse staffingreview in January 2016.

Medical staffing.

• There was sufficient medical cover outside normalworking hours and at weekends should patients needto see a doctor. Consultant cover was available on sitefrom 9am to 6pm daily and on call outside of thesehours. We were told that all consultants were within 30minutes of the hospital.

• At weekends, there was a cardiologist from 08.00 to12.00 who provided input to cardiac patients on AMU,Coronary Care Unit and the cardiology ward asrequired. Stroke Physicians were on-call 24 hours 7days a week. There was also a gastroenterologist whoprovided daily input along with in reach support withaccess to endoscopy.

• Senior managers told us there are regular hand oversbetween medical staff with wards rounds every dayincluding weekends and this reflected what we saw.

• Trust data showed that across medical services trustwide there were four consultant vacancies in each ofthe service: cardiology, acute, gastroenterology andrespiratory. Vacancies for trainee doctors posts was 19and for F1 doctors was one across medical services.

• The use of locum medical staff for the hospital duringApril 2014 and March 2015 was variable between 0%up to 27% at times across eight wards however on twooccasion’s locum agency levels were 100% on theacute frailty unit. The Acute Frailty Unit was

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established in July 2015 and formed part of the acutecore medical trainee programme. We were advisedthat gaps in rotation were to be addressed via thecurrent ward reconfiguration.

• The turnover rate for medical staff across medicinewas 8.1% and 1.25% staff sickness for the last financialyear.


• The trust had a major incident plan in place, whichlisted key risks that could affect the provision of careand treatment. There were clear instructions for staffto follow in the event of different types of majorincidents.

• Staff we spoke with were aware of the major incidentplan and how to access it.

Are medical care services effective?

Good –––


• Care and treatment was provided in line with nationaland best practice guidelines.

• Medical services participated in the majority of clinicalaudits where they were eligible to take part, forexample the stroke and diabetes audit. Recentnational audits indicated that there had been positiveprogress made to improve care for people who had aheart attack, stroke or heart failure.

• Patient’s pain relief was monitored effectively.

• Nutrition and hydration assessments were completedand patients requiring assistance were supported.Patients with swallowing difficulties on the strokeward had their needs and requirements assessed in atimely manner.

• Staff were supported and had received their annualappraisal.

• Staff on specialist wards had completed specificcompetencies to deliver safe and effective care andtreatment.

• The endoscopy unit had been formally recognisedthat it had competence to deliver against themeasures in the endoscopy GRS standards and hasreceived JAG accreditation in 2010.

• There was good collaborative working across medicalservices with focus on discharge planning.

• There was evidence that most services were deliveringor working towards a seven days a week.

• We found senior staff had a good understanding andawareness of assessing people’s capacity to makedecisions about their care and treatment and theywould carry out the assessments.

• Junior staff had basic understanding of the MentalCapacity Act and processes in place.

however,

• Mental Capacity Act training across medical services waswell below the trust target


• Medical services were using national and best practiceguidelines to care for and treat patients, for examplediabetes care and nutritional screening. The trustmonitored compliance with NICE guidance and weretaking steps to improve compliance where furtheractions had been identified.

• The trust took part in a regional advancing qualityaudit programme aimed to improve standards ofhealthcare provided in hospitals across the northwestof England, so that more patients had a betteroutcome from their treatments and care. Hospitalswho participate in this programme collect data to seewhether the required standards of care have beenmet, for example whether the correct assessment andtreatment was provided at the right time.

• Medical services participated in clinical audits forwhich it was eligible through the advancing qualityprogramme. In March 2015, audits demonstrated thetrust was not meeting the appropriate target in someareas including chronic obstructive pulmonarydisease. The service had actions plans in place, whichhad improved performance

• There were examples of recent local audits that hadbeen completed on the wards, including the care

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metrics monthly audit. The results were shared on theward noticeboard, staff told us the results of theaudits, and any learning was disseminated in teammeetings. We observed this on the minutes of a teammeeting.

• Medical services participated in the joint advisorygroup on GI endoscopy (JAG) and received JAGaccreditation for the endoscopy unit in 2010. The unitwas due to be re-accredited in March 2016. JAGaccreditation ensures the quality and safety of patientcare by defining and maintaining the standards bywhich endoscopy is practiced.

• Guidelines and polices were available on the trustintranet. Staff were aware of how to access guidelinesand policies on the trust intranet and in ward areas.Staff had access to previous audits and findings, whichwere also discussed and recorded as part of wardminutes

• A monthly audit of VTE assessments showed that VTEassessments were consistently above the trust targetof 95 % from October 2014 to 0ctober 2015.

Pain relief

• Pain was assessed using a pain tool and pain reliefwas managed on an individual basis. This wasregularly monitored for efficacy. Patients said theywere consistently asked about their pain andsupported to manage it.

• We saw completed pain assessments in patient’srecords.


• Nutritional risk assessments (MUST) were completedin all of the patient’s records we reviewed.

• Patients who could not maintain adequate nutritionwith oral intake were supported via a percutaneousendoscopic gastrostomy (PEG). Staff were trained inproviding adequate nutrition using PEGadministration.

• Dieticians and speech and language therapists wereavailable on weekdays across the trust and staff knewhow to access the services. Patients requiring urgentdietician support were seen promptly.

• Qualified staff on the stroke ward were trained inperforming swallowing assessments. This ensuredpatients were assessed in a timely manner and couldcommence on diet and fluids at the earliestopportunity.

• During our inspection, we observed patients beingoffered and provided with drinks and food includingfinger food, which supported nutritional intake. Drinkswere within reach of patients. We saw staff assistingpatients to eat and drink whilst promotingcompassion, dignity and independence.

• Catering services provided patients who lived alonewith food to take home on discharge.

• Some ward areas used additional visual prompts forstaff in order to easily identify those patients who mayneed additional support with eating and drinking.

Patient outcomes

• The risk of readmission across the hospital for allelective and non-elective admissions was generallylower than the England average of 100 however therewas increased risk of readmission in elective clinicalhaematology of 136, respiratory medicine of 128 andnon-elective geriatric medicine of 111.

• The average length of stay (LOS) at the Countess ofChester hospital for all non-elective and electiveadmissions was longer than the England averageaside from cardiology, which was six days shorter.

• The trust took part in the National Diabetes InpatientAudit in September 2015. Data showed that there wasa higher diabetes prevalence of 38% compared to anational average of 17%. The trust performed withinrange for four indicators and better than the Englandaverage in 14 out of 18 indicators, for example diabeticfoot assessment within 24 hours (69%) compared tothe England average (29%) and patients admitted withactive foot disease who were seen by themulti-disciplinary team within 24hrs (93%) comparedto and England average of 58%. Emergencyadmissions for patient with diabetes was slightlyhigher (88%) compared to an England average (86%)and patients with active foot disease were more likelyto be admitted than the national average.

• The sentinel stroke national audit programme (SSNAP)is a programme of work that aims to improve the

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quality of stroke care by auditing stroke servicesagainst evidence-based standards. The latest auditresults for April to June 2015 rated the hospital overallas a grade ‘A’. This had improved from a grade ‘D’ inJuly – December 2014 with particularly goodperformances in discharge processes.

• The trust implemented actions in 2014 following theNational Clinical Audit and Patient OutcomesProgramme ‘NCAPOP’ included appointing acardiology specialist nurse, redrafting of the categorytwo chest pain pathway and redefining the acutemedical ward with cardiology monitored beds whichwas proven effective as demonstrated in the MINAPresults.

• The myocardial ischaemia national audit project(MINAP) is a national clinical audit of the managementof heart attacks. The MINAP audit 2013/14 showedthat the trust was higher than average for two of thethree Nstemi indicators.

• The heart failure audit in 2015 showed the trust isbetter than the England average for all in hospital anddischarge indicators apart from cardiology follow-up.

• The Summary Hospital-level Mortality Indicator (SHMI)is an indicator, which reports on mortality at trust levelacross the NHS in England using a standard andtransparent methodology. Between August 2014 andJuly 2015, the SHMI score for the Countess of Chesterhospital was 103.The SHMI is the ratio between theactual number of patients who die followinghospitalisation at the trust and the number that wouldbe expected to die based on average England figures,given the characteristics of the patients treated at thehospital. Risk is the ratio between the actual andexpected number of adverse outcomes.A score of 100would mean that the number of adverse outcomes isas expected compared to England.A score of morethan 100 means more adverse (worse) outcomes thanexpected.

Competent staff.

• According to trust figures in January 2016 over 98 % ofallied health professionals, nurses and medical staffacross medical services had received their annualappraisal.

• All new nurses on the wards we visited weresupernumerary for the first two weeks. The purpose ofclinical supervision is to provide a safe andconfidential environment for staff to reflect on anddiscuss their work and their personal and professionalresponses to their work. The focus is on supportingstaff in their personal and professional developmentand in reflecting on their practice to encourageimprovement.

• Staff across medical services had completed specificcompetencies to deliver care within their specialisedservice for example on the respiratory ward staff weretrained in caring for patients with tracheostomies,pleural suction and non-invasive ventilation whichmeant that all patient’s with tracheostomies werecared for in a safe environment.

• The ward manager told us nurses on the renal unitwere also specialist link nurses for transplantation,anaemia, diabetes and home care.

• Some staff on the endoscopy unit had completedgastrointestinal nurse training packs and had receivedtraining in ionising radiation (Medical exposure). Theunit had four nurse prescribers and health careassistants who could cannulate. Some nurses on theendoscopy unit were trained up to undertakeendoscopy procedures.

• In response to the change in the NMC revalidationprocess in April 2016 the trust had formulated arevalidation group, facilitated awareness sessions andidentified staffs revalidation dates to ascertain whichgroup would require support first. An action plan wasdevised and we saw it had been updated whenactions completed.


• Multidisciplinary team (MDT) was well established onthe wards with patients having input from a range ofallied healthcare professionals (AHP) includingOccupational, physio and speech and languagespecialist. Plans of care would be available to staff toreview patients goals.

• There was a cohesive and thorough approach toassessing the range of people’s needs, settingindividual goals and providing patient centred care.Nursing staff worked alongside therapy staff to provide

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a multidisciplinary approach. For example, the criticalcare outreach team worked closely and providedsupport to staff on the respiratory support unit andAMU. All staff we spoke to described goodcollaborative working practices.

• The respiratory early discharge team consisted ofnurses and physio who supported and managedpatients with the aim to keep them at home forexample taking arterial blood gases, home oxygen andnebuliser.

• There were specialist teams, which could be accessedfor support, advice and provide joint patient careincluding the tissue viability team, diabetes andcardiac rehab team.

• MDT meetings took place every day Monday to Fridayto discuss patients on the frailty ward who werepotentially for discharge along with any ongoing ornew concerns that required actions.

• We observed a MDT, which was led by a geriatricianand included AHP, rapid response team, dementianurses and social work team handovers. Staff hadgood understanding and awareness of patients andthe meeting was structured with effectivecommunication and planning. Actions were agreedand designated to the appropriate individual

• Daily ward meetings were held on the wards wevisited. They reviewed discharge planning andconfirmed actions for those people who had complexfactors affecting their discharge. On the stroke wardthey would daily identify which patients could bestepped down from an acute bed to a rehab bed, thispromoted flow of patient’s requiring intensive stroketherapy.

• Senior nursing and medical staff would meet at 9pmevery day to handover patients including those at riskor deteriorating, determine priorities capacity anddemand.

Seven day services.

• Not all services were providing a seven-day serviceincluding the endoscopy unit, which was openMonday to Friday, and the renal unit, which delivered

a satellite service Monday to Saturday. However, staffon the endoscopy unit told us that there were plans toincrease the service to 24 hours a day seven days aweek along with increasing bed numbers.

• Consultant cover was available seven days a weekwith on call cover overnight.

• There was a designated clinical coordinator on dutyseven days a week who supported nurses andmanaged any issues at the hospital. A senior managerwas also on call overnight.

• The bed management team worked 24 hours a day,seven days a week and who supported staff inensuring that patients were placed on the mostappropriate ward to meet their needs.

• The discharge lounge was not open at weekends andtherefore patients awaiting transport or medication totake home would wait on the ward.

• Patients on the stroke ward had access to stroke cocoordinators every day from 8am until 8pm along withdaily rehabilitation therapy.

• Patients on the frailty ward had access torehabilitation therapist seven days a week.


• On discharge from the endoscopy unit, patients wouldbe provided with advice and instruction leafletfollowing their procedure; in addition, they would alsoreceive a copy of their report, which includedmedication received and results of procedure. A copywould also be sent to their GP.

• Staff had access to information they needed to delivereffective care and treatment to patients. All staff wespoke to were aware they could easily access to Trustinformation including policies, procedures and on theward computers.

• There were computers available, which gave staffaccess to patient and trust information.

• On the wards, files which included minutes to teammeetings and previous audits were available to staffand staff were encouraged to read them.


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• Data provided by the trust stated that those staff thatrequired mental capacity act training were below thetrust target of 80% with registered nurses 61.8 % andmedical staff with 35.4 % compliance. However,additional professional scientific and technical staffwho were 100%.

• Senior Staff on the wards had good understanding ofsafeguarding and the key principles of the MentalCapacity Act (2005), restraint and how these applied topatient care was basic on the wards we visited.

• Senior staff had knowledge and understanding of theprocedures relating to the Deprivation of LibertySafeguards (DOLS). DOLS are part of the MentalCapacity Act (2005). They aim to make sure thatpeople in hospital are looked after in a way that doesnot inappropriately restrict their freedom and are onlydone when it is in the best interest of the person andthere is no other way to look after them. This includespeople who may lack capacity. Senior Staff wouldcomplete all assessments as required.

• Junior staff had basic knowledge regarding MentalCapacity Act (2005), restraint and Deprivation of libertySafeguarding and understood when to escalateconcerns to senior staff.

Are medical care services caring?

Good –––


• Patients told us staff were caring, kind and respectedtheir wishes.

• We observed positive patient centred interactions withpatients.

• Patients received compassionate care and theirprivacy and dignity was maintained.

• Both patients and relatives were complimentaryabout the staff that cared for them and told us theywere involved in their care and were provided withappropriate emotional support.

• Provisions were made for carers and staff encouragedthem to be integrated as part of the team. Chaplaincyservices were available throughout the hospital forpatients, relatives and staff.

Compassionate care

• During our inspection we observed patients beingcared for with dignity, respect and kindness withprivacy maintained at all times. The majority ofpatients who were at their bedside or in bed hadaccess to call bells and staff responded promptly.

• All the patients we spoke with were positive abouttheir care and treatment. Comments included ‘’thenurses are fantastic, nothing is too much trouble‘’.Patients said that staff always introduced themselvesand they were aware who was caring from them.

• The Friends and Family test (FFT) average responserate for the Countess of Chester hospital was 39%which higher than the England average

• The NHS Friends and Family test (FFT) asks patientshow likely they are to recommend a hospital aftertreatment. Between August 2014 and July 2015, fivemedical wards scored above 88%. Thegastroenterology ward scored 100% on nineoccasions, ward 51 scored 100% on four occasions,respiratory ward scored 100% on three occasions andthe coronary care unit scored 100% on 10 occasions,which indicated that patients were positive abouttheir experience.

• In the cancer patient experience, survey the trustsored in the middle 20% for 16 out of the 34 questions.The trust scored in the bottom 20% for staff tellingpatients they could get free prescriptions.

• The trust performed about the same as similar trustsin all areas of the 2014 CQC inpatient survey.

Understanding and involvement of patients andthose close to them.

• Patients and those close to them told us that clinicalstaff were approachable and noted that although thestaff were busy they would always try to take the timeto talk to them when they needed to.

• All patients we spoke with said they had receivedongoing clear information about their condition andtreatment.

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• Relatives we spoke to said they were well informed ofpatient’s condition and plan of care. We saw evidencein patient’s records that relatives were kept informedof patient’s condition.

• Patients with learning disabilities were encouraged tovisit and have a tour of the endoscopy unit prior toadmission or their carers could attend and takephotographs of the unit to share with and minimisestress to the patient’s.

• Passes were provided to carers of patients withlearning disabilities or dementia, this ensured all staffwere aware of who they were and staff told us theyliked to integrate carers as part of the team. The passalso allowed for subsidised meals at the hospitalcanteen. In a carer’s survey in 2015, 88% of carers feltsupported by the care and information the hospitalgave them whilst their relative/friend was an inpatient.

Emotional support

• At the Countess of Chester hospital there was achaplaincy team available 24 hours a day, seven daysa week. The team consisted of one full time and threepart time chaplains and 50 volunteers, includingcatholic and protestant. Leaders of other faiths couldbe contacted if required. Staff would visits wards andoffer support as required and would take patients toHoly Communion at the Spiritual Care Centre on aSunday.

• There was a Spiritual Care Centre which wasaccessible to patients, relatives and staff of all faithand no faith. Regular Christian prayers were held alongwith meditation classes led by a Buddhist monk.Facilities included prayer mats and hand washingfacilities for Muslims.

• Visiting times met the needs of the relatives we spoketoo. Open visiting times were available if patientsneeded support from relatives.

• On the endoscopy unit and cardiac catheterisationsuite there was a consulting room, which could beused to discuss results, and patients had access to abereavement nurse specialist if required.

• On the endoscopy unit, family and friends could waitin the separate waiting area however, staff were aware

of the positive impact of having carers present forthose with additional needs. Carers were allowed tostay with the patient throughout the process if thiswas the patient’s choice.

Are medical care services responsive?



• There were on going issues with access and flow ofpatients across medical services mainly due to highoccupancy rates and difficulties in dischargingmedically optimised patients due to limited provisionsin primary care.

• Across medical services, there was a high bedoccupancy rate, which also impacted on the amountof outliers on other wards.

• There was a number of patients who were being caredfor in non-speciality beds some of these patients wereacutely ill and not medically stable therefore not inline with the trust flow policy.

• The trust had enrolled in the dementia friendly charterhowever; they were not consistently meeting allpeople’s needs as the dementia services were notaccessible to all patients and staff on all the wards.

• The ward environment were not dementia friendlythroughout although staff implemented the ‘this is me’for patients. People with dementia were highlighted onthe electronic patient record.

• There were mixed sex breaches on specialised wardssuch as the stroke and respiratory support unit. We wereinformed this mainly due to clinical reasons where thepatient could not be cared for or managed safely on analternative ward.

However,

• The discharge to assess project was implemented tohelp reduce the acute hospitalisation time of elderlypatients.

• Regular meetings were held by senior staff to try tomitigate pressures and the trust had implementednew ways of working to help facilitate flow andpatients discharges.

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• Escalation beds were used across the trust to helpwith the volume of patients including eight on wardseven beds on the acute medical unit.

• The trust had a team, which managed complaintsalthough not all complaints were responded to withinthe trust target. There were clear visible notice boardsand leaflets around the hospital with contactnumbers, advice for anyone who had any concerns orcomplaints.

Service planning and delivery to meet the needs oflocal people.

• The trust were working with commissioners in planningand delivering services to meet the needs of the localpopulation including the ‘west Cheshire way’ and the‘model hospital’. Medical services were involved severalservice development and transformational initiativesjointly with the clinical commissioning group (CCG) suchas respiratory, stroke, heart failure and frailty services.

• The premises and facilities on the endoscopy unit anddecontamination unit were appropriate for the servicesthat were planned and delivered.

• Staff told us that patients who lived in England couldaccess dementia services at the hospital however; thosepatients from Wales were referred via the electronicsystem to psychiatric services for support. This wasbeing reviewed by the trust at the time of inspection.

• The facilities and premises were not all appropriate forpatients with dementia for example there was nodesignated ward that had been adapted to have adementia friendly environment or any kind ofreminiscence room.

Access and flow

• Medical services met the national 18-week referral totreatment time targets in all specialities fromSeptember 2014 to September 2015. All specialitiesachieved 100% compliance apart from gastroenterologywho achieved 99.7% from March to September 2015.

• Trust-wide performance for the average length of stayfor all elective and non-elective admissions was longerthan the England average apart from electivecardiology, which was six days shorter.

• A teleconference call regarding patient activity and bedstatus at the trust was held daily with the clinical

commissioning groups (CCG). Actions would be agreedand assigned to an appropriate person. CCG woulddisseminate this information to services in primary careincluding General Practitioners at times of escalation..

• The trust had a patient flow policy, which provided clearguidelines to staff including the site co-ordinator teamto follow in responding to capacity and demand. Thepolicy included allocation, clarification of roles andresponsibilities in the process. Senior managers wespoke to had good knowledge and understanding of thepolicy.

• Between April 2014 and March 2015, the occupancy rateat the hospital was between 94.2% and 99.9%. It isgenerally accepted that, when occupancy rates riseabove 85%, it may affect the quality of care provided topatients and the orderly running of the hospital.

• Trust data showed that at there were eight escalationbeds on ward 51 and seven on the acute medical unit.During our inspection, staff on AMU told us there wereseven escalation beds on the ward, which had notclosed for the past 15 months. According to the ‘flowpolicy’, beds on AMU should only be used once allcapacity has been filled.

• Data showed that during 1st May to 31st October 201510% of patients across medical services had more thanone ward move during their stay. It was unclear howmany patients were moved at night as the trust statedthere was no administration staff to collate thisinformation.

• Staff on the respiratory support unit, AMU and strokeward told us there had been mixed sex breaches due to‘clinical need’. However, data provided by the trustshows in October 2015 there was a breach on the strokeward, which was not clinically justified. The patient wasmoved six hours later. There were no breaches inNovember 2015.

• On the acute stroke ward, there had been nine breachesin January 2016 and eight were reported so far forFebruary. Staff told us they were all due to clinical needand all the patients in the bay had been given anexplanation for this happening. Staff would promotedignity and respect for example keep curtains partiallyclosed. Senior staff told us bed breaches werecommunicated at bed meetings, monitored closely andpatients would be moved within 24 hours.

• Information provided by the trust showed there were alarge number of patients being cared for innon-speciality beds, which may not be best suited to

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meet their needs (also known as outliers). The patientflow policy states ‘outliers’ should be patients with animminent discharge date (preferably within 24-48 hours)whose clinical state is not likely to be adversely affectedby ward transfer. Data showed in August 2015 there were34 patients in the month, which increased to 120 inSeptember 2015, and 130 in October at the hospital. Weobserved that this included those patients that weresupported in escalation beds within Urgent Care.

• The number of outliers was visible on the electronicsystem for all staff. Senior staff including consultantsand bed managers reviewed and monitored thesepatients daily and completed risk assessments.

• During the inspection, we reviewed the records for ninemedical patients who were outliers on the surgicalwards, and found they had been seen daily by amember of the medical team. Wards that had outlyingpatients had contact arrangements for the relevantspeciality teams in and out of hours.

• In March 2015, the trust introduced pilot in which GP’scould talk directly with the physician to discusspotential medical admissions prior to directing thepatient to hospital. This has been successful in helpingto manage patient flow and this is now a permanentarrangement from November 2015.

• To assist with the access and flow of patient’s two extraconsultants and two nurse practitioners were employedto work at weekends to respond to the high demand,review patient’s and facilitate discharge. Transporthome was also provided over the weekend to assist inpatient discharge.

• The trust had implemented the discharge to assessproject to reduce unnecessary prolonged acute hospitalstay for the elderly and give patients the opportunity forfurther rehabilitation in a 24-hour care environmentwith the plan to discharge home. In 2015, the acutefrailty ward was opened at the hospital and 16‘discharge to access’ beds were opened at EllesmerePort hospital.

• The target length of stay on the frailty ward was 72 hoursand patients were referred to the discharge liaison teamon admission. Trust data shows the average length ofstay on the ward was between 5 to 10 days with 20 -27%of patients being discharged within 72 hours. Staff toldus patients would stay in longer due to delays in primarycare. Data provided by the trust shows that 89-97% ofpatients were discharged under 21 days.

• At the time of our inspection on ward 51 there were 19patients’ out of 28 who were medically fit and awaitingdischarge. On our unannounced inspection 0n 04/03/2016 there were 14 patients out of 26 who weremedically optimised, two of whom were still awaitingdischarge since our last inspection.

• During our inspection on 04/03/2016 staff told us, thefrailty consultant had started to go to ED /EAU and triagepatients to help to improve patient flow. The previousday the consultant had triaged 11 elderly patients andwas able to send nine home and two were admitted toward 51.

• The discharge team reviewed patients daily to identifywho was suitable for discharge and implemented plansfor discharge. Staff across medical services told us therewere issues with the flow of patients, which was mainlydue to difficulties in discharging patients who weremedically fit. Data from April 2013 to April 2015 showedthat the highest reasons patients were not discharged atthe hospital was due to patient or family choice (32.6%),awaiting nursing home placement (20.4%) and waitingfurther NHS non-acute care (19.1%).

• Trust data showed that at the time of inspection therewere 70 patients across medical services that weremedically optimised, of those 16 were awaiting atransfer of care. Staff on one ward told us a patient hadbeen waiting over three weeks for a specialistplacement in an elderly mental health home.

• The hospital held bed management meetings regularlythroughout the day during the week to review and planbed capacity and respond to acute bed availabilitypressures. A report of the trust patient activity was sentout to all members of staff to keep them informed.

• Senior nurses met weekdays with the divisional leadsand discussed any issues including staffing andsickness.MDT meetings which included senior managerswere held every Friday to discuss plans to help mitigateproblems that could arise at the weekend for examplestaff sickness. These plans were clearly documented forthe clinical site co coordinator covering the weekend tofollow.


• Volunteers were available at the front desk of thehospital to assist in patients, friends and family findspecific locations.

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• There was a diabetic specialist medical and nursingteam along with a diabetic pharmacist available to allpatients across the trust. Staff we spoke to were awarereferrals could be made through the patient electricrecord.

• There was a red flag on the electronic patient record forpatients with dementia and learning disabilities (LD).This would act as a reminder to staff to makereasonable adjustments for example patient be placedin a quiet area or in a side rooms and to ensure healthpassports were in place to help determine specificneeds of the patient. Staff had access to a LDcoordinator if support was required. Staff on one of thewards showed us an assessment tool, which is beingpiloted along with RA sign that would go on the board atthe back of the patient’s bed.

• The Trust used three NHS Framework approvedinterpretation and translation provider organisations:Deafness Support Network, Language Line Solutions Ltdand Manchester Council: M4 Translations and staff knewhow to access these services,

• Data provided stated that staff would make reasonableadjustments for blind and deaf patients. Documentationwas accessible in electronic format along with text andemail messaging to support their assessment. During aforum meeting it as confirmed that staff on a ward hadarranged for British Sign Language interpreters tosupport effective communication for a patient and theirpartner.

• In September 2015 the trust had signed up to thedementia friendly charter which aimed to createdementia friendly hospitals for people living withdementia and their carers for example signage that usespictures and text which is hung at a height it can be seenand having a dementia lead and champions. Trust datashowed that over 5000 people had attended theDementia awareness sessions, which incorporatesdementia friends. During our inspection, we notedyellow signs with black writing stating each specific areaon the corridors of the hospital however, they did notstate the ward name or number this could addconfusion to locating a specific place.

• Access to the Dementia team was limited as they werenot accessible across the trust for all patients, onlypatients on designated wards. During our inspection,the ward manager on the cardiology ward told us therewas a dementia patient but the patient or staff couldnot access the service.

• On the frailty ward, we observed ‘forget –me- not‘stickers on patient’s boards. This was a discreet flowersymbol used as a visual reminder to staff that patientswere living with dementia or were confused. This was toensure that patients received appropriate care, reducingthe stress for the patient and increasing safety.

• The trust used the ‘this is me’ documentation for carersto record information about patients living withdementia or a learning disability. This ensured that staffknew the patients’ likes, dislikes, and ensured theirneeds were met. Staff on the stroke ward told us thiswas effective and was also used this for patients whohad difficulty expressing themselves due to speechproblems.

• Information for patients about services and care theyreceived could be accessed via the trust intranet. We didobserved information boards and a selection of leafletsvisible on the wards. There was a limited accessibleformat those whose first language was not English. Stafftold us they gave information leaflets to patients to helpand educate them about procedures or conditions.

• There was a wide range of specialist nurses and teamsfor example alcohol liaison service, cardiac rehab andheart failure nurse who offered specialist advice to staffcaring for people with these conditions. Staff told usthey knew how to contact these specialists and feltsupported by them.

Learning from complaints and concerns.

• The trust had complaints and PALS team who wereresponsible for the day-to-day management ofcomplaints. These were recorded electronically on thetrust-wide system.

• Patients and relatives could raise concerns in variousways including email, in writing, in person or over thephone. Staff told us patients were given the complaints/PALS leaflet on admission to hospital and we observedcomplaint and PALS information and leaflets availablearound the hospital.

• Complaints were discussed at governance meetingsacross the trust including monthly divisional boardmeetings, patient experience operational groupmeeting and the quality safety patient experiencecommittee. Lessons learned and common trends andthemes would be identified.

• The trust told us they aimed to acknowledge all formalcomplaints within three working days and responded to

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formal complaints within an agreed timescale. In2014-15, the trust acknowledged 93% of all formalcomplaints within three working days, and respondedto 69% of all complaints with the agreed timescale.

• Data showed that between December 2014 andNovember 2015 there had been 222 complaints raisedacross the trust, of those 37 were regarding medicalservices. The highest proportion of complaints relatedto all aspects of clinical care. All patients and relativeswe spoke with told us they were happy with all careprovided.

• Staff understood the process for receiving and handlingcomplaints and were able to give examples of how theywould deal with a complaint effectively. Staff shared anexample of learning from a complaint in which a patienthad complained about meals times being too late. As aresult, patients were served tea at an earlier time of5pm, which also meant staff told us more staff wereavailable at this time to assist patients.

• Senior staff told us patients were asked on ward roundsif they have any issues they wish to discuss.

Are medical care services well-led?

Good –––


• Medical services were well led with evidence ofeffective communication within teams.

• The visibility of senior management was good andthere was strategy with actions, which most staff wereclear about.

• Risk registers were in place and although we could notsee any documented plan of actions or if the riskswere reviewed at meetings, however key risksreflected trust wide initiatives in place to mitigaterisks.

• Medical services captured views of people who usedthe services with learning highlighted to makechanges to the care provided.

• Staff knew how their ward performed and workedcollaboratively to make positive changes.

• There was good staff engagement with staff wereinvolved in making improvements for services. All staffwere committed to delivering good, compassionatecare and were motivated to work at the hospital.


• Values and behaviours demonstrated by ward staffincluded putting patients at the heart of everythingthey do, to have a ‘can do’ attitude, have pride in theservice they provided, strive for improvement, to bewelcoming, friendly, caring and respect each other.

• The trust had a five-year strategy plan (2014-2019) todeliver high quality care, which consisted of threeprograms: West Cheshire way, integrating specialistservices and Countess 20:20. Objectives includedproviding the right services to meet the qualitystandards, clinical outcomes along with needs andexpectations of patients, promoting sustainablepartnerships and promoting integrated services. Theplans also identified operational and strategic risksand actions to be taken.

• Staff we spoke to were aware of the values andstrategic plan however, some staff told us they wereunclear how this would affect them.


• There was ward level, divisional and corporate riskregisters across the trust.

• Staff at all levels knew that there was a risk registerand senior managers were able to tell us what the keyrisks were for their area of responsibility.

• Each risk had the date the issue was raised, the reviewdate and assigned person to deal with it. No plans ofactions were recorded through the urgent caredivision, however key risks reflected trust wideinitiatives in place to mitigate risks and plans were inplace to develop action plan processes whichincluded a narrative of how the risk was beingmanaged.

• There was a clear governance reporting structure inmedical services. It was clear from the minutes wereviewed discussion had taken regarding incidents,complaints and performance. It was also apparentthat learning was shared.

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• Regular meetings were held with senior staff andmanagement to discuss issues arising and mitigaterisk at the earliest opportunity.


• Staff could explain the leadership structure within thetrust and the executive team were accessible andapproachable.

• All staff said the team leads and ward managers weresupportive regarding any issues on the ward. The wardmanager’s told us they had access to leadership andmanagement training.

• 30% of staff who participated in the NHS staff surveyreported good communication from seniormanagement to staff; this was higher than the 2015national average of 32%.

• Doctors told us that senior medical staff wereaccessible and they received good support.

• We observed positive working relationships within allteams. Staff we spoke to said they had received theirannual appraisal.


• The trust supported the ‘speak out safely’ campaignand encouraged all staff to raise any concerns aboutpatient safety.

• This was also accessible on the hospitals intranet sitewith links to the ‘Speak Out Safely’ (Raising ConcernsAbout Patient Care) and the ‘Whistle Blowing Policy’.Ward staff were aware of these initiatives and said theywould feel comfortable accessing them.

• Staff said they felt supported and able to speak up ifthey had concerns. They said that morale fluctuatedbut was overall good across medical services and stafffelt proud of what they do.

• In the 2015 staff survey staff who felt motivated atwork scored 3.89, which is higher than the nationalaverage score of 3.87. The number of staff felt securewhen reporting unsafe clinical practice was 3.65,which was higher than the national average score of3.62.

Public engagement

• Patients on medical wards were encouraged and hadaccess to various opportunities to give feedback abouttheir care or experience at the hospital for example onthe bedside TV screens, friends and family test,inpatient experience survey and via social media, all ofwhich could be accessed via the hospitals website.

• Feedback from patients was collated at departmentallevel. This was discussed with staff at meetings, andactions were taken to improve patient experience.

• In 2015, the trust attended health and well-beingforums, which gave members of the DSN, Lesbian,Gay, Bisexual, and Transsexual people and the OlderPeople Network an opportunity to give feedback tothe trust about their care and experiences along withany recommendations they had.

Staff engagement

• Some staff told us the executive team would walkaround and visit the wards on the first of every month.All staff we spoke to recall the chief executive visitingthe wards on New Year’s Day.

• Staff told us they received weekly newsletter from thetrust via email, which kept them up to date withcurrent or ongoing issues and information.

• The trust celebrated the achievements of staff at anannual event. At the last event, medical services werewinners of awards including the stroke and dementiateam who won the Partnership award.

• This hospital participated in the NHS friends andfamily test giving staff the opportunity to speak outabout their place of work. In September 2015 of staffwould recommend this hospital to friends and familyin need of care /treatment and 88% wouldrecommend it as place to work to friends and family.Results were discussed at departmental level andsome wards were involved in a pilot scheme tounderstand findings at a local level.

• Following the survey the trust in 2015 produced ‘whocares, we do’ and ‘you said, we listened' report whichgave a brief summary of the results and actions goingto be taken by the trust.


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• The Stroke service was recently awarded InnovativeTeam of the Year 2015 by North West Coast Researchand Innovation Awards for the work the team hadundertaken to develop a robust auditing tool.

• To meet the needs of the increasing elderly populationand to assist in patient flow the trust had introducedthe GP to clinician screen and is workingcollaboratively with other agencies in delivering thedischarge to assess (DTA) project which includedintroduction of frailty ward at the hospital and the GPled ward at Ellesmere port hospital.

• Staff on AMU ward had participated in events such aszip wire and fell running to raise funds for a room onthe ward to be converted to a relative’s room with abed. The fundraising was on going at the time ofinspection with a curry night planned.

• Ward areas were rolling out care and comfort workerroles to work across the wards to assist patients withnutrition and hydration feeding, and any other basicassistance including getting newspapers.

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Safe Requires improvement –––



Responsive Good –––



Information about the serviceThe Countess of Chester Hospital carries out a range ofemergency and planned surgical services includingurology, ophthalmology, orthopaedics and general surgery.There are seven surgical wards and 15 theatres includingdesignated day case and gynaelogical theatres; that carryout emergency and elective procedures including day caseprocedures.

Data provided by the surgical services showed that 30,742patients were admitted for surgical care between July 2014and June 2015 at the Countess of Chester Hospital. Thedata showed that 67% of patients had day caseprocedures, 14% had elective (planned) surgery and 20%required emergency surgery.

As part of the inspection we visited the main theatre areasincluding the recovery area, observed parts of fouroperations and we visited six inpatient surgical wards andthe Jubilee day surgery unit. We observed three scheduledtheatre briefing meetings, one nursing handover and onemedical handover.

We spoke with 14 patients and observed care andtreatment. We reviewed 18 care records and spoke with 38staff members of different grades and specialities includingnurses, doctors, ward managers, a clinical director, adivisional director, theatre manager head of nursingand matrons.

Summary of findingsWe found that the Countess of Chester Hospital wasproviding a good service overall to the patientsaccessing their surgical services because:

• We found that staff were aware of how to reportincidents and we saw evidence that the serviceundertook robust and appropriate incidentinvestigations.

• The uptake levels of mandatory training were highfor both nursing and medical staff.

• Staff were fully aware of how to raise and managesafeguarding issues appropriately.

• Staff managed medicines well and nurse staffinglevels in the theatre areas were sufficient.

• Patients received surgical care which was evidencebased and met national guidelines.

• Clinical audits were routinely undertaken and actionas a result of these was evident.

