East Cheshire NHS Trust

We inspected East Cheshire NHS Trust as part of our new comprehensive inspection programme.

We carried out an announced inspection of Macclesfield District General Hospital on 10, 11 and 12 December 2014. The announced inspection of community healthcare services also took place at this time and we carried out an announced inspection at Congleton War Memorial Hospital on 11 December 2014.

We undertook an unannounced inspection between 6am and 12.30pm on 22 December 2014 at Macclesfield District General Hospital only. During the unannounced inspection we looked at the management of medicines and checked to see what actions the trust had taken to address concerns we raised during the announced inspection in relation to children’s and young people’s services and surgical services.

Overall, we rated East Cheshire NHS Trust 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 and responsive to people’s needs, and we rated the trust as requires improvement with regard to services being well led.

Our key findings were as follows:

Incidents

• Systems were in place for reporting and managing incidents. However, these systems were not followed consistently across all services. Incidents were not always reported in line with trust policy, which meant that data provided in relation to incidents may not provide a reliable oversight of incidents occurring in these services.
• In some services, there was poor understanding of the formal system for deciding the serious nature, or potential outcomes, of an incident or how it should be investigated. This meant that not all incidents with potential risks of harm were formally investigated or recorded or lessons shared.
• Some staff raised concerns that they were not given feedback on incidents that had been reported.

Safeguarding

• There was a clear policy in place that was accessible to staff on the intranet. However, there was a lack of clarity relating to the application of the policy.
• We found that there had been no self-referrals to adult social care in the last 18 months. We found that, when a potential safeguarding concern was identified, the incident would be investigated locally before being entered on the electronic reporting system. Only if the outcome of the investigation substantiated a safeguarding concern would it then be referred to adult social care. This was not in line with best practice.
• In addition, we were informed of an incident relating to the suspension of a member of staff for potential verbal abuse of a patient, which, on review, had not been reported via the safeguarding process.

Cleanliness and infection control

• During our inspection we identified concerns with the decontamination and storage of equipment and the maintenance of a safe environment. A number of areas showed signs of ‘wear and tear’ which meant that they could not be cleaned adequately. We raised our concerns immediately with the trust, which addressed the urgent issues.
• However, we were not satisfied that there were robust arrangements in place for monitoring the patient environment or for identifying and addressing risks in a timely manner. Policies for managing patients in isolation rooms were not always followed. Where risks had been identified, action had not always been taken in a timely way to protect patients from harm.
• We observed good practice in relation to hand hygiene and ‘bare below the elbow’ guidance and the appropriate use of personal protective equipment.

Medicines management

• The systems in place for the management, storage, administration, disposal and recording of medication, including controlled drugs and oxygen, were not robust or in line with requirements.
• 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.

Staffing

• Overall, medical treatment was delivered by sufficient numbers of skilled and committed medical staff.
• Care and treatment were delivered by committed and caring staff who worked hard to provide patients with good services.
• 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 (CCU) 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.
• The trust was actively recruiting nursing staff from overseas to try to improve staffing levels. In most areas we found that nurse staffing levels were generally adequate at the time of our inspection. However, appropriate steps had not been taken to ensure that there were sufficient numbers of suitably qualified, skilled and experienced nursing staff working in adult community services to meet the needs of service users. Adult community teams experienced staff shortages and had difficulty in recruiting.
• We also found that nurse staffing levels within the children’s unit were not always in line with Royal College of Nursing recommendations.
• The midwife-to-patient ratio averaged at one to 30. This was worse than the recommended number of one to 28. A staffing acuity guideline was in place based on Birth-rate plus. However this did not allow for this 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.

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).
• 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.

We saw several areas of outstanding practice including the following:

• Care planning in the community dental service was found to be outstanding in its care planning and we observed excellent interactions with the diverse and complex needs of patients using the service.
• A learning disabilities and autism group was in place in the trust and the trust had received an Autism Access Award from the National Autistic Society.
• The trust's home intravenous therapy service had recently piloted new projects to expand the service into new specialities. For example, cardiology and alcohol management. The team had developed policies and procedures based on best practice from other trusts and in line with national guidance.
• The Parkinson’s nurses, respiratory nurses, physiotherapists and podiatrists networked in specialist groups. They attended regular update meetings where some would present their work to peers outside the organisation.

We found evidence of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 [now the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014].The trust must take action to ensure improvements in these areas.

Importantly, the trust must:

• Ensure that there are suitable arrangements in place to respond appropriately to any allegation of abuse in order to safeguard service users against the risk of abuse.

• 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 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 the 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 sufficient numbers of suitably qualified, skilled and experienced nursing and other staff working in adult community services to meet the needs of service users.
• Ensure that there are effective systems in place to identify, assess and monitor risks relating to the health, safety and welfare of both staff and the people who use services. This includes incident-reporting systems and risk management processes for the maintenance of equipment.
• 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, community healthcare services for adults, pain relief documentation in the emergency department and ‘do not attempt cardio-pulmonary resuscitation’ (DNA CPR) forms.

