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 good. At this assessment the rating has changed to 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 for people’s safe care and treatment and staffing.

There were significant risks, including poor infection control practices, low compliance with safeguarding and sepsis training, and inconsistent mental health risk management. Staffing was challenged, with breaches in paediatric nurse staffing requirements and heavy reliance on temporary staff. We observed delays in patient flow, prolonged ambulance handovers, and occasional environmental hazards such as blocked fire exits. However, the service demonstrated a strong safety culture, timely incident investigations, and proactive initiatives to improve triage and patient care.

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.

We spoke with patients and their relatives during the assessment, and they told us they knew how to raise a complaint or concern. Patients said they would feel comfortable raising an issue with the staff caring for them and knew how to make a formal complaint, should they need to.

The service had reported 8 severe and 2 fatal incidents between January and July 2025. The most common incidents were 12-hour trolley waits, pressure ulcers and delay or failure in treatment or care. The service had not had any “never events” in the last 12 months. "Never events" are serious, preventable patient safety incidents that occur in healthcare settings and should not happen if national guidance and safety recommendations are followed.

Staff had a good understanding of how to use incident reporting systems. Staff were aware of the key themes which had resulted from recent complaints and incidents and felt confident raising issues and concerns when they arose. Senior members of staff and leaders were involved in reviewing complaints and incidents. Safety huddles provided staff with a forum in which incidents and complaints were shared and discussed. Reviews of incidents had led to improvements according to staff and leaders.

Staff we spoke with had received feedback sometimes on incidents they had submitted. Staff were also able to provide examples of methods used to share learning from incidents such as emails, meetings, and safety alerts.

The service had an up-to-date Patient Safety Incident Response Framework (PSIRF) policy which set out the approach to developing and maintaining effective systems and processes for responding to patient safety incidents and of learning. Leaders analysed incident reports and took urgent actions to manage or remove risks. Incidents were appropriately investigated.

We scored the service as 2. The evidence showed some shortfalls. The service did not always manage or monitor people’s safety in designated clinical areas. They did not always make sure there was continuity of care, including when people moved between different services. However, the service did work well with people and healthcare partners to establish and maintain safe systems of care.

The department worked collaboratively with internal colleagues and external partners to maintain patients’ safety. However, there were delays in ensuring patients were cared for in the correct area once a decision to admit had been made. The use of areas that were not designed for patient care increased the risk to safety. Not all specialties responded promptly to being contacted. Delays in discharges caused a knock-on impact to transfer to wards which meant patients remained in the emergency department for longer than required.

We saw examples of electronic discharge summaries being completed which contained all relevant information about each patients’ stay in the department if they were discharged home. Clinical responsibility for patients within the department was clearly defined. All patients within the department were cared for by the emergency department staff including those awaiting admission under other medical or surgical specialties, although this increased demand on department staff.

The service had proactively trialed multiple initiatives to improve triage and wait times such as a band 7 nurse front of house navigator to stream patients away from the service, the use of rapid assessment and treatment (RAT) teams and direct surgical referral pathways from SDEC.

Children were seen in a dedicated Paediatric ED which had a separate reception, waiting and treatment areas designed to be child friendly. Staff reported positive relationships with the Child and Adolescent Mental health Servies (CAMHS) as well as child safeguarding teams.

Bed management meetings were held 3 times per day. The purpose of these meetings was to maintain oversight and grip of patient flow across the hospital. We saw that staff worked in multidisciplinary teams supported by discharge coordinators to facilitate discharge home.

We saw examples of senior clinicians reviewing patients that arrived by ambulance to ensure that patients were seen in clinical priority order.

We scored the service as 2. The evidence showed an inconsistent standard as there was no assurance that all medical staff understood their role in safeguarding. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse and discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately. However, training was provided but not all staff completed it to the required level.

Staff in both the paediatric and adult emergency department told us they were confident in reporting safeguarding should it be required and were supported by senior staff with specialist knowledge in the trust if it was needed or if there was a complex case that required managing. Records included a flag for patients who may have safeguarding needs which alerted staff to this.

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 95.4%, however the compliance rate for medical and dental staff was at only 69.2%. For nursing staff, the compliance rate for level 3 children safeguarding was 95.5%, however the compliance rate for medical staff was at only 65.5%. Leaders were aware of this and training was being prioritised for appropriate staff to attend.

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. The trust had designated safeguarding practitioners who supported in completing risk assessments for patients who presented a risk to staff and other patients.