• Patients were assessed and provided withappropriate pain relief.

• Knowledge of the Mental Capacity Act 2005 andDeprivation of Liberty Safeguards was good in mostareas.

• Staff treated patients with kindness, dignity andrespect and patients told us that they were happywith the care they received.

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• The surgical services were responsive to the needs ofpatients.

• Information was readily available for patients in avariety of formats, which could be adapted toindividual needs.

• Patients had timely access to consultant led care.

• The service was well led and staff respected theirlocal leaders.

• There were robust governance frameworks andmanagers were clear about their roles andresponsibilities. There was clear leadership in theservice and senior managers were visible andapproachable.

• We found the culture within the service was openand managers made efforts to engage with staff andthe public.

However:

• In some areas we found that the learning from theseinvestigations was not disseminated fully.

• We found that Nurse staffing levels on the surgicalwards were not always sufficient to meet patientneeds.

• The access and flow within the surgical services waschallenging at times, however staff managed thiseffectively.

• Staff could not articulate the trusts vision and values;however they were aware of significant workprogrammes taking place.

Are surgery services safe?


Summary

We found that surgical services at the Countess of ChesterHospital required improvement in relation to safetybecause:

• Feedback from incidents was not consistent on anindividual staff basis.

• Learning from serious incidents and never events wasnot always disseminated to all areas. Which increasedthe risk of a reoccurrence.Most staff did not display an understanding of duty ofcandour.

• Training levels for level 2 safeguarding adults, werelower than the trust target of 80% for both medical andnursing staff and only 33% of medical staff who requiredlevel 3 safeguarding adults training had completed thistraining.

• There were no curtain changing schedules in thesurgical wards or the jubilee day surgery unit. Whenasked; one senior sister told us that they did not knowhow long the curtains had been in situ and could notrecall the last time that they were changed.

• We found some theatre areas to be dusty and therewere a large number of free standing medical gascylinders which posed a risk of injury.

• We also found that three trolleys in the main theatreareas which were found to be rusty.

• We found that medications were sometimes pre drawninto syringes in the theatre areas. This posed a risk ofthese medications being administered incorrectly asthey were not labelled.

• We also found that some medications were stored in anunlocked cupboard and fridge in a day surgery unit.

• Bank and agency staff were not always able to use theelectronic records system. Staff told us that this putadditional pressure on permanent staff.

• We found that the ‘five steps to safer surgery’procedures, including the use of the World Health

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Organization (WHO) checklist were not always followedin the day surgery theatre areas. The WHO checklist is aninternational tool developed to help prevent the risk ofavoidable harm and errors before during and aftersurgery.

• We found that the surgical ward areas were frequentlyshort staffed and that for six out of seven surgical wardsover a two month period there were less than 90% ofthe registered nursing staff required on duty.

However:

• We saw evidence that the service had responded andlearned from adverse incidents in some areas.

• The service collected and displayed safety thermometerdata and rates of avoidable harm were within nationalaverages.

• The uptake levels of mandatory training were high forboth nursing and medical staff.

• Staff were aware of how to raise and managesafeguarding issues.

• Infection rates were low within the surgical services andstaff observed appropriate measures to protect patientsfrom avoidable infections.

• The environment and equipment were suitable forproviding patient care and equipment was wellmaintained.

• Nurse staffing levels in the theatre areas were sufficientand there was evidence of planning to meet thedemands of the service.

• Medical staffing was sufficient and patients had accessto suitably qualified doctors when required.

• Staff were aware of the trusts major incident policy andwere able to show us a folder which contained detailson what staff were to do in the event of a major incident.

Incidents

• There was an electronic incident reporting system inplace which was available to all staff. When staff didreport incidents, managers reviewed them and tookappropriate responsive actions. We saw evidence of thisin the reviews we undertook of incident reports. All stafftold us they did not always receive feedback fromincidents that they had raised on an individual basis.

• Staff reported 2040 incidents across surgical servicesbetween 1st December 2014 and 30th November 2015.49 of these incidents were assessed as requiring furtherinvestigation which was undertaken by the trust in allcases.

• There were 16 serious incidents reported betweenOctober 2014 and September 2015.

• Of these 16 serious incidents three were categorised asnever events between January 2014 and March 2015.Never events are serious, wholly preventable patientsafety incidents that should not occur if the availablepreventative measures are in place. In response to theseincidents, the trust had undertaken root cause analysis(RCA) reviews. These reviews were thorough and robusthowever key areas of learning had not beendisseminated to staff in some of the areas affected.

• One example of this was in relation to the learning fromtwo incidents relating to incorrect tooth extraction.These incidents occurred in the theatre area of the daysurgery unit. When we spoke with four staff in the daysurgery unit at registered nurse and sister level, two stafftold us that they were aware of an incident but did notknow the details or the learning from this incident. Twoof the four staff told us that they were not aware of anynever event incidents and had not been informed of anylessons learned as a result of these incidents.

• Staff were unable to tell us of recent examples wherethey had improved their practice because of aninvestigation.

• One of eight staff were able to demonstrate anunderstanding of duty of candour. Seven out of eightstaff were unable to demonstrate an understanding inthis area.

• Staff were aware of the types of incident they shouldreport and were able to give us examples of incidentsthey would need to report such as pressure ulcers andpatient falls. We found one example where a patient haddeveloped a pressure ulcer and this had not beenreported. The patient had not been informed of theulcer and a timely apology had not been provided.

Safety thermometer

• The NHS safety thermometer is a national improvementtool for measuring, monitoring and analysing avoidableharm to patients and ‘harm free’ care. Performance

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against the four possible harms; falls, pressure ulcers,catheter acquired urinary tract infections (CAUTI) andblood clots (venous thromboembolism or VTE), wasmonitored on a monthly basis.

• The service was recording and monitoring data in linewith this initiative. Ward areas displayed this data forstaff and members of the public to view.

• Safety Thermometer information between September2014 and September 2015 showed that the serviceperformed within the expected national range for fallswith harm, catheter urinary tract infections and pressureulcers.

Mandatory training

• Uptake levels of mandatory training were high.98% ofnursing staff and 100% of medical staff had undertakentheir mandatory core induction training whichcontained subjects such as fire safety and infectioncontrol and prevention. This was above the trusts targetof 95%.93% of nursing staff and 100% of medical staffhad also completed the full day mandatory trainingcourse. This was a one day course which encompassedall mandatory training subjects including infectioncontrol and fire safety.

• Staff told us that they were offered mandatory trainingbut this was sometimes cancelled due to staffingpressures on the wards. Managers on the surgical wardsand in the theatre areas monitored rates of mandatorytraining and prompted staff to undertake training whenit was due.

Safeguarding

• The trust had safeguarding policies and procedures inplace. Staff were aware of how to refer a safeguardingissue to protect adults and children from suspectedabuse. Staff showed us how they would access the trustintranet page relating to safeguarding. The trust had aninternal safeguarding team who could provide guidanceand support to staff in all areas on safeguardingmatters.There were visible signs around the ward andtheatre areas displaying the contact details for thesafeguarding team.

• Training data provided by the trust in relation tosafeguarding showed that 100% of nursing staff withinthe surgical services had completed level 1 safeguardingadults training; this was higher than the trusts target of

80%. 74.4% of nursing staff and 29.1% of medical staffwithin the surgical services had received level 2safeguarding adults training, which was lower than thetrust target of 80%.33% of medical staff who requiredlevel 3 safeguarding adults training had completed thistraining. This was lower that the trust target. 100% ofnursing staff who required level 3 safe guarding traininghad completed this training. This was above the trusttarget of 80%.

• Training data provided by the trust showed that 79% ofnursing staff and 61% of medical staff who required level2 safeguarding children training had undertaken thistraining. This was below the trust target of 80%.

• Staff told us that they received feedback fromsafeguarding concerns and referrals they raised. Thiswas cascaded from the trust safeguarding team tofrontline staff through their line managers.


• The surgical ward areas effectively managedcleanliness, infection control and hygiene. Rates ofinfections were low and staff followed measures toprotect patients from infections.

• We observed dust on surfaces and equipment in threetheatre areas

• Staff were not aware of curtain changing schedules inthe surgical wards or the jubilee day surgery unit. Whenasked; one senior sister told us that they did not knowhow long the curtains had been in situ and could notrecall the last time that they were changed. However,domestic services recorded curtain changes as part of athree monthly changing schedule.

• The ward and theatre areas we inspected were visiblyclean and well maintained with the exception of thethree theatre areas which were found to be dusty.

• Staff were aware of current infection prevention andcontrol guidelines, and were able to give us examples ofhow they would apply these principles.

• Cleaning schedules were in place, with allocatedresponsibilities for cleaning the environment anddecontaminating equipment.

• There was adequate access to hand washing sinks andhand gels in all areas.

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• Staff were observed using personal protectiveequipment, such as gloves and aprons and changingthis equipment between patient contacts. We saw staffwashing their hands using the appropriate techniquesand all staff followed the 'bare below the elbow'guidance. Staff followed procedures for gowning andscrubbing in the theatre areas.

• We observed that patients with an infection wereisolated in side rooms where possible. Staff identifiedthese rooms with signs and information about controlmeasures in these rooms was clearly displayed.

• The service undertook early screening for infectionsincluding MRSA during patient admissions andpreoperative assessments. This meant that staff couldidentify and isolate patients early to help prevent thespread of infections.


• In the main theatre areas we observed a large numberof free standing medical gas cylinders. Such cylindersshould be safely secured to minimise the risk of injuryand fire. This was raised with staff in the theatre area.

• Equipment on the wards and in theatre areas was visiblyclean and well maintained with the exception of threetrolleys in the main theatre areas which were found tobe rusty. This was highlighted to the trust and they wereremoved immediately.

• Staff in the theatre and ward areas told us they hadaccess to the equipment and instruments they neededto care for patients. An optiflow stock system was in usein the main theatre areas which automatically listeditems removed for stock reconciliation. This system wassecure and allowed staff to access the equipmentnecessary quickly and securely.

• Staff carried out regular checks on key pieces ofequipment in all areas. Emergency resuscitationequipment was in place and records indicated that ithad been checked daily in all areas, with a moredetailed check carried out weekly as per the hospitalpolicy.

• There were adequate arrangements in place for thehandling, storage and disposal of clinical waste,including sharps.

• Bariatric equipment used for obese patients was readilyavailable.

Medicines

• We found three vials of out of date medications in themain theatre area. These were immediately discardedby staff and replaced. It is important that medicationsare not used after their expiry date as this can affect theefficacy of the medication.

• In the main theatre areas we also found syringes of predrawn up medications. This posed a risk of thesemedications being administered incorrectly as theywere not labelled. This was highlighted to staff and theywere removed immediately.

• We observed nurses undertaking medication rounds,where they undertook appropriate checks whenadministering medication including checking thepatient’s name, date of birth and allergy status. Staffalso ensured patients took their medication and did notleave medication unattended.

• Staff locked and secured medication trolleys when theywere not in use. Cupboards used to store medicationswere secure and locked appropriately in all areas withthe exception of one cupboard which we foundunlocked in the day surgery unit. This was highlighted tostaff who arranged for it to be locked immediately.

• Fridges used to store medicines were locked in all areasexcept one recovery area. The fridges were used to keepmedication only and no other items were present,ensuring minimal risk of contamination to themedication from other sources.

• The temperatures of the fridges in all areas were withinexpected ranges except for one ward area. Recordsindicated that staff checked and recorded thetemperatures on a daily basis.Medications stored withinthe fridges were kept at the appropriate temperature.

• Records indicated that staff carried out checks oncontrolled drugs on a daily basis. This was to ensurethat medicines were reconciled correctly. Controlleddrugs were stored in secure cupboards in line withlegislation on the management of controlled drugs.Controlled drugs require additional checks and specialstorage arrangements because of their potential forabuse or addiction

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• Medical staff were aware of the trust’s policy forprescribing antimicrobial medicines and had access to aformulary which guided them in prescribing the correctdoses. Appropriate antimicrobial prescribing helpsprevent patients developing certain infectionsassociated with antibiotic use.

• A pharmacist visited ward areas daily and checkedprescriptions to provide support and advice in relationto medication stock reconciliation and prescribing.

• We reviewed six electronic medication charts andmedical staff had completed all sections on all six chartsfully. The prescribing was clear and legible whichminimised the risk of medication errors.

• Ward managers reviewed incident data regularly toensure any medication incidents were investigated in atimely way.

• Discharge medications and prescriptions were managedwell and completed in a timely way.

Records

• The service and trust used electronic, computer basedpatient records. These records were found to be difficultto navigate between sections of the records when wereviewed three full sets of records. Four staff told us thatthey felt the electronic records system was sometimesdifficult to navigate.

• Bank and agency staff were not always able to use theelectronic records system. Staff told us that this putadditional pressure on permanent staff. We observed anagency staff member on one ward area and they wereunable to use the electronic records system. As a resulta permanent member of staff had to undertake therecording of patient care for patients under the care ofthis member of staff in addition to their own patients.

• Both medical and nursing records were up to date,legible and signed.


• On admission to the surgical wards and before surgery,staff carried out risk assessments to identify patients atrisk of specific harm such as venous thromboembolism(VTE), pressure ulcers and risk of falls. If staff identifiedpatients susceptible to these risks, they placed patientson the relevant care pathway and treatment plans.

• We reviewed five records specifically in relation to theserisk assessments. We found that in two out of fiverecords we reviewed in relation to VTE assessments,these assessments were not completed. We found thatin all five records patients’ risk of falls and risk ofpressure damage had been completed fully andappropriate measures to reduce these risks had beenput in place.

• An early warning score (EWS) system was in use in allareas. The EWS system was used to monitor a patient’svital signs and identify patients at risk of deteriorationand prompt staff to take appropriate action in responseto any deterioration.Staff carried out monitoring inresponse to patients’ individual needs to identify anychanges in their condition quickly. We saw examples ofstaff seeking appropriate help when a patient’scondition deteriorated.

• Most patients received observations at the frequencyspecified by the medical teams. However we found thatin one case full sets of observations including bloodpressure, pulse, temperature and respiratory rate weredelayed over a number of days. These delays rangedbetween five hours and nine hours.

• We observed parts of four operations and saw thetheatre teams undertaking the ‘five steps to safersurgery’ procedures, including the use of the WorldHealth Organization (WHO) checklist. The WHO checklistis an international tool developed to help prevent therisk of avoidable harm and errors before during andafter surgery.

• We found that this checklist and process was followedappropriately in the main theatre areas and included allthe relevant staff required.

• In the day surgery unit we observed that anaestheticstaff were not included in the sign in step of this processon two occasions and on two occasions we observedthat staff were undertaking other duties and not presentin the theatre area during the silent focus and time outstage of this process. It is important that all staff areincluded in all stages of this process as evidence hasshown this reduces the risk of errors occurring. It wasconfirmed with theatre nursing staff, that anaestheticstaff did not usually participate in this sign in step.

• We also observed that a radio was also playing music inthe theatre area during this process in the day surgery

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unit. Guidance recommends that there is minimaldisturbance and disruption during all stages of thisprocess to reduce the risk of errors and avoidable harmto patients.

Nurse staffing

• The staffing and skill mix in theatre areas was sufficient,with some periods of reduced staffing in areas becauseof last minute sickness and unexpected events.

• Staffing in the ward areas was not sufficient at times andwas not always planned to ensure that the skill mix wasappropriate for the patient groups who were beingcared for. This was reflected in the average fill rates forshifts on the surgical ward areas.

• Data provided by the trust showed that over a twomonth period the average fill rate for shifts fell below80% in relation to registered nurses on three out ofseven surgical wards. This rate was also below 90% onan additional three wards over a two month period. Thismeans that on six out of seven surgical wards over a twomonth period there were less than 90% of the registerednursing staff required on duty.

• Some staff working on surgical wards raised concernsabout staffing levels and the impact they felt this washaving on patient care. Staff told us that care was oftendelayed due to staffing shortages and that they feltunder significant pressure as a result of this.

• We observed that care was delayed in some cases onwards where there was not the required level of staffing.One example of this was on a surgical ward which hadone less registered nurse than required, we observedthat pain relief to one patient was delayed for over 30minutes and intentional comfort rounding was delayedfor four patients. These four patients were at risk ofpressure damage and required regular comfortrounding to ensure pressure relief and reduce the risk ofpressure ulcers developing.

• Each clinical area openly displayed the expected andactual staffing levels on a notice board and staffupdated them on a daily basis. The staffing numbersdisplayed on the boards were correct at the time of theinspection and reflected the actual staffing numbers inall areas.

• Ward and theatre managers carried out daily staffmonitoring and escalated staffing shortfalls to matronsand senior managers.

• We observed one nursing staff handover which wascomprehensive and well structured. . Safety informationwas handed over as part of this so that staff were awareof any issues which could affect patient safety.

• The surgical services used a nationally recognisedacuity tool twice a year to determine the staffing levelsrequired on each area. There was no acuity tool in useto assess and establish the number of staff needed onan ongoing basis within the day centre.

Medical staffing

• There were sufficient numbers of suitably qualifiedmedical staff within surgical services.

• Junior and middle grade doctors told us that they werewell supported by their seniors and consultants andwere able to access senior advice and support, as theyneeded.

• There was sufficient consultant cover available 24 hoursa day, including outside of normal working hours.Consultant cover out of hours was available on an oncall basis.

• We observed one medical handover which wascomprehensive and well structured. Medical staff wereinformed of important issues or patients who were atrisk of deteriorating.

• The staffing skill mix was sufficient when compared withthe England average. Consultants made up 35% of themedical workforce across the trust which was lowerthan the England average of 41%.

• Consultants and registrars led ward rounds consistentlyon a daily basis. We saw evidence of this in patient’srecords and we observed one ward round on an acutesurgical ward and saw that medical staff undertook theward round effectively with appropriate communicationwith other disciplines and patients themselves.

• Nursing staff told us that they were able to access24-hour medical assistance and advice easily.


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• The trust had a major incident policy in place which wasavailable on the trust intranet site. Staff were able to tellus how they would access it and showed a goodunderstanding of the policy and processes relating tomajor incidents.

Are surgery services effective?

Good –––

Summary

We found that the surgical services at the Countess ofChester Hospital were good in the effective domainbecause:

• Patients received care and treatment in line withevidence based practice and national guidelines.Clinical audits included monitoring compliance withNational Institute for Health and Care Excellence (NICE)and Royal Colleges’ guidelines.

• Most patients nutritional and hydration needs were metand managed appropriately.

• Patients were assessed and provided with appropriatepain relief.

• The service participated in local and national audits andthe results of these varied between specialities.

• The service performed better than the England averagein the Hip Fracture audit.

• Most staff had received their annual appraisal andworked well with other members of themulti-disciplinary team.

• Services were available seven days a week includingemergency services.

However:

• The service did not perform as well as would beexpected in the NELA 2014 audit. The service haddeveloped an action plan to address areas ofimprovement.

• Most staff knew how to apply the Mental Capacity Act2005 and Deprivation of Liberty Safeguards to patientsin their care however most staff did not receive trainingin these areas

Evidence based care and treatment

• Patients received care and treatment in line withevidence based practice and national guidelines.Clinical audits included monitoring compliance withNational Institute for Health and Care Excellence (NICE)and Royal Colleges’ guidelines.

• Staff on the surgical wards used care and recoverypathways and plans, in line with national guidance.

• Policies and procedures reflected current nationalguidelines and were easily accessible via the trust’sintranet site.


• The guidelines for fasting before surgery (the timeperiod where a patient should not eat or drink) were notclear. We found that most patients received the correctadvice on fasting despite this and in line with nationalguidelines.

• In one case we found that patient had not been giventhe correct advice and had been fasted for over 12 hoursfor a procedure which national guidelines suggestshould have a six hour fasting period.

• Most patients were supported with hydration and weobserved staff actively assisting patients with theirhydration needs.

• We found that there was no clear system in place toidentify patient in need of assistance with eating anddrinking. However despite this we found that staffcorrectly identified patients patients who requiredassistance nd these patients received assistance witheating and drinking as they required..

• In most of the records we reviewed fluid intake wasrecorded correctly and appropriately. However wefound that Fluid intake it was not recorded accuratelyon four fluids charts we reviewed. It is important thatcharts to record fluid intake and output are maintainedaccurately as this can affect a patients overall care andtreatment.

• Food intake was recorded accurately for most patients;however we found that charts used to record the intakeof food for two out of six patients were not completed

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every mealtime as directed. It is important that thesecharts are completed fully when they are in place toensure that patient’s dietary intake is monitoredappropriately.

• The trust had a protected meal time’s initiative whichensured that there were minimal interruptions topatient’s meal times.

• Staff told us that they were able to access specialistdietetics advice and support easily.

• Patients told us that staff offered them a variety of foodand drink and did not highlight any concerns about thefood and drink provided.

Pain relief

• Staff assessed patients pre-operatively for theirpreferred post-operative pain relief. Staff used painassessment charts to monitor pain symptoms at regularintervals.

• There was a team specialising in the management ofpain available to support staff in the surgical wards andtheatres during in hour periods of 9am to 5pm.

• Patient records we reviewed showed that staff gavepatients appropriate pain relief when required, whichwas also confirmed by the patients we spoke to.

• We observed one patient encounter a delay in receivingrequested analgesia on one surgical ward.

Patient outcomes

• Surgical services participated in national and internalaudits to monitor patient outcomes. Outcomes forpatients receiving treatment in the service were mostlybetter than the England average.

• The surgical services participated in a number ofnational clinical audits including the national hipreplacement audit, national bowel cancer audit and thenational emergency laparotomy audit.

• The national hip fracture audit measures a set ofoutcomes for patients who have suffered a hip fractureand been admitted to hospital. The service performedbetter than the England average for four of the nineoutcomes measured in the national hip fracture audit.The service performed worse in five of the nineoutcomes measured; these outcomes were the numberof patients developing pressure ulcers and the total

length of stay for patient who suffered a hip fracture.There was no action plan in place at the time of theinspection. However there were a number of audits inprogress during the time of the inspection to addressthis issue. These were detailed in the orthopaedic auditplan.

• The national bowel cancer audit measures a number ofoutcomes, which give an indication of how well patientswith bowel cancer are treated. The service performedbetter than the England average for all the indicatorsmeasured.

• The national emergency laparotomy audit (NELA) reportfrom 2014 showed that eight out of the 28 standardswere available at the Hospital. The audit highlightedthat the hospital did not have 20 of the 28 requiredstandards these included a dedicated surgicalassessment unit and did not have key policies related tothe care of emergency general surgery patients. Seniormanagers had reviewed the findings of this audit andhad implemented an action plan to address the issuesraised at the time of our inspection.

• Performance reported outcomes measures (PROMs)data between April 2014 and March 2015 showed thatthe percentage of patients with improved outcomesfollowing groin hernia, hip replacement, kneereplacement and varicose vein procedures was eithersimilar to or slightly better than the England average.This means that patients undergoing these procedureshad a similar outcome or a slightly better outcomecompared to patients in other areas of England.

• Data on hospital episode statistics June 2014 to May2015 showed the number of patients who werereadmitted to this hospital after discharge followingelective and non-elective surgery was similar or lowerthan the England average for all specialties except ENTwhere readmission rates were slightly worse. There wasno action plan in place to address this at the time ofinspection.

Competent staff

• Newly appointed staff had an induction and senior staffassessed their competency before they were allowed towork unsupervised.

• Agency and locum staff did not undergo localinductions and were not required to complete an

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induction checklist when they attended a new wardarea. We requested to see any induction paperwork fortwo agency and four bank staff members and none ofthese staff had received a local induction to the wardthey were working on.

• Senior managers managed performance effectively andwere able to tell us about examples of how theymanaged performance in previous situations.

• Data provided by the service showed 92.4% of annualappraisals during the year (April 2015 to November2015) had been completed; this was above the trusttarget of 90%.

• Medical staff told us they received routine clinicalsupervision and appraisal and had no concerns relatingto revalidation.

• The medical staff we spoke with were positive abouton-the-job learning and development opportunities andtold us they were supported well by their linemanagement.

• Most staff felt supported; however three nursing staff wespoke with told us that they felt that their managers didnot offer them opportunities to develop in their role.They told us that they were not routinely offered anytraining or development over and above theirmandatory requirements.

Multi-disciplinary working and coordinated carepathways

• There was effective daily communication betweenmultidisciplinary teams and between specialities andwe saw examples of this during the inspection. Oneexample was the daily review of patients who wereplaced on wards outside their speciality. We observedthat staff worked collaboratively to ensure they receivedthe specialist, daily reviews they required.

• One staff member told us that there was not alwayseffective daily communication between specialities.However we only found oneoccasion which reflectedthis. We found that a referral was sent on a Friday to themedical team from the surgical team and the patientsdischarge was awaiting this review. The next Thursdaythis referral was found to be lost and the medical team

declined to see the patient until a new referral wascompleted despite the fact that the referral waselectronically available. This delayed the patientsdischarge.

• Staff handover meetings took place during shift changesand ‘safety huddles’ were carried out on a daily basis toensure all staff had up-to-date information about risks.

• The ward staff told us they had a good relationship withconsultants and ward-based doctors within the surgicalspecialities.

• Staff across the services told us they received goodsupport from pharmacists, dieticians, physiotherapists,occupational therapists, social workers and diagnosticsupport.

• Medical staff told us that they often experienced delaysin receiving reports from diagnostic imaging and thisaffected patient treatment times and outcomes.

Seven day services

• Acute and emergency surgical services were availableseven days a week. Out of hours cover by medical staffwas adequate and nursing staff told us they felt wellsupported outside normal working hours. This included24 hour seven day a week anaesthetic support andcover.

• Elective surgery was carried out five – six days per weekdependent on demand.

• Junior and middle grade doctors provided out of hour’smedical care to patients in the surgical wards. There wasalso on-call cover provided by consultant surgeons.

• At weekends, a consultant saw newly admitted patients,and the ward-based doctors saw existing patients onthe surgical wards.

• There was a 24-hour emergency service with dedicatedtheatres. This meant that any patients admitted out ofhours or over the weekend could have emergencysurgery if required.

• Microbiology, imaging (e.g. x-rays and scans),physiotherapy and pharmacy support was availableoutside of normal working hours.

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• Medical staff with the exception of vascular specialiststold us that they had adequate access to urgent imagingoutside of normal working hours. This means thatpatients could have scans and x-ray’s urgently out ofhours if required.


• Medical records were easily accessible and readilyavailable on an electronic records system.

• Staff told us that they found accessing records easy inmost cases. However some medical staff told us thatthey sometimes had difficulty accessing specificsections of patients medical records, One example ofthis was within the ophthalmology speciality where wefound that visual field tests required by doctors were notalways available when the doctors required them at thetime of surgery.

• We also found that consent forms were not alwaysavailable on the date of surgery due to the electronicrecords system and this meant that consent formswould have to be completed again on the day ofsurgery. We observed that this happened on twooccasions during the inspection. It is important thatpatients having elective surgery have time to thinkabout their procedure are do not feel rushed to consentto a procedure on the date of their surgery.

• Medical staff produced discharge summaries from theelectronic patient system and sent them to the patient’sgeneral practitioner (GP) in a timely way. This meantthat the patient’s GP would be aware of their treatmentin hospital and could arrange any follow upappointments they might need. Staff provided patientswith copies of their discharge summaries on discharge.

Consent, Mental Capacity act and Deprivation ofLiberty Safeguards

• Staff had the appropriate skills and knowledge to seekconsent from patients. Staff were able to tell us clearlyabout how they sought informed verbal and writtenconsent before providing care or treatment.

• Staff sought appropriate consent from patients prior toundertaking any treatment or procedures. In one casewe found that complications were not always fullydescribed to patients prior to the consent process. Thiswas highlighted to staff who then arranged for furtherinformation to be provided to the patient.

• All patient records we looked at indicated that staff hadsought and obtained verbal or written consent beforetreatment was delivered.

• Staff on the main theatre areas and all surgical wardsexcept one were aware of the legal requirements of theMental Capacity Act 2005 and Deprivation of LibertySafeguards. Staff on one surgical ward were not able toarticulate the legal requirements of the Mental CapacityAct 2005 and Deprivation of Liberty Safeguards. Weobserved one patient on this a surgical ward who wassuffering from confusion. This patient was requesting toleave the ward and staff confirmed to us that they wouldstop the patient if they tried to leave. We found that thispatient did not have a mental capacity assessmentdetailed for any stage or decision of their treatment andthere was no application for a deprivation of libertysafeguards to be applied. This was highlighted to thesenior nursing team and arrangements were made toensure that all appropriate assessments wereundertaken.

• Three out of four staff in the day surgery unit did notunderstand the legal requirements of the MentalCapacity Act 2005 and Deprivation of Liberty Safeguards.These three staff were unable to articulate how theywould apply the Mental Capacity Act 2005 and the DOL’sin a practical situation. One example of this was apatient who presented for surgery to the unit and wasdisplaying new confusion which had developed sincethey had signed their consent form some monthsearlier. Staff did not consider that this patient’s mentalcapacity to consent to the surgery may have changed.This was highlighted to staff and they then arranged forthe patients capacity and consent to be reassessed.

• Registered nurses and health care assistants in all areasof the surgical services did not routinely receive trainingon the application and responsibilities of the MentalCapacity Act 2005 and the Deprivation of LibertySafeguards. All staff spoken to below band 6 and 7 leveltold us that they had not received this training. Seniorstaff within the service told us that this training was onlyprovided to band 6 and 7 nurses.

• A trust-wide safeguarding team provided support andguidance for staff in relation to any issues regardingmental capacity assessments and deprivation ofliberties safeguards.

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Are surgery services caring?

Good –––

Summary

We found that the surgical services at the Countess ofChester Hospital were providing a good service in relationto the caring domain because:

• Staff treated patients with kindness, dignity and respect.• Staff provided care to patients while maintaining their

privacy, dignity and confidentiality.• . Patients spoke positively about the way staff treated

them.• Patients told us they were involved in decisions about

their care and were informed about their plans of care.

• The NHS Friends and Family test showed that mostpatients were happy with the care they received in thesurgical services. Staff displayed involved patients andtheir families in decisions about their care.

Compassionate care

• We observed staff treating patient with kindness,dignity, respect and compassion. Staff took time tointeract with patients and communicated with patientsin a considerate and compassionate manner.

• The areas we visited were compliant with same-sexaccommodation guidelines. Patient’s dignity wasrespected. We observed that curtains were closedaround patient bed areas when staff were providingpersonal care. There were private areas available wherestaff could speak to patients privately if required, inorder to maintain confidentiality.

• We spoke with 14 patients, who all gave us positivefeedback about how staff treated and interacted withthem.

• The NHS Friends and Family Test (NHS FFT) is asatisfaction survey that measures patient’s satisfactionwith the healthcare they have received. The resultsshowed that the majority of the surgical wardsconsistently scored above the England average,indicating that most patients were positive aboutrecommending the hospital’s wards to friends andfamily.

• The average response rates for the surgical wards was34% which was higher than the England average of 32%.This means that 34% of the patients who weredischarged from surgical wards completed the test.

• Two staff member told us that they had observedcompleted friends and family tests results with negativeresults being intentionally destroyed by other staffmembers. However we found no evidence of thispractice during the inspection.

Understanding and involvement of patients and thoseclose to them

• Staff respected patients’ rights to make choices abouttheir care and communicated with patients in a waythey could understand.

• Patients and their families told us that staff kept theminformed about their treatment and care. They spokepositively about the information staff gave to themverbally and in the form of written materials, such asinformation leaflets specific to their condition andtreatment.

• Patients told us the medical staff fully explained thetreatment options to them and allowed them to makeinformed decisions.

• Staff identified when patients required additionalsupport to be involved in their care and treatment,including translation services. Staff were able to tell ushow they would access translation services includingsign language interpreters.

• Pre-operative assessments took place and took intoaccount individual preferences

Emotional support

• Staff demonstrated that they understood theimportance of providing patients and their families withemotional support. We observed staff providingreassurance and comfort to patients and their relatives.

• Patients told us that staff supported them with theiremotional needs.

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Are surgery services responsive?

Good –––

Summary

We found that the surgical services at the Countess ofChester Hospital were providing a good service in relationto the responsive domain because:

• The surgical services were responsive to the needs ofpatients and in most cases met individual patientneeds.

• Staff kept patients well informed of their treatment andcare.

• Information was readily available for patients in a varietyof formats, which could be adapted to individual needs.

• Patients who were not placed on a ward best suited tomeet their needs received daily medical review.

• Patients had timely access to consultant led care whichalthough it did not meet the national target of 90% mostof the time the trust did perform above the Englandaverage.

• Complaints were well managed and learning from thesecomplaints was evident.

However:

• There were some issues with access and flow within thesurgical services; however staff managed this effectively.

• Patients were not always placed in the appropriate wardsetting and a number of wards had additional bedsopen to accommodate medical patients. This led to anincreased workload for the staff in these areas.

• A consistently higher number of planned operationswere cancelled than the England average.

• The length of time patients stayed in hospital wasmostly the same or higher than the England averagewith some exceptions.

Planning and delivering services which meet people’sneeds

• Some aspects of the services had been plannedeffectively to meet the needs of the local population.

• One example of this that the senior management teamhad noted an increase in the number of patients whocould have day case surgery. Surgical services hadtherefore increased their capacity to provide day casesurgery by building a new theatre to meet this demand.

• There was also an emergency general surgery andtrauma theatre that was staffed 24-hours, seven day perweek so that operations could be performed for patientsrequiring emergency surgery at any time of the day.

• We found one example where the service was notplanned to meet the needs of the people using them.This related to the provision of specialist dementiasupport on surgical wards. The service provided careand treatment to a large proportion of elderly patientswho suffered from dementia. However we found thatthe specialist dementia nurse and team only providedsupport to patients outside the surgical services.Despite this we found that staff working on the surgicalwards provided care which met the needs of patientssuffering from dementia.

Meeting individual needs

• Information leaflets about services and treatments werereadily available in all areas. Staff told us they couldprovide leaflets in different languages or other formats,such as braille, if requested. We saw examples ofinformation leaflets in different languages available inthe day case unit. Staff told us that they could access alanguage interpreter if needed and were able to show ushow they would do this. They also had access tolanguage line which is a translation facility.

• We found that patients who suffered from dementiawere provided with care that met their needs on allsurgical wards. However, Staff did not receive training inthe care of patients with dementia and the surgicalwards did not have dementia link nurses in place. Therewere no designated ‘dementia friendly’ wards areaswithin the surgical services.

• Staff could also contact a trust-wide safeguarding teamfor advice and support for dealing with patients livingwith dementia or a learning disability.

• Staff did use a ‘this is me’ document for patientsadmitted to the hospital with dementia. Patients or theirrepresentatives completed this document and includedkey information such as the patient’s likes and dislikes.

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This document was also completed during thepre-operative stage of a patients care to ensure anyreasonable adjustments which were needed were put inplace.

• A reasonable adjustment pathway and flagging systemwas in place for patients living with a disability and inuse in all areas. This pathway alerted staff to anyreasonable adjustments that they needed to make toaccommodate the patient living with a disability. Wesaw evidence that this pathway had been used inpatient records and on boards behind patient’s beds.

• Staff told us they gave patients who identified astransgender the option to be treated in a side room forprivacy or in the main bay areas. Where possible staffaccommodated these preferences. We saw evidence ofstaff planning care for patients who identified astransgender in a way that would meet their needs. Thisplanning included specifying what preferred namepatients would like to be called and the gender theyidentified with.

• Access to psychiatric support was readily available andstaff told us they did not have any issues accessing thissupport for patients.

• Staff could access appropriate equipment such asspecialist commodes, beds or chairs to support themoving and handling of bariatric patients (patients withobesity).

• The theatre recovery areas had designated paediatricrecovery bays.

• Accessibility to all facilities and areas was good

Access and flow

• Patients were admitted for surgical treatment and carethrough a variety of routes, including pre-plannedsurgery, the emergency department and by GP referral.

• The admission, transfer or discharge of patients fromthe surgical wards was not well managed in all areas.

• Patient records showed discharge planning did notalways take place at an early stage and there wasmultidisciplinary input (e.g. from physiotherapists andsocial workers). In four out of 18 records there was noevidence of early discharge planning.

• Trust data showed that medical patients were regularlyoutlied to surgical wards (moved to a ward which is notbest suited to meet their needs due to bed availabilityissues). In August 2015 data showed that there were 34patients outlied, which rose to 120 in September andfurther increased to 130 in October 2015.

• We reviewed nine records of medical patients who hadbeen outlied to surgical wards. In all nine cases thesepatients had received a daily review by the medicalteam.

• The trust was able to track which ward accommodatedoutliers using an electronic system.

• The trusts access and flow policy stated that onlypatients with an expected date of discharge of 24-48hours should be outlied.We found that in one case apatient had been outlied to a surgical ward with anacute medical problem and social problems whichmeant they were likely to be in hospital for an extendedperiod of time.

