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The Countess of Chester Hospital Requires improvement

This service was previously managed by a different provider - see old profile

Inspection Summary


Overall summary & rating

Requires improvement

Updated 17 May 2019

Our rating of services stayed the same. We rated it them as requires improvement because:

  • Our rating for safe at this hospital stayed the same as our previous rating. We rated safe at this hospital as requires improvement. This was because we rated safe as requires improvement across all three services inspected during this inspection. There was also one service (services for children and young people) that was not inspected on this visit that was rated as requires improvement.
  • We rated effective at this hospital as requires improvement. This went down from the rating of good following our previous inspection. This was because we rated effective as requires improvement in surgery during this inspection. There was also one service (end of life care) that was not inspected on this visit that was rated as requires improvement.
  • Our rating for responsive at this hospital stayed the same as our previous rating. We rated responsive at this hospital as requires improvement. This was because we rated responsive as requires improvement in the medical care and urgent and emergency care services during this inspection. There were also two services (critical care and end of life care) that were not inspected on this visit that were rated as requires improvement.
  • We rated well-led at this hospital as requires improvement. This went down from the rating of good following our previous inspection. This was because we rated well-led as requires improvement across all three services inspected during this inspection. There was also one service (end of life care) that was not inspected on this visit that was rated as requires improvement.
  • We rated caring at this hospital as good. This stayed the same as our previous rating. Across all the services we inspected, we found staff treated patients with kindness, compassion, and respect. Patients and their relatives commented positively about the care they received.
  • We rated urgent an emergency care as requires improvement overall. Our rating went down since the last inspection. We rated effective and caring as good. We rated safe, responsive and well led as requires improvement because we identified areas for improvement in relation to the equipment, environment and layout and staff culture within the department.
  • We rated medical care as requires improvement overall. Our rating went down since the last inspection. We rated effective and caring as good. We rated safe, responsive and well led as requires improvement because we identified areas for improvement in relation to medicines management, management of risks and staff culture within the service.
  • We rated surgery as requires improvement overall. Our rating went down since the last inspection. We rated caring and responsive as good. We rated safe, effective and well-led as requires improvement because we identified areas for improvement in relation to nurse staffing levels, management of patient risks and management of patients with sepsis.
Inspection areas

Safe

Requires improvement

Updated 17 May 2019

Effective

Requires improvement

Updated 17 May 2019

Caring

Good

Updated 17 May 2019

Responsive

Requires improvement

Updated 17 May 2019

Well-led

Requires improvement

Updated 17 May 2019

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 17 May 2019

Our rating of this service went down. We rated it as requires improvement because:

  • Staff did not always keep themselves, equipment and the premises clean.
  • The service did not have a suitable environment in all wards and equipment was not always looked after well.
  • Staff did not always complete and update risk assessments for each patient. They did not consistently record risk accurately and did not always know when to escalate, or ask for support when necessary.
  • Best practice was not always followed when storing medicines.
  • The service did not use safety monitoring results well.
  • Managers did not always monitor the effectiveness of care and treatment and used the findings to aid improvement.
  • The trust did not always plan and provide services in a way that met the needs of local people.
  • Morale was poor amongst staff throughout the medical wards.
  • Staff told us that they had received verbal abuse from patients and their families who had been admitted to the escalation beds this was due to them not being happy with the lack of dignity and equipment the bed space provided.
  • We were told by staff that it was very rare to see any of the executive team.

However;

  • The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately.
  • Staff were encouraged and given opportunities to develop.
  • Staff cared for patients with compassion; feedback from patients was positive and confirmed that staff treated them well and with kindness.
  • Staff provided emotional support to patients to minimise their distress, patients consistently told us that if they became upset staff gave reassurance.
  • Staff involved patients and those close to them in decisions about their care and treatment

Services for children & young people

Good

Updated 29 June 2016

We rated services for children and young people as good because:

  • We saw evidence that incidents were being reported and that information following clinical incidents was fed back to staff in daily safety briefings.

  • Cleanliness and hygiene was of a high standard in areas we visited and staff followed good practice guidance in relation to the control and prevention of infection.

  • Care was delivered by caring and compassionate staff and the differing needs of children and young people were considered when delivering care.

  • Facilities were available for parents to stay with their children.

  • 97.6% of children and young people were seen within the 18 week target time and correspondence with GPs following admission or treatment was sent in a timely fashion.

  • The hospital at home service enabled children to be treated in their own home or reduced their stay in hospital.

  • Managers had a good knowledge of performance and were aware of the risks and challenges to their service.

However,

  • Nurse staffing levels on the children’s unit did not reflect Royal College of Nursing (RCN) standards (August 2013) and nurse staffing levels on the neonatal unit did not meet standards recommended by the British Association of Perinatal Medicine (BAPM).

  • The neonatal unit lacked storage space and resources for barrier nursing.

  • There was not always a member of nursing staff on duty with Advanced Paediatric Life Support (APLS) on the children’s unit.

Critical care

Good

Updated 29 June 2016

We have rated critical care services as good because:

  • Incidents were reported and acted upon and used continuously as a service improvement tool

  • Safety thermometer data was collected and displayed in public areas for patients and relatives to view.

  • Performance results were also shared with staff in critical care in a monthly unit newsletter, together with results from relative’s surveys.