Professor Sir Mike Richards

Chief Inspector of Hospitals

East Cheshire NHS Trust provided adult community services across east and south Cheshire and Vale Royal. Services we inspected were provided in people’s own homes, nursing homes, clinics and GP practices.

The trust had taken measures to increase nursing capacity. However, adult community teams experienced staff shortages and had difficulty in recruiting. Community nurses told us that there were limitations when it came to seeing emergency patients due to staffing and time pressures. Staff shortages had compromised the standard of record keeping and of the recording and investigation of incidents.

Training records showed that most community staff had completed appraisals in the last 12 months and mandatory training including training in the Mental Capacity Act 2005. However, several staff, including senior clinical staff, did not know what the term ‘deprivation of liberty’ meant or how to apply the Mental Capacity Act 2005 to their work.

The service did not adequately monitor the quality of service provision to identify or manage risks in order to assure people’s welfare and safety. Incident reporting and investigation were inconsistent across the adult community health services. Community nurses did not always report and investigate incidents in line with the trust’s incident-reporting policy. Evidence of learning from incidents in the community nursing services was also limited.

The vision for the service was unclear and staff felt that the trust was focused on hospital care rather than community services. Although staff knew who the chief executive was, they were unclear on the management structure above their immediate line manager. Most staff was unable to tell us who the director of nursing was. Allied health professionals were unaware of which directorate they came under and some were unaware of who their next-level managers were. There was good local leadership across allied health professionals and specialist nursing teams. However, there was a lack of leadership from immediate line managers within community nursing teams. While some staff told us that the chief executive had liaised with them about the restructuring of the service, some community nursing staff felt that they did not have a voice in the organisation.

Community services for adults were unable to provide us with a clear overview of what their performance indicators were and what the outcomes were for patients. Podiatrists and physiotherapists told us that they were meeting their targets but did not have evidence of this. Staff had limited access to the trust’s intelligence data or any information the trust gathered. This meant that services and the trust did not have robust oversight of the quality of services provided.

Community services delivered evidence-based practice in line with national guidance. Staff worked within their scope of practice and in accordance with the recommendations of their professional governing bodies. Across all services, care and treatment of patients were delivered with empathy and compassion. We observed staff interacting with patients in a professional and respectful manner. Staff promoted and maintained the dignity of patients when they delivered care in various community settings, such as community clinics and patients’ own homes. Staff were aware of the need to be sensitive to people’s religious and cultural needs. All teams were aware of the demographics in their area and how they needed to adapt the way they worked to meet the needs of patients.

We found mixed evidence of staff engagement with the trust board. We were told by community staff that the trust was focused on Macclesfield District General Hospital and they felt separate from the acute trust. We were told that senior managers were not visible.

Management and team leader posts had been condensed, making visibility across the whole district challenging.

The trust had restructured services in order to meet the needs of the population, but the changed structures had not been embedded at the time of the inspection. There was little evidence that children, young people and families had been involved in decisions about the service redesign.

There were systems in place for reporting and investigating incidents and there was evidence that learning from incidents occurred. Safeguarding arrangements were embedded in practice and staff were well supported with regular safeguarding supervision.

The clinics we visited were clean and well maintained and staff followed infection control procedures. Staff were passionate about providing person-centred care and understood the importance of engaging with families in order to understand their situation and the support they required.

Staff aimed to assess and deliver treatment in line with current legislation, standards and evidence-based practice. We found that staff numbers were sufficient to deliver the Healthy Child Programme but this was new to teams as they were becoming fully staffed following significant recruitment.

There were processes in place for reporting and learning from incidents. Staff were clear about what incidents to report and how to do this. Managers were confident that incidents were being reported appropriately. Staff knew how to raise a safeguarding alert and were familiar with the Mental Capacity Act and deprivation of liberty safeguards. Staff had access to training and felt well supported. They had annual appraisals that identified training needs.

There were good joint working arrangements in place and team members were respected and listened to. Patients were treated respectfully, with sensitivity and patience, and were involved in the planning of their care and discharge. Services were responsive to the individual needs of the patients they were caring for.

Staff generally felt well connected to the trust and were clear about the purpose of the services they provided. External organisations had been used to help staff teams improve the quality of services they provided and we saw examples of local initiatives that had led to an improved service for patients.

Total staffing numbers were adequate at the time of our inspection but staff skill mix and registered nurse staff numbers was not always in line with the trust’s planned figures. Bank and agency staff were used to cover staff vacancies and there were processes in place to ensure continuity of care as much as possible.

East Cheshire NHS Trust provides a range of specialised dental services for people with complex or special needs, vulnerable people and those who find it difficult to access general dental services because of their particular needs.

The community dental service had systems and processes in place to keep patients and staff safe. There were robust processes to identify and manage potential risks to patients, including the use of effective infection control measures. Each clinic was clean and well maintained.

Patients told us that they were treated with dignity and respect when accessing and receiving treatment. Patients and their representatives spoke highly of the care provided and said that care was delivered by staff who were compassionate and understanding of their needs. There was good collaborative working between the service and other healthcare services to ensure good patient outcomes.

Initiatives had been established to improve the service and to use the resources effectively. Staff we spoke with felt supported in their roles and that their managers were approachable and accessible.