Macclesfield District General Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant the effectiveness of people’s care, treatment and support did not always achieve good outcomes or was inconsistent.

The service was in breach of regulations 11 and 12 for safe care and treatment and consent.

There were significant risks, including poor compliance with Mental Capacity Act standards, delays in non-invasive ventilation (NIV) treatment, and inconsistent monitoring of sepsis and audit outcomes. Care planning for people with dementia and learning disabilities was often incomplete, and consent processes were weak. We saw delays in speech and dietetic assessments alongside gaps in alcohol support and ineffective discharge coordination. However, the service demonstrated strong multidisciplinary teamwork.

We have not awarded this service a score for Effective.

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

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

We reviewed 11 patient care records; 5 patient care records were of people with a learning disability.

Staff did not always update care plans when required and care plans were not always completed. We saw that only 1 of the 5 records of people with a learning disability had a healthcare passport in their notes. This meant staff caring for patients did not always know their likes and dislikes or sensory needs. However, we did see evidence that staff used reasonable adjustments care plans to assess people’s additional needs.

People told us they knew what their next steps were and felt they could ask staff if they did need clarification.

However, people told us they knew what their next steps were and felt they could ask staff if they did need clarification.

Staff used recognised tools to assess pain for patients and those who were unable to communicate verbally.

We scored the service as 1. The evidence showed significant shortfalls. The service did not plan and deliver people’s care and treatment with them. They did not always follow current evidence-based good practice and standards.

The service took part in national checks to see how well it supported people with dementia. In the 2024 National Audit of Dementia, the service scored in the middle range compared to other services for two areas. However, it was in the lowest group for checking whether people with dementia were in pain. Another area that had worsened was starting care plans for people with dementia within 24 hours. In the previous year, 85% of people had care plans started on time and in 2024, this fell to just 39%.

The most recent Chronic Obstructive Pulmonary Disease Audit in 2024 results were varied with 3 of the 6 metrics within the expected range, 2 better than expected and 1 worse than expected. The most recently published Chronic Obstructive Pulmonary Disease Audit in 2024 results were varied with 3 of the 6 metrics within the expected range, 2 better than expected and 1 worse than expected. The trust’s performance for patients receiving non invasive ventilation (NIV) within 2 hours of arrival was 0%. The trust reported that this had increased to 11% for the period of April 2024 to May 2025.

Leaders in respiratory told us that NIV was a challenge in the service as there was limited NIV equipment and only 6 CPAP machines in the hospital. NIV could only be done on Ward 11 or critical care due to requiring specialist trained staff. We heard of instances where beds were not available on ward 11 for NIV for patients acutely unwell and that treatment was delayed whilst waiting for a bed.

The service also internally audited the time from patients attending ED to having NIV started (door to mask time) and this demonstrated that the acutely unwell patients were waiting longer than the standard of 2 hours with 1 incident report stating a door to mask time of 17 hours although the patient was in respiratory distress. Issues with NIV requirements were known to leaders and were on the divisions’ risk register.

Standards for acute NIV were not met which was a breach of regulation 12.

Staff told us there were delays for speech and language therapy (SALT) and dietician assessments which delayed the right level of care for patients. In the 6 months prior to our inspection all high priority referrals for patients who were nil by mouth was 100% for being seen within 2 working days, however there were delays for patients rated moderate and routine priority with an average wait time of 4.5 working days. The target for these referrals was within 3 days.

The service did not have a standard operating procedure in place for SALT at the time of our inspection but were in the process of drafting one.

We requested the waiting times for dietetic assessments however this was not received for the medical care service. The overall trust average waiting time for dietetic assessment was consistently longer than the internal standard.

However, nutrition and hydration audits showed that wards were mostly compliant with their internal standards for nutrition and hydration. Nutrition and hydration charts we reviewed were completed appropriately.

The endoscopy service had received accreditation from the Joint Advisory Group on GI Endoscopy (JAG) from their most recent assessment in February 2025.

Staff on the respiratory unit were 100% compliant with NIV training.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well across teams and services to support people. However, they made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff on CCU told us that consultants and resident doctors starting times were not aligned which meant patients experienced delays for their care, treatment and discharges.

