Our rating of services stayed the same. We rated it them as requires improvement because:

• We rated safe, effective and well led as requires improvement. We rated effective, responsive and caring as good. We took into account the current ratings of services not inspected this time.
• We found medicines were not consistently dispensed, recorded, stored correctly and safely within the medical wards. Storage of medicines on medical wards did not always follow best practice medicine guidelines.
• We found equipment stored in front of fire escapes on some medical wards.
• On the children’s ward, there was a shortage of band 6 nurses who had the advanced paediatric life support training.

However:

• The ratings for medical care, surgery, maternity and children and young people had improved.

When we carried out our inspection we spoke to patients on the surgical and children’s wards.

On Ward 2 one patient expressed satisfaction with the ward saying their experience was “all positive, nothing negative” and that they “rate this hospital highly”. Another said “It is 200% in here -absolutely amazing. You hear all this about how awful things are in hospitals but I have no complaints.” A third said “Cracking experience. These girls turn themselves inside out to make sure you get the care - they are so patient I could never possibly be as patient as they are and what is unusual is that it is all of them not just one or two”.

The relative of a patient with dementia told us; “Considering this is a surgical ward he has had an exceptional level of care – better than a lot of wards where you would have expected more of them in terms of understanding his dementia and meeting (his) needs”.

On the Children’s Ward when asked if they wished to comment one parent said, ”just how good they have been”.

Patients also commented on staffing levels. One said “There is nearly always someone around and if not I ring and they come almost straight away usually”. Another patient commented “I have been surprised at how many staff there are”.

Another said “They seem to have plenty of staff and they take time to talk to you one to one when they have time. There is some nice banter but they’re respectful with it.”

During this unannounced inspection we visited three wards and the Patient Advice and Liaison Service (PALS). We visited a 21 bed, surgical day case ward (Ward 2) which on the day of the inspection was being utilised as a medical ward, we visited a respiratory ward (Ward 4), which had temporarily extended its bed numbers to 34, and a 28-bedded Orthopaedic ward with occasional elective surgical patients (Ward 5).

All parts of the hospital we saw during our visit were clean and we observed staff to be professional, treating patients with consideration, dignity and respect.

We met 13 patients over three wards, reviewed eight patient records and met ten members of staff during the course of our visit.

We saw that patients consented to treatments and were provided with sufficient information to make informed decisions.

Staff informed us that the trust had taken action to address the gaps in staff levels across the trust with investment to increase staffing levels already taking place. However we found that the balance of permanent staff to agency or bank staff on one ward impacted on the delivery of consistent care to patients. Patients we spoke with found the staff on ward 2 to be exceptionally busy whilst on the other wards this was not the case.

We found of the eight patient records reviewed, some incomplete initial assessments and gaps in five records of the patients risk assessments or their reviews.

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

During our visits to wards 6 and 11 we spoke with 12 patients. The majority told us they were very satisfied with their care and their needs were being met. Many recognised that staff were busy but they told us this had not impacted on the care they were receiving. For example one said, “The nurses come when I ask and come regularly to check I’m Ok”. Another said, “The staff are brilliant. Nothing is too much trouble”. A third told us, “The nurses are always polite and kind and help me when I need help”. We spoke with two relatives who also were very positive about the care their family member had received.

All but one of patients we spoke to, who were able to eat meals, said they were satisfied with the food provided by the hospital. No one said they got hungry or thirsty and all were aware they could ask for more food or drink if they needed. One patient said, “I enjoy the food and there is always enough to eat”. Another said, “The food is good and there is good variety”.

As part of our inspection of the trust on 15 September 2011 we visited three wards: ward 3 (acute general medicine), ward 6 (orthopaedics) and the MAU (Medical Admissions Unit). During our visit to these wards we spoke with 15 patients. They all told us they were being treated with dignity and respect. For example, one said, ‘Staff are considerate and treat me as an individual’. Another said, “Staff are friendly, introduce themselves and always explain what they are going to do”. All those who we asked said they were satisfied with the information they were given and that updates from nurses and doctors met their needs.