• Data provided by the service showed that multiplesurgical wards were consistently used to supportmedical patients. Staff told us surgical patientssometimes experienced delays in accessing the wardsdue to beds being filled with medical outliers.

• Data showed that the service was performing above theEngland average for the national 18 week referral totreatment target between September 2014 and August2015. However, the service missed the target of 90% inthe general surgery, trauma and orthopaedics and oralsurgery specialities, with oral surgery performing at64.4%, trauma and orthopaedics at 89.7% and generalsurgery at 86.4%. This means that most patients referredto the surgical specialities started consultant ledtreatment within 18 weeks of being referred. Managerswithin the service told us this was because the trust hadtaken on additional surgeries for pateints out of area toassist other providers and to ensure patients receivedthe most timely care possible.

• NHS England data showed that the number of cancelledoperations within the trust remained consistentbetween 2014 and 2015 but was above the Englandaverage for all four quarters of 2014-2015. This meantthat a higher number of patients had their plannedoperations cancelled in this service compared to otherservices of a similar size in England.

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• Patients told us they had easy access to surgical servicesand had experienced minimal delays in accessingtreatment.

• The average length of time that patients stayed inhospital after having surgical treatment was higher thanthe England average for three out of four non- elective(unplanned) specialities and was about the same as theEngland average in the general surgery speciality.

• The average length of time that patients stayed inhospital after having surgical treatment was around thesame or lower than the England average for three out offour elective (planned) specialities and higher than theEngland average in vascular surgery.


• Notice boards within the clinical areas and outside wardareas included information including any comments forimprovement.

• Patients told us they knew how to make a complaint.Posters were displayed around the hospital detailinghow to make a complaint.

• Leaflets detailing how to make a complaint were readilyavailable in all areas.

• The trust recorded complaints on the trust-wide system.The local ward managers and matrons were responsiblefor investigating complaints in their areas.

• We reviewed two complaints which had been raised inrelation to surgical services and found that theinvestigations and responses were robust andundertaken appropriately.

• We saw evidence of learning from complaints and thislearning was disseminated through newsletters, staffmeetings and safety huddles.

Are surgery services well-led?

Good –––

Summary

We found that the surgical services at the Countess ofChester Hospital were providing a good service in relationto the well led domain because:

• The surgical services were well led at local line managerlevel and at divisional level.

• There were robust governance frameworks withindivision and managers were clear about their roles andresponsibilities.

• Risks were appropriately identified, monitored andthere was evidence of action taken where appropriate.

• There was clear leadership throughout the service andstaff spoke positively about their managers and leaders.

• Senior managers were visible and known to staff andstaff felt able to able approach them and raise concerns.

• Staff told us the culture within the service was open upto their head of nursing level.

• Senior staff told us that they felt the divisional clinicalleaders were open to challenges and willing to makechanges to improve patient care.

• We found that the board had made efforts to engagewith staff through different mediums and hadimplemented a speak out safely campaign.

However:

• The trusts vision was not embedded throughout thedivision. Staff were unclear what this vision was andwere not able to tell us what the trusts values were.

Services vision and strategy

• The trusts vision was to provide integrated care at itsbest. This was based on the trusts strategic vision anddirection which included three work streams; the WestCheshire Way, integrated specialist services andCountess 20:20.

• All staff we spoke with were not able to articulate thesevalues and vision to us; however the values theydisplayed reflected the trusts vision and values.

• The trust was also participating in the ‘model hospital’project. This was an improvement program whichfocused on value, high reliability, operationaltransparency and accountability. The trust wereundertaking this work with external individuals tobecome the blueprint for a model hospital. All staff wespoke with were aware of this programme and spokepositively about it.

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• There was a robust governance framework within thesurgical services. Senior managers were clear on theirroles in relation to governance and they identified,understood and effectively managed quality,performance and risk.

• Managers had risk registers in place for all areas of thesurgical services. Managers regularly reviewed, updatedand escalated the risks on these registers whereappropriate. There was a system in place that allowedmanagers to escalate risks to trust board level throughvarious meetings.

• There was a clear alignment of risks recorded and whatstaff told us was concerning them. This showed thatmanagers were in touch with the opinions and concernsof their staff and showed that they acted on theseconcerns.

• Audit and monitoring of key processes took place acrossthe ward and theatre areas to monitor performanceagainst objectives. Senior managers monitoredinformation relating to performance against key quality,safety and performance objectives and they cascadedthis to ward and theatre managers through monthlyreports.

• There was regular clinical governance and risk meetingheld within the surgical services and we saw minutesfrom this meeting.

• Concerns had been raised formally with the trust boardby staff in relation to the use of additional beds onsurgical wards during times of pressure and associatedstaffing shortages as a result of this. We saw evidence ofthis in email and letter form. Staff told us that they hadnot received a full response to these concerns and theyfelt that their concerns had not been taken seriously.

Leadership of this services

• The leadership within the surgical services at local anddivisional level reflected the vision and values set out bythe trust. Staff spoke positively about local leaderswithin the services. Local leaders were visible, respectedand competent in their roles.

• All staff told us that they valued and respected theirlocal line managers and divisional leaders.

• The head of nursing for the division had a largeworkload and an area of responsibility which includedmultiple services. Despite this staff told us that she wasvisible and approachable and they felt that sherespected and valued them.

• Medical staff told us their senior clinicians supportedthem well and they had access to senior clinicians whenthey required. All medical staff were aware of who themedical director was and spoke positively about them.

• We observed that there were regular emails andupdates from the trust board team to all staff. We alsofound that the chief executive and other trust boardmembers made efforts to connect with staff and keepthem updated. One example of this was the chiefexecutives blog which was available for all staff to read.

• The chief executive and director of nursing had alsoheld open door sessions and meetings with staff andward managers.

Culture within this services

• Staff we spoke with told us they felt respected andvalued by their local and divisional leaders.

• We found that there was an open culture within thesurgical services and staff felt able to raise conecrsn withtheir local line managers.

• We found that concerns were raised staff and the trustboard were responded to.

• The trust had also implemented a speak out safelycampaign which encourages staff to raise concernsabout patient safety.

• The trusts also had whistle blowing policy which wasreadily available on the trust intranet site.

Public engagement

• Staff told us they routinely engaged with patients andtheir relatives to gain feedback from them. Informationon the number of incidents, complaints and the resultsof the NHS Friends and Family test were displayed onnotice boards in the ward and theatre areas.

• The surgical services participated in the NHS friends andfamily test, which gives people the opportunity toprovide feedback about care and treatment theyreceived.

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Staff engagement

• Staff told us they received support and regularcommunication from their line managers.

• Staff participated in regular team meetings across thesurgical services.

• The Chief executive and other board member regularlywrote blogs and published these on the trusts websitefor staff to access. These blogs included pertinentthemes and also developments within the trust.

• We saw evidence that the trust board regularly sent outemails and communications to staff across the trust,informing staff of progress with various projects andconveying important messages.

• The Chief executive and director of nursing had held anumber of open door sessions and meetings with wardmanagers and staff.

• Staff told us that the head of nursing and matrons forthe division had an open door policy and were availableto all staff.


• Staff and managers within the division were striving toimprove the care and treatment patients received andwere working to continually improve services. Oneexample of this was the development of a new theatreand day case area to increase the number of electivepatient operations.

• The service had a robust business plan for the year inplace with clear objectives and progress towards theseobjectives monitored.

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Safe Good –––






Information about the serviceThe critical care unit at the Countess of Chester hospitalprovided a service to patients who required advance care,in a purpose built critical care unit. In April 2014 a new,two-storey wing was opened on the first floor of thehospital, replacing the old High dependency unit (HDU)and Intensive therapy unit (ITU).

The facility is a 21-bedded unit with 15 beds in use, wherecare is provided to all patients in single rooms. Thisincludes three additional beds to support emergencyvascular patients receiving care from the South Merseyarterial centre hub that is now based at hospital. The unithas a purpose built 100% side room facility. This allows thecritical care team to overcome a number of challenges withinfection prevention and control, maintain privacy anddignity as well as prevent sleep deprivation and theassociated effects this has on prolonging recoveryfollowing critical illness.

There are also two relatives’ suites providing overnightfacilities. The room is prioritised for short-term use only.

The unit admits around 763 patients a year and betweenthe 1 July 2015 and 30th September 2015, the critical careunit admitted 213 patients.

The unit is an active member of the Cheshire and Merseyadult critical care operational delivery network.

During the course of the inspection visit, we spoke with 9relatives and over 35 staff of all grades, nursing, medicaland allied health professionals.

Summary of findingsWe have rated critical care services as good because:

• Incidents were reported and acted upon and usedcontinuously as a service improvement tool

• Safety thermometer data was collected anddisplayed in public areas for patients and relatives toview.

• Performance results were also shared with staff incritical care in a monthly unit newsletter, togetherwith results from relative’s surveys.

• There were sufficient numbers of suitably skillednursing and medical staff to care for the patients.

• The service took part in the intensive care nationalaudit and research (ICNARC) data so we were able tobench mark its performance and effectivenessalongside other similar specialist trusts.

• The trust performed well, however data indicatedsome concerns regarding delayed discharges.

• The trust had an outreach team with five critical caretrained, dedicated members of staff who supportedwards in the early detection and treatment of acutelyunwell patients.

• There was evidence if a multidisciplinary approach tocaring for the patients. Ward rounds includedconsultants, a physiotherapist, a pharmacist, a juniordoctor, a nurse, SHO and a member of the outreachteam.

• There was adequate number of nursing and medicalstaff to provide a seven-day service.

Criticalcare

Critical care


• Staff were aware of the vision for the service and hadstrategy’s in place for innovation and improvement.

However,

• We did find that that the unit fell below the intensivecare society’s recommended level of staff who held apost registration award in critical care nursing.

Are critical care services safe?

Good –––


• There were systems in place for reporting and learningfrom incidents.

• There were sufficient numbers of suitably skilled nursingand medical staff to care for the patients.

• We found a recruitment drive in place and the unit hadpermission to over recruit to compensate for sicknessand maternity leave.

• We found a good ratio of one consultant to sevenpatients. A designated consultant was on call atweekends who did not have on call responsibilitieselsewhere in the hospital.

• The critical care service had an outreach team with fivededicated members of staff, all critical care trained, torecognise and care for an acutely unwell patient on thewards around the hospital.

• On occasions, the outreach team would support theatrerecovery staff, to care for a Level three patient, due toaccess and flow problems within the critical care unit.

However,

There was no major incident awareness at local level. Allstaff we spoke to did not how to respond if there was amajor incident, or what was expected of them.

Incidents

• Staff in critical care were aware and were encouraged toreport incidents and learning was shared from findings.Staff used an electronic system to report incidents,which were sent automatically to senior staff as an alert.

• Data from the National learning and reporting systembetween October 2013 and September 2015 indicatedthat no never events associated with critical care hadbeen reported. .

• Two serious incidents had been reported by the unitbetween October 2014 to 2015.Both were investigatedand actions identified from learning through routecause analysis investigations and action planning.

Criticalcare

Critical care


• Critical care reported 66 incidents between October2015 and January 2016 through the national learningreporting system (NLRS). All were reported as no or lowharm.

• We reviewed documentary evidence of regular anddetailed mortality and morbidity meetings, which wereheld monthly. These meetings had a multidisciplinaryapproach, events were reviewed and any learning pointswere identified and cascaded to relevant teams.

• Regional bariatric mortality and morbidity meetingswere attended regularly by a representative from thecritical care unit and any issues were fed back to theparent team for learning.

• Senior staff attended the Cheshire and Mersey adultcritical care operational delivery network meetingsquarterly. Findings from this forum, including seriousincident investigations including learning was cascadedto all staff to improve safety.

• We saw evidence of regular critical care delivery groupmeetings, which had a multidisciplinary approach,attended by pharmacy, outreach team and practiceeducators, amongst others. Quality and safety in criticalcare were discussed at these meetings and the recentintensive care national audit research centre (ICNARC)data.

• Senior staff were aware of the principles of ‘duty ofcandour’ (the regulation introduced for all NHS bodiesin November 2014, meaning they should act in an openand transparent way in relation to care and treatmentprovided), However, whilst senior nurses were able toexplain what was meant by the term, junior medical andnursing staff, were not familiar with what was meant by‘duty of candour’ and couldn’t recall having had anytraining on the subject. However, they did understandthe responsibilities about being open and transparent.

Safety thermometer

• The NHS safety thermometer is a local improvementtool for measuring, monitoring and analysing patientharms and ‘harm free’ care. Safety thermometer datawas submitted from the unit and reported at trust level.This included data on patient falls, pressure ulcers,urinary catheter related infections and episodes ofvenous thromboembolism. Results showed that it hadbeen five days since the unit had last reported apressure ulcer and 102 days since the last patient fall.

• Safety thermometer data was collected and displayed inpublic areas for patients and relatives to view.

Mandatory Training

• Mandatory training figures for critical care were reportedat business group level, and data reported in February2016 showed that over-all compliance was in line withtrust targets.

• In February 2016, the business unit reported mandatorytraining core subject compliance as; fire training 86.5%,conflict resolution 85.4%, equality and diversity 97.8%,information governance 91%, safeguarding children83.1%, local induction 100% and medical devices 76.3%.The trust target was 80 % for safeguarding children and95% for local induction, so they were above the trusttarget.

• As part of Mandatory training, staff had undertakenmental capacity act (MCA) and Deprivation of liberty(DOLs) training. Staff knew where to find informationonline and knew how to contact the safeguarding teamfor advice.

• Staff who had not yet undertaken training in conflictresolution and safeguarding children were all bookedonto training at the time of our visit.

• There was no major incident training.

• There was no specific duty of candour training.

Safeguarding

• Staff were aware of safeguarding policies andprocedures, and could verbalise the process used toescalate a concern. Low level concerns of safe guardingwere raised electronically and then the safeguardingteam were alerted. For all mental capacity incidents,DOLs and Independent mental capacity act (IMCA)referrals, a band 6 completed the documents.

• Safeguarding training was part of the trust mandatorytraining programme. The trust target was 80% for allsafeguarding. In February 2016, critical care compliancewas; 100% of administration and clerical staff hadcompleted level one adult safeguarding and 67% hadcompleted level one child safeguarding. 78% of nursingand midwifery staff had completed level 2 adultsafeguarding and 82% of nursing and midwifery staffhad completed level two child safeguarding.

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• All clinical areas, staff areas and relative’saccommodation were clean and fit for purpose.

• All equipment was clean and in a good state of repair.We observed that some equipment had been labelledas clean by using a green sticker system; however, thissystem was not used for all equipment.

• All beds on the unit were single rooms, which meantthat patients who had an acquired infection would beisolated. Rooms and equipment were cleaned inbetween use, using hydrogen peroxide steam cleaningto minimize the risk of cross infection. This was aseven-day service.

• On entry to the unit was a hand washing system withtemperature control and timing device to support handwashing by staff and visitors before entering the unit,which people used.

• There were sufficient supply of hand gel, hand soap andpersonal protective clothing (PPE) at the point of care.We observed staff appropriately washing their hands,using hand gels and wearing personal protectiveequipment (PPE) when delivering personal and clinicalcare. We also spoke to relatives, who had all observedthis practice.

• The most recent validated ICNARC data for 1 July to 30September 2015 showed that the unit had no cases ofunit acquired (MRSA) or Clostridium difficile infections (Cdif). This applied to the presence of MRSA in any sampletaken for microbiological examination forty-eight hoursafter admission to the unit.

• The unit had two negative pressure isolation rooms,which could be used to support patients where therewere specific infection prevention requirements. Thesehad a separate lobby and one directional airflow inorder to isolate the patient from the rest of the unit.

• The critical care unit was subject to monthly audits ofhand hygiene. The results for hand hygiene datashowed 100% compliance from May to September 2015;however, compliance had dropped to 87% in October2015. The trust aim was for all areas to routinelydemonstrated 95% hand hygiene compliance.

• We observed that staff followed policies and proceduresin the safe handling and disposal of sharps. Results of atrust wide sharps audit September 2015, showed

improvement in compliance with use of the temporaryclosure mechanism had improved from 64%compliance in 2014 to 89% compliance in September2015, which reflected what we saw.

Environment and Equipment

• The critical care unit is a purpose built unit, whichopened in 2014 and complies fully with health buildingguidance, HBN 04-02, which is best practice guidance onthe design and planning of new or reconfiguredhealthcare buildings.

• The sluice, equipment and utility rooms all had codedaccess doors, but were found to be unlocked.

• We reviewed the resuscitation equipment; includingdefibrillators and difficult airway management trolleysand all were in date. All emergency equipment, whichwas checked daily, signed and dated.

• There was a rolling equipment replacement programmesupported by the medical engineering team (EMBE),which ensured that the unit had a sufficient equipmentto meet patient’s needs. This reflected what we saw onthe unit.

• Some ventilators were due to be replaced as part on arolling programme. In the interim procedures were inplace to loan this equipment and service arrangementswere in place from the company.

• Four dialysis machines were on a loan contract,however not all of them had heaters. We were told thata procurement process was underway to purchase newmachines.

• We saw evidence on the risk register that both issueswith the ventilator machines and dialysis machines hadbeen raised at trust level.

• The blood gas machine was overseen by the point ofcare testing co-ordinator. Nursing staff were all trainedin using the machine and interpreting results. If theequipment did fail, a second machine was available inthe main laboratory.

• All equipment on the unit was listed on the hospitalintranet in order for staff to access instructions, manualsand cleaning instructions.

Medicines

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Critical care


• We found that the unit had appropriate systems in placeto ensure that medicines were handled safely andstored securely. Medicines were stored in the drugsroom on the unit and access was required withindividual swipe cards.

• There were three secure control drugs cabinets,accessed by key, which was kept with the team leader.We observed that when a control drugs cabinets wasopened, an alert was sent to the nursing stationsoutside the room, by the way of a red light indicator.

• In addition to the secure control drugs cabinets, asecure coded cabinet was in use for storage of otherdrugs, equipment and syringes. The staff required apersonal code for entry and the requested drugslocation was highlighted to staff. This made thewithdrawal of medication and equipment safe, quickand efficient for the staff. The system then automaticallyre-ordered the equipment from the stores, or themedicine from the pharmacy.

• There were two drugs fridges within the drugs room, thefirst was a secure fridge containing controlled drugs,including morphine. The keys for this fridge were keptwith the team leader. A second fridge was not secure;this contained medicines for emergency incubation,where quick access was required.

• The drugs fridges displayed the internal fridgetemperature, which was monitored daily and recordedby the unit housekeeper, we observed that this wasmaintained daily and was signed and dated accordingly.

• There were registers in use for the controlled drugs anda separate register for patient’s own drugs. We carriedout random controlled drugs checks, whichdemonstrated that actual stock matched the stockaccounted for in the registers. The pharmacist carriedout a three monthly audit of the controlled drugs, tocheck that the medicines were being recorded correctly,the stock was appropriate and in date.

• There were two dedicated specialist pharmacists forcritical care and a pharmacist attended on the warddaily and as part of the multidisciplinary morning wardround.

• The pharmacist regularly reviewed medications andreturned any that were no longer required to thepharmacy

• The unit used an electronic prescribing system andprescriptions could be ordered at any time of the dayand night.

• The Trust does not use red allergy bands; however analert is printed onto the allergy bands. Allergies wererecorded on the opening screen of the electronicnursing notes at the patient’s bedside and werehighlighted in red.

• There was pharmacy cover five days a week and thepharmacist was available out of hours for advice bytelephone.

Records

• The critical care unit used a mix of paper andcomputerised records; the nursing notes were recordedon computer at the patient’s bedside, but patient noteswere paper based.

• We looked at five patient care records. These werepaper based and comprised of a range of clinicalrecords, assessments and plans. These included;venous thromboembolism (VTE) risk, delirium,nutritional risks, pain scores and skin care bundles.Although entries were comprehensive, two out of thefive records displayed the time of decision to admit thepatient to critical care and three out of the five recordswere signed and dated by the consultant. No recordsshowed the author’s professional registration number.For example, General medical council (GMC) or Nursingand midwifery Council (NMC) registration numbers.

• We saw evidence of a ‘Do not attempt CardiopulmonaryResuscitation’ (DNACPR) form accurately completed andan associated Mental Capacity Act (MCA) assessment,which was within a patients paper records.

• Physiotherapy notes were kept on paper and notavailable at the patient’s bed side, howeverphysiotherapy plans were verbalised with nursing staff.

• We saw some patient records left insecure on trolleysoutside patient’s rooms, which could have beenaccessed by visitors to the unit.

• The unit was using electronic prescribing; this has beenshown to have positive impact on patient safety byreducing medication and transcription errors.


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Critical care


• All patients were monitored appropriately according topolicies and procedures. Staff were able to accessspecialist medical support promptly to support patientswho condition had changed and required review andintervention.

• The unit had a twice daily, multidisciplinary ward round,which included a pharmacist. A pharmacy was available24/7 and was on call after 4.30 pm.

• We found that the trust used the national early warningscoring system (NEWS) to identify patients who may beat risk of their condition deteriorating. Early warningscoring systems are widely used in hospitals to trackpatient deterioration and to trigger escalations inclinical monitoring and response. National adoption ofthe National early warning system (NEWS) system isadvocated.

• The critical care service had an outreach team with fivededicated members of staff, all who were critical caretrained. The team supported staff to recognise and carefor acutely unwell patients in the ward setting andprovide expert advice and act as a point of escalation.The outreach team covered from 8.30am to 9.30pm,seven days a week. . The outreach team saw on averagefive patients per day. The team could not refer directlyto the critical care unit.

• The clinical site co-ordinator responded to the acutelydeteriorating patients at night.

• The outreach team were integral in the care of patientswith Acute Kidney Injury (AKI) and ensuring compliancewith NICE CG 169 (2013) and in helping to raise theprofile, recognition and treatment of SEPSIS (NICE CGdue 2016).

• On occasions, the outreach team would support staff intheatre recovery, to care for a Level 3 patient whowaiting to be transferred to critical care there due toaccess and flow problems within the critical care unit.This was not usual and was based upon a riskassessment. This was reported as an incident andmonitored by the trust.

Nursing staffing

• Staffing levels were monitored regularly with anappropriate staffing tool and we found adequatestaffing to meet peoples care need and which were inline with national standards.

• The unit had 71.5 whole time equivalent nurses in postas of October 2015.

• Over the previous year the unit had recruited 18 newnursing staff, however they lost 15 due to promotion andprogression to other areas. In order to support safestaffing levels, the unit recruited above establishment tocompensate for sickness and maternity leave.

• The unit had been using bank staff and agency staff, butwere within the required range and were not utilisinggreater than 20% on any one shift.

• An Induction was carried out for any agency staff whoworked on the unit.

• A new focus group for band 7 nurses had been set up inorder for information and data from managementmeetings to be shared with nurses.

• A service improvement lead was in post on the unit, forone day a week, funded by the critical care network,which aimed to support nursing skills and competencyon the unit.

• The unit employed 6.25 whole time equivalent (WTE)health care assistants (HCA), there was one HCA on dutyeach shift.

• Each shift on the unit had a member of staff identified ina supernumerary capacity, however due to staffinglevels this was not always possible.

Medical staffing

• The unit had nine whole time equivalent (WTE)consultants, 50% of their time was spent in anaesthesia.There were 3.6 WTE funded trainees, 2nd on tier and 6junior tier WTE, 4 of the junior fellow’s work 50% incritical care and 50% in vascular surgery.

• We found appropriate medical cover both in and out ofhours on the critical care unit. Two consultants werepresent on the intensive care unit in the day and oneconsultant was on call overnight. The consultantsremained on the unit as required, were contactable bytelephone, and would attend at the unit within 30minutes. The consultants did not have on callresponsibilities elsewhere in the hospital.

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Critical care


• A second on call anaesthetist was assigned to criticalcare at all times and was onsite to respond immediatelyto medical emergencies and airway managementsupport.

• The consultant/patient ratios were good for a hospitalof this size with a ratio of one consultant to sevenpatients.

• An Induction was carried out for any agency staff whoworked on the unit.


• There were major incident policies and procedures inplace, however all staff we spoke with on the unit werenot clear on their roles and responsibilities regardingmajor incident.

• We spoke to the critical leads with regards to criticalcare policy for a major incident and they stated that itwas currently being reviewed at a trust level and wouldbe cascaded to staff.

• Staff we spoke to knew what to do if there was a fire, asit was covered in their mandatory training.

Are critical care services effective?

Good –––


• A range of local policies and procedures based onup-to-date evidence and best practice were followed,including guidance from the National Institute forHealth and Care Excellence (NICE), relevant royalcolleges and core standards for intensive care units.These were up to date and were easily accessible tostaff.

• The unit took part in local and national audits, includingthe intensive care national audit and research centre(ICNARC). This meant that the care delivered andoutcomes for patients were benchmarked againstsimilar units nationally.

• We found that the staff were competent and there was agood skill base mix on the unit.

• We saw strong evidence of multidisciplinary andmulti-professional working in critical care.

• Ward rounds included consultants, a physiotherapist, apharmacist, a junior doctor, a nurse, SHO and a memberof the outreach team.

• Patients had access to dieticians, pain teams and thephysiotherapists took the lead in tracheostomymanagement in the hospital setting.

• Physiotherapists also held courses to teach patients,relatives and staff on how to care for patients requiringlong-term tracheostomy care.

However,

• The unit did fall below the acquired level of staffrecommended by the intensive care society who held apost registration award in critical care nursing, howeverpatient’s needs were being met.


• A range of local policies and procedures based onup-to-date evidence and best practice were followed,including guidance from the National Institute forHealth and Care Excellence (NICE), relevant royalcolleges and core standards for intensive care units.These were up to date and were easily accessible tostaff.

• The unit took part in local and national audits, includingthe intensive care national audit and research centre(ICNARC). This meant that the care delivered andoutcomes for patients could be benchmarked againstsimilar units nationally.

• The unit were part of the Cheshire and MerseysideCritical Care Network

• The unit employed a research nurse, who was involvedin screening for ventilator-acquired pneumonia (VAP)RAPID 2.

• The unit were auditing ventilation-acquired pneumonia(VAP) and in September 2015, they reported 89%compliance with the VAP bundle. The unit monitoredVAP bundles and reported on the level of compliance,any short falls were recorded via their safety briefing andaction taken.

• Guidelines for delirium were followed and whilstpatients were not screened routinely on admission tocritical care for delirium, all patients were screened dailyonce admitted.

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Critical care


• There was a range of local policies, procedures andstandard operating protocols in place, which were easilyaccessible via the trust wide intranet.

Pain relief

• We reviewed five patients’ records and noted painscores were recorded appropriately and pain wasdiscussed at ward rounds.

• The unit had a dedicated pain team available to supportpatients on the critical care unit. The pain team did notroutinely visit the unit, but would attend on referralsmade to them.

• There were processes in place to access patient’s painand the pain scores were recorded on the patients carerecords and monitored. A recent patient surveyhighlighted that pain may not be as well managed asthe patients would like, however all family membersthat we spoke to stated that pain was well managed fortheir loved ones.

• Most of the critical care consultants have specialisttraining in management of acute pain.


• We found that there were policies and procedures inplace to support patients nutritional and hydrationneeds. Patients nutritional needs were risk assessed andresults were acted upon appropriately.

• There were no protected meal times for the highdependency patients on the ward. The purpose ofprotected meal times is to allow patients to eat theirmeals without unnecessary interruption and to focus onproviding assistance to those patients unable to eatindependently.

• Staff and patients had access to specialist nutritionaladvice from the dietician team. The dietician reviewedall patients requiring specialist feeding includingnasogastric support and attended afternoon wardrounds daily as part of the multidisciplinary process.

• During our visit we observed that nutritional andhydration needs of patients were being met, however,one relative told us that there had been communicationproblems between themselves and staff when thereloved one was stepping down from nasal gastric feedingto oral feeding.

• Patients fluid requirements were assessed regularly andwe reviewed patient records which showed this.

Patient outcomes

• The unit demonstrated submission of continuouspatient data contributions to INARC. This meant that thecare delivered and mortality outcomes were beingmonitored against the performance of similar unitsnationally.

• The latest published ICNARC data for the period July toSeptember 2015 showed that for ventilated admissions,mortality was comparable with similar units, althoughthe mean length of stay was longer.

• Data showed that for admissions with severe sepsis orpneumonia, the unit mortality was generally higher thanfor comparable units.

• In terms of elective surgery, the mortality data was inline with comparable units and for emergency surgicaland trauma admissions, unit mortality was generallybetter than comparable units were.

• In terms of outcomes for patients, the worse performingarea shown in the latest ICNARC data was for delayeddischarges, of which 20% of discharges were delayed.Over 30% of the recorded delays were greater than 4hours, but less than 24 hours and approximately 12% ofpatients waited between one and two days to bedischarged once they had been judged clinically fit to doso.

• Approximately 1% of patients from the unit werereadmitted to the unit within 48 hours of discharge,which was better than the national average.

Competent staff

• 40% of nursing staff on the unit held a post registrationaward in critical care nursing. 8% of nursing staff werecurrently undertaking the course. This meant that theunit was 2% below the acquired level of staffrecommended by the intensive care society. The trustwere aware of this and plans were in place to becomefully compliant within the new financial year.

• The critical care unit had two designated full timeclinical practice nurse educator in post that supportedstaff appraisals annually. Data from February 2016showed that 97.8% of critical care nursing staff hadreceived their appraisal.

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Critical care


• One member of staff told us that they had not had anappraisal for several years, but this had been bookedthe week after our inspection.

• All nursing staff appointed to critical care were allocateda period of eight to12 weeks supernumerary to allowtime for registered nurses to develop basic skills andcompetencies to safely care for critically ill patients.

• The unit regularly used agency staff, all of which carriedout an induction to the unit.

• Agency staff had partial access to electronic systems,which had improved accessibility to key information;however, agency staff were limited in what they caninput on the computer system, they could write notes,but could not order prescriptions electronically.

• Nursing staff completed a set of core competencies aspart of induction to the unit and then they wereresponsible to demonstrate their competency inpractice going forward.

• The unit followed the national competence frameworkfor adult critical care nurses. The matron for the unitsigned off all competencies.

• There were 11 staff consisting of band 7 nurses and fiveoutreach team staff, who were qualified in advanced lifesupport.

• Nurses were assessed as competent to carry out keyduties in preparing ventilators and respiratoryequipment in preparation for use and decontaminationof equipment.

• Staff said that whilst there was no formal training forcontinuous positive airways pressure (CPAP) safetychecks, nurses learnt as they carried out their duties butthere was no formal competency assessment.


• A physiotherapist in critical care saw all patients.Patients who had been ventilated for three days or morewere assessed and if appropriate, routinely had 40minutes of physiotherapy as per National institute forhealth and care excellence (NICE) 83 Guidance.

• The physiotherapy team took the lead in tracheostomysupport for staff, patients and families in the hospital.One physiotherapist we spoke to ran courses to teachpatients, relatives and staff on how to care for patientsrequiring long-term tracheostomy support.

• Patients had access to speech and language therapist(SALT) for swallowing assessments and thephysiotherapists were able to make referrals to SALT andthe dietician if necessary.

• A dietician was always available for the critical care unitand all patients who required naso gastric feedingsupport were seen by the dietician.

• The outreach team reviewed all patients on wards whohad been discharged from the critical care unit.

• Consultant lead multidisciplinary rounds took placeeach day, which consisted of; two consultants, aphysiotherapist, a pharmacist, a junior doctor, a nurse,senior house member (SHO) and a member of theoutreach team. New referrals to the unit were discussed,together with staffing levels and bed availability.

Seven-day services

• A consultant was present at the unit from 8.30am to6.30pm, Monday to Friday and one consultant is on-callovernight and weekends. A second on-call anaesthetistwas assigned to intensive care at all times.

• The unit had one consultant on call at weekends, theyundertook full ward rounds in the morning and thenagain in the afternoon, or evening prior to leaving. Theyremained contactable by telephone and would attendthe unit within 30 minutes; they did not haveresponsibilities anywhere else in the hospital.

• The pharmacist covered a five day week, with an on-callpharmacist available out of hours and on bank holidays

• Physiotherapy services were provided daily, includingthe weekend and were on-call after 4.30pm.


• Risk assessments, care plans and test results werecompleted at appropriate times during a patient’s careand were accessible to staff.

• Guidelines, policies and procedures were easilyaccessible to staff on the trust intranet site

• The unit used a blend of electronic patient systems andpaper records to record and report patient informationincluding electronic prescribing and electronicpathology and radiology reporting. Prescriptions forintravenous infusions and patients notes were allrecorded on paper.

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Critical care


• Agency staff had partial access to electronic systems,which had improved accessibility to key information;however, agency staff were limited in what they caninput on the computer system, they could write notes,but could not prescribe medication electronically.

Consent and Mental Capacity Act (include Deprivationof Liberty Safeguards if appropriate)

• Staff were competent and aware of the mental capacityact and deprivation of liberty safeguarding protocols.We saw an example of staff supporting a patient whowas identified as lacking capacity using the mentalcapacity act principles and two-stage capacity test.Clinical staff included family who knew the patient bestin decision-making related to tracheostomy insertionand emergency treatment.

• Staff were aware of policies and procedures relating toobtaining consent and the processes related to bestinterest decision making.

Are critical care services caring?

Good –––


• Patients, relatives and their friends were listened to andprocesses were in place for their feedback to bereviewed and acted upon.

• 100% of relatives in the relative satisfaction survey saidthat they felt their relative's privacy and dignity weremaintained on the unit.

• We spoke to nine patient’s relatives during our visit, whoall gave positive feedback about the staff and told usthat they were caring and respectful.

• Patient diaries were in use at the unit which helpedpatients fill gaps in the memory after a stay in criticalcare and helped patients to understand what hadhappened to them.

Compassionate care

• We spoke to nine relatives who all told us that the staffin critical care were caring and respectful to them andthe patients.

• One relative we spoke to told us that staff had took thetime to play music to her daughter whilst she was in theunit, taking into consideration that she was theyoungest patient on the ward at that time.

• Patient diaries were in use in the unit, but not routinely.Intensive care patient diaries are a simple but valuabletool in helping patients come to terms with their criticalillness experience. Research has shown that diariesenable patients to make sense of their intensive careexperiences and they reduce the risk of developingdepression, anxiety and post-traumatic stress disorder(PTSD) for both patients and relatives.

• The patient diaries were only used for level threepatients and were not given out routinely. We noted thatno diaries had been given out from 26 December 2015to 8 February 2016.

• We reviewed the relative satisfaction survey for intensivecare for the period of April to June 2015, 92% of relativessaid that staff had approached them at the bedsidewhilst they were visiting, introduced themselves andexplained what they were doing.

• 100% of relatives in the same survey said that they felttheir relative's privacy and dignity were maintained onthe unit.

• Single rooms ensured that patient’s privacy and dignitywas continually maintained during episodes of physicalor intimate care. The windows to the adjoining roomshad blinds and the doors to the rooms could be closed.

• On entrance to the unit, we saw a large, wall mounted,electronic screen in the corridor, and we saw furtherscreens along the unit. The screens displayed the roomnumbers and patient’s name and due to the position ofthe screens, a patient’s name was in full view to anyvisitors to the unit, however staff found this technologysupportive in ensuring patients were seen promptly byvisiting staff.


• Patient information leaflets were available in therelative’s waiting rooms, which provided information ona variety of subjects including; MRSA, infectionprevention, C dif, pressure ulcers, and VTE.

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Critical care


• On admission to the critical care unit, patients andrelatives were given a ‘Visitors guide to the intensivecare unit’ booklet, which covered all aspects of theintensive care unit, including information about visitingtimes, relative accommodation, parking, patient dairies,research and rehabilitation.

• The ‘Visitors guide to the intensive care unit’ was alsoavailable on request in large print, braille, on compactdisc and in other languages.

• We spoke to relatives who had been given the ‘Visitorsguide to the intensive care unit’, information oninfection prevention and an ‘Intensive care unit relativesatisfaction survey’, on admission of their relative.

• The unit provided an information booklet for patients,relatives and carers about DNACPR decisions, thebooklet explained what CPR is, how it can be carried outand the possible outcomes. There was also informationabout talking to counsellors, a Patient Advice andLiaison Service (PALS) and the Chaplin, at the back ofthe booklet.

• We observed delays for families and non-critical carestaff entering the unit due to the shortage of receptionstaff and observed the ward phone not being answered.One relative told us that they had attempted to contactthe unit by telephone for over a day and eventuallyanother relative had to attend the unit in person for apatient update.

• The unit had a dedicated specialist nurse in organdonation who spoke to relatives when treatment wasbeing withdrawn. The information in the ICU bookletalso prepared relatives for the questions that may beasked.

Emotional support

• The critical care staff arranged and led a memorialservice once every three months in the hospital chapel,for relatives who had lost loved ones in the unit.

• Direct feedback was given to us from a relative whosespouse was receiving palliative care at the unit.Relatives told us that their child had some learningdifficulties and two senior doctors took time to listenand explained everything; the care was described as’Fantastic’.

