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

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

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

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 26 February 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’ for effective, caring and well led. We found that services were provided by compassionate, caring staff and patients were respected and treated with dignity. However, improvements were needed to ensure that services were safe and responsive 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 on surgical 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 methods of 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 and though staff recognition awards.

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

Access and Flow

• The trust had established policies and both internal and external escalation procedures in place to support access and flow across the trust which were co-ordinated though meetings held at various points though the day to assess and prioritise patient movements in the trust. This included a designated hospital team who were responsible for patient 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 target on 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 and delayed discharges due to the complexity of patient’s needs. Some medical patients were being nursed in non-speciality beds. Trust data showed In August 2015 data showed that there were 34 patients in total, which rose to 120 in September and further increased to 130 in October 2015. We observed that this data included those patients 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 Chester Hospital 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 in transfers of care. These were due to a variety of reasons including packages of care and decisions about community living arrangements.

• The trust was working closely with other strategic leaders to plan system delivery, strategy and plans in order to support elective and emergency admissions, attendances and discharges to the hospital. As part of this, the trust had introduced a number of initiatives including a general practitioner admissions unit (GPAU) which opened at the end of the announced aspect of this inspection. During the unannounced inspection, we observed that the general practitioner admissions unit (GPAU) was having a positive impact on flow though the hospital and there had been a reduction 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 2014 to September 2015.

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

• In January 2016, the trust achieved the referral to treatment (RTT) targets, of 95%, in all areas and specialities with the 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 better than the England average from 2013/14 to 2015/16, although October and November 2015 were below the target of 85% 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 and emergency 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 were knowledgeable on preventing infection.

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

• Staff generally followed good practice guidance in relation to the control and prevention of infection in line with trust 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 preoperative assessments. 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 based tool. The trust was also in the early stages of using a workload management tool (NHPPD) from the recently published Lord Carter model hospital review. The hospital was also piloting an national activity monitoring tool, to gain robust data on required nurse staffing levels going forward.

• The trust undertook biannual nurse staffing establishment reviews as part of mandatory requirements. As part of this, key objectives were set though this work to support safer staffing. Data provided as part of this review in January 2016 identified that over-all the trust had maintained over 95% of staffing levels planned against actual levels 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 – 30 registered nurses from Spain.

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

• However, nurse-staffing levels, although improved, remained a challenge across most areas. Staffing levels were maintained by staff regularly working extra shifts and with the use of bank or agency staff. Inductions were in place for 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; approval had been obtained to increase medical staffing in this area.

• The number of palliative care consultants was below the recommended staffing levels outlined by the Association for Palliative Medicine of Great Britain and Ireland, and the National Council for Palliative Care guidance, which states 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 the service 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, seven days a week. The trust had recently recruited three interventional radiologists to manage the increasing workload.

Mortality Rates

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

• The Summary Hospital-level Mortality Indicator (SHMI) is a set of data indicators, which is used to measure mortality outcomes at trust level across the NHS in England using a standard and transparent methodology. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die based on average England figures, given the characteristics of the patients treated at the hospital. Between August 2014 and July 2015 the trust score was 103, which was slightly higher than the 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 regionally for 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 refreshments throughout 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 clear system in place to identify patient in need of assistance with eating and drinking. We found that most patients received 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 were comprehensive 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 to patient referrals.
• There was an infant feeding team and ‘Bosom buddy’ volunteers to provide breast-feeding support. Mothers with babies 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, fluid balance charts were completed so that oral intake could be monitored when required and when intravenous fluids were administered.
• The trust were rolling out care and comfort worker roles to work across the wards to assist patients with nutrition and hydration.

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

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

Importantly, the trust must:

• Ensure that adequate numbers of suitably qualified staff are deployed to all areas within the surgical services to ensure safe patient care.
• Ensure that patients placed in areas outside their speciality meet the trusts criteria and ensure that there is suitably qualified 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 the risks 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 and competent 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 discharge lounge.

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 mix on the wards was not always sufficient to meet the needs of the patients as staff with specialised competencies for their area of work would be moved to support ward areas that required additional staff.

In critical care:

• 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 are delayed 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 be admitted to the critical care unit.

• Consider supporting critical care patients who have been discharged from hospital to identify any psychological support 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.

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

• The trust should consider improving the environment for children in the outpatients department as it is not child-friendly.

• The trust should ensure that all resuscitation equipment is checked and positioned appropriately in order that it is available 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

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.

What we found about the standards we reviewed and how well the Countess of Chester Hospital was meeting them

All of the patients we talked to said their needs were met. Most of the patients said that the staff were very helpful and responded to call bells promptly. All said that they were given information and encouraged to take part in drawing up their plan of care and felt confident that if they didn’t understand anything they could ask for further explanation. One patient said “the staff are very good at explaining things, they speak in your language”. Another said “the information is given at my level”.

Patients said that the staff always asked permission before carrying out any examinations or care and also regularly asked if they had any concerns. They said staff asked them how they wanted to be addressed, were respectful and always maintained their privacy. All said they had never been embarrassed or felt uncomfortable while care was being carried out.

Patients told us that they enjoyed the meals, the food was good and they were given enough to eat, although two people on the longer stay ward said they would like more variety in the menus. They said that they were given help to eat if they needed it and they had never missed a meal. Patients confirmed that there always snacks and drinks available.

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

• Our rating for safe at this hospital stayed the same as our previous rating. We rated safe at this hospital as requires improvement. This was because we rated safe as requires improvement across all three services inspected during this inspection. There was also one service (services for children and young people) that was not inspected on this visit that was rated as requires improvement.
• We rated effective at this hospital as requires improvement. This went down from the rating of good following our previous inspection. This was because we rated effective as requires improvement in surgery during this inspection. There was also one service (end of life care) that was not inspected on this visit that was rated as requires improvement.
• Our rating for responsive at this hospital stayed the same as our previous rating. We rated responsive at this hospital as requires improvement. This was because we rated responsive as requires improvement in the medical care and urgent and emergency care services during this inspection. There were also two services (critical care and end of life care) that were not inspected on this visit that were rated as requires improvement.
• We rated well-led at this hospital as requires improvement. This went down from the rating of good following our previous inspection. This was because we rated well-led as requires improvement across all three services inspected during this inspection. There was also one service (end of life care) that was not inspected on this visit that was rated as requires improvement.
• We rated caring at this hospital as good. This stayed the same as our previous rating. Across all the services we inspected, we found staff treated patients with kindness, compassion, and respect. Patients and their relatives commented positively about the care they received.
• We rated urgent an emergency care as requires improvement overall. Our rating went down since the last inspection. We rated effective and caring as good. We rated safe, responsive and well led as requires improvement because we identified areas for improvement in relation to the equipment, environment and layout and staff culture within the department.
• We rated medical care as requires improvement overall. Our rating went down since the last inspection. We rated effective and caring as good. We rated safe, responsive and well led as requires improvement because we identified areas for improvement in relation to medicines management, management of risks and staff culture within the service.
• We rated surgery as requires improvement overall. Our rating went down since the last inspection. We rated caring and responsive as good. We rated safe, effective and well-led as requires improvement because we identified areas for improvement in relation to nurse staffing levels, management of patient risks and management of patients with sepsis.