The 15 patients we spoke to were also very positive about how their care and welfare needs were being met. They used words such as, excellent, lovely, hard working, caring, cheerful, attentive and considerate to describe the staff who look after them. All those who we asked said they were helped when needed. All but one said they did not have to wait too long for attention. The one patient who said he had to wait too long said this had only happened once during the night. One patient also said they had concerns regarding the cleanliness of equipment on one occasion but this had been addressed immediately. No one else said they had any concerns.

The majority of patients felt there were enough staff on the wards. A few said they were concerned that staff maybe too busy but when asked, apart from the one person who said he had to wait too long in the night, they did not think this had impacted on their care.

The patients we spoke to were not positive about the hospital’s food. The majority felt that it was not good or of poor quality. The main concern was over the evening meal which we were told is a sandwich. Several patients did not like the quality of this sandwich and said it was not enough to eat for an evening meal. However, most said they could ask for other food if they were hungry.

Macclesfield District General Hospital is part of East Cheshire NHS Trust and provides a full range of hospital services, including urgent and emergency care, critical care, general medicine including elderly care, emergency surgery, elective surgery in most specialties, cancer services, paediatrics, maternity care and a range of outpatient services.

East Cheshire NHS Trust serves a population catchment area of approximately 450,000. Inpatient services are provided from two hospital sites – Macclesfield District General Hospital (main site) and Congleton War Memorial Hospital (intermediate care service). Outpatient services are provided in Macclesfield District General Hospital and in community bases in Congleton, Handforth, Knutsford, Wilmslow and Poynton. In total, the trust has 376 beds.

East Cheshire NHS Trust is a non-foundation trust. NHS trusts are run slightly differently to foundation trusts. NHS foundation trusts, first introduced in April 2004, are independent legal entities and have unique governance arrangements. They are free from central government control and are no longer performance-managed by health authorities. As self-standing, self-governing organisations, NHS foundation trusts are free to determine their own future.

We carried out this inspection as part of our comprehensive inspection programme. This report also includes our findings for the minor injuries unit at Congleton War Memorial Hospital.

Overall, we rated Macclesfield District General Hospital as ‘requires improvement’. We have judged the service as ‘good’ for caring. We found that services were provided by dedicated, caring staff. Patients were treated with dignity and respect and were provided with appropriate emotional support. However, improvements were needed to ensure that services were safe, effective, responsive to people’s needs and well led.

Our key findings were as follows:

Cleanliness and infection control

• Patients received care in a clean, hygienic and suitably maintained environment. Staff were aware of and applied infection prevention and control guidelines.
• We observed good practices in relation to hand hygiene and ‘bare below the elbow’ guidance and the appropriate use of personal protective equipment, such as gloves and aprons, while delivering care.
• Policies for managing patients in isolation rooms were not always followed in surgical services.
• During our inspection we identified serious concerns with the storage of breast milk and the inappropriate storage of decontaminated equipment with clean equipment. We raised our concerns immediately with the trust. We reviewed the action the trust had taken as part of our unannounced inspection and were assured that the trust had taken the necessary steps to address our concerns. However, we identified other concerns in relation to infection control such as the decontamination arrangements for toys in the inpatient and outpatient areas and for cots on the special care baby unit. We also found that staff were unclear about the decontamination arrangements for a breast bump. As a result the matron for the service asked the breastfeeding team to review the process.
• Some areas of the maternity unit had signs of wear and tear which meant that they could not be cleaned. This included bare and worn wood around sinks and in the sluices. Chipped shelving in the clinical areas, offices and sluices and wooden doors and doorways with bare wood were present. The trust had recognised these areas required improvement as part of their capital improvement programme 2014/15. However, we raised these issues with the service during the inspection and no improvement programme was discussed.
• During the inspection we raised concerns regarding a damaged wall in the day case theatre. The trust took immediate action to address our concerns. We also found a shower room where the edges of the shower and around the floor were not sealed, allowing water to get between the wall and the floor covering and mould was visible to that area and to the patient call bell cord. An infection control audit report for ward 1 showed that this had been identified in August 2014 but no remedial action had been taken. This was raised with staff and the edges were sealed by the maintenance team during the inspection.