Are critical care services responsive?



• Challenges for the unit were related to delayed patientdischarges which had been reported on the risk register;over 20% of discharges were delayed. 30% of dischargeswere delayed for 4 to 24 hrs and approximately 12%were delayed for 24 to 48 hrs, however the results werestill in the expected range for a hospital of this size.

• We found that on ten occasion’s patients had to stay intheatre recovery, due to staffing and bed issues withinthe critical care unit and during our visit we were madea aware of a patient being nursed in the theatrerecovery until a bed came available. Patients stayedbetween 40 minutes and 11 hours.

• This also had an effect on elective surgery cases whichare regularly being cancelled due to the staff/bedshortage in critical care.

However,

• The unit offered overnight accommodation to patient’sfamily and friends, for short-term use. The rooms wereimmaculately kept and well equipped and had beenfunded by a local charity.


• The trust planned and built the new unit in 2014 afteridentifying that the previous unit did not meet patient’sneeds due to a poor environment and small bed spaceareas. The design of the new unit considered this andthe risks associated with transmission of infection. Inaddition to this, the unit was planned in preparation forthe transfer of vascular services.

• The unit did not offer a follow up clinic for patients whohad been discharged from the unit; however, patientswere seen on the ward by the outreach team.

• The unit were aware of their need to improve access to aclinical psychologist for the patients and it had beennoted as a recommended action in the

• The unit had two overnight en-suite bedrooms availableto family and friends, for short-term use. The rooms

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Critical care


were well equipped and had been funded by a localcharity. During our visit, we saw a relative who hadtravelled a considerable distance being offered theroom to sleep in, prior to driving again.

• Staff told us that they were able to access cold snacksfor patients who had missed meals due to being awayfrom the unit.

• There were facilities for visitors to make hot drinks in asmall kitchen area and in the waiting room outside thecritical care, entrance had a water machine.

• The critical care physiotherapists held a follow up clinicfor rehabilitation after discharge. The patients receivedsix sessions of rehabilitation.


• Decisions made to withdraw care were discussed withrelatives and this involved a multidisciplinary team. Wesaw evidence of this in patient’s notes.

• Learning disability passports were in use on the unit,which worked on a traffic light system, for exampleindicating what the patient preferred to be called, andwhat their likes and dislikes were which supported theirindividual needs.

• Relatives who were visiting a patient who had been incritical care for more than 48 hours were given a carpark pass free of charge, which could be used for up tofour weeks.

• The latest available ICNARC data showed that the unitwas performing the same as comparable units for earlyreadmissions and post unit hospital deaths and duringthe last quarter performed better on post unit deathsthan other units. Early readmissions are classified asbeing unit survivors that are subsequently readmitted tothe critical care unit within 48 hours of discharge andpost unit deaths are classified as being unit survivorsthat die before ultimate discharge from acute hospital,(excluding those discharged for palliative care).

Access and flow

• Challenges for the unit were with delayed discharges,which had been reported on the risk register. Data fromICNARC for the period of 1 July 2015 to 30 September2015 showed that over 20% of discharges were delayed.

30% of discharges were delayed for 4 to 24 hrs andapproximately 12% were delayed for 24 to 48 hrs,however the results are still in the expected range for ahospital of this size.

• We were told that on occasions patients have to stay inthe theatre recovery, due to staffing and bed issueswithin the critical care unit. The trust provided us withthe monthly audit for recovery occupancy for April toMay 2015, for both level 2 and level 3 patients; 10patients remained in theatre recovery due to lack ofcritical care beds. The waiting time ranged from 40 minsto 11 hours; eight of the patients waited over four hoursbefore being transferred. The outreach team, or criticalcare trained theatre staff would care for the patientwhilst they remained in recovery.

• During our visit, it was discussed at the critical caremorning handover that they would be unable to takeadmissions to the unit that day and level twoemergency cases had to be held in theatre recoveryuntil a bed became available. One elective surgery casewas also cancelled due to staff/bed shortage in criticalcare.

• Access and flow pressures had an impact on operationaleffectiveness. For the year 2015/2016 there had been 51cancelled elective surgery cases. These had been for avariety of reasons, not just the lack of critical care bed.For example, when an emergency patient would takepriority over an elective case.

• Access and flow difficulties within critical care was dueto a number of combined issues; staffing, layout of theunit and the hospital being a centre for vascular surgery.The unit was a 21 bed single rooms unit, dealing with amix of level two and 3 patients. The beds are flexible tomeet demand, though not more than eight level threepatients can be accommodated at any one time. Anurse supporting level two patients would be 1:2;however, the patients being cared for may be anywherein the unit and not necessarily in adjacent rooms,therefore staffing needs were risk assessed.

• The critical care leads told us that they kept a vacantbed in critical care whenever access and flow allowed,accommodating for any emergencies and this reflectedwhat we saw.

• Patients were reviewed in person by a consultant inintensive care within 12 hours of admission to the unit.

Criticalcare

Critical care


• Out of hours, discharges were closely monitored. For theperiod 01 July to 30 September 2015 the ICNARC datashows that there were 213 admissions to critical careand 10 night time discharges, 5 of those being to thewards. These had been for a variety of reasons, not justthe lack of critical care beds. The last quarter shows animprovement in this data and the out of hoursdischarges are better than comparable units.


The trust’s website contained information on how to raise aconcern both informally and as a formal complaint, whichincluded contact numbers and email address for PALS. Wealso saw PALS information and reporting cards in therelative’s waiting room on the unit.

• Staff learnt from complaints or concerns by completinga self-reflection form and the content would bediscussed with the matron and then filed in theirpersonal file.

• The matron reviewed any complaints and incidentsreported and information was displayed on the staffnotice board for staff to review.

• Results from the safety thermometer data and relativessurveys were included in a monthly unit newsletter forall staff in critical care to review.

• Generic feedback themes are included in the dailysafety briefs, for example, a pressure sore incident wasrecently discussed and a case study carried out for staffto learn from.

• The unit was active in the Cheshire and Merseysideadult critical care operational delivery network andshared learning from complaints across this network.

• The critical care matron attended the planned caredivisional meetings and a critical care delivery group,which were held twice a month, where complaints,incident trends and patient/ relative feedback arediscussed.

• Once a month, a band 7 nurse staff meeting is held anda band 6 nurse staff meeting bi-monthly to learn fromcomplaints and concerns.

Are critical care services well-led?

Good –––


• Staff were aware of the vision for the service and hadstrategy’s in place for innovation and improvement.

• There was an effective governance structure in place,which ensured that all risks to the unit were discussedwithin the trust and through regional networks.

• The critical care unit had a designated consultantclinical lead and a team of experienced senior nursesled the nursing team. There was strong leadership in theunit with many new ideas, which had beenimplemented for improving communication amongstthe staff.

• The service took part in the intensive care national auditand research (ICNARC) data so we were able to benchmark its performance and effectiveness alongside othersimilar specialist trusts. The trust performed well,however data indicated some concerns regardingdelayed discharges.

• Staff told us they felt supported by senior leaders on theunit.

• Incidents were reported and acted upon and usedcontinuously as a service improvement tool Safetythermometer data was collected and displayed in publicareas for patients and relatives to view. Results wereshared with staff in critical care in a monthly unitnewsletter, together with results from relative’s surveys.

• The staff we spoke to felt respected and valued andwere all passionate about working in critical care. Allstaff we spoke to said that they felt supported andconfident to raise any issues or ask for support.


• The unit had a business case in progress to expand theservice to be able to support 12 ventilated patients aspart of a wider vision and strategy. This meant they willrequire three additional ventilators and appropriatelytrained staff.

• Staff were aware of the vision for the service and hadstrategies in place for innovation and improvement. Thetrust-wide critical care delivery group, highlighted anumber of priority recommended actions as part of this,for example; Improvement of patient flow, reducedelayed discharges and discharges out of hours and

Criticalcare

Critical care


Increase percentage of qualified nursing staff with apost-registration qualification in critical care, all ofwhich were being addressed as part of the strategygoing forward.


• There was an effective governance structure in place,which ensured that all risks to the unit were discussedwithin the trust and through regional networks.

• The lead nurse in critical care attended planned caregovernance meetings and cascaded key information inthe unit.

• There was a multidisciplinary attendance at the criticalcare network meeting which were held quarterly.

• Critical delivery group meetings were held regularly andattended by multi professional representatives frompharmacy, outreach and education. ICNARC data wasreviewed and discussed.

• There was a risk register for the unit, which were up todate included controls and measures to mitigate risks.The risk register was updated regularly and risksreviewed and acted upon.

• One high-risk issue that was highlighted on the units riskregister referred to blood heaters not being suppliedwith hired hemofiltration machines. Four of the dialysismachines were on loan; we were told that theprocurement process was under way to purchase newmachines, which will mean the unit will have the abilityto carry out calcium citrate dialysis.


• The critical care unit had a designated consultantclinical lead and a team of experienced senior nursesled the nursing team. There was strong leadership in theunit with many new ideas, which had beenimplemented for improving communication amongstthe staff.

• Staff told us they felt supported by senior leaders on theunit.

• We spoke to the practice educators about thepercentage of staff on the unit who had not yet attaineda post registration award in critical care nursing; theytold us that this was due to financial difficulties. The unit

had been refused funding for training, due to overspending the previous year, which was confirmed whenwe spoke to the critical care leads and was identified onthe March 2016 risk register.

• The unit was aware of ICNARC data and their position inthe network in comparison to other similar critical careunits and the critical care leads told us they put a lot ofeffort into improving their performance from the data.


• The staff we spoke to felt respected and valued andwere all passionate about working in critical care. Allstaff we spoke to said that they felt supported andconfident to raise any issues or ask for support.Communication was an area within critical care that wewere told had not always been effective. Recently newmonthly band 7 nurse staff meeting and bi-monthlyband 6 nurse staff meetings had greatly improved this.

• The staff in the unit felt supported in undertaking furthertraining, however, the outreach team told us that theyfelt they needed more guidance in their roles and theydid not always feel as supported as the rest of the team.They were due to set up a specific subgroup within theCheshire & Merseyside critical care network for outreachstaff, with the view for them to receive more guidanceand support in this area.

• The practice educators told us that each nurse is part ofa support group whom they can go to with anyproblems or issues. There is also an occupational healthservice that the nurses can refer themselves to.

• The current matron had recently arranged an away daywith nurses to improve communication, relations andsharing of information. This had been welcomed by thestaff who felt that there was a supportive culture on theunit.

• Staff told us that they felt actively engaged and theirviews were considered. A junior doctor told us of anincident where he was dealing with an emergency andhe found it difficult to communicate with the 10-teammembers of nursing staff around the bedside due tonumbers and noise levels. He completed an incidentreport raising his concerns; his views were listened toand actions were then taken to prevent this situationfrom reoccurring.

Public and staff engagement

Criticalcare

Critical care


• The critical care unit’s matron produced an informativenewsletter for staff, which had key information andnews. Staff said they found this supportive.

• Within each ‘Visitors guide to the intensive care unit’booklet handed out, was an intensive care unit relativesatisfaction survey. Relatives can anonymouslycomplete the survey if they wish to do so and patientshave the option if they are well enough to complete it.There were 16 questions in total, with simple ‘tick’ boxmultiple choice answers. The results from these surveyswere analysed weekly and shared with the staff, patientsand relatives. The results for the relatives weredisplayed on the notice board in the waiting room andthe results for the staff were shared in the monthlynewsletter.

• One issue raised from the relative’s survey was that thelighting in the relative’s waiting room was too bright inthe evenings, a number of surveys relayed this feedbackand the unit addressed this, changing the light switch inthe waiting room to a dimmer switch, so that in theevening the relatives could dim the lights.

• In a recent survey relatives were asked when they cameto visit if they were kept up to date on the condition ofthe patient, 88% answered ‘yes’.


• The unit was participating in the provision ofpsychological support to people in intensive care(POPPI). The study is being led by a Professor fromICNARC and a Dr from University College Hospital,London. POPPI is a research study which aims toimprove patients’ well-being after a stay in the intensivecare unit by teaching nurses how to; provide a calm,therapeutic environment for critically ill patients, detectpsychological distress in critically ill patients andprovide stress support sessions to their more distressedpatients.

• The Critical Care building is less than two years old andHBN04-02 was used in developing the design for thenew unit. The 100% single rooms eliminated a numberof previous problems in the unit for example bedspacing too close together, only curtains to restrict viewand maintain dignity and confidentially during care andprocedures, no confidential space to discuss sensitiveissues with patients, or relatives. Staff told us theenvironment had improved staff morale, it is light andairy and staff have commented that they feel morevalued by the Trust.

Criticalcare

Critical care


Safe Good –––






Information about the serviceThe Countess of Chester maternity services provided careto women in Chester and Ellesmere Port and thesurrounding areas including North Wales.

The service provided midwife and consultant led maternitycare.

The trust provided antenatal care at different venuesincluding children’s centres, GP surgeries or the woman’sown home. The trust provided medical input at thehospital antenatal clinic. Qualified ultra-sonographerscompleted ultrasound scans at the antenatal unit.

The service included the obstetric day unit, fetal medicinedepartment, medical disorders clinic and a high-risk clinic.There was also a clinic for women who had experienced aprevious caesarean section.

The inspection team visited the central labour suite (CLS),Cestrian ward the antenatal and post-natal ward and ward40 the gynaecology ward. We visited the antenatal day unitand the obstetric theatre on the labour suite.

We talked with 10 women and three family membersreceiving a service from the maternity service. We recordedcontact with 41 members of staff from the areas we visitedincluding lead consultants, business manager, head ofmidwifery services and gynaecology lead nurse; juniordoctors, ward sisters, shift leaders, a range of midwives andtrained nurses, health care assistants and ward clerks. Thisnumber also included students.

We reviewed the care pathway from antenatal to postnatalcare for eight women and their babies

The Countess of Chester maternity services provided careto women in Chester and Ellesmere Port and thesurrounding areas including North Wales.

The service provided midwife and consultant led maternitycare.

The trust provided antenatal care at different venuesincluding children’s centres, GP surgeries or the woman’sown home. The trust provided medical input at thehospital antenatal clinic. Qualified ultra-sonographerscompleted ultrasound scans at the antenatal unit.

The service included the obstetric day unit, fetal medicinedepartment, medical disorders clinic and a high-risk clinic.There was also a clinic for women who had experienced aprevious caesarean section.

The inspection team visited the central labour suite (CLS),Cestrian ward the antenatal and post-natal ward and ward40 the gynaecology ward. We visited the antenatal day unitand the obstetric theatre on the labour suite.

We talked with 10 women and three family membersreceiving a service from the maternity service. We recordedcontact with 41 members of staff from the areas we visitedincluding lead consultants, business manager, head ofmidwifery services and gynaecology lead nurse; juniordoctors, ward sisters, shift leaders, a range of midwives andtrained nurses, health care assistants and ward clerks. Thisnumber also included students.

We reviewed the care pathway from antenatal to postnatalcare for eight women and their babies


Maternity and gynaecology


Summary of findingsWe rated Maternity and gynaecology as good because:

• The trust had systems in place to review midwiferystaffing levels using latest national guidance(National Institute of Clinical Excellence : SafeMidwifery staffing for Maternity units 2015 NG4) andwere in the process of employing addition midwivesfollowing the most recent review in January 2016.

• Clinical areas at the point of care were clean.• The trust provided clear procedures for reporting

incidents and the electronic reporting system wasaccessible to the majority of staff. The trust treatedincidents seriously and ensured completedinvestigations using staff external to the serviceincluding external peer review.

• Multiagency and disciplinary working wasestablished and promoted the best outcome formothers and their babies.

• The record keeping systems were effective ensuredaccurate and up-to-date information about patientswas readily available.

• Women were cared for with kindness andcompassion and were positive about the standard ofcare and treatment provided by the maternity andgynaecology services.

• The service encouraged and supported learning anddevelopment. The ratio of supervisors of midwives tomidwives was 1:14 which better than therecommended 1:15.

• The trust ensured staff followed best practiceguidance and participated in national and localaudits in relation to care and treatment.

• The majority of staff felt communication betweenward staff and senior managers was effective.

• Midwives subscribed to the philosophy of the nursingand midwifery council six of compassionate care andwe saw this in practice”. There was limitedinvolvement of stakeholders or the general-public inthe trusts long-term plans for the service.

• The gynaecology ward and clinics were well run bythe gynaecology service and ward managers.

However,

• The number of midwives employed did not meetbest practice Birthrate Plus recommendations. Thisresulted on the closure of the unit and delays inprocedures for women using the service on rareoccasions.

• The layout and security detection arrangementsmeant mothers and babies weren’t alwaysmonitored, however access to the unit wasmonitored by close circuit television at key pointsacross the unit, and access was restricted either by astaffed reception or swipe access door.

• General cleanliness in non clinical areas on thecentral labour suite and Cestrian ward needed toimprove.

• We did not find evidence that emergency responsetraining included drills for dealing with commonobstetric emergencies was in place duringinspection, however the trust advised us that thiswas covered on induction and also using innovativeskills and drills training.

• The trust did not provide maternity midwives, healthcare assistants and midwife assistants withindividualised appraisals.

• The trust did not employ a specialist bereavementmidwife; however, there were two link bereavementmidwives.

• The management system for audits needed to beimproved and sharing the lessons learnt fromincidents, audits and complaints was not wellestablished.

• There were not enough opportunities for midwives tomeet and review the safety of the ward or unit duringeach shift.




Are maternity and gynaecology servicessafe?

Good –––


• Systems were in place for reporting incidents and thesewere reviewed and investigated

• Medication management and record keeping wererobust.

• There was appropriate consultant, middle grade andjunior grade obstetric cover.

• Infection control measures were in place and used bymidwives and doctors.

• Processes including methods for alerting staff toongoing concerns and multi-agency working, promotedadult safety and child protection.

• The trust had systems in place to review midwiferystaffing levels using national guidance (NationalInstitute of Clinical Excellence : Safe Midwifery staffingfor Maternity units 2015 NG4) and were in the process ofemploying addition midwives following the most recentreview in January 2016.

However,

• Feedback about learning from incidents was not alwaysdisseminated to all staff effectively.

• The environment and facilities needed to improvebecause there was one single obstetric theatre.

• The layout and security detection arrangements meantmothers and babies weren’t always monitored, howeveraccess to the unit was monitored by close circuittelevision at key points across the unit, and access wasrestricted either by a staffed reception or swipe accessdoor. A swipe access system was also being introducedon exit of the labour unit.

• The number of midwives employed did not meet bestpractice guidance.

Incidents

• In the period 01/12/2014 to 30/11/2015 the trustreported one never event in maternity services. Neverevents are serious, largely preventable patient safetyincidents that should not occur if the availablepreventative measures had been implemented.

• The root cause analysis report indicated that in this casea robust investigation had been completed and actiontaken to strengthen processes and protect against arepeat incident. Action included a robust final countingregime for equipment used during surgical proceduresand additional failsafe if a doctor was disturbed at theend of a procedure.

• There was a clear process for reporting incidentsthrough an electronic incident recording system. Thepolicy was available through the trusts intranet site.Nurses, midwives and doctors told us the system waseasy to use. Detailed guidance was available to supportstaff using the system.

• Staff stated they felt comfortable filing incident reportsand the trust scored above average compared to theEngland average. Midwives and maternity shift leaderswere able to articulate changes resulting from incidents,for example investment in specialist cardiotocographytraining had been introduced in response to incidentpatterns.

• The trust recorded 843 maternity and gynaecologyincidents in the period December 2014 to November2015. Most were reported as no or low harm. 18 requiredfurther investigation.

• We reviewed five obstetric secondary reviews and tworoot-cause analysis completed in 2015. There wereprocesses in place to monitor incident investigation atboth departmental governance meetings and at trustlevel.

• The trusts plans indicated that individual staff or teamswere to reflect on incidents. However, reports did notalways include detailed information about new orrevised instructions were shared with the wider service.Action plans did not include timescales by whichreflections and the impact of new learning wereevaluated or assessed. We did observe however, thatthere was a rolling ½ day programme of learning fromincidents which was in place which includeddissemination of shared learning across surgical,obstetric and gynaecology services.




• We noted that some action plans did not havemeasurable outcomes and timescales, and did notalways focus on all findings. For example, oneinvestigation found that access to information from allservices involved in providing antenatal care may haveimproved the outcome, however addressing this wasnot one of the actions. This meant the trust may miss ordelay opportunity for improvements.

• Four of the seven investigations reviewed did notinclude information about contacting the patients orkeeping updated about the progress of theinvestigation, however this was information wasrecorded and monitored at trust governance level,however it was unclear on how information oncompletion of fulfilling duty of candour responsibilitiesin a timely way was cascaded to staff.

• The processes of peer review to provide impartialscrutiny following a significance event was not evident.For example, one investigation identified a series ofomissions and delays in care. The findings were notreviewed independently to ensure the actions takenwere robust and appropriate.

• The trust reported that safety briefings before handover,monthly mortality meetings and updates on the intranetwas used to share the lessons learnt from investigationswith staff.

• Handovers occurred at the beginning of shifts theseoccurred twice a day. A safety check through staff ‘safetyhuddles’ (very small quick meetings) did not occur andso opportunities to update staff about changes in riskfactors on the units more frequently than every 12 hourswere not built into the day.

• Gynaecology services presented evidence such as atraining presentation detailing the lessons learnt from aserious incident and staff were able to articulate lessonslearnt.

Safety thermometer

• The NHS safety thermometer is a national improvementtool for measuring, monitoring and analysing patientharms and 'harm free' care. There are different topics toreview depending on the specialism.

• The trust had developed a spread sheet which providedmonthly data about obstetric and neonatal outcomescompared against national averages.

• Information about some safety topics for example theproportion of women with infections within 10 days oflabour and the proportion of term babies who neededto transfer to special baby care unit was measured.

• Between December 2014 and November 2015 thematernity services scored above (better) than theaverage England score of 63.% combined measure forharm free care five times and equal to the average scorethree times.

• The information about safety was not available ordisplayed in a format which was accessible to patientsand the public.


• Clinical areas were clean and tidy. Cleaning scheduleswere in place and reports indicated these kept.

• The area behind the adult resuscitation equipment onthe central labour suite was dirty. There was a visiblebuild up of dirt in the vents in the doors on the laboursuite and room corners.

• The placenta fridge in the dirty sluice on the centrallabour suite was stained inside and out. This fridgecontained a bucket with unlabelled contents. Thetemperature readings for this fridge were not recorded.This was identified to staff during our visit.

• The maternity service had been identified as an outlierfor puerperal sepsis in 2014. The trusts investigationsfound that the issues concerned the reporting ofpuerperal sepsis and the trust concluded in April 2015that actual infection rates for that period had beenwithin acceptable ranges.

• Between December 2014 and January 2016 safetythermometer data showed that the maternity servicesscored below (better) than the average England score of7% for infection within 10 days of labour.

• The maternity services reported no cases ofhospital-acquired Methicillin-Resistant StaphylococcusAureus (MRSA) or Clostridium difficile (C. difficile)between May and October 2015 prior to the inspection.

• Hand hygiene audits on the labour unit between Mayand October 2015 showed staff achieved 100%compliance. The results on Cestrian ward indicated theaudit had been omitted on one occasion; however staffhad achieved 88% to 100% for the same period.




• We saw that midwives and doctors used hand cleansinggel, liquid soap, hand towels and personal protectiveequipment appropriately.

• Clear guidance was in place and equipment available toprotect staff and the public from cross contaminationand infection risks including respiratory illnesses.. Thetrust provided midwives with tailor fitted masks for usewhen required.

• We observed visitors using hand-cleansing gel as theyentered the wards.

• However we observed domestic staff handling wastematerials without proper use of gloves or aprons, thiswas brought to the attention of senior staff.

• Records indicated that the trust ensured antenatal andadmission blood tests to screen for infection werecompleted as appropriate.


• There was one theatre available for maternity services.The trust used room 15 on the labour suite as a secondtheatre when needed. This had occurred 10 times in the3 months prior to the inspection. We saw checklists andobserved that appropriate safety equipment and checkstook place, however best practice guidance identifiedthat all but the smallest consultant-led units (CLUs)should have two theatres.

• The need for a second theatre was on the speciality riskregister and the senior management team indicated thiswas on the agenda for reconfiguration of the estateincluding the women and children’s building. Howevernotes from governance meetings did not provide insightinto future plans in relation to this.

• Entrance to the CLS was controlled by the receptionistsituated in the main foyer to the maternity building.Babies were not security tagged and there were nocontrols to exiting the maternity units, however accessto the unit was monitored by close circuit television atkey points across the unit, and access was restrictedeither by a staffed reception or swipe access door. Aswipe access system was also being introduced on exitof the labour unit.

• Some staff were not clear on procedures of what tooutlined in the trust missing babies policy, howeverthere were established policies and risk assessments inplace.

• The trust had not conducted missing infant drills and sostaff, including security staff had not practiced what todo if a baby went missing. .

• Service level agreements were in place to ensureequipment was maintained and serviced.

• The neonatal unit was close to the labour ward sobabies could receive specialist treatment quickly.

• There was one side room situated away from the mainward areas for women who needed more privacy.

• Adult resuscitation equipment was available in eachclinical area and records indicated that daily checks ofthe equipment had taken place on the wards we visited.

• There was a baby resuscitaire in each room and labelsindicated checks occurred as required.

• Cardiotocography (CTG) equipment used by midwivesto monitor the baby’s heart rate and contractions of theuterus during labour was available. Records indicated toensure accurate readings machines were correctlymonitored and calibrated.

• There were two birthing rooms with birthing pools. Wewere informed that staff had not tested evacuation fromthe pool to bed in the event of maternal collapse and anadjustable bed was not available in the room.

Medicines

• We reviewed the medication records of eight patients.These records were completed appropriately includinginformation about allergies.

• There was a detailed policy for storing andadministering medication. We saw that medicines,including intravenous fluids, were stored appropriately.

• Medicines requiring refrigeration were stored within thecorrect temperature, and daily checks were made.

• Controlled medication was stored securely and hadappropriate checks in place. The controlled drug entrylog on the antenatal unit indicated that this medicationwas checked by two qualified staff at the change-over ofeach shift and before administration.

• Medication protocols were changed in line with bestpractice guidance for example in June 2015 the timing




of measles mumps and rubella (MMR) vaccination incertain women was reviewed to meet Department ofHealth guidance, ‘Immunisation against infectiousdisease’ (2013) (the Green Book) guidance.

Records

• We reviewed eight sets of records these were complete,dated and timed. The signatures were legible andnames identifiable in most instances.

• We reviewed the complete care pathways for antenatal,delivery and postnatal information for three women.Records were complete and showed that each womanhad individualised care plans for pregnancy and labour,each had received appropriate antenatal screening andassessment of risk to promote safe treatment. The trustensured the allocation of named midwives orconsultants to women..

• Records were up to date and completed at the time ofcontact.

• The trust was in the process of consolidating theelectronic record keeping system in use.

• Discharge reports and referrals were made to healthprofessionals through the electronic recording system.Women were given a copy of the information sent totheir Gp; this included the date of birth, sex and weightof the baby and whether mother was breast or bottlefeeding.

• We read the pregnancy communication books carriedby two women and entries indicated that midwives andother health professionals used these to record visitsand tests as appropriate.

Safeguarding

• The maternity service worked closely with thesafeguarding nurse specialist. The safeguarding nursespecialist and midwives interviewed worked in keepingwith robust safeguarding and child protection policies.

• The policy and guidance about female genitalmutilation was been updated and staff indicated theyhad attended training about how to report and respondto this safeguarding concern.

• There was a single system for communicatingsafeguarding concerns between the safeguarding team,midwives and medical staff. Concerns were flagged onthe electronic reporting system. This information washighlighted in code on a whiteboard in the clinical room.

• The mandatory training data provided by the trustconfirmed 89% of maternity and gynaecology midwivesand nurses had completed level three children’ssafeguarding training.

Mandatory training

• The trusts maternity education and training reportDecember 2015 indicated 98% of midwives and supportworkers were up to date with mandatory training.

• 78% of doctors were up to date, the trust had reviewedthe reason for low figure and a plan was in place toensure staff completed this training.


• The trust ensured women received screening at therequired milestones and the results shared with womenand their GP appropriately.

• Processes were in place to ensure comprehensive riskassessments and maternal screening protocols werecompleted in line with best practice guidance.

• In keeping with antenatal and new born screeningprogrammes best practice the trust had commissionedthree screening co-ordinators. Each had specialistresponsibilities for example sickle cell and thalassaemiascreening, fetal anomaly and Downs syndromescreening and infectious diseases.

• The coordinators were also responsible for counselling,education, training and audit. They worked fromCestrian ward and the fetal medicine unit.

• The 2014/15 screening results indicated the trustperformed better than the England average in keyperformance indicators for all areas of antenatalscreening.

• The trust ensured risk assessments completed duringbirth, protected women from harm because the serviceused the modified early obstetric warning score(MEOWs) to check the vital signs of women duringlabour. This ensured deterioration was quicklyrecognised and treated.




• The result of the April to September 2015 audit whichwas reported in November 2015, indicated MEOWs wascorrectly used almost 100% of the time between Apriland August 2015 but dipped to 66% in September dueto all entries not being dated and signed and noescalation when the scored triggered a response.Results were monitored and processes were in place toact upon results.

• The World Health Organisation (WHO) surgical checklistsfor maternity surgery were in place and monitored. Thefive steps to safer surgery checklist for maternity were inuse. This is a set list of safety questions that ask andanswer before, during and after a caesarean section tomake sure women and babies are kept safe during theprocedure.

• WHO checklist audits cpmpleted in March, July andSeptember 2015 indicated overall 87% compliance; thiswas below the trust target of 100%. The results werediscussed at key governance meetings and in October2015 and monitoring arrangements increase increasedto monthly from January 2016.

• Midwives used a handheld doppler instrument or acardiotocography (CTG) monitor, as appropriate, tolisten to the baby’s heart rate during labour. This meantaction was taken to provide urgent or emergencytreatment.

• There were four transitional care cots’ for babies whodid not need to admission to the neonatal unit butneeded some nursing input. Nursery nurses from theneonatal unit performed isolated care tasks for thesebabies, however transition arrangements were unclear.

• The issue had been highlighted at governance meetingshowever plans to resolve the issue were not identifiedneither was the risk placed on the divisional risk registerto ensure senior staff were involved in reviewing theconcern.

Midwifery staffing

• The trust had systems in place to review midwiferystaffing levels using national guidance (NationalInstitute of Clinical Excellence : Safe Midwifery staffingfor Maternity units 2015 NG4) and were in the process ofemploying addition midwives following the most recentreview in January 2016.

• The staff was below (worse than) the current nationalbenchmark for midwifery staffing set out in the royalcollege of obstetricians and gynaecologists guidance(RCOG) (Safer Childbirth: Minimum Standards for theOrganisation and Delivery of Care in Labour) which is1:28 across both community and hospital staff. The ratiofor the service was 1:31 midwives to babies born.

• The unit had identified this and had put plans in placeto recruit 3.5 additional midwives. 3.5 midwives. Wenoted, however, that this would bring the staffing ratioto 1:29 that would not comply with RCOG guidelines,but would achieve birthrate plus national guidance of1.29.

• In December 2015 the service completed a baselineassessment of maternity staffing needs using NICE safestaffing guidelines N64 and staff were instructed tocomplete a ‘red flag’ log to record in keeping with thisguidance. This was to record all events caused by staffshortages such as delays in inductions or plannedcaesareans sections, midwives been transferred fromone unit to another, midwives working longer shifts ormissing breaks. This had been put in place to evaluatemidwifery staffing needs going forward.

• The red flag log summary reported 25 instances ofdelayed procedures between August 2015 and January2016. The information identified delays in induction oflabour in excess 24 hours when best practice guidancestipulated women should have their induction of labourstarted within 2 hours of admission for the procedure.

• Women we talked with commented on a shortage ofstaff at night and indicated they call bells took a while toanswer during the night. Women receiving antenatalcare said they rarely saw their named midwife or thesame midwife.

Medical staffing

• The trusts medical staffing information confirmed 60hours consultant cover for the delivery suite. This meantthe service met the recommendation in the saferchildbirth best practice guidelines.

• There was a robust process of recruitment andinduction for locum doctors.

• The trust ensured detailed clinical handovers.




• Feedback and staff rosters indicted that out of hour’smaternity anaesthetic cover often included locumanaesthetists. The consultant anaesthetists haddeveloped a detailed induction protocol and guidancemanual. The head of midwifery services stated this issuehad been discussed at governance meetings.


• There was a major incident policy however this was nottested within maternity and gynaecology.

• There was a clear business continuity plan and actionflow chart for managing patients in adverse situationssuch as closure of the unit. The plan included liaisingwith ambulance services and the maternity units in theNorth West network to make sure women wereredirected to an alternative service.

Are maternity and gynaecology serviceseffective?

Good –––


• The trust provided women’s care and treatment in linewith current evidence-based guidance, standards andlegislation.

• There were arrangements in place to audit the care andtreatment provided.

• Women received pain relief as required.• There were opportunities for professional development

for midwives and nurses in women’s services.• Multidisciplinary team working was well planned and

effective.• Newly employed and qualified midwifery staff had

received appropriate training for them to carry out theirrole effectively.

However,

• a number of planned audits had not been completed.Outcomes for women using the maternity service werein line with England average but local targets forimprovements were not always set.


• The trusts care pathways for antenatal; intra partum andpostnatal care were in keeping with best practice

guidance. For example we saw that NICE pathway 64was followed in the event of a congenital anomaly beingidentified during screening and (NICE) antenatal careguidance 62 was followed for low risk women.

• Policies, procedures and pathways were based onnational guidance. We observed that the service selfassessed against national guidance and were fullycompliant.

• The obstetrics and gynaecology division provided aforward audit programme. This identified 32 audits themajority of which had commenced in 2015. Three itemswere coded ‘green’ indicating completion. Theremainder were coded ‘red’. Data provided did nothighlight the progress towards completing the otheraudits and it was difficult to identify which were overdueand which were on target. We observed that these werebeing monitored though the wider trust auditcommittee.

• Minutes between June – January 2016 for managementmeetings, ward meetings and community midwiferymeetings indicated that outcomes of audits were notdiscussed and it was unclear at the time ofinspection how findings were disseminated. The trustadvised us that this done by the practice developmentmidwife.

• Maternity services had identified the need for additionalsupport to co-ordinate clinical audit and a lead personwas identified in November 2015.

Pain relief

• Care plans showed all the women had received painassessments and appropriate pain control wasprovided. We talked with 10 women about pain controlall confirmed appropriate pain relief had beendiscussed.

• Women who were post-natal stated pain control hadmet their needs during and after delivery.

• Pain management was timely and effective. Epidural,entonox, pethidine and codeine analgesia were readilyavailable.

• For women with special needs or safeguardingconcerns, liaison and discussion about pain control with




the person and their social worker, support worker orbirthing partner always occurred. Midwives describedscenarios and action taken when they had attendedvulnerable women during labour.


• The trust met the UNICEF baby friendly criteria forreaccreditation in April 2013. At that time it was foundthat there was effective antenatal discussion aboutbreast feeding, the service valued donor breast milk andskin to skin contact for mother and new-born baby wereembedded into practice. They had completed an auditand had set targets and update the findings from the2013 reaccreditation as suggested in the UNICEF Blissguidance in 2015 which demonstrated compliance.

• There was an infant feeding team and ‘Bosom buddy’volunteers to provide breast feeding support. Motherswith babies on the neonatal unit were encouraged andsupported to express milk for their babies.

• Women on the maternity and gynaecology units wereprovided with snacks, meals and drinks while on theunit, fluid balance charts were completed so that oralintake could be monitored when required and whenintravenous fluids were administered.

Patient outcomes

• The maternity and gynaecology units used plans of carein line with best practice provided by the Royal collegesand national institute for health and care excellence(NICE). Systems were in place to monitor whetherwomen received the care and treatment expected.

• The trust reported 1,841 births between June andOctober 2015. There were nine stillbirths reportedduring this period, which was in keeping with theaverage of 1:200 births (Nhs Choice).

• The trust contributed data to the Royal College ofObstetricians and Gynaecologists (RCOG) clinicalindicators reported in August 2015. RCOG resultsindicated the trust performed in line with the nationalaverage for:- normal vaginal deliveries; overall numbersof induced labours; numbers of planned and emergencycaesarean sections; numbers of deliveries involvinginstruments and numbers of 3rd and 4th degree tears.

• The trusts internal performance measures data June2014 to October 2015, however, stated the percentage of

inductions of labour ranged between 27% and 36% andscored ‘red’ in terms of internal compliance ratings. Thecaesarean section rate scored between 25% (green) and34% (red). We discussed these findings with the seniorstaff who indicated that maternal choice was animportant factor in the figures.

• The number of woman having a serious haemorrhageafter birth scored green, indicating effective care, foreach month during this period.

• The score for maternal readmissions within 42 days ofcaesarean sections was in line with the Englandaverage.

