Cheadle Royal Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Safe:

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question Inadequate. The service was in breach of legal regulation in relation to Regulation 12 Safe Care and Treatment and Regulation 18 Staffing. At this assessment the rating has changed to Requires Improvement.

Requires improvement: This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

At this assessment, the service was in breach of legal regulation in relation to Regulation 12 Safe Care and Treatment, Regulation 15 Premises and Equipment and Regulation 18 Staffing.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

Description: The provider did not always have a proactive and positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

• Lessons were learnt from incidents. Learning was shared with staff and staff could explain changes in practice. We saw changes in practice following incidents including the stock of Naloxone for use in opioid overdose.
• Trust publications entitled Cascade were shared with staff to explain actions taken following incidents and lessons learnt. Monthly patient safety meetings took place with senior managers and ward managers, the cascades were shared in that meeting too.
• Records did not always include action taken or decision making processes, following incidents and their review by the multidisciplinary team.
• Handover records did not have risk assessments completed on all wards. Staff were being encouraged to complete the handover on the electronic care record, some wards were using the electronic care record and paper records, however in handover staff told us, and we observed on Redwood ward, that the paper records were used. Handover paper records were not completed in full on Alder ward and Evergreen ward. This meant staff were not receiving consistent information about risks of patients, incidents that may have occurred and changing needs of patients.
• The acute and PICU wards reported 192 serious incidents in the last 12 months. Incidents included patients failing to return from leave, staff not conducting observations as prescribed, self harm requiring medical intervention, patient’s physical health deterioration and incidents of violence and aggression.
• All permanent staff we spoke with knew what incidents to report and how to report them. However agency staff that we spoke with did not fully understand the process.
• Staff understood the duty of candour. They were open and transparent, and gave patients and families a full explanation if and when things went wrong.
• Not all staff received feedback from investigation of incidents, both internal and external to the service. We reviewed team meeting minutes and there was no recorded discussion or standard agenda item regarding learning from incidents and changes in practice apart from on Maple ward.
• Lessons learned was a standard agenda item for the ward governance meetings. The multidisciplinary team attended these meetings.
• Staff told us they were debriefed and received support after a serious incident.

Description: We work with people and our partners to establish and maintain safe systems of care, in which safety is managed, monitored and assured. We ensure continuity of care, including when people move between different services.

• The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could be safely met. Stakeholders confirmed that the service explained the reasons why they could not accept referrals.
• Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. We saw that ward rounds involved the multidisciplinary team, and the external professionals involved, including care coordinators.

Description: We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We concentrate on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect, and we make sure we share concerns quickly and appropriately.

• Safeguarding was a priority for the service. Monthly safeguarding assurance meetings took place which fed into the clinical governance meetings. Patients mostly told us they felt safe on the wards, however one patient did not feel safe on Pankhurst ward and two patients felt unsafe on Willows ward.
• Staff were trained in safeguarding, knew how to make a safeguarding alert, and did that when appropriate. There were 3 different safeguarding training courses that staff completed; Safeguarding Adults levels 1 and 2 with 95% compliance, Safeguarding Children levels 1 and 2 with 94% compliance and Safeguarding Combined: Adults and Children Young People - level 3 with 100% compliance.
• Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.
• Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies.
• Staff followed safe procedures for children visiting the service. Following the on site assessment, a family visiting room was created in the main hospital corridor as there was limited space for family visits to take place prior to this.
• Staff received accredited training in physical intervention. Restraint, restrictive practice and blanket restrictions were recorded and reviewed. Use of blanket restrictions were discussed and evaluated in the ward governance meetings and clinical governance meetings.