Records

• The standard of record completion varied across the services. In emergency services, critical care and surgical services we found that medical and nursing notes were structured, legible, complete and up to date.
• However, we found gaps in the completion of records relating to medication, demographics, growth charts and individualised care plans on the children’s ward. We also found evidence of the retrospective completion of records.
• There were variations in the completeness of ‘do not attempt cardio-pulmonary resuscitation’ (DNA CPR) forms across the hospital.
• Records in the outpatients department, occupational therapy, physiotherapy and orthotics department and on the children’s ward were not stored securely in line with requirements.

Staffing levels

• Overall, medical treatment was delivered by sufficient numbers of skilled and committed medical staff.
• Consultant cover in critical care services was limited due to only six of the nine consultants being trained in intensive care. This meant that only 80% of patients were assessed by a consultant within 12 hours of admission to the critical care unit and the provision of two daily ward rounds was not achieved at weekends.
• A shortfall in the number of junior doctors in urgent and emergency services meant that the trust had to employ locum staff from November 2014 to February 2015 to cover shortages. The trust was also having difficulty recruiting to four additional registrar posts. In addition, there were four vacancies for junior doctors’ in critical care services. Shortfalls were covered by locum, bank and agency staff.
• Care and treatment were delivered by committed and caring staff who worked hard to provide patients with good services.
• Although we found that staffing levels were adequate at the time of our inspection, there was no flexibility in numbers to cope with increased capacity and demand, or short-notice sickness and absence.
• The trust was actively recruiting nursing staff from overseas to try to improve staffing levels.
• The midwife-to-patient ratio averaged at one to 30. This was higher than the recommended number of one to 28. No recognised acuity tool was used to assess the number of midwives required. A staffing acuity guideline was in place based on Birth-rate plus. However this did not allow for the assessment to be done daily.

Mortality rates

• Our ‘intelligent monitoring’ report of July 2014 showed that there was no evidence of risk for summary hospital mortality level indicators or for hospital standardised mortality ratio indicators.

Incidents

• Systems were in place for reporting and managing incidents. However, these were not followed consistently across all services.
• In maternity services, there was poor understanding of the system for deciding the serious nature, or potential outcomes, of an incident or for how it should be investigated. This meant that not all incidents with potential risks of harm were formally investigated or recorded or lessons shared.
• Incidents were not always reported in line with trust policy in outpatients and diagnostic imaging services or in children’s and young people’s services, which meant that data provided in relation to incidents may not provide a reliable oversight of incidents occurring in these services.

Nutrition and hydration

• Patients had a choice of nutritious food and an ample supply of drinks during their stay in hospital. Patients with specialist needs in relation to eating and drinking were supported by dieticians and by the speech and language therapy team.
• The patient records we reviewed included an assessment of patients’ nutritional requirements based on the malnutrition universal screening tool (MUST).
• Where patients were identified as being at risk, there were fluid and food charts in place and these were reviewed and updated by the staff.
• Children and young people were offered a choice of meals that were age appropriate and supported individual needs such as gluten-free and sugar-free. Children told us that they enjoyed the food. Parents told us that the food was good quality and there was a lot of choice, including healthy options.

Medicines management

• The systems in place for the management, storage, administration, disposal and recording of medication, including controlled drugs and oxygen, were not robust and in line with requirements.
• In urgent and emergency services, controlled drugs registers had not always been signed by two staff members when controlled drugs were dispensed. Also, controlled drugs that were wasted (unused) during a treatment had not been recorded since February 2014. Systems to dispose of controlled drugs were not being followed.
• In maternity services, the policy for checking stocks of controlled drugs was not followed in practice and we found medication in stock that was past its expiry date stored in an open box with other vials that were in date. This did not comply with the trust’s policy ‘Safe and secure handling of medicines’. We brought this incident to the trust’s attention and it took immediate action to address our concerns.
• In children’s and young people’s services, the administration and recording of medication did not always occur in a timely manner.
• Anticipatory prescribing in end of life care was common, in line with best practice. This meant that pain relief and other medication could be started quickly if patients became unwell.

We found breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 [now Health and Social Care Act 2008 (Regulated Activities) Regulations 2014] and the trust needs to make improvements in these areas.

