Macclesfield District General 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

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained 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.

The service was in breach of regulations 12 and 18 for people’s safe care and treatment and staffing.

There were significant risks, including poor management of pressure ulcers, low compliance with some risk assessments and observations, inconsistent safeguarding practices, and poor management of patient risks. We saw environmental hazards such as blocked fire exits alongside staffing shortages, poor mandatory training compliance and heavy reliance on temporary staff.

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.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had had 8 severe and 1 fatal incident between January and July 2025. The most common incidents were falls, pressure ulcers and moisture lesions. The service had had no never events in the last 5 years. We reviewed incident investigation reports and saw that these were had been done in a timely manner.

Staff knew what incidents to report and how to report them. Staff understood the duty of candour and patients told us of examples where this had been done. Staff received feedback from investigation of incidents, both internal and external to the service.

The service had a practice development team that staff told us were supportive and that there were training opportunities available to staff. We saw good examples of learning from falls and pressure ulcers to prevent reoccurrence such as additional staff training including simulations.

Staff had identified that the new Electronic Patient Record (EPR) system allowed for Malnutrition Universal Screening Tool (MUST) assessments to appear in the record as completed when they were not which posed a risk that an incorrect score could be generated, and patients would not receive the nutritional support they required. Staff had escalated this, and the trust had sent communications out to staff to ensure staff were aware of this and they were working to address this issue.

We scored the service as 2. The evidence showed some shortfalls. The service did not always have processes to make sure there was safe continuity of care, including when people moved between different services.

The service had an escalation policy outlining the processes to be used when the hospital reached full capacity. However, we received 2 copies of this policy, both the same version of the document which showed different review dates, with one copy of the policy past its review date. This policy had not had an impact assessment review to identify any potential effects to patient safety, equality and diversity and patient effectiveness.

The service had an exclusion and inclusion criteria policy for admissions to the wards based on the ward specialty and the training of the staff.

As part of the trust’s continuous flow process, staff on the wards identified patients who were suitable to “sit out” to release a bed for admission. Primarily patients due for discharge would be identified as the next patient, however in some instances this would also be patients who did not have a confirmed discharge that day. We heard from staff that sometimes this meant the patient would need to be reallocated a bed later that day. We saw that the continuous flow process had been appropriately risk assessed.

We scored the service as 2. The evidence showed some shortfalls. The service had safeguarding processes in place and staff were mostly trained in safeguarding children and adults; however, the service did not monitor restrictive practices.

The service had policies for safeguarding both children and adults at risk. Both policies were detailed and included appropriate topics such as indicators for abuse, how to make a referral and safeguarding for transition from child to adult services.

Staff were mostly trained in safeguarding however compliance rates with the different levels of training was inconsistent. For nursing staff, the compliance rate for level 3 adult safeguarding was 88%, however the compliance rate for medical and dental staff was at only 44%.

The compliance rate for safeguarding of children training was better with 80% compliance for medical staff and 94% for nursing staff.

The service did not monitor restraint, and leaders were unable to answer how compliance with the restraint policy was assessed.

We scored the service as 1. The evidence showed significant shortfalls. The service did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service was an outlier in the North-West for pressure ulcers. We found that patients were not being cared for appropriately to prevent pressure ulcers, despite the Trust undertaking quality improvement initiatives. In the 6 months prior to the inspection the service had had 98 patients who had developed pressure ulcers whilst admitted.

Pressure relieving mattresses were in use across the wards. A patient's mattress was very hard and they said they were uncomfortable and struggling to sleep. We therefore asked 5 staff of varying grades what the different settings on the mattress pump meant and how they knew which to use. They all responded they did not know, and it was automatically set.

The service had an adult sepsis policy that was introduced in July 2025. This was an updated version of the policy with the NICE guidance changes from January 2024. This gave clear guidance for staff on when to commence the sepsis pathway, however referenced several policies that did not exist within the trust.

Compliance with observation targets was an average of only 67% across medical care for March to May 2025. This was below the trust target of 75%.

Staff did not always assess patients Venous Thrombo-Embolism (VTE) risk. Data submitted by the trust showed that on average only 69% of patients were assessed for VTE within the 14-hour target.

The low compliance rates for VTE and observations and the poor management of pressure ulcers was a breach of regulation 12.

We scored the service as 1. The evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment.

The estate had issues with the aging building, with areas unkempt and cluttered; we were told due to lack of storage space. We observed that fire exits were blocked and saw electrical equipment charging next to oxygen cylinders which was a fire risk. We raised this at the time of the inspection and immediate action was taken; however, we revisited the medical wards during the well-led assessment in September and found the service’s compliance with fire safety had not improved. This was a breach of regulation 12.

Some wards had old call bell systems that did not show the location of the emergency bell but a code that was linked to the bay which staff would then have to translate to attend the correct area. The trust had risk assessed this and taken actions to reduce the risks identified.

Emergency equipment had all been tested and had stickers on to say when the next test was due. Staff mostly undertook checks of emergency equipment in the 3 months prior to the inspection with some gaps in the checking of the hypoglycaemia box on 1 of the wards.

We observed that chemicals listed under the Control of Substances Hazardous to Health (COSHH) were stored correctly.

We observed Portable Appliance Testing (PAT) tests were in date across medical care.