We saw examples of staff assessing patients' capacity and documenting it within the patient notes. All clinicians were able to articulate how they would assess a patient with mental health issues including the appropriate risk assessment. Mental Capacity Act training was incorporated into both safeguarding and mental health training modules

Nursing staff compliance for The Oliver McGowan Mandatory Training on Learning Disability and Autism was 95.9%. Medical and dental staff compliance was at only 72.4%.

We scored the service as 2. The service did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We found that mental health risk management plans were not formulated and clearly recorded following assessment. The risk rating tools did not lead to clear management plans specifying the level of observation. The level of identified risk in patient care records did not lead to a robust care plan. We found actual risk management in the department including the use of one-to-one observations did not correspond to the level of risk identified in patient's records. This was a breach of regulation 12 safe care and treatment. We raised this at the time of inspection and the trust took immediate action. We revisited the ED during the well-led assessment in September and found the service’s compliance had not improved.

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 in the trust. The trust had policies, processes and risk assessments in place to manage risks and emergencies. Staff used risk assessment tools to keep patients safe and were trained in least restrictive restraint. All security staff had received training in how to manage violence and aggression and de-escalation and least restrictive interventions.

The department had effective processes and tools for assessing patients when they first presented to the department and monitored patients for signs of deterioration when they remained in the department for extended periods of time.

The trusts used the National Early Warning Score (NEWS 2) to assess patients at risk of deterioration in the department and enable staff to take appropriate action. In the paediatric department this was the Paediatric Early Warning Score (PEWS). Staff were clear how to escalate patients that needed clinical review. Records we reviewed showed that staff completed the observations and scores as required by the protocol and properly escalated for review where they needed to.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Staff followed safe procedures for children visiting the department. Access to the paediatric waiting room was provided by staff at the reception after a brief assessment of the patient. Access to ED was via a door buzzer system and staff carried electronic passes to gain entry.

We observed that all handovers were undertaken in a designated area where patient confidentiality could be maintained. All areas of the emergency department were physically clean.

The designated mental health assessment room and adjacent facilities were fully Psychiatric Liaison Accreditation Network (PLAN) compliant. However, staff told us that the room was not always sufficient for the number of people requiring this care.

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

Staff had access to the equipment they required to keep patients safe and did not report any shortages in environment. We spoke with a range of staff who confirmed that when equipment broke, they had access to replacement equipment promptly.

Clinical staff knew where to find the equipment they needed to respond to an emergency and had received appropriate training to enable effective use of it. Resuscitation equipment was readily available and easily accessible. The hospital had systems to ensure it was checked regularly, fully stocked, and ready for use.

There were systems which ensured clinical waste was appropriately segregated, and disposed of. During our inspection we observed sharps bins were mostly correctly assembled and labelled in line with national guidelines.

The design of the environment mostly followed national guidance. The waiting rooms within each area had a screen which displayed the waiting times. Patients had access to drinking water and plenty of chairs to sit on. However not all areas within the department were suitable for their purpose. We saw patients being cared for in the corridor next to the ambulance triage area which compromised their privacy and dignity.

On the Medical Assessment Unit (MAU) we observed a fire door blocked by equipment, we raised this at the time of the inspection and immediate action was taken to clear the area.

We scored the service as 1. The evidence showed significant shortfalls. The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not work together well to provide safe care that met people’s individual needs.

The trust did not always ensure there were enough staff with the right skills, training and experience because of low compliance with specific mandatory training requirements. This was a breach of regulation 18 staffing.

Standards for children in the emergency care setting, from the Royal College of Paediatrics and Child Health (RCPCH), which recommends every emergency department treating children must be staffed by 2 registered children's nurses who must possess recognisable post-registration trauma and emergency training. The paediatric emergency department currently had 2.9 whole time equivalent (WTE) children’s nurses. We reviewed the staffing rota which showed the department was frequently staffed with only 1 nurse. This was a breach of regulation 18 staffing. To mitigate the risk the trust supplemented the department with adult nurses who had completed a locally produced paediatric workbook and assessment, but many adult nurses who were tasked to work in the paediatric ED told us they did not feel safe or equipped to treat children. We revisited the UEC during the well-led assessment in September and found the service’s paediatric staffing still failed to meet the RCPCH recommendations despite recruiting an additional 2 WTE children's nurses. We reviewed the staffing rota which now showed all shifts were covered by 2 nurses, however these were not always registered children's nurses.

The Royal College of Paediatrics and Child Health (RCPCH) guidance also states the service must employ a Paediatric Emergency Medicine consultant with dedicated session time allocated to paediatrics, must always have a member of staff with APLS (or equivalent) training on duty and must employ a play specialist. The trust did not meet these requirements, and this was a breach of regulation.