Importantly, the trust must:

• Ensure that there are robust systems in place for the management, storage, administration, disposal and recording of medication, including controlled drugs and oxygen, in line with requirements.
• Ensure that records contain accurate information in respect of each patient and include appropriate information in relation to the treatment and care provided, particularly with regard to children’s and young people’s services, pain relief documentation in the emergency department and ‘do not attempt cardio-pulmonary resuscitation’ (DNACPR) forms.
• Ensure that records in children’s and young people’s services are stored securely in line with regulatory requirements.
• Ensure that there are effective processes in place for the decontamination and storage of clean and contaminated equipment and for the monitoring of this, particularly in relation to children’s and young people’s services.
• Ensure that the environment within medical wards, surgical wards and maternity services is well maintained and fit for purpose so that appropriate standards of cleanliness can be maintained.
• Ensure that there are effective systems in place to identify, assess and monitor risks relating to the health, safety and welfare of people who use services and staff. This includes incident-reporting systems and risk-management processes for the maintenance of equipment.

In addition, the trust should:

• Consider improving arrangements for clinical supervision to ensure that they are appropriate and support staff to carry out their responsibilities effectively, offer relevant development opportunities and enable staff to deliver care safely and to an appropriate standard.

In urgent and emergency services

• Ensure that the four-hour target data is recorded accurately at the minor injuries unit (MIU) at Congleton War Memorial Hospital.
• Assess all patients for pain relief as they enter the emergency department and ensure that the pain score and any administered pain relief are recorded accurately.
• Review the timeliness of access to interpreter services.
• Review the process to manage bariatric patients.
• Consider implementing a pain audit for paediatrics.

In surgical services

• Take appropriate action to ensure that there is adequate provision of suitable showering facilities for patients within the orthopaedic wards.
• Take appropriate action to ensure that all staff receive clinical mandatory training.
• Take appropriate action to improve performance relating to length of stay for general surgery patients in the hospital.
• Take appropriate action to improve compliance with national targets for 18-week referral-to-treatment time (RTT) standards.
• Consider taking action to ensure that there are appropriate management arrangements in the theatres department.

In medical care services

• The trust should ensure that mental capacity assessments are recorded appropriately and that all staff understand the requirements of the Mental Capacity Act and deprivation of liberty safeguards.
• The trust should take steps to ensure that all staff are included in lessons learned from incidents and near misses and have a full understanding of the trust’s governance processes.
• Action should be taken to ensure that any chemicals are stored appropriately and that ‘out of bounds’ areas are secured appropriately.

In critical care

• Consider a review of services to manage patients safely over a 24-hour period.
• Consider reviewing the level of cover provided by consultants to ensure that there are twice daily rounds and that the assessment of admissions to the CCU can be achieved within the recommended 12-hour period.

In maternity and gynaecology services

• Ensure the safe storage of medical gases, disposable medical equipment and other items on the ward.
• Ensure that risks associated with the use of the birthing pool are assessed and appropriate emergency evacuation equipment is provided.
• Ensure that all staff are up to date with mandatory training.
• Ensure that there are systems for the safe management of patients during operations and in the event of emergencies. This should include joint working with the theatre staff and assurance that midwives who may be requested to assist in theatre are competent to do so.
• Take action to reduce the number of gynaecology operations cancelled at short notice.
• Ensure that the facilities for patients undergoing a termination of pregnancy provide privacy and dignity.

In children’s and young people’s services

• Ensure that there are robust monitoring arrangements in place to make sure that areas are appropriately locked in children’s and young people’s services.
• Ensure that all staff are aware of arrangements for recording and accessing information relating to safeguarding in children’s and young people’s services. This includes obtaining assurance that consultant assent arrangements are followed in line with trust policy.
• Ensure that staff receive relevant training to support children and young people with mental health needs.
• Ensure that staff are competent and confident in the use of continuous positive airway pressure (CPAP) equipment.
• Ensure that there are monitoring and escalation procedures in place to make sure that there are enough staff with the appropriate skills in order to meet the needs of children and young people.

In end of life care

• Ensure that there are robust arrangements in place for out-of-hours consultant cover and that these arrangements are communicated clearly to all staff, particularly the specialist palliative care team (SPCT).
• Ensure that all staff receive appropriate end of life training.

In outpatients and diagnostic imaging services

• Ensure that equipment is maintained in line with the manufacturers’ recommendations.
• Take action to reduce the number of clinic cancellations.

Professor Sir Mike Richards

Chief Inspector of Hospitals