Description: We work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

• Patients received support from staff to manage risks associated with their health and wellbeing. Policies and procedures were in place for staff including a Physical intervention policy and an Incident reporting and management policy. Staff were knowledgeable about risks.
• We reviewed 18 care records including risk assessments / risk management plans during the assessment. All risk assessments were in place and created to a good standard.
• In the 6 months from June to December 2024, there had been 231 restraints on Featherstone ward, 152 on Willows ward, 135 on Pankhurst ward, 88 on Maple ward, 37 on Evergreen ward, 30 on Alder ward and none on Redwood ward. The highest, Featherstone was a male psychiatric intensive care unit, who cared for people when they were acutely unwell.
• In the last 3 months from September to December 2024, there had been 39 uses of rapid tranquilisation; 9 on Maple ward, 8 on Featherstone ward, 8 on Pankhurst ward, 6 on Alder ward, 4 on Willow ward and 4 on Evergreen ward.
• In the last 3 months from September to December 2024, there had been 33 uses of seclusion and one use of long-term segregation.
• Staff mostly involved patients in care planning and risk assessment. However on Pankhurst ward, Alder ward and Featherstone ward, the care plans we reviewed did not show patient involvement.
• Staff mostly communicated with patients so that they understood their care and treatment, we saw the team engaging well with patients during the ward rounds we observed on Alder ward and Pankhurst ward. However on Evergreen ward, the team did not effectively communicate with the patient whose ward round we observed, staff repeated questions without allowing the patient time to process the information, were not prepared for the meeting and did not know the patient well.
• Staff enabled patients to give feedback on the service they received, via the healthcare patient satisfaction survey.
• Staff ensured that patients could access advocacy. There were 2 advocacy providers and contact details were displayed on the ward and patients told us they saw the advocates.

Description: The provider did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

• Staff carried out regular risk assessments of the care environment. Each ward had a ligature risk assessment in place. However the risk assessments did not include identified ligature points on the ward. Ligature points were included in a separate document called Ligature Audit. This meant it was difficult for staff working on the ward and new staff to know what the environmental risks were on the ward and how to mitigate them.
• Ward layouts did not allow staff to observe all parts of the ward. Blind spot audits were completed for each ward. However the response to identified blind spot said “Manage identified blind spot through local procedure”, when we asked staff they did not know what the local procedure was. This meant staff were not consistently mitigating the risk of the blind spots. The blind spot audit for Maple ward, did not contain all blind spots, there was an alcove into bedroom doors that was not included on the audit. The blind spot audit for Featherstone ward did not include all blind spots as there was an alcove at the entrance to the laundry that was not included in the audit. The blind spot audit for Redwood ward did not include all blind spots as there was a blind spot in the laundry next to the storage that was not included in the audit. This meant staff were not aware of all of the risks of the environment and what they needed to mitigate. There was no system to accurately and consistently share with new staff on the wards what the ligature risks and blind spots were, this was down to the staff member facilitating the induction, this meant there would be variations, and staff would not be given consistent information.
• The ward complied with guidance on eliminating mixed-sex accommodation.
• Staff had easy access to alarms and patients had easy access to nurse call systems. However there were not always enough alarms for the inspection teams, these had to be borrowed from other wards. Stakeholders told us there wasn’t always enough alarms for visitors to the wards.
• Seclusion rooms allowed clear observation and two-way communication, and had toilet facilities and a clock.
• Clinic rooms were fully equipped with accessible resuscitation equipment and emergency drugs that staff checked regularly.

Description: The provider did not always make sure there were enough qualified, skilled and experienced people, who received effective support, supervision and development and worked together effectively to provide safe care that meets people’s individual needs.

• The service had good establishment figures with 85% for registered nurses and 90% for health care assistants. There were 9.6 (WTE) registered nurse vacancies across the 7 wards and 41.6 (WTE) health care assistant vacancies, a number of posts had been recruited to and the applicants were working through pre employment checks. There were 123 leavers over the whole site in the last 12 months. Average sickness was 4% within the last 12 months across the 7 wards.
• Managers had calculated the number and grade of nurses and healthcare assistants required. There was an establishment dashboard in use.
• The ward manager could adjust staffing levels daily to take account of case mix. We saw that daily flash meetings took place with ward managers and the operations director to discuss staffing for the day and make any required changes.
• When necessary, managers deployed agency and bank nursing staff to maintain safe staffing levels. Average bank staff usage over the last 6 months was 0.9% for bank registered nurses and 15% for bank health care assistants. Average agency staff usage over the last 6 months was 12% for agency registered nurses and 6% for agency health care assistants.
• We reviewed staff rotas and agency induction checklists and found when agency staff were used, those staff did not always receive an induction to the ward. On Alder ward, 25% (1out of 4) agency staff records reviewed had not had an induction onto the ward. On Maple ward 67% (6 out of 9) agency staff records reviewed had not had an induction onto the ward. On Evergreen ward, 60% (3 out of 5) agency staff records reviewed had not had an induction onto the ward. On Featherstone ward, 25% (1 out of 4) agency staff records reviewed had not had an induction completed in full, there were pages missing. On Redwood ward 67% (4 out of 6) agency staff records reviewed had not had an induction onto the ward. On Pankhurst ward 80% (4 out of 5) agency staff records reviewed had not had an induction onto the ward. On Willows ward 25% (1 out of 4) agency staff records reviewed had not had an induction onto the ward. This meant not all staff were familiar with the ward layout, including location of emergency equipment and how best to support the patients on the wards.
• Staffing levels allowed patients to have regular one-to-one time with their named nurse.
• Staff shortages rarely resulted in staff cancelling escorted leave or ward activities.
• There were enough staff to carry out physical interventions (for example, observations, restraint and seclusion) safely (and staff had been trained to do so).
• There was adequate medical cover day and night, and a doctor could attend the ward quickly in an emergency.
• Staff had received and were up to date with appropriate mandatory training with an overall compliance of 94% across the 7 wards.
• The provider’s supervision policy stated that nursing and allied healthcare professional staff should have monthly clinical supervision and quarterly managerial supervision. We reviewed the supervision overview for clinical supervision for the wards for 2024 and found that Evergreen was the highest with 92%, Alder with 88%, Willows with 74%, Maple with 72%, Featherstone with 63% and Pankhurst ward with 47% compliance. This meant staff were not receiving clinical supervision in line with the policy.