• The trusts score for maternal readmissions within 42days of delivery for women with normal deliveries was2.8% and worse than the England average of 1.9%.

• The midwifery service completed a local audit report.The ‘Summary report April-September 2015 inclusivemidwifery care matrix’ dated November 2015 providedinformation about the outcomes of eight audits.

• This included information about the audit of medicalrecords, care of women in labour, Cardiatocography(CTG), induction of labour, Modified observation(Meows) and neonatal observations.

• The results were at times unclear for example all auditsscored ‘green’ in all areas and yet compliance for staffcompleting Meows assessment ranged between 100%and 66% over the time of audit.

• The action plan for this report was to email staff aboutthe omissions identified and discuss with the individualmidwife if the issues were identified in a single case. Theactions did not include sharing the results and learningservice or trust wide.

Competent staff

• We interviewed 41 midwives and doctors of all gradesand seniority and all indicated that the trust provided awide range of opportunities for developing expertise inmaternity practice and obstetrics. Learningopportunities included funding for external study days;support to attend conferences; training and seminarsprovided by consultants linked to mortality andmorbidity reviews; in-house on-line training developedin response to updated policies and external on-lineworkshops provided by the royal colleges.




• Midwives were particularly complementary about aninteractive cardiotocography (CTG) training package.

• New starter induction programme was provided forclinicians who completed the examination of thenew-born.

• Midwives were able to maintain their full range of skillsbecause they rotated into the community, day unit,labour suite and Cestrian ward.

• The 2015 training report indicated 98-99% of staffattended allocated study days; those who did notattend were followed up.

• The trust achieved approximately one supervisor ofmidwives to every 14 midwives this was better than therequired numbers.

• The trust was not able to confirm the number ofmidwives provided with individual appraisals. The trustprovided group appraisal and staff who felt theyrequired individual expected to approach their linemanager to arrange individual appraisal.

• Staffing also included breast care nurses who providedbreast feeding support and guidance and speciallytrained midwives who ran specialist clinics such asdiabetic clinic, there was also a research midwife.


• Midwives rotated between the different midwiferyservices this promoted multidisciplinary working. Therewere good working relationships between doctors andmidwives.

• The trust enabled effective and seamlessmultidisciplinary joint working between the units, alliedhealth professionals, the community midwives,including an independent maternity service provider.

• We witnessed positive interactions and liaison withgeneral practitioners and pharmacy this resulted inpositive outcomes for patients ready for discharge.

• Paediatricians were on call for the maternity unit andmidwives were aware of which paediatrician was on callout of hours. This meant new-born babies receivedappropriate care and treatment.

• There were clear guidelines that midwives used toaccess clinicians outside the maternity service. Thisinformation included contact details and bleepnumbers.

Seven-day services

• Consultant cover and antenatal assessment wasavailable seven days a week.

• A consultant obstetrician was on call out of hours. If aconsultant lived more than 20 minutes away they sleptat the hospital.

• Imaging and radiotherapy was available out of hours.

• Pharmacy was available seven days a week.


• Staff had access to information through an electronicreport keeping system, paper records held by thepatient and on the units. Information was readilyavailable for all staff including locum doctors.

• We noted that key policies and procedures such as theemergency escalation policy were available in printformat on the wards and in the reception area.

• Networked computers were available in all key areasand staff could access the internet and the trust intranetweb pages.


• We spoke to 10 women who said midwives providedenough information to help make informed decisionsabout their care and treatment.

• Staff described the different types of consent and wewitnessed staff giving choice and waiting for verbal andimplicit consent when supporting women.

• Doctors and midwives had received training in gaininginformed consent.

• We saw consent forms signed and dated for womenwho had undergone planned or emergency caesareanssections.

• The correct termination of pregnancy notification formswere completed and sent to the chief medical officer asrequired by the department of health.




• Staff had received appropriate training in mentalcapacity and deprivation of liberty safeguards.

Are maternity and gynaecology servicescaring?

Good –––


• Women said midwifery and nursing staff were caringand information about choices was provided in a waythey understood.

• We observed woman-centred care and saw staffresponding respectfully to requests for support.

• The service did not have a dedicated bereavementmidwife however, some staff had received specialistbereavement training and so the trust could be assuredthat bereaved parents were supported in a caring way.

• Facilities had been provided to enable midwives tosupport grieving families sympathetically.

Compassionate care

• The national 2014 maternity survey completed bypatients showed that this trust achieved better ratingsthan average for antenatal care; care in hospital afterthe birth; support while feeding baby and care at homeafter the birth.

• The maternity friends and family test (FFT) data returnfor January 2016 scores was low (1.9%) however allrespondents indicated they were likely to recommendthe service. The trust had introduced new FFT collationmethods to try and increase the number ofrespondents.

• Gynaecology FFT outpatient response was 31% and90% were likely to recommend this service.

• Ten women and three family members wereinterviewed. They were in the antenatal clinic, deliverysuite, triage, antenatal/postnatal ward and gynaecologyunit.

• Women described positive experiences and felt doctors,nurses, health care assistants and allied health care

professionals were kind and helpful. They felt theirfamily was looked after and felt they had been givenenough information about results and what to expectduring their time on the unit.

• One woman on the Cestrian ward commented that atnight they had to wait for assistance however staff werealways pleasant and helpful.

• During our inspection we observed caring, respectfuland compassionate interactions between staff andwomen and their families.

• There were systems and processes in place to makesure women and families who had experienced a stillbirth or a miscarriage were treated with compassionand sensitivity. Examples included admission to aseparate area away from mothers with their babies. Thetrust offered photographs of babies who had died andmothers could decide when these were taken home.

• Midwives were not especially involved with supportingparents to make funeral arrangements as this wasmanaged by the bereavement service.

• Curtains were used in bay areas which ensured dignityand privacy was maintained.


• Processes were in place to involve women and theirbirth partners.

• Birth partners were supported to remain with women inlabour. There was a reclining chair in each room forpartners to use.

• Birth partners told us they felt involved in care andtreatment. We observed staff involving and supportingfamily members appropriately.

• Staff recorded the choices made by women in relationto pain control, breast feeding and preparedness forbeing discharged.

• We witnessed staff explaining care, treatment andprocesses in easy to understand terms.

• The tone and language used in records to describe careand treatment indicated midwives and doctors had arespectful and caring attitude towards patients.




• Visiting hours on Cestrian were extensive 9am to 9pmfor partners and 11am to 9pm for others. This meantwomen and babies did not have protected time for rest.The service was planning to survey women aboutvisiting hours.

Emotional support

• Staff considered the emotional needs of women andtheir partners during the handover of shifts.

• The advanced midwife practitioner and fetal medicinemanager had completed counselling module NM205and a bereavement counselling course.

• All midwives received training on induction to enablethem to provide appropriate counselling to antenatalpatients in relation to screening for fetal abnormalitiesso that parents can make an informed choice regardingwhether or not to have the screening. Reports indicatedthis training was updated annually on the mandatorytraining programme.

• An external workshop in November 2014 delivered bythe charity SANDS (Stillbirth & neonatal death) wasattended by 20 midwives. The aim of the course was toenable participants to develop the knowledge, insightand skills to provide high quality, sensitive care toparents who experience the death of a baby, before,during or shortly after birth.

• Assessments for anxiety and depression werecompleted, and women were referred to an externalmental health team if perinatal mental health care wasrequired.

• Mothers were supported to spend time with their baby ifadmitted to the neonatal unit to enable bonding.

• The head of midwifery stated 100% of bereaved parentsattended the pregnancy risk clinic which was consultantled. The fetal medicine midwife also reviewed each caseand counselled women and their partner about theirexperience.

• Babies who needed antibiotic screening or medicationhad to be taken down to the neonatal unit fortreatment and so mothers who were not well enough toescort their babies were separated from their babies fora procedure that could be completed at the bedside.

Are maternity and gynaecology servicesresponsive?

Good –––

We rated responsive as good because:

• The service was open to suggestions from people whoused the service other maternity services,commissioning agencies and outside auditors.

• Action was taken to resolve access and flow concernswhen new issues were identified.

• Specialist midwives were employed and systems werein place to ensure the individual needs of women andbabies were met.

• Individual staff were supported to learn from complaintsand concerns however processes for wider learningwere not evident.


• The maternity services used information from patientsurveys to plan service delivery provided to localpeople. For example the 2015 antenatal satisfactionscreening survey showed an increase in the number ofwomen reporting that they had received their results orfeedback about scans and tests on the same day as thetest and additional counselling had been provided. Thismeant women had more time with the midwives andsonographers.

• The trust worked collaboratively with HealthwatchEngland and used independent feedback to assist withplanning services for example the service had refitted asmall office so this could be used when dischargingmothers.

• The trust worked regionally and members of obstetricand maternity services attended the “Saving babies inNorth England” meeting which uses best practice toplan services aimed at reducing the number of intrapartum stillbirths in the region.

Access and flow




• The maternity service had closed six times during 2015due to activity. This had been managed through theescalation policy which involved working with otherlocal maternity services and emergency ambulanceservices.

• The trust took action to try and prevent delays in theservice. For example meeting notes and discussion withthe senior managers indicated that the trust hadreviewed planned inductions of labour (IOL) to prevent abacklog caused by unforeseen changes on the laboursuite. Verbal feedback at meetings indicated the changewas having a positive effect; however on the day ofinspection we found two women who had experiencedsignificant delays in their procedures, however nowomen were sent home without the procedure beingundertaken.

• All the midwives were talked with stated delays in IOL’swas a regular occurrence.

• The admission process was clear and women rang theday unit, however, if out of hour’s woman were able tocontact for help directly.


• Specialist midwives and processes were in place forsupporting patients with complex needs such asdiabetes, teenage pregnancy, learning disabilities andmental health needs. However a drugs and alcoholspecialist midwife weas not in place, but processes werein place to support patients and families.

• Interpreter request forms and invoices showed patientshad access to these services. The policy was clear andthere were no barriers to accessing translation services.

• If patents could read English, clearly written and easy tounderstand patient information leaflets aboutgynaecological and obstetric procedures were availablein waiting areas.

• The trust was introducing a specialist system forchecking how well a baby was growing during theantenatal period. This specialist ‘growth chart’ wouldhelp midwives to identify if a baby was small or large fordates. This would help women, midwives andobstetrician decide on how to manage the delivery ofthe baby.

• Individualised growth charts were introduced for newantenatal bookings in October 2015. The firstmeasurement was not due to be taken until 24 weeksgestation and so more time was needed to confirmpositive improvements.

• Specialist advice was available to support people withbariatric needs.


• The complaints report indicated that maternity andgynaecology services had received 22 formal complaintsabout the service. An individual report about themesand management of complaints had not beencompiled, however information from individual reportsindicated complaints were reviewed and in-depthinvestigations completed when required.

• The outcome usually involved speaking with theindividual member of staff involved.

Are maternity and gynaecology serviceswell-led?

Good –––


• The vision for maternity services was based on the 6 C’s,care, compassion, competence, commitment, courageand communication, outlined in the chief nursing officerfor England’s national nursing strategy 2012. Midwiveswere able to articulate this.

• The senior managers were active members of Cheshireand Merseyside maternity, children and young peoplestrategic clinical network steering group and so involvedin influencing maternity services for a catchment areawider than Cheshire

• Whilst there were some gaps in systems for sharinginformation from learning from incidents andmonitoring of audit performance at a departmentallevel, however there were over-arching governancearrangements in place within maternity andgynaecology services which monitored risk, quality andperformance which ensured that information wasshared.

• The senior management team described early plans toreview the layout, use of the facilities on the maternity




unit, and improve liaison with local community groups.Plans also included a closer working relationship withother maternity services so that effective ways ofworking could be shared.

• The immediate leadership of the maternity and thegynaecology services was visible to staff and were awareof the day to day challenges of the service.

• An open, transparent culture was evident where theemphasis was on the quality of care delivered towomen. The service encouraged a ‘no blame’ culturewhere staff could report when errors or omissions ofcare had occurred.

• The trust worked to promote innovation, improvementand sustainability. The trust had employed a researchmidwife with a remit to prioritise obstetric studies. Herrole included working with obstetricians, midwives,women and centres of excellence to develop projectswhich would influence best practice guidance in thefuture.

• The service had recently introduced hypnobirthing forwomen using the service.

However,

• Ward staff were aware of the short and long-term goalsfor the service but did not feel involved in the plans tobring about the changes.

• Action plans for governance and improvement were inplace, however they did not always include specific,measurable, achievable and time-limited goals.


• The trust had a strategic plan for the future and strategythrough the model hospital concept hospital’. This is anew strategy for measuring quality focussed on widerconcepts of value, reliability, operational transparencyand accountability.

• The ‘summary strategic plan document for 2014-19’indicated that the site strategy and capital prioritiesincluded refurbishing the women and children’sbuilding in two phases.

• At the time of our inspection, the local maternityservices strategy 2014-2019 ‘Delivering excellence inmaternity care’ we were not provided with a frameworkfor future development. The document described thecurrent services and provided a list of intentions,however the trust advised us that forward plans andactions were monitored monthly.

• The vision for maternity services was based on the 6 C’s,care, compassion, competence, commitment, courageand communication, outlined in the chief nursing officerfor England’s national nursing strategy 2012. Midwiveswere able to articulate this.

• The senior managers were active members of Cheshireand Merseyside maternity, children and young peoplestrategic clinical network steering group and so involvedin influencing maternity services for a catchment areawider than Cheshire.


• There were governance arrangements in placemonitored key risk and quality measurements thoughobstetric and gynaecology services, for example the riskregister, all incidents and investigations, clinical auditand research.

• At the time of inspection, we found that the risk registerincluded three items rated moderate or above whichwere the interface between the maternity services andan independent provider, lack of a second theatre whichhad been entered on to the register in January 2015 andthe need to be compliant with cardiotocography (CTG)best practice guidance placed on the register in 2013.The risk register was reviewed was part of governancemeetings as a standard agenda item and minutesshowed discussions that supported risk register entryand escalation to trust board.

• The speciality risk register did not include low staffinglevels, however staffing levels were part of the trustwide executive risk register and we saw details actionsthat had been taken and monitoring arrangements thatwere in place.

• Action plans for governance and improvement were inplace, however they did not always include specific,measurable, achievable and time-limited goals.

• The speciality risk register had been updated inFebruary 2016 and included the need for more robustmanagement of audits and outcomes.


• Maternity and gynaecology formed part of the plannedcare business unit. The leadership of the maternity




services was stable however the service was beingreviewed at board level to make sure futuredevelopments met the needs of the population, wassustainable and based on best practice.

• The immediate leadership of the maternity and thegynaecology services was visible to staff and were awareof the day to day challenges of the service.

• Senior staff were seen in clinical areas and had a goodawareness of activity within the service during theinspection. Staff we spoke with informed us the matronwould be work clinically if needed. Staff were clearabout who their manager was and who the seniorconsultant and head of midwifery were.


• An open, transparent culture was evident where theemphasis was on the quality of care delivered towomen. The service encouraged a ‘no blame’ culturewhere staff could report when errors or omissions ofcare had occurred.

• We observed strong team working, with medical staff.Maternity, obstetrics and gynaecology staff said theyworked well together as a team.

• The gynaecology and maternity services had aneffective working relationship and worked flexible topromote the best outcome for women receiving care.

Public engagement

• There was an active local maternity network whichinvolved stakeholders and service users in place to helpinform maternity services going forward.

• The trusts strategy plan for 2014-2019 for maternityservices did not include information about how the trustwould inform and involve the general public about theplans, however we were advised that actions werein place and this was monitored monthly.

Staff engagement

• Staff were engaged in making plans for thedevelopment of the maternity services. The results ofthe CQC staff survey showed that Countess of Chestermidwives involvement with future development wasneither worse nor better than the national average.

• Evidence confirmed staff involvement in the futurestrategy through surveys and consultation. Withinmaternity and gynaecology senior staff were able toarticulate the ‘model hospital’ strategy and minutesfrom meetings indicated some elements such as valueand accountability had been introduced to midwives atteam meetings.

• The women and children’s division senior managementteam told us they were developing on unit level staffsurveys. This was at the early planning stage and so notyet evident in meeting notes and reports provided bythe trust.


• The trust worked to promote innovation, improvementand sustainability. The trust had employed a researchmidwife with a remit to prioritise obstetric studies. Herrole included working with obstetricians, midwives,women and centres of excellence to develop projectswhich would influence best practice guidance in thefuture.

• The service had recently introduced hypno birthing forwomen using the service.

• The maternity service at the Countess of Chester wasunder review.




Safe Requires improvement –––






Information about the serviceCountess of Chester Hospital provides a range of paediatricand neonatal services within its Women and Children’sbuilding. Both the neonatal unit and children’s unit aresituated on the ground floor. The neonatal unit has 20 cotsand provides critical care, high dependency care, specialcare and transitional care for newborn babies. Thechildren’s unit has 34 beds, which include a 22-bed wardarea incorporating two high dependency beds and sixadolescent beds. There is also a six-bed paediatric daysurgery area and a six-bed acute assessment unit. Adedicated paediatric outpatient clinic is located next to theward.

Hospital episode statistics data (HES) showed there were4,343 children and young people seen between September2014 and August 2015, 95.3.% of cases were emergencyadmissions, 17% were day case admissions and 1.1% wereelective admissions.

We visited the Countess of Chester Hospital between the 16and 19 of February 2016 and performed an unannouncedvisit on the 4 March 2016. We inspected a range ofpaediatric services including the children’s unit, theneonatal unit, surgical theatres and the paediatricoutpatients department.

We spoke with ten patients and/or carers, observed careand treatment and inspected nine sets of records andseven prescription charts. We also spoke with 44 staff ofdifferent grades including nurses, doctors, consultants,

medical students, ward managers, specialist nurses, andplay specialists. We received comments from people whocontacted us to tell us about their experiences and wereviewed performance information about the trust.

Servicesforchildrenandyoungpeople

Services for children and young people


Summary of findingsWe rated services for children and young people asgood because:

• We saw evidence that incidents were being reportedand that information following clinical incidents wasfed back to staff in daily safety briefings.

• Cleanliness and hygiene was of a high standard inareas we visited and staff followed good practiceguidance in relation to the control and prevention ofinfection.

• Care was delivered by caring and compassionatestaff and the differing needs of children and youngpeople were considered when delivering care.

• Facilities were available for parents to stay with theirchildren.

• 97.6% of children and young people were seenwithin the 18 week target time and correspondencewith GPs following admission or treatment was sentin a timely fashion.

• The hospital at home service enabled children to betreated in their own home or reduced their stay inhospital.

• Managers had a good knowledge of performanceand were aware of the risks and challenges to theirservice.

However,

• Nurse staffing levels on the children’s unit did notreflect Royal College of Nursing (RCN) standards(August 2013) and nurse staffing levels on theneonatal unit did not meet standards recommendedby the British Association of Perinatal Medicine(BAPM).

• The neonatal unit lacked storage space andresources for barrier nursing.

• There was not always a member of nursing staff onduty with Advanced Paediatric Life Support (APLS) onthe children’s unit. The unit ensures APLS trainedstaff are included for day duty and gaps at night-timeare mitigated by nursing staff being PILS trained andmedical staff being APLS trained.

Are services for children and youngpeople safe?


We rated safe as requires improvement because:

• Nurse staffing levels on the children’s unit did not reflectRoyal College of Nursing (RCN) standards (August 2013)and had resulted in eight incidents between January2015 and January 2016, of which two detailed directimpact to patients.

• We found nurse staffing levels on the neonatal unit didnot meet standards recommended by the BritishAssociation of Perinatal Medicine (BAPM). BetweenJanuary 2015 and January 2016, 11 incidents wererecorded that related to the acuity of patients andstaffing breaching BAPM standards and on sevenoccasions in that period the neonatal unit had beenclosed to admissions.

• Nurse staffing was recorded as a risk on the divisionalrisk register for both the children’s unit and the neonatalunit however, the risk to the neonatal unit was firstrecorded in 2010.

• The neonatal unit lacked storage space and resourcesfor the care of patients who required strict infectioncontrol measures.

• Patient’s medical records were not securely stored onthe children’s unit.

• Emergency resuscitation equipment was in place butrecords indicated that daily checks of the oxygen,suction and the defibrillator were not consistentlycompleted.

• Controlled medicines were stored correctly however notconsistently checked as per the trusts policy.

• There was not always a member of nursing staff on dutywith Advanced Paediatric Life Support (APLS) on thechildren’s unit however, the unit was funded for fourtraining places per year and plans were in place to trainall nurses at band 5 and above. Most registered nursingstaff on the neonatal unit were qualified in New bornLife Support training (NLS) and plans were in place forthe remaining staff to attend the course.




• The trust target for safeguarding adults training was notmet by all staff however safeguarding policies andprocedures were in place, staff were aware of their rolesand responsibilities and knew how to raise matters ofconcern appropriately.

However,

• Incidents were reported appropriately with the majoritybeing low or no harm to the patient and lessons learnedwere shared with staff by the daily safety brief or groupemail.

• The wards and clinical areas were visibly clean. Staffwere aware of and adhered to current infectionprevention and control guidelines.

• We reviewed nine sets records, which were generallycompleted to a good standard.

• Staff were aware of the trusts Major Incident Policy andwhere to locate it.

Incidents

• Incidents were reported using an electronic reportingsystem. Staff could demonstrate the process andreceived feedback both individually and via the dailysafety brief or group email sent to all staff within thechildren’s unit.

• There were no never events or Serious Incidentsreported by the trust between November 2014 andJanuary 2016 within children’s services. Never eventsare very serious, wholly preventable, patient safetyincidents that should not occur if the relevantpreventative measures have been put in place.

• One serious incident was recorded by urgent andemergency care between November 2014 and January2016 that involved failure to obtain a bed for a child.Staff within the children’s unit told us there had been ahigh demand for beds during the recent winterregionally and nationally as well as locally. During theincident medical staff cared for the patient in theaccident and emergency department until a bed couldbe found.

• Between January 2015 and January 2016, 254 incidentswere recorded by the children’s unit, neonatal unit andpaediatric outpatient’s clinic. Of these, 252 werereported as low or no harm.

• Nineteen of the incidents classified as no harm relatedto staffing levels and acuity of patients within the units.

• Between December 2014 and November 2015, 11incidents were reported that required furtherinvestigation. We reviewed documentation relating tothree of the incidents and found actions identifiedbecause of an incident review.

• Safety thermometer was in use on the neonatal unit tomonitor device related pressure ulcers and results as atJanuary 2016 showed 100% harm free care. The NHSSafety Thermometer is a local improvement tool formeasuring and monitoring ‘harm free’ care.

• Staff we spoke to were unfamiliar with the term ‘Duty ofCandour’ (the regulation introduced for all NHS bodiesin 2014, meaning they should act in an open andtransparent way in relation to care and treatmentprovided) however they could describe the principleand the circumstances it was used.

• Perinatal and neonatal mortality and morbiditymeetings were held separately to allow time fordiscussion and numbered five and two respectively inthe last year. Key messages and learning points werethen given to staff.

• Two paediatric mortality and morbidity meetings hadbeen held in the last year and governance meetingswere held monthly. Meeting minutes were producedand sent electronically to staff.

• All child deaths were reviewed by a named paediatricianfrom the Child Death Overview Panel (CDOP). This was acommunity paediatrician who sat with the LocalSafeguarding Children’s Board (LSCB).


• The wards and clinical areas were visibly clean. Staffwere aware of and adhered to current infectionprevention and control guidelines such as the ‘barebelow the elbow’ policy. We observed staff usingpersonal protective equipment such as aprons whendelivering care.

• The had been no cases of MRSA blood stream infectionon the children’s or neo-natal unit.

• Hand washing facilities, including hand gel were readilyavailable in prominent positions in each clinical area.

• There were arrangements in place for the handling,storage and disposal of clinical waste, including sharps.




• Hand hygiene monitoring between May 2015 andOctober 2015 showed that the neonatal unit scored100% with the exception of June when this fell to 98%.The childrens unit also achieved 100% with theexception of September when the results were 96%.

• Patient-led assessments of the care environment(PLACE) audit for 2015 showed the trust scored higherthan the national average for cleanliness across thetrust.

• Patients transferred to the childrens unit from anotherhospital were routinely screened for MethicillinResistant Staphylococcus Aureus (MRSA) and isolateduntil results were available. Patients who had previouslytested positive for MRSA were also screened onadmission.

• Cleaning checklists were present in the milk roomhowever we noted five dates between the 22nd January2016 and our inspection when the chart was notcompleted.

• Staff on the neonatal unit told us they encouragedparents to question nurses and doctors abouthandwashing, if they felt able.


• The neonatal unit lacked storage space resulting inequipment such as cots and incubators being stored onthe corridor. Lack of space and resources for barriernursing was recorded as a risk on the departmental riskregister on the 1st March 2015 and a major fundraisingappeal was ongoing during our inspection to raise fundsto build a new neonatal unit.

• A door from a staff resource room on the neonatal unitthat led to an internal courtyard was unable to besecured. This had been reported however, staff couldnot tell us how long this had been broken. We looked atthis again at our unannounced inspection and foundthat this situation had not been resolved.

• Doors to storage rooms were left open on the neonatalunit despite have clear signs that indicated they werefire doors. We raised this with staff during our inspectionand were told that if the doors were kept shut thestorage areas became too hot. No thermometer wasevident in any of the storage rooms.

• Emergency resuscitation equipment was in place on theward, but records indicated that daily checks of theoxygen, suction and the defibrillator were notconsistently completed. Between the 1st January 2016and 17th February 2016, checks on the equipment kepton the corridor in the children’s unit were not recordedon four occasions. A more detailed check wasundertaken weekly and records showed this wascompleted however, we did observe blood culturebottles in the treatment room resuscitation trolley onthe children’s unit that were out of date. Staff weremade aware of this and took immediate action toreplace them.

• The clinical areas we visited had controlled access andthe children’s unit was colourfully decorated withdifferent coloured paw prints on the floor to guidepatients and visitors to various areas of the unit.However, the kitchen door on the children’s unit wasunlocked allowing access to patients despite beingdesignated a staff only area.

• Equipment we observed that had portable appliancetesting stickers (PAT) were in date and most equipmenthad electro-biomedical engineering stickers (EBME)however; staff were unaware when equipment had beenserviced.

• Clinical waste storerooms on the main access corridorto the neonatal unit and paediatric outpatients’ clinicwere found to be unlocked and a container of usedbatteries was observed. We informed staff who removedthe container and doors were subsequently locked.

Medicines

• Medicines, including controlled drugs were storedsecurely in line with legislation.

• Records indicated that there were eight occasionsbetween the 1st January 2016 and our inspection whenthe controlled drugs had not been checkeddaily on thechildrens unit as per trust policy.

• Fridge temperatures were checked and recorded dailyand included the minimum and maximum range.

• We observed medicines being given to patients bynursing staff on the childrens unit. Standard operatingprocedures (SOP) were followed, medication was givenin accordance with the prescription and patient detailswere checked.




• The trust had implemented electronic prescriptioncharts. Of the seven prescription charts reviewed allwere signed, dated and had allergies and the age of thechild documented. Six of the seven had the weight ofthe child recorded and the one record where it wasappropriate, had a documented reason for not givingmedication.

• Processes were in place to ensure the safe issue ofmedicines at the point of a patients discharge.

Records

• The trust used a combination of paper and electronicrecords. Nursing records and prescription charts wereelectronic, medical notes remained in paper format.

• We reviewed nine sets of records on the children’s unit,which were generally completed to a good standard.Eight records were signed and dated, all had a plan ofcare, an assessment of pain was recorded if appropriate,however only two records had evidence that nutritionalneeds had been addressed.

• Medical records for patients for patients due to beadmitted or that had been discharged were placed in astoreroom opposite the ward reception desk on thechildren’s unit. This was not locked despite having akeypad lock and was therefore accessible to patientsand visitors.

• Records of inpatients were stored in an unlocked trolleybehind the ward reception desk. This was alsoaccessible to patients and visitors particularly betweenthe hours of 6pm and 8am when the reception desk wasnot staffed.

Safeguarding

• A safeguarding screen was part of the admission processusing the electronic patient record. These ensuredenquiries were made about any allergies or involvementin drug trials as well as child protection issues includingcontact with children’s services or social workerinvolvement.

• Safeguarding policies and procedures were in placeacross the trust and these were available electronicallyfor staff to refer to.

• Staff were aware of their roles and responsibilities andknew how to raise matters of concern appropriately.Safeguarding training formed part of the trusts

mandatory training programme and the children’s unitorganised three study days a year to enable staff toattend an annual update. This was reported to includetopics such as Female Genital Mutilation.

• The trust target for safeguarding training was 80%. Dataprovided by the trust for the children’s unit indicated100% of administrative and clerical staff and 60% ofestates and ancillary staff had completed level 1training. Nursing and midwifery registered staff, medicaland dental staff and additional clinical services requiredlevel 3 training and attendance rates were 88.3% fornurses, 93.8% for medical staff and 94.8% for clinicalservices staff. Some medical and dental staff alsorequired Level 4 and 5 training and attendance for thiswas 100%.

• The trust safeguarding adults training target was 80%.Level 1 training was required by staff in additionalclinical services, administrative and clerical staff,estates, and ancillary staff. However only additionalclinical services staff achieved this with an attendancerate of 82.9%. The lowest attendance rate was byadministrative and clerical staff at 50%. Medical anddental staff, nursing, and midwifery registered staffrequired level two training and attendance rates were59% and 79% respectively.

• A named midwife for safeguarding children and asafeguarding lead doctor where identified within thetrust.

• Serious case reviews (SCR) were discussed at asafeguarding peer review meeting and given to staff inthe daily safety brief, ward meeting or by group email. Aserious case review takes place after a child dies or isseriously injured and abuse or neglect are thought to beinvolved.

• Electronic and paper referrals were made to paediatricliaison and details of primary care professionals wereobtained as part of the admission process. This ensuredcommunication with community health professionalswho were involved with the child, enabled informationregarding current safeguarding concerns to be sharedand ensured continuity of care between hospital andcommunity.

• Qualitative information was provided to the LocalSafeguarding Children’s Board (LSCB) quarterlyregarding the number of attendances at A&E for under




18 year olds for self-harm related issues, attemptedsuicide or for drug or alcohol related issues that werereported to the liaison health visitor. This highlightedany key trends, risks or issues and as well as any trainingor resource issues.

• Figures for quarter one to three 2015-2016 indicatedthat 292 attendances were recorded for self-harmrelated issues and/or attempted suicide and 52 for drugor alcohol related issues. All children and young peoplewho attended with self-harm or suicidal ideation wereadmitted to the children’s ward; 16-18 year olds wereassessed in A & E and referred on as appropriate.

Mandatory training

• All staff attended trust induction when they started workat the hospital and new nursing staff within thechildren’s unit received support from the practicedevelopment lead to achieve competencies withmedical equipment.

• Staff received training in areas such as infectionprevention, medicines management, informationgovernance and fire training. Training was deliveredonline as well as face to face.

• The trust target for mandatory training was 95%.Records showed that training completion rates amongstaff in the reporting unit for children were 100% formedical and dental staff and 98% for nursing andmidwifery registered staff.Additional clinical servicesattended either full or half day and attendance rateswere 98% and 50% respectively. Administrative andclerical staff and estates and ancillary staff requiredhalf-day training and attendance rates were 100%.

• Staff reported receiving an email reminder whentraining was due and the practice development leadwithin the children’s unit kept a database andsupported staff attendance.

• Conflict resolution was not identified as mandatory forall staff on the children’s unit however all neonatal staffwere scheduled to attend. We were told the decisionwas based on manager’s discretion.


• The trust used Paediatric Early Warning Scores (PEWS)to monitor a child’s condition. This included observation

of the patient such as pulse and respiratory rate. If achild’s condition deteriorated, the score for theobservations increased and gave an indication thatintervention maybe required.

• Monthly monitoring of care metrics took place on thechildren’s unit. This is a standard of measurement fornursing care, which can be monitored against agreedstandards. Appropriate escalation of patients using thePEWS was one of the standards and total scores forNovember 2015 was 100%, December 2015 was 90%and January 2016 was 100%.

• Of the records reviewed, a PEWS charts was not presentin one case and one record did not have documentedaction taken when appropriate.

• Care metrics recorded monthly on the neonatal unitincluded infection control and privacy and dignity, painmanagement and patient observations and total scoresfor November 2015 was 100%, December 2015 was 99%and January 2016 was 100%.

• Managers told us that there was not always a member ofnursing staff on duty with Advanced Paediatric LifeSupport (APLS) on the children’s unit. HoweverallAdvanced Paediatric Nurse Practitioners (APNP) hadcompleted APLS training and one APNP was on duty inthe Assessment unit between 8am-9pm, seven days perweek.

• Data from the trust showed that in October 2015 65% ofshifts had APLS trained nurses on duty, in November2015 this was 62% and in December 2015 the figure was64%. This meant that there was no member of nursingstaff on night duty with APLS on a regular basis however;managers told us onsite medical staff provided support.

• All hospital consultants are APLS trained (7); all registrarlevel doctors (7wte) and also a number of the SHOs aretrained. Seven nursing and midwifery registered staffhad completed APLS training, however there wasfunding for four nurses to be trained per year and planswere in place for all band 5 staff and above to attend.

• All staff band four and above were trained in PaediatricImmediate Life Support (PILS) and new staff attendedthis course within six months of commencing with thetrust.




• All but three registered nursing staff on the neonatal unitwere qualified in Newborn Life Support training (NLS)and plans were in place for the remaining staff to attendthis course which was available as a rolling programme,renewable three yearly.

• Transfers of infants between hospitals were completedby the Cheshire and Merseyside Neonatal NetworkTransport service.

• Children and young people up to the age of 16 yearswho required child and adolescent mental healthservices (CAMHS) were admitted to the ward from the Aand E department and were seen by the CAMHS teamwhen medically fit.

Nursing staffing

• The expected and actual staffing levels were displayedon a notice board were displayed within the children’sunit.

• Staffing within the children’s unit did not follow RoyalCollege of Nursing (RCN) standards (August 2013) whichrecommends a staff ratio of 1:3 for children under twoyears of age and 1:4 for children above 2 years of age.Staff informed us that the System to Escalate andMonitor (STEAM) acuity tool had been trialled however,this was no longer used and no other acuity tool hadreplaced it. Staffing issues were escalated through bedmeetings. Staffing was being addressed going forwardas part of service redesign which was due to be in placeby June 2016, looking at more flexible ways of working.

• A skill mix review of the nursing establishment had beencompleted in June 2014 with a subsequent update inDecember 2015 where it was recognised that the trustdid not meet all of the RCN recommendations,particularly concerning HDU patients. North WestRegional guidance on HDU patients in a district generalhospital stated a 1:1 ratio.

• Staff and managers reported that the demand for bedsand the acuity of patients throughout the winter hadbeen high. Trained staff numbers on the children’s unitwere eight for the morning shift, seven for the afternoonshift but only three trained stafffor 22 beds on a nightshift however the six bedded assessment bay and sixsurgical day case beds were closed overnight.

• At night a fourth nurse was requested from the nursebank if both high dependency beds were in use

however, this had not always been achieved duringDecember 2015. Managers reported that staff from thechildren’s unit worked on the nurse bank and soadditional shifts were usually covered by staff familiarwith the ward.

• Data from the trust showed that staff levels forDecember 2015 were reviewed and on six occasionsstaffing met the RCN standard, howeveron 11 days up to1.5 additional staffwere required and on 14 days afurther two or more additional staff were required whenbed occupancy and acuity of patients was taken intoaccount.

• Care at night on the children’s unit was recorded as arisk on the divisional risk register from 29/1/16 andmanagers told us that a business case had beensubmitted to increase the nursing establishment to fourtrained members of staff at night.

• The children’s unit also had four band 5 nurse vacanciesrecorded as a risk on the divisional risk register howeverwe were advised that two posts had been filled andrecruitment was ongoing.

• A Patient Flow policy was in place that detailed thecircumstances when the children’s unit would beclosed.

• Between January 2015 and January 2016, eightincidents were recorded relating to staffing on thechildren’s unit. Three detailed that staff had missedbreaks due to the workload on the ward, two detaileddirect impact to patients due to medicines beingadministered late and patients not receiving 1:1 care asrequired and one related to parental concern regardingstaffing levels with particular reference to nights.

• Data from the trust showed that the children’s unit hadbeen closed on two occasions in November 2015 andthree occasions in December 2015 due to the numberand acuity of patients, and staff sickness. The unit hadalso closed on a number of occasions in December 2015for a few hours to facilitate discharges.

• Day case surgery was also cancelled on the 4thDecember for the day, 7th December Monday – Fridayfor the week and on the 14th December for the day dueto dependency of patients and staff numbers.




• Staff told us that during particularly busy timesadditional staff would be drawn from the assessmentunit, the hospital at home service and the clinicaldevelopment nurse and ward manager would take onclinical duties.