The joint working between the hospital bed team and the transfer of care hub was not effective as they were working to different goals. The criteria for which patients were considered to be ready for discharge was different between the teams so one team was concerned about patients stranded in hospital and the other team felt that there were very few patients with no criteria to reside.

We observed handovers and saw these were structured and included patient’s risks. We observed board rounds and saw that they had strong clinical leadership with consideration of patient's length of stay. Staff had safety huddles at the start of shifts to handover any information of risk. We observed good multi-disciplinary working on the wards with occupational therapists, physiotherapists and pharmacists on the wards.

We scored the service as 2. The evidence showed some shortfalls. The service did not always support people to manage their health and wellbeing, so people could not always maximise their independence, choice and control. The service did not always support people to live healthier lives.

The service had access to an external alcohol support service but this was only 5 days a week. The service did not have an internal specialist for alcohol reduction and management.

In the most recent Chronic Obstructive Pulmonary Disease (COPD) Audit in 2024 the service was within the expected range of current smokers with COPD prescribed smoking-cessation pharmacotherapy.

The trust had a treating tobacco dependency service which was to identify all patients admitted to the hospital who smoked and offer nicotine replacement therapy, provide specialist support for the duration of the patient's hospital stay, and onward referral to community-based services.

We scored the service as 2. The evidence showed some shortfalls. The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

Staff used recognised tools to detect and respond to clinical deterioration; however, the trust had changed to an electronic patient record system 3 weeks prior to our visit and the policy for the use of this tool was still for the old system.

Leaders audited performance in relation to sepsis monthly and for the 4 months prior to our inspection the compliance was on average 82%. However, screening performance was significantly lower, averaging just 64%, which is below the expected standard. While key treatment elements such as IV antibiotics within one hour consistently achieved strong results around 85–90% and blood cultures between 95–100%, gaps in early screening remained a breach in regulation 12.

The trust sent evidence of participation in national clinical audits, however these demonstrated that the trust was not submitting data to these audits on time or responding to recommendations from audit outcomes and had outstanding actions from recommendations as far back as 2023.

The trust had a ward accreditation scheme, which assessed each area or ward at various increments based on the previous rating. Most medical care wards were scored as having “some shortfalls” with 8 as amber, with the other 2 wards scored as “good” at green.

Every month a condensed version of this assessment was undertaken on every ward to monitor continuous compliance.

We scored the service as 1. The evidence showed significant shortfalls. The service did not tell people about their rights around consent or respect these when delivering care and treatment.

Staff did not always follow the requirements of the Mental Capacity Act (MCA). We found staff did not always assess patients’ capacity appropriately. Records showed staff had at times assumed patients lacked capacity because they had a learning disability and were using MCA assessments broadly and not on a decision-specific basis.

Best interest processes were initiated without establishing whether patients lacked capacity and in other cases no best interests had been done for patients who were assessed as lacking capacity.

We gave feedback to leaders on our findings and following this the trust undertook a review of all records of patients lacking capacity across the trust, this showed that the issue was widespread. The audit carried out showed in total that out of 26 patients that were deemed to lack capacity, 14 had not had any best interests decision recorded and 8 were on a Deprivation of Liberty Safeguards (DoLS) but had no documentation of MCA.

The trust provided us with previous audits undertaken by their legal team which showed that this was a longstanding issue that dated back to the start of those audits in October 2024. This was a breach of regulation 11.

Following our feedback leaders continued to audit MCA and DoLS documentation, these demonstrated that records were now being completed appropriately, however most staff were still unable to answer questions about MCA and best interest meetings were still not being consistently done.

Leaders acknowledged that further improvements were required to ensure consistent application of the Mental Capacity Act (MCA) standards and had an improvement plan in place.

We revisited the medical wards during the well-led assessment in September and found the service’s compliance had somewhat improved for MCA.

The service did not audit consent processes or documentation. The service did not audit the use of rapid tranquilisation.

The trust acknowledged the shortfalls in consent processes and provided some actions to mitigate this, however no actions to address the root cause of the problem.

Not all staff had completed training in consent, with a compliance rate of only 56% for clinical staff in medical care.

Most staff had completed training about learning disabilities, with an overall compliance in the division at 94%, for medical and dental staff however compliance was below the target at 71%. This was similar to training for dementia with most staff compliant except for medical and dental staff with a compliance of 56%. Medical staff told us that completing training was difficult due to pressures such as staffing and workload.