The service had 10 WTE consultants working within the UEC which was 2 WTE short of the RCEM guidance recommendation. The trust was able to demonstrate that this was mitigated using long-term consultant bank staff.

Staff did not have regular appraisal with the compliance rate for UEC at 61% for all staff groups. Staff did however say they found appraisals worthwhile.

Managers calculated and reviewed the number and grade of staff needed for each shift according to best practice and department need. Staffing levels for corridor care were 1 registered nurse for every 6 patients receiving corridor care.

The department had a dedicated practice development nurse to provide support and education to clinical staff and to improve their professional practice. Staff were extremely complimentary about having this role in the team and how they had made a positive difference to performance. There was a structured development programme for all staff that included unit and role specific induction programmes and supernumerary periods for new nurses to the team.

Managers supported staff to progress through regular development meetings and yearly constructive appraisals of their work. Staff had the opportunity to discuss training needs and were supported to develop their skills and knowledge. Staff told us they found the appraisal process useful, and they were encouraged to identify any learning needs they had, and any training they wanted to undertake. Staff were supported by their managers and the practice educator to improve their practice where indicated.

Emergency nurse practitioners (ENPs) and emergency care practitioners (ECP’s) were used in the department. They were qualified to assess, diagnose, treat and discharge patients with certain injuries without having to refer to a doctor.

People using the service told us that the department ‘seemed understaffed at times’ but they felt staff were doing the best they could.

We scored the service as 1. The evidence showed significant shortfalls. The service 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.

On MAU we observed a patient in a side room who had been identified as having an infectious disease. Whilst some staff were observed entering the side room in appropriate Personal Protective Equipment (PPE) we saw nursing staff enter without any PPE and did not seem to be aware of the infection risk. We also observed domestic staff enter the same room without PPE and change the clinical waste bin and proceed to walk it through the department. We revisited the UEC during the well-led assessment in September and still observed staff entering isolation bays without donning PPE or changing PPE as required.

We observed staff were not always bare below the elbow in line with the trust’s guidance. Staff were observed to wear watches, long sleeves and jewellery. We also observed staff undertaking cannula care and phlebotomy using poor aseptic non-touch technique (ANTT) sometimes without gloves, and staff wearing gloves when not clinically indicated and moving between clinical areas without first changing gloves.

We also found sharps bins overflowing, one bin contained batteries which posed a potential risk when incinerated, and one bin contained patient medication which should not be disposed of this way. This was a breach of regulation 12 safe care and treatment. We revisited the UEC during the well-led assessment in September and found that compliance had somewhat improved regarding sharp bin management.

Staff did not always complete mandatory training for infection prevention and control, with nursing staff compliance at 55.67% and medical staff at 27.59%. The total overall compliance in the division for all staff was 50%.

The service had 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 monthly audits in more depth; the trust provided the most recent ones undertaken for UEC between January and July 2025 which showed all were above the trust target of 75%.

Data provided by the trust showed staff mostly adhered 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 in March/April, compliance across UEC was 79.6% which was below the 90% target. In May/June compliance scores were at 100%. The service had an action plan in place to improve these scores which was detailed and contained dates by which the actions needed to be completed by. Following our feedback during the inspection around PPE use and hand hygiene the IPC team conducted weekly audits to measure improvements from the action plan.

We observed that cleaning checks had been completed on the UEC areas and commodes were clean with dated stickers. Clinical curtains in all areas were also clean and had been changed within the past 6 months.

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 during this time.

We saw the wards were generally clean and tidy and people using the service told us they thought the environments were clean.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

The urgent care departments including the ED and MAU were supported by a dedicated pharmacy team 5 days a week from Monday to Friday. The assessing doctor recorded patients’ drug allergies and regular medicines. The pharmacy team worked closely with ward staff to identify and prioritise patients requiring a review of their medicines.

We saw that high-risk and time-critical medicines were given correctly. There was also good accessibility to time-critical medicines to ensure that these medicines were given in a timely manner.

Risk assessments for venous thromboembolism (VTE) were completed promptly and medicines were prescribed appropriately. We saw that the prescribing of antibiotics followed trust policy and national guidance.

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.

Medicines, including controlled drugs and intravenous fluids, were stored securely and appropriately.

There was a process in place to manage safety alerts. The Central Alert System Policy outlined procedures for patient safety alerts and MHRA alerts amongst others. Senior staff we spoke with were clear how this was managed and their responsibilities under it.