• Staffing within the neonatal unit did not meet standardsof staffing recommended by the British Association ofPerinatal Medicine (BAPM).

• Staffing on the neonatal unit was recorded as a high riskon the divisional risk register however this had been inplace since 1/6/2010 and both staff and managers toldus this remained a concern. A business case had beenprepared for submission for additional staff. Data fromthe trust showed that, as at 4/1/16 the ratio of qualifiedto unqualified staff on the neonatal unit was 73% to27% compared to 80:20 as recommended by BAPM.

• We reviewed staff rotas on the neonatal unit betweenthe 1st and 10th of December 2015 and found that outof 20 shifts covering days and nights BAPM standardswere not met on any occasion. Further review of staffrotas between 1st and 10th of January 2016 showedthat BAPM standards were met on 15 occasions covering20 day and night shifts.

• Between 29/1/15 and 26/1/16 11 incidents wererecorded that related to acuity of patients and staffingbreaching BAPM standards and on seven occasions inthat period the neonatal unit had been closed toadmissions.

• Staff on the neonatal unit also administered intravenousantibiotics to babies on the maternity unit. Parentswould attend the neonatal unit with their child andduring our inspection; five children required this service,which added to the workload within the neonatal unit.

• The neonatal unit had four cots designated for babiesthat required transitional care. These were described as‘floating’ cots and were based within the maternity unitbut cared for by neonatal staff. Staff would be allocatedto care for the infants however if they also had patientson the neonatal unit this would involve workingbetween the neonatal unit and the postnatalwardduring their shift meaning that there would be timessome patients were not observed. Staff told us that ifspace was available, mothers and infants were broughtto the neonatal unit to be cared for. Transitional Carehad been recorded on the risk register since 01/09/12.

• We observed a nursing handover that was completedusing a tape recorder. Staff pre-recorded the nursinghandover, which was subsequently played to the staff atchange over at the start of their shift. This providedinformation such as the name, age, diagnosis,observations, medications and treatment plan ofpatients on the ward. This approach meant that staffcould not ask questions or seek clarification however;we observed staff obtaining additional information fromcolleagues as required following the handover.

Medical staffing

• The percentage of consultants working in paediatricswithin the trust was 30% which was lower than theEngland average of 35%.The percentage of registrarswas 51%, which is the same as the England average, and6% of the medical staff

• Consultant paediatric and neonatal cover was provided24 hours per day.

• The trust had 6.8 whole time equivalent consultants(WTE) who took part in ‘paediatrician of the week’ rota.A shortage of a paediatric consultant was recorded onthe divisional risk register on 21/10/15 however;managers informed us that approval had been obtainedto increase the complement to 8.8 wte.

• Consultant shortage had led to the trust not meeting theRoyal College of Paediatrics and Child Health (RCPCH)‘facing the future’ standards 2015 of providing twoconsultant led medical handovers per day and everychild being reviewed by a consultant paediatricianwithin 14 hours of admission.

• We observed a clinical handover, which includeddiscussion of clear management plans and review ofx-rays. Opportunistic teaching of junior staff took place,staffing issues were identified and proposals made foradequate deployment of staff.

• The trust also employed Advanced Paediatric NursePractitioners (APNP) who worked in the children’sassessment unit seven days per week 8am to 9pm.


• The trust had a documented major incident plan whichlisted key risks that could affect the delivery of servicesand a Corporate Business Continuity Plan.




• Staff were aware of the trusts major incident policy andwhere to locate it.

• Managers told us there was no winter management planspecifically for the children's unit.

Are services for children and youngpeople effective?

Good –––


• Care and treatment was delivered in line withevidence-based guidance. Policies and procedures werein place and staff knew how to access them.

• Tools were available to assess pain in children andyoung people and pain relief was available.

• Induction processes were in place for new staff anddocumentation was in place on the children’s unit toorientate temporary staff to the ward.

• Good multidisciplinary (MDT) working was noted inareas we visited and policies were in place for thetransition of patients from paediatric to adult services.

• Staff were aware of the principles when obtainingconsent from a child and we observed staff tailoringtheir approach appropriately to the age of a child.

However,

• The trust had no nutritional assessment tool usedroutinely for patients admitted to the children’s unit.

• Appraisal rates did not achieve the trust target of 95%.


• The service used National Institute for Health and CareExcellence (NICE) guidelines to determine care andtreatment provided for example the management ofbabies with suspected or early onset neonatal infectionand when to suspect child maltreatment.

• There were a number of evidence-based pathways inplace that staff were familiar with such as care ofoncology patients with febrile neutropenia.

• The neonatal unit belonged to the North West NeonatalOperational Delivery Network and was working with theeight other units in the area to standardise practice andequipment. This was to assist with the transfer ofpatients between units.

• Policies and procedures were in place and could beaccessed via the trust’s intranet. Staff were aware of howto access them.

• The neonatal unit had achieved level 3 Baby Friendlyaccreditation and were signed up to the Bliss BabyCharter, which is a practical guide to help hospitalsprovide the family-centred care for premature and sickbabies.

Pain relief

• The neonatal unit had an integrated pain managementand observation chart and used a procedural painassessment tool to improve pain management for sickand premature babies. This used methods such as usedswaddling and containment for procedures. An auditwas completed after the introduction of the painassessment tool and an action plan put in place topromote continued use and evaluation.

• Analgesia and topical anaesthetics were available tochildren who required them in the ward and outpatientsdepartment.

• Patients we spoke with described how staff assessedtheir pain using a number scoring system both beforeand after providing pain relief and we saw assessmentof pain documented in records as appropriate.

• The trust had no nutritional assessment tool usedroutinely for patients admitted to the children’s unithowever; paediatric dietetic referrals were initiated forpatients admitted with a feeding problem or eatingdisorder.

• Patients told us that there were ‘reasonable’ foodchoices and staff could provide additional options ifmealtimes were missed for any reason.

• A dietician was available to support infants in theneonatal unit who required assessment due to slowweight gain.

• Infants on the neonatal unit were weighed twice weeklyand fluid balance was monitored.




• Designated breast milk fridges were kept on theneonatal unit and children’s unit and mothers wereencouraged to express breastmilk. Adonor milk bankfacility was also available

• The trust provided data for the National Neonatal AuditProject. The latest published report was 2015 using 2014data and showed there was a documented consultationwith 100% of parents within 24 hours of admission; thisensures that parents have a timely explanation of theirbaby’s condition and treatment. Thirty two per cent ofeligible babies were discharged feeding only mother’smilk and 24% taking some mothers milk. Results alsoshowed 98% of children were screened on time forRetinopathy of Prematurity (ROP). ROP is an eyecondition that can affect babies born weighing under1501g or 32 weeks gestation and action plans weredeveloped to address areas of improvement.

• The rate of multiple (two or more) emergencyadmissions within 12 months (July 2014 to June 2015)among children and young people aged 1-17 years withasthma was 16.5% compared to the England average of16.8%.

• Children and young people aged 1-17 years admitted ontwo or more occasions with diabetes was 18.8%compared to the England average of 13.6% betweenJuly 2014 and June 2015. However, data from thediabetes specialist nurse indicated that betweenOctober 2015 and January 2016 only two patients hadbeen admitted to the children’s unit with diabeticketoacidosis (DKA).

• The hospital took part in the National PaediatricDiabetes Audit. This identified that in the period 2013/14the percentage of children with controlled diabetes was22.2% compared to the England average of 18.5%.

• A child health audit programme was in place to monitorcompliance to clinical care pathways for example theguidelines for the management of patients withdeliberate self-harm.

• Admission of term infants to the neonatal unit wasaudited monthly and discussed at the Clinical Incidentgroup to identify any trends.

Competent staff

• Staff identified their learning needs through the trustsappraisal process and the trust target was 95%.Trust

data showed that between April 2015 and November2015 87% of staff in the children’s reporting unit hadreceived an appraisal. Junior medical staff and medicalstudents said teaching was good and they feltsupported.

• Induction processes were in place for new staff, whichincluded competency assessments for medical devicesfor both registered and unregistered nursing staff.

• New staff to the neonatal unit was allocated a mentorand we observed completed documentation on thechildren’s unit used to orientate temporary staff to theward.

• All trained staff on the children’s unit had completedcompetencies for medical devices used in HDU.

• Managers in the children’s unit reported that it had beendifficult for staff to maintain competencies to care forpatients with tracheostomies due to the low number ofchildren admitted to the unit. However, staff hadreceived clinical updates from both internal andexternal sources including training provision fromphysiotherapy staff and the complex care team.

• The number of neonatal staff Qualified in Speciality(QIS) was 81.3% and a rolling programme was in placefor new staff to complete this training. This is a standardlevel of knowledge and skills for nurses within neonatalcare.

• Managers described how they managed poor staffperformance including holding discussions with staff,support for retraining and use of human resourcepolicies and procedures.


• Good multidisciplinary (MDT) working was noted inareas we visited. Clinical staff told us there were goodworking relationships between medical and nursingstaff.

• Records we reviewed indicated multi-disciplinary (MDT)working as appropriate and paediatric pharmacysupport was available Monday to Friday.

• Children referred to child and adolescent mental healthservices (CAMHS) were usually seen the next day




between Monday and Friday and a Service LevelAgreement was in place for the trust to provide medicalcare to patients as part of the Childrens Eating DisordersService (CHEDS).

• Psychologist support was available to provide supportfor CHEDS and CAMHS patients.

• Monthly MDT meetings were held on the children’s unitfor oncology patients and senior clinicians meetingswere held weekly in the neonatal unit.

• Meetings were held with social care and communityprofessionals as required for example in cases involvingsafeguarding or that required discharge planning.

• Play specialists were available 8am-4.30pm Monday toFriday in the children’s unit and attended theatre withpatients as required.

• Summary letters were sent to a patients GP followingdischarge and GPs were also advised by telephonewhen a baby was discharged from the neonatal unit.Health Visitor liaison informed community professionalswhen a baby was admitted to the neonatal unit.

• Policies were in place for the transition of patients frompaediatric to adult services and audit data indicatedthat service users and professionals were satisfied withthe process however, it was noted that respondentnumbers were small.

Seven-day services

• Seven-day services were provided on the children’s unitincluding the assessment unit as well as the neonatalunit, X-ray and ED, however outpatient appointmentswere only scheduled Monday to Friday.

• Play specialists only worked Monday to Friday and nocover was provided during the weekend.

• Consultant on-call cover was provided out of hours.


• Policies and procedures were kept on the trusts intranetand staff were familiar with how to access them.

• There were mobile computers around the wards toenable nursing documentation and prescription chartsto be viewed and completed as well as to support wardrounds.

• Vaccinations given were recorded in the child’s PersonalChild Health Record (PHCR).

• GP discharge letters were sent following discharge fromthe children’s unit to ensure continuity of care in thecommunity.

• Discharge summaries were provided to parents and GPswhen babies were discharged from the neonatal unit.

Consent

• Play specialists frequently supported children andyoung people for all procedures undertaken.

This ensured that information was provided at anappropriate level and that patients understood whatwas happening

• Staff described how they worked on the principle ofverbal consent for some procedures such as takingobservations of temperature and pulse and weobserved staff tailoring their approach appropriately tothe age of a child.

• Staff could describe the principles of Gillick competencyused to assess whether a child had the maturity to maketheir own decisions and how decisions were made withthe involvement of parents.

• We observed the procedure of obtaining writtenconsent for a child going to theatre and accompaniedthem to the anaesthetic room to see how this wasreviewed.

• Staff on the neonatal unit described how support wasrequested from extended family and the safeguardingteam when dealing with parents who may lack capacity.

Are services for children and youngpeople caring?

Good –––


• Parents and children were positive about the care theyhad received. They felt supported and involved in theirchild’s healthcare and received information that waseasy to understand.




• Care was provided by committed and compassionatestaff that treated patients and their relatives withkindness and respect.

• Services were available for families that experienced theloss of a child.

However,

• Privacy on the neonatal unit was limited.

Compassionate care

• The children’s unit presented as a calm environmentduring our inspection and call bells were observed to beanswered in a timely fashion.

• Care was provided by committed, compassionate staffthat were enthusiastic about their role.

• Staff were observed treating patients and their relativeswith kindness and respect both in person and on thetelephone.

• Staff on the neonatal unit were described as ‘ amazing’and ‘reassuring’ and boosted parents confidence whilestaff on the children’s unit got to know patients aspeople.

• Privacy on the neonatal unit was reported as an issue byparents due to the lack of space and limitations of theenvironment. Portable screens were used if motherswished to express breast milk or breastfeed their babybut the unit was reported to be ‘crowded’ and ourobservation supported this.

• The children’s unit scored the same as other trust for 23questions in the Children’s survey in 2015; however, itscored better than others for parents feeling like thehospital staff took good care of their children.

• Friends and family results were displayed on the wall bythe reception desk in the children’s unit and indicatedthat in January 2016 100% of respondents wouldrecommend the service to friends and family. Data hadbeen collected for the first time in January 2016 as thetrust had moved to a new company in an effort to makethis process more child friendly and posters and cardsobserved had a monkey logo to encourageparticipation. Managers told us they were working withthe company and linking with local partners to engagechildren in a competition to name the monkey.

• Parental experience surveys from families who hadreceived care in the neonatal unit were collectedthrough Bliss and results received by the unit offeredopportunities to identify areas where they wereperforming well and areas that required improvement.Staff told us that action plans were written as a result offeedback and actions we reviewed that were ratedamber included the requirement for a specific guidelinefor social interaction and touch which is regularlyreferred and adhered to by staff and identifying adedicated individual to coordinate a baby’s dischargeplan from the moment of admission.


• Patients and parents told us they felt fully informedabout their care planning, that staff spent timeexplaining what was happening and providedinformation that was easy to understand. Parents stated‘they will explain as many times as needed until youunderstand’.

• Patients and parents felt involved with their future careand were confident that they were taught skills requiredbefore discharge, for example parents on the neonatalunit had been taught how to administer medicines andreceived a resuscitation demonstration.

• A variety of leaflets were available for parents on theneonatal unit covering a variety of topics includingdischarge from hospital.

• Parents were encouraged to stay with their children onthe children’s ward and there were chairs at the bedsidethat converted to beds and parents had access toChristopher Wing. This was a residential facility next tothe children’s unit that had bedrooms, a kitchen, sittingroom and shower room and was originally opened withdonations from a family whose child had passed away

Emotional support

• Parents felt confident about leaving their baby in theneonatal unit and stated they could always telephone toask about the baby overnight. On return, a report wasalso given to them telling how their baby had been sincetheir last visit.

• Play specialists accompanied children and parents totheatre. Children admitted requiring Child and




Adolescent Mental Health Services (CAMHS) weresupported by ward staff who received guidance fromCAMHS and paediatric medical staff, however, there wasno registered mental health nurse on the ward.

• Parents were provided with the contact number for theward on discharge to allow them to telephone for adviceif they had any problems and in some cases were givenopen access to the ward for 24-48 hours.

• The children’s unit had a quiet room away from theward. This was a designated area to allow professionalsto hold private or sensitive conversations with patientsand relatives.

• A designated specialist cot was available on theneonatal unit so that in the event of a baby passingaway parents and family members could spend timewith their infant.

• Parents had the choice of transferring their baby or childto a local hospice after they had passed away wherebereavement and sibling counselling could be arranged.

Are services for children and youngpeople responsive?

Good –––


• Paediatric services met the needs of children, youngpeople and their families. Most areas were children weretreated were child friendly and facilities on the children’sunit catered for the needs of children of different ages.

• Facilities were available for parents to be with their childat all times.

• Interpreting services were available as required.• 98% of children and young people were seen within the

18-week target time and correspondence with GPsfollowing admission or treatment was sent in a timelyfashion.

• The Hospital at Home service enabled children to betreated in their own home or reduced their stay inhospital.

• The service received few complaints but lessons learnedfrom the complaints were shared with staff.

However,

• The environment within the neonatal unit waswelcoming but lacked space and privacy for motherswho wished to breastfeed and parents who wanted tospend time with their baby.


• The environment on the children’s unit including thepaediatric outpatient’s clinic was child friendly. Aplayroom and an adolescent lounge was available onthe ward so that children and young people hadactivities appropriate to their age. The adolescentlounge had games consoles and televisions as well asan outside area. We saw leaflets in this area appropriateto the needs of teenagers.

• Every bed in the ward and day case area had anoverhead television that was free to use until 8pm andcards were given to patients on arrival to access Wi-Fi.This enabled patients to access social media viatelephone or laptop so they could keep in contact withfriends and family.

• The six adolescent beds on the ward were separatedinto two three bedded bays, one for male patients andone for female patients, each with bathroom facilitiesand connected by the adolescent lounge.

• Children were also seen in some adult outpatientclinics, the x-ray department and emergencydepartment within the hospital. Facilities for childrenwere observed but limited within the adult outpatientand diagnostic waiting areas however, Audiology had achildren’s area and paediatric room and A & E had adedicated children’s treatment and assessment areacalled ‘Kids Zone’.

• Children attending for day case surgery could beaccompanied by their parents into the anaesthetic roomand an appropriately decorated section was set aside inthe recovery area however, this was only separated bycurtains.

• Parents were encouraged to stay with their child on theward. There were chairs at the bedside that converted tobeds and Parents had access to Christopher Wing. Thiswas a residential facility next to the children’s unit that




had bedrooms, a kitchen, sitting room and shower roomand was originally opened with donations from a familywhose child had passed away. Parents told us this gave“the chance to get 5 minutes to recapture yourself”.

• There were no facilities for parents to make hot drinkson the children’s ward however, drinks could be broughtin and put in thermos flasks.

• The environment in the neonatal unit was welcomingbut lacked space and privacy for mothers who wished tobreastfeed and parents who wanted to spend time withtheir baby.

• There were two rooms with en-suite facilities that couldbe used by parents on the neonatal unit who wished tostay overnight as well as access to Christopher Wing.

• Open visiting was available to parents with infants onthe neonatal and children’s unit and support wasavailable with parking charges.

Access and flow

• Admission to the children’s unit was either via A & E, GPreferral to the assessment unit however, patients withknown conditions had direct ward access with a patientpassport.

• The assessment unit was open 8am-9pm every day andany patients requiring care after 9pm were admitted tothe ward.

• Babies admitted to the neonatal unit that requiredintensive care for longer than 48 hours were transferredto a specialist unit.

• Data from the trust indicated that 98% of patientsreferred to paediatric services were seen within the18-week target however figures from January 2016indicated that outpatient clinic Did Not Attend rates(DNA) were 9.4% compared to the trust target of 5%.

• Bed occupancy rates were reviewed at the paediatricspeciality meetings. Data from the trust showed thatbed occupancy rates between February 2015 andJanuary 2016 ranged from 37% to 64% on the neonatalunit and 35% and 69% on the children’s unit howeverthis was a snapshot at 08.00 and staff told us that thisdid not take into account the number of patients whomay have been admitted and discharged home withinthe time frames. Specific dependency and acuity datafrom the children’s unit showed that occupancy rates for

the children’s ward was 31% to 100% in November 2015and 45% to 95% in December 2015. During this periodday case surgery was cancelled for eight days and thenever event occurred that involved failure to obtain abed for a child.

• The median length of stay in the trust is lower than theEngland average.

• Care summaries were sent to the GP on discharge toensure continuity of care in the community. Figuresfrom January 2016 showed that 96% of e-dischargeletters were sent within 48hours against a trust target of92% and 81.3% of outpatient letters were sent within 14days against a trust target of 50% in Paediatrics.

• Urgent clinic appointments were available within thepaediatric outpatient department.

• Child and adolescent mental health services (CAMHS)were available Monday to Friday. Children referred toCAMHS were usually seen the next day if admittedSunday to Thursday. Staff told us there had been a pilotof providing weekend cover however, this had notcontinued.

• The trust had set up a Hospital at Home service in 2012to reduce the time children spent in hospital andprevent re admissions. The Hospital at Home servicewas available Monday to Friday 8am-9pm and 8am-6pmSaturday and Sunday and allowed children requiringtreatment such as intravenous antibiotics or sufferingwith infections or respiratory problems whereappropriate, to be cared for at home. This meantchildren did not have to experience an unfamiliar wardenvironment and families did not have the disruption tofamily life associated with a hospital admission.

• Ward staff rotated into the community to provide thisservice and it had been extended in 2015 toaccommodate referrals from GPs to reduce the numberof children admitted to hospital. Feedback from bothchildren and families was reported to be positive.

• Data provided by the trust showed that January 2015 toDecember 2015, 708 children had care delivered by theHospital at Home service and between July 2015 andDecember 2015 49 admissions to hospital had beenavoided. Data was provided by staff delivering theservice, however further data analysis was in progress.




• At the time of our inspection, the Hospital at Homeservice was only available to patients who resided in theWest Cheshire area. Patients in North Wales did not haveaccess to the service and figures showed that betweenJanuary 2015 and December 2015 109 referrals weredeclined from the North Wales area. This meant that 109children who lived in North Wales were either admittedto hospital or stayed in hospital longer than childrenwho lived in Cheshire in that period.


• Interpreting services could be arranged to supportfamilies whose first language was not English and staffconfirmed they knew how to access these however wedid not see this in use during our inspection.

• Children who were inpatients on the children’s unit formore than seven days had a play specialist assessmentcompleted and a play plan drawn up to ensure theirdevelopmental progress was supported during theiradmission.

• We observed additional information on the list ofpatients to be admitted to the ward for day case surgerythat indicated preferences such as to come in tohospital in the school holidays or a preference to beplaced on the morning theatre list.

• Paediatric outpatient appointments were co-ordinatedfor patients with multiple attendances where possible tominimise the number of visits to the hospital required.

• Leaflets were available within the areas we visited onsubjects such as breastfeeding and information aboutthe ward. Information was also available in paediatricoutpatient’s clinic regarding the paediatric clinicsupport line. This provided additional support andinformation to parents and children on a variety ofissues such as arranging blood tests, the use of localanaesthetic cream before blood tests and advice aboutmanaging a child’s condition.

• Parents with children going to theatre were given pagersso that they could leave the ward and be promptlyinformed when their child was out of theatre.

• Formal transition processes were in place for childrenmoving to adult services including children diagnosedwith diabetes.

• We were told a pathway for children at the end of lifewas being written during our inspection however, aspecialist nurse for oncology and palliative care was inpost to support children and their families.


• Information leaflets were available within the areas wevisited advising patients about Patient Advice andLiaison Service (PALS) and the trusts procedures if thewished to make a complaint.

• Staff were aware of the complaints process. Staff told usthey would try to resolve issues immediately and if thiswere unsuccessful would direct the patient and familyto the ward manager and PALS.

• Between December 2014 and December 2015, sixcomplaints were recorded by the trust relating topaediatrics.

• Managers shared lessons learned from clinical incidentsand complaints during the daily safety brief and bygroup email to staff within the children’s unit.

Are services for children and youngpeople well-led?

Good –––


• Managers had a good knowledge of performance intheir areas of responsibility and they understood therisks and challenges to the service.

• Quality and performance were monitored throughpaediatric and divisional dashboards.

• Staff were aware of the trusts vision and values and dailysafety briefings were held to inform staff of currentissues.

• Managers were visible and approachable and staffreceived a weekly email, which contained updates onrelevant trust information.

• There was an open and honest culture in the serviceand the views of patients and their relatives wereactively sought.

• Paediatric speciality meetings and clinical incidentmeetings were held monthly however there was not anamed executive at board level for Children and YoungPeople’s Services at the time of our inspection.





• Staff were aware of the trusts vision and values todeliver safe, kind, effective care.

• A lead nurse supported by managers in the neonatalunit and children’s unit led Paediatric services. A carepackages service manager was also in post.

• The trusts strategic plan included the refurbishment ofthe woman’s and children’s unit which was to be partfunded by charitable donations and the Babygrowfundraising appeal was in progress during ourinspection.


• Quality and performance were monitored throughpaediatric and divisional dashboards. This covered datasuch as, number of referrals, length of inpatient stay andwaiting times for outpatient appointments.

• Monthly paediatric speciality meetings were held whichward unit managers attended, the lead nurse forchildren’s services and doctors. These meetings werechaired by the clinical lead consultant paediatrician anddiscussed relevant governance issues including thedivisional risk register, finance and staffing as well asreviewing activity against key performance indicators toidentify emerging trends.

• Corporate and divisional risk registers were in place,managers knew the risks and mitigating actions withintheir departments.

• Safety briefings were held daily and providedinformation on topics such as safeguarding and clinicalissues including implementing and monitoring careplans for high-risk patients.

• Clinical incident meetings took place monthly andfeedback was provided to staff via group email.

• Managers told us that there was not a named executiveat board level for children and young people’s servicesat the time of our inspection. However close links withdivisional management ensured any issues were raisedthat required board scrutiny.


• Nursing staff told us managers were visible andapproachable.

• Doctors told us that senior medical staff were helpfuland supportive and teaching provision was good.

• Most staff reported the trust board were not visiblehowever; they were supportive of events held for theBabygrow appeal, which was raising funds to provide anew neonatal unit.

• Staff received a weekly email, which contained updateson relevant trust information.


• Staff were passionate about their work and werecommitted to providing high quality care in sometimesdifficult circumstances because of busy periods or lowstaff numbers.

• There was an open and honest culture in the service.Staff we spoke to were candid about the challenges theyfaced within the service and were proud of what workedwell.

• Staff morale fluctuated and was dependant on howbusy the units were however all staff reported theircolleagues were supportive of each other and felt therewas effective team working.

• Managers of both the neonatal and children’s unit spokehighly of the hard work and commitment shown by theirstaff.

• NHS staff friends and family test results in September2015 indicated that 94% of staff

• would recommend this Trust to friends and family inneed of care or treatment and 88% of staff wouldrecommend the Trust to friends and family as a place towork.

• Results of the 2015 NHS Staff Survey from across thetrust showed that 82% of staff was satisfied with thequality of work and patient care they were able todeliver compared to the average of 83% for acute trusts.

Public engagement

• The children’s unit actively sought the views of patientsand their relatives and had recently changed to a morechild friendly approach to obtain the views of childrenand young people.




• A ‘book of thank you’ was present on the reception deskin both the inpatient and outpatient areas of thechildren’s unit for parents and children to addcomments.

• Information was gathered regarding parentsexperiences on the neonatal unit by Bliss and given tothe trust.

• Parents and patients were involved with the Baby growfundraising appeal and parents were represented on theneonatal project board, which meant they could reviewdesigns and plans for the planned neonatal unit andprovide their views and ideas.

• Displayed above every cot on the neonatal unit was theCheshire and Merseyside Neonatal Network Partnershipparents’ agreement. This was described as a parent andstaff promise and included commitments such as staffwould introduce themselves and answer questionshonestly. It also requested certain promises fromparents for example that they asked whatever theywanted to know or if they did not understand somethingand to make sure the unit had their contact details.

Staff engagement

• Team meetings were planned quarterly within thechildren’s unit and a suggestion box was availableduring the month prior to the meeting for staff to submitany topics for discussion.

• The children’s unit had won the outstandingachievement award in June 2015.


• The neonatal unit had achieved level three baby friendlyaccreditation.

• The neonatal unit were nominated for an AQuA(Advancing Quality Alliance) award following thedevelopment of a procedural pain assessment chart.

• The Hospital at Home service was introduced in 2012 toreduce the length of inpatient stay for children and toprovide acute care at home. This meant that childrenwere able return to their normal activities despite theneed for on-going care such as intravenous antibiotics.This extended in 2015 to take direct referrals from G.P'sin West Cheshire in an attempt to avoid some hospitaladmissions.

• The Paediatric Diabetes team had developed a tool foreducating newly diagnosed children and their families.In addition, an annual education programme has beendevised for different age groups to ensure children,young people and their families receive updatesthrough multi-disciplinary education.




Safe Good –––

Effective Requires improvement –––



Well-led Requires improvement –––

Overall Requires improvement –––

Information about the serviceThe trust provides a consultant led specialist palliative carenurse team [SPCT]. The SPCT team support all clinicalareas in the Countess of Chester Hospital and EllesmerePort Hospital, providing specialist palliative care, adviceand support for adult inpatients who are affected by cancerand other life limiting illnesses.

The SPCT provide an advisory and supportive service,whilst the medical and nursing management of the patientremains the responsibility of the ward teams. The SPCTprovide ward support, and facilitate the transfer of thepatient from the curative to the palliative approach for theirincurable illness. The trust has a bereavement team thatprovide support to relatives following the death of thoseclose to them. There are established links with charitableand voluntary organisations providing hospice care,counselling and bereavement support.

We visited Countess of Chester Hospital as part of ourannounced inspection on 16 - 19 February 2016. During thisinspection, we visited inpatient wards including ward 43(Elderly care ward), 44, 49,33 and 52 where the trust hadidentified patients that were receiving palliative or end oflife care. In addition, we visited the spiritual centre,bereavement office, hospital mortuary and the deceasedviewing room.

We observed care and spoke with 26 members of staffacross all disciplines including, bereavement services,mortuary staff, chaplaincy, nursing staff, medical staff,allied health professionals and porters. We spoke with thelead specialist nurse, palliative medicine consultant

(clinical lead), executive lead for palliative care and thebusiness performance manager. We spoke with two peoplereceiving support from the SPCT and their relatives, and wespoke with five relatives of people who were identified asclose to the end of life. We interviewed an SPCT nurse,following which there was limited observation of her workas she provided advice and support for a patient and theirfamily.

We received comments from people who contacted us totell us about their experience, and we reviewedperformance information about the trust. We observedhow care and treatment was provided.

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End of life care


Summary of findingsWe rated end of life services as requires improvementover-all because :

• There was an insufficient number of general nursingstaff who had received appropriate training regardingend of life care and the replacement for the LCP, thecare and communication record. The trust informedus that training had been undertaken, however staffwe spoke to were not aware of this.

• The trust performed worse than the England averagein five of the seven organisational key performanceindicators for the National Care of the Dying Audit2014. However an action plan is currently in place toaddress the issues identified in the 2014 audit.

However,

• There was a three-year strategic work plandeveloped by the Trust Supportive and End of LifeCare Group. We found this had been communicatedto most general ward teams. We found evidence ofan overarching monitoring of the quality of theservice across the trust. Complaints were respondedto appropriately.

• Staff were able to describe safeguarding proceduresand provided us with examples of how these wouldbe used.

• All of the general nursing staff we spoke with wereaware of how to report an incident or raise a concern.

• Appropriate equipment was available to patients atthe end of their life; the equipment at the hospitalwas adequately maintained.

• Medicines were managed appropriately.• Patients were involved in care planning and decision

making. Staff were respectful and treated patientswith compassion.

• Specialist nurses were visible, competent, andknowledgeable.

• The trust had a dedicated specialist palliative careteam [SPCT] who provided good support to patientsat the end of life. Care and support was given in asensitive and compassionate way.

• On the wards staff worked hard to meet and plan forpatient’s individual needs and wishes.

• Staff within the [SPCT] team were very motivated andcommitted to meeting patients’ different needs atthe end of life and were actively developing their ownsystems and projects to help achieve this.

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End of life care


Are end of life care services safe?

Good –––

We have rated safe as good because:

• Staff were able to describe safeguarding procedures andprovided us with examples of how these would be used.

• All of the staff we spoke with were aware of how toreport an incident or raise a concern.

• Staff were observed to be using personal handsanitising equipment when entering wards to visitpatients and personal protective equipment wasavailable for the SPCT if required.

• Appropriate equipment was available to patients at theend of their life; the equipment at the hospital wasadequately maintained.

• Medicines relating to symptom and pain control forpeople at the end of their lives were managedappropriately.

• Records were clear, legible and up to date. Records wereviewed included completed risk assessments forexample, falls, nutrition and pressure relief.

• The specialist palliative care team provided records ofmandatory training completed by the nurses in theteam. The records showed all members of the SPCTwere up to date with all of their mandatory training.

• Nursing staff on all of the wards we visited couldarticulate what to do if a patient deteriorated. Ward staffwere aware of the escalation processes to seek seniormedical and nursing support and were able to definewhat they would do in an emergency.

However,

• There was an insufficient number of general nursingstaff who had received appropriate training regardingend of life care and the replacement for the LCP, the careand communication record. The trust informed us thattraining had been undertaken, however staff we spoketo were not aware of this.

• The palliative care consultant staffing levels across thetrust were not in line with the recommended nationalguidelines.

• Information in relation to the care and treatment ofpatients at the end of their lives, was not consistentlyavailable to ward staff, however records when available,were adequately completed.

Incidents

• There were no never events or serious incidents relatingto end of life care reported between November 2014and October 2015.

• There had been 23 incidents related to end of life andmortuary services between December 2014 andNovember 2015. All incidents were identified as no orlow risk, and procedures were followed to investigateand act upon findings appropriately.

• Staff were aware of how to report an incident or aconcern and gave examples of the types of things theywould report. For example, staff we spoke with wereable to tell us about the process they would use tocomplete an incident form if they had any concernsregarding the care and treatment of patients at the endof their life.

• Incidents relating to patients were investigated andserious incidents were escalated to the serious incidentpanel. We found formal mechanisms were in place toshare learning regarding end of life patients across otherteams, for example, bereavement services and generalward teams, which supported patients and their familiesat the end of life.

• We reviewed records and documentation, whichconfirmed that the trust maintained an updated list ofincidents and issues relating to patients. For example,we saw records, which confirmed that issues relating topatients at the end of their life, such as preferred placeof death, had been reported on the trust wide system.

• When patients were re-admitted through the accidentand emergency department, information was readilyavailable. We reviewed the trusts paper and electronicpatient management systems at the time of theinspection and found that DNACPR details were thereand immediately accessible to staff.

• Medical and nursing staff demonstrated anunderstanding of their individual responsibilities inrelation to the duty of candour.


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End of life care


• The trust had policies for the prevention and control ofinfection and hand hygiene. Both were available on thetrust’s intranet and staff could show us how to accessthem.

• Staff were observed to be using personal handsanitising equipment when entering wards to visitpatients and personal protective equipment wasavailable for the SPCT if required.

• The mortuary was visibly clean, well ventilated and freefrom odours. A member of staff told us that it wascleaned Monday to Friday and we saw documentaryevidence, which confirmed the cleaning had takenplace.

• The Human Tissue Authority (HTA) licensed mortuaryservices. The service had undergone a HTA inspection inApril 2015 and HTA certification was visible in themortuary.

Medicines

• We reviewed the trust’s policy for the management ofcontrolled drugs and anticipatory medications forpatients at the end of their life, found these werecurrent, and reflected guidance.

• The senior nurse on each of the wards we visited wasable to describe the process used in relation to theadministration of controlled drugs for people at the endof their life.

• Anticipatory medication was prescribed appropriately.We reviewed two medication administration recordcharts on two of the wards we visited and sawappropriate prescribing.

• Written prescribing guidelines were available for doctorsto prescribe appropriate end of life medicines tomanage patient’s pain, anxiety and other symptoms.

• Records showed that patients referred to the specialistpalliative care team had their medicines reviewed by theteam. This was done in consultation with other medicalstaff involved in the patients care.

Records

• We looked at four care plans used to assess and recordpatients’ care needs and found that they reflected

national guidance. These records were clear, legible andup to date. Records included completed riskassessments for example, falls, nutrition and pressurerelief.

• We reviewed five DNA CPR forms held in patient recordson three different wards. These were fully completed.They contained information including who hadapproved the final decision, and who was consulted inthe process of a decision being made. We noted thatDNA CPR forms were filed in patients’ notes in such away that there were easily accessible to staff.

• We reviewed the trust electronic patient datamanagement system. Staff recorded decisions related toDNA CPR and completed documentation. Thisinformation was readily available to staff on theelectronic system.

• Risk assessment forms completed by ward the nursingteams on the wards we visited, were complete, legibleand easily accessible.

• We were told the trust carried out an annual audit of donot attempt cardio-pulmonary resuscitation (DNA CPR)forms.Information received from the trust prior to ourinspection confirmed this.

• Recording systems were in place in the mortuary toensure patients were admitted and kept appropriately.The mortuary records we reviewed, which includedbody release forms, were accurate, complete, legibleand up to date.

Safeguarding

• There were trust wide safeguarding policies andprocedures in place, which were accessible via thetrust’s intranet site.

• Staff knew how to report and escalate concernsregarding patients who were at risk of neglect andabuse.

• Records supplied by the trust indicated that all staff inthe specialist palliative care team had completed leveltwo safeguarding training for adults and children.

• Staff were able to describe safeguarding procedures andprovided us with examples of how these would be

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End of life care


applied. Staff were able to tell us about safeguardingconcerns they had raised previously and said they hadalways been supported by their line manager in raisingconcerns.

Mandatory training

• The specialist palliative care team provided records ofmandatory training completed by the nurses in theteam. The records showed all members of the SPCTwere up to date with all of their mandatory training.