Description: The provider did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

• Staff maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date.
• There were areas on each ward that were not clean, did not have good furnishings and were not well-maintained. The environments in all acute wards and PICU’s except Evergreen and Redwood ward had significant environmental risks, were unclean and were not well maintained. For example, there was stains on the floor, cracked material on furniture, paint peeling, mould and damp in showers and toilets, stained furniture and dirt in between Perspex and windows. Evergreen and Redwood wards had recently been refurbished and there were some cleanliness issues that showed on the wards, and the furniture were not being regularly reviewed, maintained and updated. Repairs were not completed in a timely manner, for example on Alder ward, staff had been requesting a new washing machine since July 2024 to enable more patients to do their own washing, this issue had not been resolved at the time of our assessment in December 2024. The environmental concerns that we identified were not all recorded on the maintenance logs. This meant patients were in an environment that was not supportive of their recovery.
• Cleaning records were not easily available on the wards, they were completed by the cleaning providers.
• Staff did not adhere to infection control principles. On every ward staff were not bare below the elbow, most staff were wearing fleeces, we also saw nurses with long sleeved tops on under their tunics. Staff had long nails, nail varnish on and false nails. Staff had watches and jewellery on. Staff were not following the Standards of Dress, Uniform and Personal Appearance policy dated 03/08/2023 which states “ 6.2 Appearance - With regard to personal appearance the following applies: Fingernails must be kept short at all times to protect from any scratching and any infection. Nail varnish is not permitted for any colleagues who have direct contact with service users. 6.3 Clothing - Arms must be bare below the elbow to allow appropriate hand hygiene. This is defined in the Department of Health’s “Bare Below the Elbows” guidance and IPC03 Hand Hygiene. 6.5 Finger rings - One plain metal band may be worn. No rings with stones are to be worn when dealing directly with service users’ care as scratches and abrasions to the skin could occur.”

Description: The provider did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happen.

• Staff did not follow good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, use of covert medication) and did not follow national guidance. We saw that controlled drug registers were not always completed accurately.
• Staff did not always follow instructions when administering medicines and we found that patients had not received their medicines within the prescribed interval so had received doses of medicines too close together. Actions were put in place at the time of the assessment to prevent this happening again. Staff did not always follow instructions for medicines prescribed as when required. For two patients we found that they were administered over the maximum prescribed dose in 24 hours.
• Staff did not review the effects of medication on patients’ physical health regularly and in line with NICE guidance, especially when the patient was prescribed a high dose of antipsychotic medication. We found the monitoring of patient’s physical health whilst prescribed medicines was not always recorded in their care notes, so we could not be assured this was always being completed.
• Patients did not always receive their medicines as prescribed as stock was not always available.

However:

• Patients who had received rapid tranquilisation had this documented in their notes including any outcomes and post dose observations. The service audited the use of rapid tranquilisation.
• Staff told us and records confirmed that staff were trained and had been competency assessed to manage medicines.
• A pharmacist visited wards regularly and was available if required to support patients with their medicines.
• Medicines were stored securely and in areas that were being temperature monitored.
• Patients allergies were recorded accurately.