We scored the service as 1. The evidence showed significant shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development.

In medical care we found services relied on high use of temporary staffing including bank and agency. For medical staffing between April and June 2025 the average bank and agency fill rate of shifts was 20%, mostly of bank staff.

For nursing staff during the same period, the average agency/bank fill rate was 21%, which was similar to medical staffing. However, it varied more between wards, with 1 ward in June having over 32% of shifts filled by bank and agency workers.

Leaders told us that medical cover out of hours was a risk, and they were working on a business case to this.

Staff told us and we observed that the establishment for the Cardiac Care Unit (CCU) was 2 registered nurses on each shift. The nurses told us that when patients required transfer to other hospitals for procedures such as pacemakers and angiograms that a nurse would have to go with the patient. This meant the unit would be left for long periods with just 1 nurse to 4 patients and they also had to also monitor the further 8 remote telemetry patients that could be anywhere within the hospital. This was a risk as the wards with telemetry patients would be unaware when a patient had an arrythmia or had an arrest and relied on CCU contacting the ward to inform them.

We escalated our concerns during the assessment, and the trust took immediate action to address CCU staffing and provide assurances.

Patients told us that the wards seemed understaffed at times.

Medical staff told us that training was often cancelled or difficult to attend due to the acuity/complexity of patients’ needs on the wards and staffing levels. We saw that medical staffing mandatory training compliance rates were consistently lower than the other staff groups with an overall average compliance rate of 62% for all mandatory training. This was a breach of regulation 18. However, staff said that senior support was good at the trust.

Only 25 out of approximately 143 nursing staff in medical care were trained in the management of Naso-Gastric (NG) tubes, the trust told us that this had been identified as a risk as the trust’s NG lead had not been replaced but there was a plan in place to improve this. This risk was not on the division’s risk register.

Staff told us that providing cover for gastrointestinal specialty consultants was difficult and this meant that patients sometimes saw 4 different doctors in 1 week. Patients also told us this and that it meant their plan had been changed frequently as each had a different opinion.

Staff did not have regular appraisals with a compliance rate for medical care at 67%.

The ward manager could adjust staffing levels daily to take account of case mix.

Respiratory nursing staff had completed training in Non-Invasive Ventilation (NIV).

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection.

The service had a range of IPC policies covering a range of common infections. Staff audited compliance with cleanliness standards monthly which had a high compliance rate. The IPC team undertook annual audits in more depth; the trust provided the most recent ones undertaken for 3 wards which showed all were below the target of 90% at 72-88%.

We observed that cleaning checks had been completed on the wards and commodes were clean with dated stickers. However, we observed resuscitation trolleys that had dust on. This is an IPC risk and also increases fire risk when using a defibrillator.

Staff did not always assess and monitor cannulas for visual infusion phlebitis, and we observed some cannulas were left in patient’s arms for long periods of time. We were unable to find evidence of visual infusion phlebitis checks, and this had also been raised on 1 ward in the trust’s IPC audit in June.

CCU did not have anywhere to isolate patients who had infections but required CCU care. Leaders told us there was a process that staff followed when a patient with an infectious disease required CCU care to ensure that both infection prevention control measures and cardiology needs were considered. Patients with infectious diseases could also be cared for on the cardiology ward in side rooms if they were available. However, staff told us that there had been an instance of a patient cared for in CCU with MRSA.

Staff did not always adhere to IPC principles, internal audits showed that in the last 2 audits undertaken by the IPC team looking at uniform, PPE use and hand hygiene that only 1 ward was compliant in March/April, and no wards scored above the 90% target in May/June. Compliance scores ranged from 60% to 96%. The service had an action plan in place to improve these scores which was detailed and included dates by which the actions needed to be completed. Following our feedback during the inspection around PPE use and hand hygiene the IPC team conducted weekly audits to measure improvements against the action plan.

Staff did not always complete mandatory training for infection prevention and control, with nursing staff compliance at 77% and medical staff at 40%. The total overall compliance in the division for all staff was 70.4%.

However, the trust was in the best 25% of trusts for most Health Care Acquired Infection (HCAI) indicators between December 2024 and February 2025, which meant that the trust was managing HCAI effectively in comparison to other trusts.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

We found that Parkinsons medications were not always being given consistently in line with NICE Quality Standards.

We observed oxygen prescribing was inconsistent and not always completed.

Staff followed policies for medicines management and antimicrobial prescribing guidelines. We saw evidence that when rapid tranquilisation (an injectable medicine to help calm a person who is distressed) was required, staff followed guidance from the National Institute for Health and Care Excellence (NICE) on monitoring, observation of the person following rapid tranquilisation. However, leaders did not monitor or audit rapid tranquilisation to ensure compliance with the policy or regulation.

The wards were supported by the pharmacy team 5 days a week, Monday to Friday, to undertake medicines reconciliation when patients were admitted to the wards, review patients’ medicines, speak with patients about their medicines if needed and facilitated discharges.

We saw evidence of effective communication of medicines issues between pharmacists and other healthcare professionals. Staff told us that pharmacy professionals were visible on wards and would attend ward rounds and multi-disciplinary team meetings to provide medicines advice and support.

People’s allergies were recorded on the electronic prescribing system.

Medicines including controlled drugs and intravenous fluids were stored securely.