• Overall, the trust failed to meet the organisational keyperformance indicator [KPI] for continuing education,training and audit for all staff involved in the care of thedying patient. Information we received from the trustprior to our inspection, confirmed that the trust hadplans in place to address this by employing a new end oflife facilitator and had a training programme in place.This role is expected to have a substantive input relatingto a programme of mandatory education and trainingfor general ward staff. Areas covered by the proposedtraining are to include communication skills, advancecare planning & end of life care, incorporating suchaspects as hydration and nutrition. However, at the timeof our inspection the post had not been filled, and staffwe spoke to had not received training.

• Senior managers confirmed this training had not beenkept up to date for nursing/clinical support workers butconfirmed that this was an area, which would beaddressed when the vacant post for an end of lifefacilitator was filled.


• The SPCT monitored the trust’s performance in line withestablished best practice for patients who requiredpalliative or end of life care.

• Nursing staff on all of the wards we visited couldarticulate what to do if a patient deteriorated. Ward staffwere aware of the escalation processes to seek seniormedical and nursing support and were able to definewhat they would do in an emergency. Ward staff hadcontact details for the SPCT and confirmed the teamresponded promptly when needed.

• In the eight patient records we reviewed, we noted thatthere was evidence of risk assessments beingcompleted appropriately. Risk assessments for venousthromboembolism (VTE), pressure ulcers, nutritional

needs, falls and infection control risks for patientsreceiving palliative/end of life care were conducted bythe nursing teams on the wards where patients werebeing cared for.

• A system was in place to identify patients individualneeds, such as those patients at the end of life by use ofa discreet symbol on the patient detail ‘white boards’visible at the nursing station on each of the wards wevisited. Staff showed an understanding of these symbolson the wards we visited.

• Patients on the general wards who had been given apalliative diagnosis had easy access to call bells and weobserved their calls were responded to promptly. Thiswas supported by relatives that we spoke to.

Nurse staffing

• Staffing for end of life care was the responsibility of allstaff across the wards and not restricted to the specialistpalliative care (SPCT) team.

• The trust’s SPCT consisted of a lead nurse for palliativecare (0.4 WTE) and three palliative care clinical nursespecialists (3.4 WTE).

• The team responded to all referrals from cliniciansthroughout the trust for adult patients who hadcomplex support and/or complex symptommanagement needs during end of life care. Thisincluded support to families of patients referred.

• The specialist palliative care team screened andallocated all new referrals on a daily basis. Current workand new allocations were reviewed every morning bythe team and work was allocated based on patient needand urgency.

• The SPCT worked across the trust, as part of amulti-disciplinary team, which also included the rapiddischarge team, consultants, general ward nursingteams and medics.

Medical staffing

• The trust currently had one WTE consultant and 1.0 WTEfor the emergency department and AMU. This wasbelow the recommended staffing levels outlined by theAssociation for Palliative Medicine of Great Britain andIreland, and the National Council for Palliative Care

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End of life care


guidance, which states there should be a minimum ofone WTE consultant per 250 beds. This trust has 680beds, which equates to a consultant requirement inexcess of three WTE consultants.

• Weekend and out-of-hours on-call advice for generalward staff was provided by the local hospice using anadvice line, staffed by nurses with medical support..Staff could use this facility to access specialist adviceand support for symptom control or holistic advice.


• The trust had a major incident policy in place, but notall ward staff we spoke with were aware of it. Patientneeds were prioritised and staff assisted on the wards tokeep patients safe.

• In the event of a major incident, the mortuary had apolicy for staff to consult. Mortuary staff described thesearrangements.

• Staff we spoke with within both the mortuary and SPCTteams were aware of the plans and described the actionthey would take in the event of a major incident.

Are end of life care services effective?


We rated effective as requires improvement because:

• The trust performed worse than the England average infive out of seven of the organisational key performanceindicators of the National Care of the Dying Audit 2014.

• These included continuing education and training forstaff, the development of clinical provision/protocolspromoting patient privacy and access to specialistsupport.

• The specialist palliative care team [SPCT] was availableMonday to Friday, from 9am to 5pm. Out-of-hours;telephone support for general ward staff was providedby nursing staff or medical staff if required using thelocal hospice advice line. This meant that End of Lifeservices provided by the trust were not fully available topatients and their families outside of normal workinghours.

However,

• 7 out of the 10 clinical key performance indicators werehigher than the England average, in particular;medication prescribed for the five key symptoms thatmay occur during the dying phase.

• Specialist palliative/end of life care team members werecompetent and knowledgeable and there wereexamples of multidisciplinary team working.

• The specialist end of life team was valued by ward staff.The team were reported to be accessible, responsiveand effective in supporting patients with complex end oflife care needs and staff training needs.

• Patients had appropriate access to pain relief.• Staff within the specialist team were suitably qualified to

perform their roles and had the opportunity to enhancetheir skills through additional specialist training.

Evidence based care and treatment

• The specialist care (SPC) team worked in line with bestpractice and national guidelines such as NationalInstitute for Health and Clinical Excellence (NICE) qualitystandard 13 relating to end of life care for adults. Clinicalaudits included monitoring of NICE compliance andother professional guidelines.

• Staff within the SPCT were highly trained and had agood understanding of existing end of life careguidelines.

• The trust’s end of life care plan had previously beenbased on the Liverpool Care Pathway (LCP) for the dyingpatient. The SPCT was in the process of developing anew personalised care plan. The SPCT lead nurse told usthat, following the withdrawal of the Liverpool CarePathway (LCP) in 2014, an individual care andcommunication record had been introduced on allwards except critical care and AMU. However, we sawthe care and communication record in situ on only oneof the wards we visited. This incorporated the nationaldocument 'One chance to get it right' (2014), and aimedto support staff with identifying patients’ preferencesand wishes earlier in illness, in order for improvedadvance care planning to take place. We were notassured that all staff had access to the document orappropriate training in using it, however plans were inplace to formalise training going forward.

• Patients received effective support from amultidisciplinary team, which included specialistpalliative care nurses and consultants. However, data

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End of life care


received from the trust prior to inspection confirmedthat the trust had not achieved the NCDA organisationaltarget relating to patient access to specialist support forcare in the last hours or days of life.

Pain relief

• Staff were able to access clear guidance on theprescription of medications to be given ‘as required’ forsymptoms that may occur in patients during the lasthours or days of life, such as pain, anxiety, nausea,vomiting and breathlessness. Patients identified asrequiring end of life care were prescribed anticipatorymedicines. These ‘when required’ medicines wereprescribed in advance to promptly manage any changesin patients’ pain or symptoms.

• Pain was reviewed for efficacy, and changes were madeas appropriate to meet the needs of individual patients.We spoke with the relatives of two patients who told uspain relief had been provided in a timely manner.

• Staff confirmed that syringe drivers were accessible if apatient receiving end of life care required subcutaneousmedication for pain relief. We were told this service wasavailable seven days a week and during out of hoursperiods. However prior to our inspection we were madeaware of two incidents where patients had requiredsubcutaneous pain relief and there had been a delay inreceiving the medication they required. This meant thaton occasion patients at the end of their life may nothave their pain managed effectively. This was confirmedby patient’s relatives we spoke with and by incident dataprovided by the trust prior to our inspection.


• The trust participated in the National Care of the DyingAudit, which found that 26% of patients had undergonea review of their nutritional needs, which was belowthan the national average of 48%.Data received from thetrust prior to inspection confirmed that reviews ofpatients hydration requirements were below thenational average.

• Patients’ records we reviewed for those identified asbeing in the last hours or days of life showedinconsistencies in relation to whether patient’s nutritionand hydration needs had been evaluated andappropriate actions followed. These recordsdocumented subsequent discussions with relatives.

Three relatives of patients we spoke with told us thatward staff had not clearly explained what steps werebeing taken to ensure their relatives were receivingappropriate hydration.

• Nutritional assessments were completed and nursingrecords, such as nutrition and fluid charts werecompleted accurately on some of the wards we visited.However, due to the partial implemented of the trustswe saw that menus catered for cultural preferences.

Patient outcomes

• The trust performed worse than the England average infive out of seven of the organisational key performanceindicators of the National Care of the Dying Audit 2014.These included continuing education and training forstaff, the development of clinical provision/protocolspromoting patient privacy and access to specialistsupport.

• The results of the National Care of the Dying Audit(NCDA), published in May 2014, showed that 7 out of the10 clinical key performance indicators were better thanthe England average, in particular; medicationprescribed for the five key symptoms that may occurduring the dying phase. In addition, 96% of patients hadundergone a review in the last 24 hours of life, whichwas higher than the England average of 82%.

• The trust failed to achieve organisational keyperformance indicators relating to patient access tospecialist support for care in the last hours or days oflife. However, the NCDA also reported 96% of patientshad been recognised as dying and at the end of theirlives, which was higher than the England average of61%.

• Patients received care in line with national guidelines.Clinical audits included monitoring of NICE and otherprofessional guidelines were in place, we noted that of13 audits one had been completed and nine wereactive..

Competent staff

• Appraisals for staff were completed appropriately andstaff spoke positively about the process. The trustprovided appraisal data for 2015, which showed that allstaff had undergone a yearly appraisal.

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End of life care


• The SPCT confirmed they received monthly clinicalsupervision to support them in their role and they hadreceived an appraisal in the last 12 months.

• Records showed that the SPCT had regular one to onemeetings. Staff told us they received clinicalsupervision monthly with a level four psychologist, andwere meeting their mandatory training requirements.This was supported by information we had receivedfrom the trust, this assured us that staff working withinthe SPCT were competent in their roles.

Multi-disciplinary working

• Multi-disciplinary meetings were held on the wards todiscuss and co-ordinate patient care. Patients at the endof life were included in this discussion, so all staffinvolved could contribute to effective and consistentcare for these patients.

• Staff discussed patients with a palliative/end of lifeprognosis and SPC team involvement, at themultidisciplinary meeting. This helped to ensure thatinformation regarding patients at the end of their lifewas effectively shared among the different nursing/medical teams working with them.

• The SPCT lead told us that members of the team,attended SPCT multidisciplinary team meetings and thiswas monitored to ensure attendance of 66% wasachieved. This was undertaken to help identify andcoordinate care for an individual approaching the end oflife or requiring supportive care. Records confirmed thatmembers of the team regularly attendedmultidisciplinary team meetings.

• The SPCT said they supported other healthprofessionals to recognise and consider when patientsmay be approaching the need for palliative or end of lifecare.

• Records confirmed that staff met as a clinical reviewgroup weekly, during which SPCT staff had theopportunity to discuss relevant issues.

Seven-day services

• The hospital consultant and the SPCT offered a five-dayMonday-Friday 8am - 5pm service across the trust’shospital sites. Out of hours cover/support for staff, was

provided by a hospice covered by nursing staff withmedical support via telephone. This meant that End ofLife services provided by the trust were not fullyavailable to patients out of normal working hours.

• All ward staff we spoke with said the SPCT respondedpromptly to referrals, with many patients being seen thesame day or within 24 to 48 hours. However, all thegeneral ward staff we spoke with said that if a patientcame in after 5pm on a Friday or over the weekend,there was a delay of at least 48 hours in accessingspecialist end of life services.

• Diagnostic services were available to staff 24 hours aday, seven days a week.


• General ward staff we spoke with were not able to tell usabout the new guidance which supports care of thedying person and those important to them, or trainingthey had received regarding improved advance careplanning. This meant that we were not assuredthat staff were aware of where to accessinformation following the withdrawal of the LiverpoolCare Pathway. We noted that some training had beenprovided and there was plans in place goingforward, however this did not reflect what staff told us.

• Nurses and doctors on all the wards we visited told usthey felt they did not always have sufficient access toinformation in order to support clinicaldecision-making, specifically relating to patients at theend of their lives. Staff we spoke with told us this was aparticular issue out of hours and at weekends.

• We saw examples of patients being supported to movebetween services and teams, for example, from thehospital to their own home. We reviewed records, whichconfirmed information to support their care wasavailable to staff in a timely way.

Consent, Mental Capacity act and Deprivation ofLiberty Safeguards

• The trust had a consent policy in place. The policyincluded advance decisions, lasting power of attorney,mental capacity guidance and the use of IndependentMental Capacity Advocates where necessary.

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End of life care


• Staff received mandatory training in safeguardingchildren and vulnerable adults, which included aspectsof the Mental Capacity Act (MCA) 2005 and Deprivationof Liberties Safeguards (DOLS).

• Both specialist nurses and general nursing staff wereable to describe their duties and responsibilities underMCA. SPCT nurses and general ward staff were able todefine procedures to us and provided us with examplesof how these would be applied.

• Staff within the SPC team understood the legalrequirements of the MCA. Records we received from thetrust prior to our inspection confirmed high levels ofstaff training.

• In all cases we reviewed, do not attemptcardio-pulmonary resuscitation (DNA CPR) anappropriate senior clinician signed forms. Patients’views relating to resuscitation were clearly recorded intheir notes and on the form. It was clearly noted whenthe DNACPR should be reviewed once in place.

Are end of life care services caring?

Good –––


• Palliative and end of life services were delivered byhighly trained, caring and compassionate staff.

• We observed that staff treated patients with dignity andrespect and planned and delivered care in a way thattook into account the wishes of the patients.

• Staff within the specialist team were highly sensitive tothe needs of patients who were seriously ill andrecognised the impact this had on the individual patientand those close to them.

• The patients and relatives we spoke to told us they feltinvolved with care and were treated with dignity andrespect.

• Staff provided a caring service and people told us thatthey generally felt happy with the care and support boththey and their families received.

• Interactions between staff and patients demonstrated akind and compassionate approach. Staff within the

specialist team were highly sensitive to the needs ofpatients who were seriously ill and recognised theimpact this had on the individual patient and thoseclose to them.

• Patients received compassionate care and their privacyand dignity were generally maintained. A minority ofpeople felt their experience could have been better withimproved communication between medical and nursingstaff and relatives.

• Patients felt staff on the wards were, “always really busy”and that more staff were needed. Despite that, staffcame quickly when they were called and were“respectful and kind” when they were delivering care.

Compassionate care

• Patients were treated with compassion and empathy, byboth the SPCT and general ward nursing staff. Weobserved staff speaking with patients and providingcare and support in a kind, calm, friendly and patientmanner.

• Patients said the staff had been nice and kind and theyhad no complaints about care they had received. Weobserved patients and relatives were treated withcompassion.

• Ward staff told us where possible, end of life patientswere accommodated in side rooms to increase dignityand privacy for them and those visiting.

• The patients and relatives we spoke with were mostlycomplementary about staff attitude and engagement.Comments received from patients demonstrated thatstaff cared about meeting patients’ individual needs. Forexample one person, whose relative received care andsupport commented; “All the staff have been kind.”Another relative commented; “They [staff] are goodreally…. It just hard having to sit in a ward full of people.They do their best and keep the curtains pulled, but aprivate room would have made things easier.” Staff wespoke with confirmed that there were no side roomsavailable at this time, however they were doing theirbest to ensure the dignity and privacy of both thepatient and their relatives were protected.

• Porters told us staff in clinical areas and mortuary staffhandled patient’s bodies in a respectful way. This wasconfirmed by relative’s feedback via thank you cards,which we reviewed.

Endoflifecare

End of life care


• Ward staff reported to us how respectful hospital porterswere when caring for deceased patients before theywere transferred to the mortuary.

Understanding and involvement of patients andthose close to them

• We witnessed staff awareness of people’s beliefs andobserved how they changed their approach accordinglyby communicating with patients and relatives usingterminology and language that people couldunderstand.

• Patients and their relatives described how staff hadworked to establish a good rapport with patients, theirrelatives and close friends. All of the people we spokewith were highly complementary regarding the way staffhad cared for and supported them.

• Staff provided patients with information on how tocontact the SPCT. People we spoke with told us that thespecialist team were able to advise them on where toobtain additional support and information. Relativessaid they felt nursing staff involved in their loved one’streatment and explained each of the optionaltreatments available.

• On the wards, we saw examples where families wereencouraged to participate in aspects of care of theirloved one, for example, mouth care.

• A minority of people felt their experience could havebeen better with improved communication betweenmedical staff and relatives. One person commented;” Iknow it’s a job to them and that they are always sobusy….. but if the Dr doesn’t explain what’s going on,everything is just harder to cope with.”

• Patients reported that they felt staff on the wards were,“always so busy” and that more staff were needed.However all of the patients we spoke with said thatdespite being so busy, staff came quickly when theywere called and were “kind and calm” when they weredelivering care.

Emotional support

• Although specific information leaflets or booklets wereavailable on the wards we visited, people told us thatstaff had not always informed them about local servicessuch as counselling services and services providingassistance with anxiety and depression. One person

commented; “It depends who is on really, some of thestaff are lovely and really take time to see how I amdoing. Others just seem to rush about and don’t reallytell you anything. It makes it difficult to know who to askif I have any questions.”

• There was a quiet space on most wards where sensitiveconversations could be held and staff confirmed thesewere used to talk with relatives and patients. However,not all of the patients’ records we reviewed confirmedthat discussions of sensitive conversations that hadbeen held with patients and/or relatives.

• There was a bereavement office, which issued deathcertificates and provided relatives with information onsupport services available to them, and what to dofollowing a death. Prior to our inspection, we hadreceived positive feedback from families regarding thebereavement service. This feedback detailed thekindness and support people had received from thebereavement team.

• Chaplaincy services were available on request. Thechaplaincy team were able to offer spiritual support topatients of all or no faiths as they had developed closelinks with local churches and members of variouscongregations.

Are end of life care services responsive?



• We found people’s diverse needs were not fully met andthat there was not always appropriate provision of carefor patients and their families in line with their personalor religious wishes.

• Chaplaincy service a multi-faith prayer room,however during our inspection of the service, we saw anindividual of a faith other than Christian, having to prayin the middle of the open service room. As this room isadjacent to the chaplaincy office, we were not assuredthat support was fully available to everyone who mayrequire it.

• Relatives' access to deceased patients within themortuary was restricted and did not provide assurance

Endoflifecare

End of life care


that the service was run to meet the needs of peoplewho use the service and their families. This meant thatEnd of life care services were not always responsive tothe needs of the local population they served.

However,

• Patients had adequate access to the SPCT duringnormal working hours, (9am until 5pm Monday toFriday) and staff were able to identify those whoneeded the service.

• Specialist palliative care team members were visibleand staff knew how to contact them to secureappropriate advice and support for patients.

• The trust had a new draft strategic plan that aimed toimprove and connect services to prevent patientshaving their care compromised with admissions andreadmissions to hospital.

• The SPCT had a flexible referral process. Ward staff toldus the SPC team responded promptly to referrals,usually within 24 to 48 hours.


• SPCT staff had a good understanding of the needs of thelocal population. Staff worked as part ofmultidisciplinary teams and routinely engaged withlocal hospices, the trust discharge team, adult socialcare providers and other professionals involved in thecare of patients.

• The SPCT had established links with communitypalliative care services and the community services,such as district nurses.Staff said this promoted sharedlearning and expertise and enabled complex patientswho switched between services to have consistent care.

• General nursing staff on the wards told us they wereconfident patients could access end of life care serviceswhen needed, during normal working hours. The SPCTroutinely engaged with nursing staff, local hospices andadult social care providers so patients could be referredpromptly and to provide advice, where necessary.

• There was open access for relatives to visit patients whowere at the end of life.


• The chaplaincy service responded to the spiritual needsof end of life patients and their families. This included

providing last rites services. However, we noted thatwhilst the chaplaincy service had access to a multi-faithroom, during our inspection of the service, we saw anindividual of a faith other than Christian, having to prayin the middle of the open service room. As this room is awalk through to the chaplaincy office, we were notassured that support was fully available to everyonewho may require it.

• Mortuary services did not fully meet the needs offamilies of those who had died. For example, we notedthat families could only view their deceased relativeduring specific viewing times laid out by the mortuary.In discussion with the mortuary manager, we were toldthat this was due to Post Mortem’s [PM’s] beingundertaken during the mornings. However we notedthat the visiting times remained the same on those dayswhen there were no PM’s being undertaken. This did notassure us that mortuary services were meeting people’sindividual needs.

• Staff within the SPCT were responsive to patients’ needsand provided an appropriate level of care and support,based on prognosis, and the individual complex needsof each patient. Staff communicated on a daily basiswith ward nurses and we observed staff regularlychecking patients’ electronic records.

• Patients’ needs were assessed and care and treatmentwas planned and delivered in line with their individualcare plan. We saw that risk assessments werecompleted by staff and updated as the patient’scondition changed.

• We saw records, which confirmed that where a patientwas identified as having issues relating to learningdisabilities, dementia or cognitive impairment staffcould contact specialist nurses within the trust foradvice and support.

• The SPCT were part of a multi-disciplinary teamresponsible for arrangements for rapid discharge toensure patients at end of life died at their preferredplace.

• Patients who used the service were asked about theirspiritual, ethnic and cultural needs as well as theirmedical and nursing needs. General ward staff took theneeds and wishes of the patients into account whencaring for them.

Endoflifecare

End of life care


• There was a policy in place for the rapid release of adeceased patient from the mortuary. Medical andmortuary staff demonstrated an understanding of theprocesses to follow. This enabled the cultural wishes offamilies to be respected.

• There was printed information available for patients andtheir relatives, including leaflets on what they needed todo after their relative died, as well as the emotionalsupport available. However, we noted that all of thisinformation was only readily available in English.

• Staff could access an interpreter for patients whose firstlanguage was not English if needed.

Access and flow

• There was a clear standard set for referring patients tothe specialist palliative care team (SPCT). End of life carewas delivered when required by ward staff throughoutthe hospital. The SPCT was accessible during normalworking hours each day. Outside of those hours, advicewas available to staff via telephone.

• Referrals to the SPCT were made by ward staff using thetrusts information technology system or by telephone.The team met daily Monday to Friday to review currentwork and allocate new referrals, which were prioritisedand allocated based on urgency and need.

• The trust had a rapid discharge service for discharge to apreferred place of care (PPC). Following on from NICEguidance, the National End of Life Strategy (2008) wasclear that people at the end of life should be able tomake choices about their place of death. The rapiddischarge pathway was to support patients to bedischarged from hospital in the last hours and days oflife.

• Ward staff said that on occasion, delayed discharges ofdays or weeks impacted on end of life patients. Staffsaid this was due to the time taken by the localauthority to arrange the appropriate care packages forpatients. During this inspection, there were no patientsthat were delayed in being discharged from the trust.

• Doctors and nurses told us they had access todiagnostics and test results promptly. This wasconfirmed by records we reviewed.


• Complaints were handled in line with the trust policy.Records we reviewed confirmed that all complaintsshould be recorded on a centralised trust-wide system.The clinical leads would then investigate formalcomplaints relating to specific teams.

• Data received from the trust prior to our inspection,confirmed that complaints and concerns raised over the12 months prior to our inspection had been handled inline with trust policy. We also noted that outcomes frominvestigations were shared among staff across the trustin order to aid further learning. This assured us that thetrust had an overview of complaints and the actionsthat arouse following receipt of a complaint or aconcern.

Are end of life care services well-led?


We rated well-led as requires improvement because:

• None of the general ward staff we spoke with could tellus about the trusts vision for palliative care or end of lifeservices.

• Robust processes had not been fully implemented, toensure staff were trained, supported and appraised inrelation to End of Life Care.

• There was a new care and communication document,developed by an integrated group includingrepresentation from the local hospice and thecommunity palliative care team. However, we foundthat this had not, as yet, been communicated to andembedded within, all general ward teams.

• Ward and ancillary staff had limited awareness aboutthe trusts audit strategies in relation to End of Life care.

However,

• Records we reviewed confirmed that actions were beingtaken by the trust in response to incidents.

• The Specialist Palliative Care Team[ SPCT] were awareof issues relating to their specialties and had developedappropriate strategies to ensure incidents wererecorded and fed into the wider trust.

Endoflifecare

End of life care


• We saw evidence that the individual teams working withpatients and their families, were raising incidents usingthe trust internal system.

• The Specialist Palliative Care Team[ SPCT] were awareof issues relating to their specialties and had developedappropriate strategies to ensure incidents wererecorded and fed into the wider trust.


• We spoke with 26 members of staff as part of thisinspection. Whilst senior managers and members of theSPCT were clear on the trusts vision for palliative care/end of life services, none of the general ward staff wespoke with could tell us about the trusts vision forpalliative care or end of life services (a framework forcare and support for patients and staff). Nor could anyof the general ward staff we spoke with, give usexamples of how the existing service strategy was beingused to deliver trust services.

• General ward staff had limited awareness about thetrusts audit strategies in relation to End of Life care. Forexample, no one within bereavement services or generalwards was able to tell us about the audit schedule ofkey processes, or if one was in place.


• We saw evidence of an effective, overarchingperformance quality system for specialist palliative orend of life care. Records we reviewed confirmed that thevarious aspects of the service were monitoring their ownperformance with monthly updates which consisted ofreviewing patient feedback, waiting times from referralto first appointment, patients care files, and access todeath certification.

• We saw evidence that the individual teams were raisingincidents/concerns, using the trust internal system. Thiswas supported by data provided to us prior toinspection, which evidenced the actions being taken bythe trust in response to incidents being highlighted bythe staff. This meant that there effectivecommunications in place to support governance, riskmanagement and the quality of the End of Life servicesoverall.

• Information received from the trust prior to inspectionconfirmed that a trust board member had beenidentified in line with national best practice.

• During our inspection we were told that audit results fordo not attempt cardio-pulmonary resuscitation (DNACPR) forms are discussed at the resuscitationcommittee. This was supported by the records wereviewed which confirmed action plans and sharedlearning had been undertaken because of these audits.

Leadership of this service

• The SPCT demonstrated effective local leadership andthe leader understood the challenges to provide goodquality palliative and End of Life care services across thetrust.

• The specialist palliative care (SPCT) nurses weredescribed by colleagues as knowledgeable, supportiveand passionate about end of life practice. Several staffmembers of the team said the team was brilliant to workin because of team’s good communication andexcellent peer support.

• Staff throughout the trust told us that the SPCT teamwere visible, approachable and accessible. Ward staffwe spoke with valued the expertise and responsivenessof the SPCT and said patient outcomes and clinicalpractice improved because of the support theyprovided.

Culture within this service

• Staff reported that working with the SPCT was agenerally a positive experience. Staff we spoke with toldus that their major source of support when caring forpatients at the end of their life was the other ward teammembers and the team manager. In discussion with us,ward staff said that they felt the specialist team was asource of support for patients. However, none of thegeneral nursing staff we spoke with could give usexamples of being supported by the SPCT.

• Staff we spoke with across the trust were positive aboutthe bereavement service as a whole. Staff said they feltthat both the chaplaincy and the bereavement officewere responsive and supportive to both patients andtheir families.

Endoflifecare

End of life care


• Staff within the SPCT were highly motivated and positiveabout their work. Staff told us they received constantpositive support and guidance from their immediateline manager.

Public engagement

• The bereavement officer gave out information leaflets tofamilies when they came in to pick up death certificates.

• On some of the wards we visited, we saw information forrelatives, relating to financial advice and support/bereavement counselling services and details relating toaccessing occupational therapy and social worksupport. However, this information was not availableacross all wards were patients receiving palliative or endof life care.

• Surveys were used to evaluate users of the serviceexperience.

Staff engagement

• We found that the annual appraisal system worked welland that staff were up to date or had received dates fortheir appraisals. Staff reported that this was useful andgave an opportunity to address any problems.

• Staff had an annual appraisal, which they told usworked well, and as a small team, they had theopportunity to raise and discuss any problems witheach other.

Endoflifecare

End of life care


Safe Good –––






Information about the serviceOutpatient and diagnostic services are provided mainly atthe Countess of Chester Hospital (COCH) but also there is asmall unit at Ellesmere Port Community Hospital. Therewere 444,045 outpatient attendances between July 2014and June 2015.

The Outpatient Department clinics includes OPD1, OPD2,OPD3, OPD4, breast, ear, nose and throat (ENT) &audiology, eye clinic, paediatrics, gynaecology, antenatalclinic and maternity ultrasound. The main outpatientclinics include all medical and surgical specialities such ascardiology, rheumatology, vascular, urology, generalsurgery, orthopaedics and orthodontics. The clinics aresituated in different locations in the hospital accessed viathe main entrance and corridor.

The radiology department is located near the accident andemergency department and includes the main x-ray andscanning facilities such as computerised tomography (CT),magnetic resonance imaging (MRI) and interventionalradiology services (IR).

We spoke to about 70 staff members of all grades andabout 20 patients. We observed care and viewed records of18 patients. We also held an event at the Countess ofChester hospital where patients and relatives shared theirexperiences as well as receiving comments via our website.

Summary of findingsOverall we found the outpatient and diagnostic serviceas good because:

• There was strong reporting culture with staffreporting incidents via the trusts electronic system.There was some learning from incidents, althoughsimilar incidents continued to be reported inradiology areas.

• Systems were in place for the maintenance ofequipment. Processes were in place for dailychecking of resuscitation equipment.

• Any prescribed medications were stored in lockedcupboards and there was no controlled drugs orintravenous fluids stored in outpatients at COCH.Patients’ records were maintained on paper and viaelectronic systems, although; plans for changes inelectronic systems were in place.

• Staff had received mandatory training, althoughsome groups were not up-to-date with safeguardingrequirements. There was some staff shortagesidentified, although recruitment processes were inprogress.

• There was a caring culture embedded in all areasvisited and from all members of staff we met. Weobserved good, compassionate care being delivered.

• Reception staff were polite and helpful. Patients andtheir relatives were very positive about the staff inoutpatients and radiology. They said they weresupportive and communicated well. We observedrespectful interactions between staff and patients.


Outpatients and diagnostic imaging


• Staff actively involved those close to patients withinitiatives in place to support relatives of patientswho attended regularly.

• There was specialist staff in clinics with goodmultidisciplinary working, although not all had beenappraised annually.

• Services were available seven days a week.• Consent for procedures was obtained although by

different clinicians.• There were audit plans in place and good use of the

WHO safety checklist, for radiological interventions,was observed.

• The outpatient and diagnostic services wereavailable at both Countess of Chester Hospital(COCH) and Ellesmere Port Hospital (EPH). The mainactivity was at COCH with a small department at EPHfor routine care of patients in the local area.

• Targets of referral to treatment targets were withinnational guidelines, however; there was a widevariation in waiting times for individual consultants.Extra clinics were arranged, out of hours and atweekends to manage the demands of the localpopulation.

• There was support for patients with individual needsincluding visually impaired, hearing impaired,learning disability or dementia.

• There was evidence of learning from complaints andhow changes had been implemented.

• There was a clear vision and strategy for the future.• The management teams were stable and committed

to patient well-being in both out patients anddiagnostics despite challenges.

• There were governance processes embedded withaction plans in progress to improve services. Waitinglist initiatives took place to meet demands of thelocal population.

• There were regular meetings, at all levels. Staff feltsupported by their line managers and there wasgood team working in the departments.

• There were several innovations taking place withplans to increase services.

• Radiology trust guidelines and standard operatingprocedures were in place although not always clearand robust. There had been recent reviews ofprocedures.

• There were delays in reporting in radiology, whichmeant there could be delays in treatment. The trusthad responded to increased demand by outsourcingx-ray reporting.

However,

• There was dust found on some medical equipment.

• In the nuclear medicine department of radiology, weobserved that a prescribed medication was notalways signed as administered.

• There were delays in reporting in radiology, whichmeant there could be delays in treatment. The trusthad responded to increased demand by outsourcingx-ray reporting.




Are outpatient and diagnostic imagingservices safe?

Good –––

We rated as good because:

• There was strong reporting culture with staff reportingincidents via the trusts electronic system. There wasevidence of learning from incidents, although similarincidents continued to be reported in radiology areas.

• Any prescribed medications were stored in lockedcupboards and there was no controlled drugs orintravenous fluids stored in outpatients at COCH.

• Processes were in place for daily checking ofresuscitation equipment. In the nuclear medicinedepartment of radiology we observed that a prescribedmedication was not always signed as administered.

• Systems were in place for the maintenance ofequipment.

• Patients’ records were maintained on paper ad viaelectronic systems, although; plans for changes inelectronic systems were in place.

• Staff had received mandatory training, although somegroups were not up-to-date with safeguardingrequirements.

However,

• There was some dust found on medical equipment thatwas addressed on inspection.

• There was some staff shortages identified, althoughrecruitment processes were in progress.

Incidents

• Incidents were reported by the trusts electronicreporting system.

• The trust had a higher than average reporting cultureand staff were confident and competent in reportingincidents. Staff could request feedback from incidents ifrequired.

• There were no never events reported betweenNovember 2014 and October 2015. Never events arevery serious, largely preventable safety incidents thatshould not occur if the available preventative measuresare in place.

• Between 1st December 2014 and 30th November 2015,there were 379 incidents mostly reported as no harm.

• From November 2015 to February 2016, there were 75 IR(ME) R incidents; most were reported as no harm. (Theionising radiation (medical exposure) regulations (IR(MER) R) 2000 is legislation intended to protect a patientfrom the hazards associated with ionising radiation).These included 13 delays in x-ray film being reported, 27incorrect referrals, and four misidentification of patientand nine wrong body part requested.

• From January 2015 to February 2016, there were 11 IR(MER) R notifications submitted. These were noted asminor incidents with normal to low reporting numbers.

• The radiology department had appointed a patientsafety lead in 2015 to monitor incidents and act uponfindings.

• Between May 2015 and December 2015, there were fourunexpected deaths in the radiology department, whichwere investigated as part of a thematic review.

• The thematic review by the quality, safety and patientexperience committee (QSPEC), in February 2016,reviewed radiology incidents that had increased from201 in 2013 to 404 in 2015. This review identified unclearprocesses regarding patient transfer and recommendedthat all patients being transferred back to their ward /area should be escorted to CT / MRI.

• The lone worker policy highlighted the trust’sresponsibilities in supporting lone working staff in thedepartment.

• Examples of lessons learned were provided including inoutpatients where incorrect labelling, on a patient’srecords was identified prior to any treatment beingprovided.

• In radiology, there was sharing of lessons learned thatincluded an ‘away day’ in July 2015 where real scenarioswere discussed as well as in staff meetings.

• The trust provided an example of when internalguidelines were not followed. This was reported as aserious incident, which was investigated appropriatelywith completed action plans.




• Serious incidents trust wide were discussed indepartmental meetings. Human factor training wasintroduced as part of mandatory training requirements.This included how and why errors are made and howthey can be avoided.

• The interventional radiology - IR task and finish group, inDecember 2015, reported that incidents weredecreasing although there was an emerging concernregarding availability of anaesthetic sessions.

• Radiology introduced ‘PAUSED’ cards and posters(patient, anatomy, user checks, system/settings,exposure, and draw to a close) as an additional checkprior to a procedure to protect patients.

• Staff were aware of their responsibilities to be open andtransparent with patients, however; not all understoodthe term Duty of Candour (the regulation introduced forall NHS bodies in November 2014, meaning they shouldact in an open and transparent way in relation to careand treatment provided). The term was included inmandatory training.


• The outpatient clinic areas looked visibly clean, atCOCH, although there was dust seen on someequipment, for example, tops of resuscitation trolleys,behind x-ray machines, underneath bed trolleys and ontop of cupboards. Cleanliness in CT was highlighted inthe February 2016 staff team meeting.

• There were laminated cleaning schedules in the outpatents department which staff followed.

• We observed that staff followed good practice inrelation to the control and prevention of infection. Staffwere ‘bare below the elbow’ in clinical areas as per thetrust policy on infection control. There were wall -mounted hand gel dispensers visible in all areas.

• Internal audits of hand hygiene scores between May2015 and October 2015 showed a red rating of 83% inMay, 97% (amber) in October 100% (green) in June.Results were not available July, August & September.

• Infection control training, included in mandatorytraining, had been completed by 89% of staff, which wasbelow the trust target of 95%.


• There were four main outpatient areas and othersmaller clinics throughout the Countess of Chesterhospital (COCH) as well as the diagnostic radiologydepartment. The outpatient areas, at COCH includeopen reception close to the seating for waiting patients.Outpatient areas at COCH were accessible for peoplewith additional needs.

• Maintenance contracts were in place to ensure thatspecialist equipment in the outpatient and diagnosticareas were serviced and maintained as needed.

• The system for checking resuscitation trolleys hadrecently changed for adult trolleys. Adult trolleys, at theCountess of Chester hospital, were secured with aplastic tag and had been checked weekly and recordedappropriately. The paediatric resuscitation trolley inOPD 1 did not include a secure tag and along with thedefibrillator was checked daily; however, previousrecords had not been stored.

• Fridge temperatures were checked daily and recordedappropriately.

• Oxygen cylinders were stored in purpose built holders,at COCH, however; dusty.

• In the respiratory clinic, there was a spirometry machine(equipment used to diagnose lung conditions) in use.There was an updated machine, however; staff had notyet received training to operate this.

• At COCH, the ophthalmology and pre – op assessmentareas included display boards to monitor thecompletion of daily tasks.

• A patient led assessment of the care environment(PLACE) audit took place in OPD1 in November 2015with all areas passing. In a PLACE assessment atEllesmere Port, in August 2015, radiology was describedas having ‘décor very tired’. Staff told us that there wereplans in place to update one of the two radiologyrooms. As a trust, the PLACE score, for condition was89%. Other trusts, in England, scored between 80% and100%.

Medicines

• There were processes in place for managing and storageof medication in the outpatient and diagnosticdepartments.




• Any prescribed medications were stored appropriatelyin locked cupboards and there was no controlled drugsor intravenous fluids stored in outpatients at COCH.

• In the nuclear medicine department of radiology, weobserved that nine out of eleven patient records ofprescribed medication, of adenosine, (a drug used forheart conditions) were not signed and completed whichmeant it was not evident if patients had received it.

• Medicines management was included in mandatorytraining that was 89% across all staff groups; below thetrust target of 95%.

Records

• Patient records were made up of a combination ofpaper records and electronic records. Paper recordswere colour coded to identify if there was an additionalelectronic version.

• Patient’s records were stored centrally and transferredto outpatient areas prior to clinics starting. These werestored with the reception staff until required.

• Any notes not available were identified on a checklist.Reception staff then located any missing records. Ifneeded a copy of the GP referral or electronic recordsfrom the clinician or test results could be obtained.

Safeguarding

• Staff were aware of their roles and responsibilities insafeguarding and knew how to raise matters of concernappropriately.

• Outpatient and diagnostic areas were open with easyaccess including patients and visitors from the accidentand emergency department. Radiology staff expressedconcerns about security, however; other departmentspreferred an open system. A swipe card system wasrecently introduced on the interventional radiologycorridor to reduce inappropriate access.

• Any patient at risk or vulnerable was identified in theirmedical records, which alerted staff. Staff we spoke towere aware of where this information was held.

• Staff attended safeguarding training that showed that79% of outpatients and diagnostic staff had receivedsafeguarding adult’s level two and safeguardingchildren’s level two. The trust target was 80%.

• For staff employed in additional clinical services, 100%had received safeguarding level three training for bothadults and children. There was 50% of medical anddental staff that had received level three training.

Mandatory training

• Mandatory training was delivered using face-to-facetraining and e learning.

• Staff received training in areas that included infectionprevention, medicine management, informationgovernance, fire training, clinical risk and patient safety,transfusion, manual handling and resuscitation.

• There was 100% of medical & dental staff and alliedhealth professionals that had received mandatorytraining, 95% of healthcare scientists and 94% fornursing staff. The trust target was 95%.


• We observed reception staff confirming the identity ofpatients on arrival to the departments.

• Staff received training in resuscitation as a requirementof mandatory training. Resuscitation trolleys were easilyaccessible at COCH.

• If a patient presented as a concern, in OPD, observationsof vital signs would be taken. Consultant doctors wereavailable in the department if needed.

• The lead nurse carried a bleep and was contactable foremergencies.An example of this being implemented wasthat a patient had left the department but collapsed inthe corridor. There were processes in place to managethe situation and transfer the patient safely to theaccident and emergency department close by.

• In radiology, the World Health Organisation (WHO)safety checklist for radiological interventions was inplace. (This is adapted from the National Patient SafetyAgency (NPSA) surgical checklist to detect any potentialerror before it leads to harm).

Nursing & Radiology staffing

• Nursing staff in the departments worked effectivelyacross both sites to meet the demands of the service.The outpatient’s department’s staff included registerednurses and dental nurses, advanced practitioners andhealth care assistants.




• The lack of specialist nurses, out of hours, in radiologywas highlighted on the risk register.

• There was a vacancy rate in OPD and diagnostics of 13%although recruitment processes were in process. Therewas a sickness rate of around 3%.

• There was 120 staff employed for diagnostics. Thisincluded radiographers and support staff. Fifty of theradiographers were band six qualified.

• Any shortfalls were filled with bank or locum staff.

• There were five radiographers that worked in thedepartment each weekday evening until 8pm, threeradiographers until midnight and two to cover until theearly morning shifts.

• A radiographic support worker was available until8.30pm to assist with escort duties for the wards andaccident and emergency department. In addition, theclinical site supervisors were available to cover wardareas if a ward member was needed for escorting apatient. The radiology department accepted patientsfrom the wards until 10pm.

Medical staffing

• Medical staffing was provided to the outpatientdepartment by various specialties that ran a range ofclinics. Medical staff undertaking clinics were of allgrades; there were usually consultants on duty tosupport lower grade doctors.

• There was a turnover rate of 12% and a sickness rate of0.54% for the last financial year.

• There was an appropriate mix of general radiologistsand interventional radiologists. The Trust has 4interventional radiologists which was appropriate forthe service.

• Diagnostic imaging reporting was regularly outsourcedto meet reporting time targets. There was a service levelagreement and contract written for this and radiologistsundertook quality checks in line with departmentalpolicies.


• There were trust wide major incident and businesscontinuity plans in place.

Are outpatient and diagnostic imagingservices effective?

Good –––

We inspected but did not rate effective. Our findings were:

• Radiology trust guidelines and standard operatingprocedures were in place although not always clear androbust. There had been recent reviews of procedures.

• There was specialist staff in clinics with goodmultidisciplinary working, although not all had beenappraised annually.

• Services were available seven days a week at theCountess of Chester hospital, whereas Ellesmere Porthospital offered a week day service.

• Consent for procedures was obtained although bydifferent clinicians.

• There were audit plans in place and good use of theWHO safety checklist, for radiological interventions, wasobserved.


• Care and treatment was evidence-based and providedin line with best practice guidance.

• Standard operating procedures (SOP’s) were in place tosupport staff and there was a process in place to reviewand update these based on latest national guidance.

• The feedback from the radiation protection advisor wasthat IR (ME) R guidelines were being followed well;however, we observed that trust guidelines weredifficult for staff to locate on the trust intranet system.

• Trust guidelines were not always clear, for example theadministration protocol for Buscopan (medication usesto treat abdominal discomfort) in magnetic resonanceimaging (MRI) administration was not complete whenviewed on the trusts intranet.

• We observed good practice in radiology that included apre assessment pathway was in place for interventionalradiology patients.

• The radiology department was part of the trustsimprovement projects that has included training newclerical staff, a new GP referral system and thecommunication of urgent reports to G.P.s




• Evidence of good practice was observed with the WorldHealth Organisation (WHO), safety checklist forradiological interventions.


• There were water dispensers available in all waitingareas.

• Staff were able to provide food, for patients, if needed inthe OPD area at COCH.

Pain relief

• Staff could access appropriate pain relief for patientswithin clinics and diagnostic imaging settings forexample, medication was available as part of the painmanagement clinic.

• There were processes in place to assess patient’s painlevels and act appropriately

Patient outcomes

• The service had key performance indicators foroutpatients and radiology in line with nationalstandards and targets.

• Radiology was working towards Imaging ServicesAccreditation Scheme (ISAS) licenced by the RoyalCollege of Radiologists.

• Radiology was also accredited with another trust withdual reporting by radiographers and cardiology teams.

• There were local audit programmes for radiology andanticoagulation in place. There were monitoringarrangements in place to review findings of clinicalaudits and monitor progress.

• In a review of IRMER related incidents, (reportcompleted February 2015), 73% of IRMER relatedincidents were due to misidentification, 93% of IRMERnear miss incidents were referrer errors. This report doesnot support findings within national CQC IRMER relatedincidents which show 38% were referrer errors, 20%were wrong site/side, 81% were near miss i.e. picked upwithin radiology before radiation dose given and 7% ofIRMER related incidents were due to radiology error.

• Audits of the WHO interventional radiology safetychecklist showed partial compliance of 93% for the

period of July to September 2015 and 95% October 2015to December 2015 The areas identified as requiring themost work were identified as the “sign in” and “sign out”process.

Competent staff

• Staff were supported in their development using theappraisal process, which was undertaken annually. Thetrust target was 95%. The average for all groups was79% in outpatients and diagnostics, although medical &dental staff were 96%, and nursing and midwiferyregistered were 91%. Staff also attended group andindividual supervision sessions.

• All staff held the required professional registration andreceived notice when it was due to expire.

• There were specialist nurse practitioners andradiologists in the departments.

• In the outpatient department specialist includeddieticians, physiotherapists as well as specialist nursesin all specialities. Support workers were trained tocannulate patients and were assessed usingobservation competency assessment. This meanttrained nurses were able to perform other duties.

• Patient group directives (PGD’s) were in place fornursing staff in the ophthalmology clinic and staff hadbeen assessed as competent to prescribe medicationsusing PGD’s.

• In the cardio, respiratory and vascular (CRV) departmenteight staff were registered with the Registration Councilfor Clinical Physiologists (RCCP) and five staff wereaccredited with the British Society of Echocardiography(BSE). There was also a vascular clinic scientist who wasa member of the Society of Vascular Technicians (SVT);three staff had undertaken the post graduate certificatein vascular ultrasound. One member of staff had passedthe International Board of Heart Rhythm Examination(IBHRE).

• There were approximately 55 members of staff that hadreceived training in IR (ME) R Regulations 2000 during2015.


• There were systems in place for working withneighbouring trusts, in radiology, as a central ‘hub’ atthis trust.




• The respiratory team supported wards with a ‘buddy’system, internally and liaised with neighbouring trusts.

• There were specialist staff that supported outpatientsand diagnostics such as physiotherapists, occupationaltherapists, dieticians, speech and language therapists.

• Doctors, nurses, allied health professionals and clericalstaff worked well together.

• The lead radiologist led multi-disciplinary teams andthe consultant met twice a week for peer review. Therewas also a team briefing board in interventionalradiology.

• We were told there was good working with the strokeservice to enable patients to receive CT scans, whichwere performed within an hour of request.

• The reporting radiographers were supported byconsultant and registrar radiologists when needed.

Seven-day services

• At the Countess of Chester hospital, clinics were openweekdays 8am to 8pm and radiology services wereroutinely open until 8.30pm. There were also outpatientclinics at weekends from 8.30am until 5pm dependenton the needs of the population. The radiographydepartment was open 24 hours a day. Overnight thedepartment was opened for emergencies referred fromaccident and emergency as well as ward areas.

• There were two computerised tomography (CT)scanners. (a scan that uses X-rays and a computer tocreate detailed images of the inside of the body). The CTscanning service has a 24/7 on-call service, seven days aweek. At weekends between 10am and 2pm CT runs aroutine in-patient service. The CT scanning service has a24/7 on-call service, seven days a week. At weekendsbetween 10am and 2pm CT ran a routine in-patientservice.

• There were two Magnetic Resonance Imaging (MRI)scanners. The MRI was open for 12 hour days Monday toFriday and 7 hours on Saturday and Sunday foroutpatients, and between 11am and 2pm forin-patients.

• After 5pm, on weekdays, one of each of the scannerswere utilised for elective patients that included waitinglist initiative and the other for emergencies.


• Staff accessed information from the trusts electronicsystems and paper records that were readily available.

• The radiology department used picture archivecommunication system (PACS) to store and shareimages, although systems were not integrated. A newelectronic system was due to be implemented whichincluding speech recognition technology. This systemwas being implemented to support quicker reporting inorder to meet the Royal College of Radiologistguidelines.

• Policies and procedures were available on the trustsintranet where the most current versions were stored.

• Staff received information, via the intranet in a weeklynewsletter.


• Consent for interventional radiology (IR) was obtained indifferent ways including by the referring clinician prior tothe IR appointment or on the day of the procedure. Inaddition, radiologists obtained consent to treatment onthe day of a procedure or IR radiographers were trainedand designated to obtain patient consent.

• The trust target for training in mental capacity was 80%.Only 40% of outpatients and imaging staff had receivedtraining. This included nursing & midwifery registeredstaff, medical & dental staff, allied health professionalsand healthcare scientists.

• Obtaining informed consent of patients was highlightedon the risk register following audits carried out involving29 senior doctors. The results were between 54% and67% documentation accuracy for January 2015 to March2015. The report in October 2015 includedrecommendations and an action plan that included areview of the policy and consent forms.

Are outpatient and diagnostic imagingservices caring?

Good –––





• There was a caring culture embedded in all areas visitedand from all members of staff we met.

• We observed good, compassionate care beingdelivered.

• Reception staff were polite and helpful. Patients andtheir relatives were very positive about the staff inoutpatients and radiology.

• They said they were supportive and communicated well.We observed respectful interactions between staff andpatients.

• Staff actively involved those close to patients withinitiatives in place to support relatives of patients whoattended regularly.

Compassionate care

• We observed that the privacy and dignity of patientswas maintained during consultations. They took placein individual closed rooms in both outpatients anddiagnostics.

• We observed staff being compassionate towardspatients. Patients waiting, for planned out of hourscomputerised tomography (CT) scans said they hadreceived good verbal explanation of the test, at thehospital although no written explanatory leafletreceived at home prior to the investigation.

• Patients were very positive about the care they receivedfrom all staff in the CT department and said that staffwere helpful and supportive.

• A patient satisfaction survey was completed in October2015, in outpatients and diagnostics. The resultsshowed that 96.2% of patients were “satisfied with theservice that was provided”. When asked, “was thereanything you particularly liked?” 81.65% said the staffdescribed as friendly, reassuring, polite, respectful,professional, courteous, cheerful, helpful, considerateand charming.

• The NHS friends and family test (FFT) (a survey, whichasks patients whether they would recommend the NHSservice they have received to friends, and family whoneed similar care) showed a response rate of 30% (5546responses) in January 2016 in OPD. There were 91.3% ofpatients who said they were “Likely to recommend”. Achange in the provider has included a text messagingservice had resulted in an improved response rate.

• A swipe card system had been installed on theinterventional radiology corridor. This meant that therecovering patients were given more privacy.

• The layout of the reception desks and waiting areasmeant that there was no space for a privacy line andconversations could easily be overheard. Reception staffwere polite and friendly and if patients preferred not toconfirm details verbally, they could be written down, toprotect confidential information.


• There were very visible ‘meet and greet’ and volunteerstaff directing to all areas as well as other staff, clinicaland non – clinical actively directing patients and thoseattending with them.

• There were many family groups in all areas inspected.These could accompany patients if required.

• Patient identified with complex needs were able to waitin a quiet room if preferred with the aim to be seen asquickly as possible.

• There was a call system that kept people updated ofwait times as well as calling patients. Nurses alsocollected patients personally.

• A ‘carers’ strategy’ was in place that supported familiesincluding access to drinks whilst waiting as well as a‘bleep’ system which enabled patients to

Emotional support

• There were a number of leaflets available that could bemodified for people to understand, such as in alanguage, other than English or large print.

• There was a learning disabilities champion to supportpatients.

• There were a number of clinical nurse specialists andtherapists in a variety of clinic areas to supportindividual patient need such as the respiratory team,breast clinic and orthopaedics.

• There were rooms available where staff could speak topatients and families in private.

• There was a spiritual care centre, at the Countess ofChester Hospital and a chapel at Ellesmere PortHospital.




Are outpatient and diagnostic imagingservices responsive?

Good –––


• Radiologists work with other neighbouring trusts as partof an acute hub of hospitals. At the Countess of Chesterhospital, outpatient clinics and the radiologydepartment were routinely open in the evenings, onweekdays and at the weekend in response to patientneed.

• National targets of referral to treatment times werewithin national guidelines, however; there was a widevariation in waiting times for individual consultants.

• Waiting list initiatives took place to meet demands ofthe local population.

• In January 2016, the trust achieved the referral totreatment (RTT) targets, of 95%, in all areas andspecialities with the exception of ear, nose and throat at94%.

• All three cancer wait measures (patients seen within twoweeks, 31 day wait and 62 day wait) were generallybetter than the England average from 2013/14 to 2015/16, although October and November 2015 were belowthe target of 85% for 62-day wait at 77% and 79.8% forthe planned care division.

• There was support for patients with individual needsincluding visually impaired, hearing impaired, learningdisability or dementia.

• There was evidence of learning from complaints andhow changes had been implemented.

However,

• There were delays in reporting in radiology due toincreasing demand, which meant there may be delays intreatment, however: the trust had responded to this andwere outsourcing X-ray reporting to support this.Reporting had been identified, on the risk register, ashigh priority. The trust target to be signed in 14 days was90%.

• There was no data available for waiting times in theoutpatient department or if a clinic starts late.


• The main out – patient and diagnostics services wereprovided at the Countess of Chester Hospital andpeoples needs were considered in service planning anddelivery.

• Radiologists work with other neighbouring trusts as partof an acute hub of hospitals. At the Countess of Chesterhospital, outpatient clinics and the radiologydepartment were routinely open in the evenings, onweekdays and at the weekend in response to patientneed.

Access and flow

• There were 444,045 attendances between July 2014 andJune 2015.

• Clinics and diagnostic imaging appointments wereplanned in order to meet national referral to treatmenttargets.

• In January 2016, the trust achieved the referral totreatment (RTT) targets, of 95%, in all areas andspecialities with the exception of ear, nose and throat at94%.

• All three cancer wait measures (patients seen within twoweeks, 31 day wait and 62 day wait) were generallybetter than the England average from 2013/14 to 2015/16, although October and November 2015 were belowthe target of 85% for 62-day wait at 77% and 79.8% forthe planned care division.

• The trust target for outpatient letters sent within 14 dayswas 50%. Between January 2015 and January 2016,7.6% to 30.9% of rheumatology letters were sent.Targets were achieved in cardiology, clinicalhaematology, endocrinology, gastroenterology andgeneral medicine.

• The trust target for did not attend (DNA) for a newappointment was 5%. There were consistently higherpercentages, monthly, between January 2015 andJanuary 2016. The trust sent out text reminders prior toappointments.

• The trust target for echocardiography (under six weeks)was 95%. Between January 2015 and January 2016, thetrust achieved this target in January and February 2015.(The lowest was 61% in August 2015).




• There were 9% of appointments cancelled by patients,(July 2014 to June 2015), compared to an Englandaverage of 6%.

• Similarly there were 9% of appointments cancelled bythe trust (July 2014 to June 2015), compared to anEngland average of 7%.

• Between December 2015 and February 2016 the mainreasons for cancellations of procedures was by thepatient on the day of the examination including 48 forCT scans, 52 for MRI and 89 for ultrasound scans.

• For radiology, the trust target to be seen within threeweeks was 90%. Between January 2015 and October2015, for appointments for computerised tomography(CT), magnetic resonance imaging (MRI) andnon-obstetric ultrasound, this target was achieved oncein January 2015 for CT. The national target for 100% tobe seen within six weeks was nearly achieved for eacharea: three times for CT (98% - 99% otherwise), twice forMRI (99% otherwise) and six times for ultrasound (99%otherwise) for the same time period. There were out ofhours scanning clinics arranged in the evenings.

• Reporting was on the risk register, as high priority. Thetrust target to be signed in 14 days was 90%. For CT scanJanuary 2015 to January 2016) this target was notachieved, except for January 2015 and May 2015, andranged between 54% and 78% in other months. For MRI,same time period, the reporting rates were between50% and 81% with the exception of January 2015 andMay 2015 when targets were achieved.

• The trust had identified reporting as an issue andreporting of x-rays, CT scans and MRI scans had beenoutsourced to an external company with volumesincreasing through 2015, particularly with plain x-rays torespond to increasing demand.

• There were waiting list initiatives implemented whenthe needs of the local population increased with theprovision of additional clinics as required.

• There was no data available for waiting times in theoutpatient department or if a clinic starts late. Weobserved announcements on the ‘call system to expectat least a sixty minute wait for orthopaedic clinics.


• Access to the out – patient areas, at the Countess ofChester hospital, was via a central corridor. All thesignage was colour coded yellow. This meant signs wereeasier to see for visually impaired patients and visitors.The main boards, however; were colour – coded indifferent colours that may be confusing to follow. Theoutpatient entrance displayed details of the clinics inoperation.

• An audio email system was available, for appointments,for visually impaired patients and appointment letterswere available in larger fonts.

• The waiting areas in the main outpatients includedstandard seating, but; no raised seating was observed.This meant the seating might not be suitable for apatient with mobility difficulties. In the healthy ageingunit, at Ellesmere Port Hospital, the waiting roomincluded high – back chairs with arms.

• There was an interpreter service available if needed fornon-English speaking patients and staff knew how toaccess this service. Leaflets were written in Englishalthough the patient advisory liaison leaflets (PALS)were available in languages other than English whenrequested.

• Sign language experts were available for the hearingimpaired. Learning disabilities champions supportedpatients identified as having a learning disability.Patients were able to wait in a quiet room, if needed,and seen as quickly as possible. ‘

• Reasonable adjustment’ cards were used for somepatients, such as people with autism, that familiessubmitted to reception staff which supported patient’sindividual needs.

• Staff were seen displaying the ‘purple flower’ identifyingthat they were dementia friends. Dementia training waspart of mandatory training requirements for all staff.

• Transgender training had been introduced for receptionstaff and staff participated in disability and equalitymeetings.

• A ‘one stop’ shop was available where patients attendedfor multiple appointments, at the hospital, in one daywhich reduced the need for patients attending onmultiple occasions




• There was a community ultrasound service provided torural locations to support patients getting diagnostictests promptly.

• Patients were offered ‘bleeps’ if there a prolonged waitin the outpatient department or they were attending fora number of clinics or investigations This meant theywere able to move around the hospital until ‘bleeped’ toreturn for the appointment.

• An example was given of nurses and doctors’ providinghome visits for a patient, as it was more appropriate tomeet their individual needs.

• Out patients were in the process of developing abooking system that identified available rooms to bookadditional clinics as part of waiting time initiatives.

• There were bariatric outpatient facilities, however; thesewere provided by an external company


• Complaints were managed in line with the trustprocedure for listening and responding to concerns andcomplaints policy. There were Patient Advice andLiaison Service (PALS) leaflets available that includedhow to request a copy in a language other than English.

• Between December 2014 to December 2015, there were44 complaints for outpatients and diagnostics, most ofwhich were responded to in a timely manner. Threeremained open whilst under investigation.

• Patients we spoke to complained about lack of carparking, particularly disabled spaces and waiting timesin the queue at reception and to be seen for anappointment. The Out – patients department hasimplemented a ‘bleep’ system meaning that patientswere able to leave the department and return for theirappointment.

Are outpatient and diagnostic imagingservices well-led?

Good –––

We rated as well-led because:

• There was a clear vision and strategy for the future.

• The management teams were stable and committed topatient well-being in both outpatients and diagnosticsdespite challenges.

• There were governance processes embedded withaction plans in progress to improve services.

• There were regular meetings, at all levels. Staff feltsupported by their line managers and there was goodteam working in the departments.

• There were several innovations taking place with plansto increase services.


• The trusts vision was based on the model hospital. Allstaff we spoke to were familiar with this vision. Thetrusts long-term strategy was based on three keyprogrammes of work, which focused on working withinternal and external stakeholders across Cheshire. Staffwere aware of the long-term strategy for the trust andthe local strategy related to outpatients and radiology.

• The strategy for outpatients included: “streamlining thebooking processes, reception areas and treatmentrooms to ensure they are utilised as effectively aspossible.”

• The trusts ‘operational plan document for 2015 – 16included the expansion of vascular services andintegrated interventional radiology provision withneighbouring trusts.


• Staff reported on risk, incidents, and complaints. Theydiscussed incidents at departmental meetings, led bythe service line manager and clinical directors attendedto discuss trends and serious incidents.

• Staff completed daily situation reports in theoutpatients departments (OPD) that included detailsabout clinics, which identified and risks to delivery ofkey outpatient targets.

• The trust corporate risk register and the divisionalregister included interventional radiology processes,incident trends and a lack of reporting capacity had ledto a backlog in reporting. There were controls measuresin place and staff updated registers regularly. Staff wereaware of the risks recorded in the register.




• There were processes in place to evaluate the quality ofcare delivery including internal inspections and actionsfor improvement were identified and acted upon.

• The quality, safety and patient experience committee(QSPEC) met monthly and reports were presentedincluding a thematic review of outpatient anddiagnostic areas in February 2016.

• There were clinical IR task and finish group meetings,radiation protection supervisors group meetings, districtradiological safety committee meetings and clinical(heads of department) HODs meetings, whichmonitored key risk and quality measures.

• Staff held monthly meetings that included OPDgovernance meetings, radiology directorate meetings,senior nurse forums and heads of nurses met with thedeputy director of nursing. Meetings were used tocascade key information to staff.

• The integrated radiological services reported quarterlyon key safety issues and gave recommendations withsupported the departments risk and governanceframework. The integrated radiological services report,in January 2016 included a number ofrecommendations including that there was no“common system for document management across alldepartments that use ionising radiation” and“documentation should be standardised whereverpossible.” It was also recommended that a trustradiation safety policy should be created.


• Staff found the local managers of the service to beapproachable and supportive. Most staff we spoke withtold us they were content in their role and many staffhad worked at the hospital for many years.

• Staff felt they could approach managers with concernsbut some medical staff in diagnostic imaging did notalways feel listened to, or confident action would betaken.

• We saw good, positive, and friendly interactionsbetween staff and local managers.

• The managers of the out patients and radiology serviceswere visible in the departments and meet with stafftwice daily.

• Managers had acted upon staff concerns and put plan inplace to improve access and flow.

• Consultant radiologists had contacted senior executiveswith their vision for the future. Managers listened andunderstood, however; it was felt that other prioritieswere being considered first due to financial constraints.

• A business case had been proposed to develop theservice to include an interventional radiology day caseunit

• Radiology attended meetings, as required with thedirector of nursing to escalate any issue that includedan increase in complaints or increase in cancellations.


• All staff told us that they were supported by their linemanagers.

• Radiographers said it was a good hospital to work in andthere was good teamwork in radiology.

• Some staff felt they could speak up and air their views,although other staff did not feel that the seniormanagement team were approachable and wouldsupport them.

Public engagement

• Volunteers provided support to patients and staffthroughout outpatient areas, directing patients andrelatives to waiting areas.

• There were opportunities doe the public to providefeedback in the outpatient department via the friendsand family test. The trust had recently changed providerfor recording of any patient feedback with positiveresults.

• There were information leaflets displayed in all areas wevisited available for members of the public to take.

• There were support groups for different specialities suchas a ‘drop in’ with the respiratory team at the Countessof Chester hospital or Age UK with the healthy ageingteam at Ellesmere Port hospital.

Staff engagement

• There was a weekly newsletter, available on the trustsintranet for staff.




• Staff attended monthly meetings held in the outpatientsdepartment; the minutes were cascaded to all staff, viaemail. An additional hard copy was also available.

• Student quality ambassador newsletters were availablefor students.

• Staff attended monthly radiology meetings with theminutes cascaded to all radiology staff.

• The business manager, for the respiratory team heldmonthly staff meetings, which enabled staff to shareideas.


• The trusts ‘high quality care costs less programme’(HQCCL) included “identifying efficiencies from fourwork streams; outpatients, theatres, flow andprocesses.”

• The HQCCL has included the ‘No need to bleed’ pilot.This meant that people were having blood tests whennecessary.

• The colorectal OPD model offered a variety ofcommunication methods for the vast majority ofpatients that will have normal results via moderncommunication techniques such as videoconferencing.

• Nurse led clinics were available in vascular clinics thatincluded a combination of face-to-face consultationsand telephone appointments.

• In ophthalmology, a cataract one-stop clinic wasavailable for routine cataract procedures. In addition,virtual clinics were available for triaging patients to theappropriate care pathway.

• A virtual fracture clinic is planned which would be run aconsultant, senior orthopaedic clinical nurse specialistand secretary in attendance. Patients would then begiven a diagnosis and their treatment planned.

• There were breast pathways for identified groups ofpatients to ensure seen appropriately.

• Initiatives in radiology have included rural communityultrasound, implementation of specialist techniquesand the adoption of SCoR ‘pause’ posters and cards toreduce misidentification events.




Outstanding practice

• The sentinel stroke national audit programme(SSNAP) latest audit results rated the trust overall asa grade ‘B’ which was an improvement from theprevious audit results when the trust was rated as agrade ‘E’.

• The trust were rolling out care and comfort workerroles to work across the wards to assist patients withnutrition and hydration.

• We observed a theatre morning briefing whichincluded all staff within the theatre areas. Thisbriefing ensured that all staff were aware of theatrewide issues and safety concerns and also ensuredthat staff felt they were part of the wider theatreteam.

Areas for improvement

Action the hospital MUST take to improveUrgent and emergency care

• Ensure that there are sufficient staff trained in adultand children’s safeguarding procedures in theaccident and emergency department.

Medical care (including older people's care)

• Ensure there are sufficient numbers of suitablyqualified and skilled staff on medical wards.

• Ensure that all medications are stored in a secureenvironment at all times.

Children and young people's services

• Ensure staffing levels are maintained in accordancewith national professional standards on the neonatalunit and paediatric ward.

• Ensure that there is one nurse on duty on thechildren’s ward trained in Advanced Paediatric LifeSupport on each shift.

• Improve the waiting times for reporting of radiologyinvestigations.

Surgery

• The trust must ensure that adequate numbers ofsuitably qualified staff are deployed to all areas withinthe surgical services to ensure safe patient care.

• The trust must ensure that patients outlied outsidetheir speciality meet the trusts criteria and the areaswhich they are outlied to are staffed by suitablyqualified staff.

• The trust must ensure that patients nutritional andhydration needs are met at all times.

• The trust must ensure that all staff are able tounderstand and apply the Mental Capacity Act 2005and the Deprivation of Liberty Safeguards.

Action the hospital SHOULD take to improveIn urgent and emergency care services :

• The trust should review medical record storage toensure that records are accessible for staff easily, butmitigate the risks of the public being able to accessrecords.

• The trust should ensure all premises and equipmentused by the service provider are clean.

• The trust should review processes to improve accessand flow through the accident and emergencydepartment.

• The trust should review processes of managingpatients own medications in accident andemergency areas.

In medical care services :

• The trust should ensure the electronic paper recordssystem is robust and staff are sufficiently trained andcompetent in using and understanding the system.

Outstandingpracticeandareasforimprovement

Outstanding practice and areas for improvement


• The trust should ensure all patients’ records aresecure.

• The trust should ensure at all patients and staffacross the trust has access to dementia services.

• The trust should ensure that all staff receivemandatory training including mental capacity acttraining.

• The trust should consider that basic monitoringequipment (blood pressure machine) is available inthe discharge lounge.

In surgery :

• The trust should ensure that all staff receive theadequate level of safeguarding training.

• The trust should ensure that all staff are treated withdignity and respect during their course ofemployment.

• The trust should ensure that staff are able and feelcomfortable to raise concerns.

• Staffing levels on some wards were below 95% of theplanned target with levels less 90% on someoccasions. Staff worked extra shifts and agency staffwere used on a regular basis to ensure patient safety.At night the staff skill mix on the wards was not alwayssufficient to meet the needs of the patients as staffwith specialised competencies for their area of workwould be moved to support ward areas that requiredadditional staff.

In critical care:

• Ensure that all critical care staff are aware of Duty ofCandour regulations and their responsibilities withinthis.

• Ensure that there are robust procedures in place tomonitor impact and reduce the numbers of patientsthat are delayed in being discharged from the criticalcare unit.

• Ensure that there are robust procedures in place tomonitor impact and reduce delays of patientswaiting to be admitted to the critical care unit.

• Consider supporting critical care patients who havebeen discharged from hospital to identify anypsychological support that may be needed.

• Ensure that the critical care unit achieves 50% ofnursing staff have a specialist critical carequalification.

In maternity and gynaecology :

• The trust should ensure that all areas, all fridges andequipment are clean and checked as required.

• The trust should ensure robust systems are in place toevaluate and improve their practice in respect ofincidents and all investigations relating to the safety ofthe service.

• The service should review procedures for evacuationfrom the birth pool and consider regular drillsincluding practising removing women from the pool.

• Undertake robust risk-assessment for the women andchildren’s building so that the risks associated withbaby safety are maximised.

• Deploy sufficient clinical and midwifery staff with theappropriate skills at all times of the day and night tomeet the needs of patients using the service.

• The provider should provide staff with opportunity toand need for staff to receive yearly individualappraisals.

• The provider should consider producing regularupdates specifically about the stages maternity andgynaecology audits have reached.

• The provider should consider ways of supportingwomen to feel confident in choosing a birth planwhich does not require intervention unless necessary.

• The provider should ensure the general public aregiven opportunities to comment on their strategicplans.

Children and young people’s services:

• The trust should take steps to ensure thatresuscitation equipment is checked in line with trustpolicy.

• The trust should ensure that the door to the kitchen onthe children’s ward is locked and access restricted asappropriate.

• Consideration should be given in relation to safestorage of records on the children’s ward. The notestrolley and storage cupboard should be kept locked toensure safe storage.

• The trust should ensure controlled medicines arechecked daily in line with trust policy.




• Consideration should be given to the introduction of aroutine nutritional assessment tool for all patients onthe children’s ward.

• The trust should ensure staff attend mandatory andsafeguarding training as required for their role.

• Consideration should be given for the development ofa winter management plan.

End of Life:

• Ensure the roll out of the Care and Communicationdocumentation across the trust.

• Ensure all staff have appropriate End of Life trainingand support.

• Evaluate and improve their practice in respect of thequality of people’s experience.

• Ensure all staff are aware of the vision and strategyfor end of life services.

In outpatients and diagnostic imaging services:

• The trust should improve the waiting times forreporting of radiology investigations.

• The trust should ensure staff are assured thatequipment has been maintained safely.

• The trust should consider the layout of the waitingarea to provide privacy for patients when confirmingconfidential details.

• The trust should consider improving theenvironment for children in the outpatientsdepartment as it is not child-friendly.

• The trust should ensure that all resuscitationequipment is checked and positioned appropriatelyin order that it is available in an emergency.

• The trust should ensure all equipment and clinicalareas are free from dust.

• The trust should ensure that all guidelines are clearand followed using national guidance for bestpractice.




Action we have told the provider to takeThe table below shows the fundamental standards that were not being met. The provider must send CQC a report thatsays what action they are going to take to meet these fundamental standards.

Regulated activity

Nursing care

Treatment of disease, disorder or injury

Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

Health and Social Care Act 2008 (Regulated Activities)

Regulations 2014, regulation 17 Good Governance

How the regulation was not being met:

Records were not always accurate, complete anddetailed records in respect of each person using theservice because:

Some records lacked detail in relation to nutrition andhydration on surgical wards.

HSCA 2008 (Regulated Activities) Regulations 2014,Regulation 17 (2) (c)

Regulated activity

Diagnostic and screening procedures


Regulation 18 HSCA (RA) Regulations 2014 Staffing


Regulations 2014, Regulation 18: Staffing


There were not always sufficient numbers of suitably

qualified, competent, skilled and experienced persons

deployed to meet the needs of the patients in surgery,medicine, paediatrics and neonatal services.

There were delays in reporting of diagnosticinvestigations in radiology.

In addition, there was an insufficient number of staff onduty per shift with training in paediatric life support onthe paediatric unit.

Regulation

Regulation

This section is primarily information for the provider

Requirement noticesRequirementnotices


HSCA 2008 (Regulated Activities) Regulations 2014,

Regulation 18 (1) (2) (a)

Regulated activity

Treatment of disease, disorder or injury Regulation 12 HSCA (RA) Regulations 2014 Safe care andtreatment

Health and Social Care Act 2008 (Regulated Activities)Regulations 2014 ( Part 3)

Regulation 12 (2)(g)

How the regulation was not being met:The proper and safe management of medicines was notalways followed because:

Staff on ward 52 did follow policies and proceduresabout storing medicines safely.

HSCA 2008 (Regulated Activities) Regulations 2014.Regulation 12 (2) (g).

Regulated activity

Diagnostic and screening procedures


Regulation 13 HSCA (RA) Regulations 2014 Safeguardingservice users from abuse and improper treatment


Regulations 2014, Regulation 13: Safeguarding serviceusers from abuse and improper treatment.


Safeguarding training was not provided for in line withbest practice guidance.

This is because there were not sufficient numbers of stafftrained in level 3 safeguarding children in urgent andemergency care.

In addition, not all staff understood how to apply themental Capacity Act 2005 principles deprivation ofliberty safeguards.

Regulation

Regulation




HSCA 2008 (Regulated Activities) Regulations 2014,Regulation 13 (2) (5)




Action we have told the provider to takeThe table below shows the fundamental standards that were not being met. The provider must send CQC a report thatsays what action they are going to take to meet these fundamental standards.


Enforcement actionsEnforcementactions


Action we have told the provider to takeThe table below shows why there is a need for significant improvements in the quality of healthcare. The provider mustsend CQC a report that says what action they are going to take to make the significant improvements.

Why there is a need for significantimprovementsStart here... Start here...

Where these improvements need tohappen


Enforcement actions (s.29A Warning notice)Enforcementactions(s.29AWarningnotice)


Documents

CountessofChesterHospitalNHSFoundationTrust ......Hospital QualityReport CountessofChesterHealthPark LiverpoolRoad Chester CH21UL Tel:01244365000 Website: Dateofinspectionvisit:February2016