  • There were sufficient numbers of suitably skilled nursing and medical staff to care for the patients.

  • The service took part in the intensive care national audit and research (ICNARC) data so we were able to bench mark its performance and effectiveness alongside other similar specialist trusts.

  • The trust performed well, however data indicated some concerns regarding delayed discharges.

  • The trust had an outreach team with five critical care trained, dedicated members of staff who supported wards in the early detection and treatment of acutely unwell patients.

  • There was evidence if a multidisciplinary approach to caring for the patients. Ward rounds included consultants, a physiotherapist, a pharmacist, a junior doctor, a nurse, SHO and a member of the outreach team.

  • There was adequate number of nursing and medical staff to provide a seven-day service.

  • Staff were aware of the vision for the service and had strategies in place for innovation and improvement.

However,

  • We did find that that the unit fell below the intensive care society’s recommended level of staff who held a post registration award in critical care nursing.

End of life care

Requires improvement

Updated 29 June 2016

We rated end of life services as requires improvement over-all because :

  • There was an insufficient number of general nursing staff who had received appropriate training regarding end of life care and the replacement for the withdrawn Liverpool Care Pathway [LCP] the care and communication record [CCR].

  • The trust performed worse than the England average in five of the seven organisational key performance indicators for the National Care of the Dying Audit 2014. However an action plan is currently in place to address the issues identified in the 2014 audit.

However,

  • There was a three-year vision developed by the trust's end of life committee. We found this had been communicated to most general ward teams. We found evidence of an overarching monitoring of the quality of the service across the trust. Complaints were responded to appropriately.

  • Specialist palliative care nurses we spoke with were able to describe safeguarding procedures and provided us with examples of how these would be used.

  • All of the general nursing staff we spoke with were aware of how to report an incident or raise a concern.

  • Appropriate equipment was available to patients at the end of their life; the equipment at the hospital was adequately maintained.

  • Medicines were managed appropriately.

  • Patients were involved in care planning and decision making. Staff were respectful and treated patients with compassion.

  • Specialist nurses were visible, competent, and knowledgeable.

  • The trust had a dedicated specialist palliative care team [SPCT] who provided good support to patients at the end of life. Care and support was given in a sensitive and compassionate way.

  • On the wards staff worked hard to meet and plan for patient’s individual needs and wishes.

  • Staff within the [SPCT] team were very motivated and committed to meeting patients’ different needs at the end of life and were actively developing their own systems and projects to help achieve this.

Maternity and gynaecology

Good

Updated 29 June 2016

We rated Maternity and gynaecology as good because:

  • The trust had systems in place to review midwifery staffing levels using latest national guidance (National Institute of Clinical Excellence : Safe Midwifery staffing for Maternity units 2015 NG4) and were in the process of employing addition midwives following the most recent review in January 2016.

  • Clinical areas at the point of care were clean.

  • The trust provided clear procedures for reporting incidents and the electronic reporting system was accessible to the majority of staff.The trust treated incidents seriously and ensured completed investigations.

  • Multiagency and disciplinary working was established and promoted the best outcome for mothers and their babies.

  • The record keeping systems were effective ensured accurate and up-to-date information about patients was readily available.

  • Women were cared for with kindness and compassion and were positive about the standard of care and treatment provided by the maternity and gynaecology services.

  • The service encouraged and supported learning and development. The ratio of supervisors of midwives to midwives was 1:14 which better than the recommended 1:15.

  • The trust ensured staff followed best practice guidance and participated in national and local audits in relation to care and treatment.

  • The majority of staff felt communication between ward staff and senior managers was effective.

  • Midwives subscribed to the philosophy of the nursing and midwifery council six of compassionate care and we saw this in practice.

  • There was an active local maternity network which involved stakeholders and service users in place to help inform maternity services going forward.

  • The gynaecology ward and clinics were well run by the gynaecology service and ward managers.

However,

  • The number of midwives employed did not meet best practice Birthrate Plus recommendations. This resulted on the closure of the unit and delays in procedures for women using the service on rare occasions.

  • The layout and security detection arrangements meant mothers and babies weren’t always monitored, however access to the unit was monitored by close circuit television at key points across the unit, and access was restricted either by a staffed reception or swipe access door.

  • General cleanliness in non clinical areas on the central labour suite and Cestrian ward needed to improve.

  • During inspection we did not find evidence of emergency response training did not included drills for dealing with common obstetric emergencies. However, the trust informed us that this was covered on induction and also using innovative methods of teaching.

  • The trust did not provide midwives, health care assistants and midwife assistants with individualised appraisals.

  • The trust did not employ a specialist bereavement midwife; however, there were two link bereavement midwives.

  • The management system for audits needed to be improved and sharing the lessons learnt from incidents, audits and complaints was not well established.

  • There were not enough opportunities for midwives to meet and review the safety of the ward or unit during each shift.

Outpatients and diagnostic imaging

Good

Updated 29 June 2016

Overall we found the outpatient and diagnostic service as good because:

  • There was strong reporting culture with staff reporting incidents via the trusts electronic system. There was some learning from incidents, although similar incidents continued to be reported in radiology areas.

  • Systems were in place for the maintenance of equipment. Processes were in place for daily checking of resuscitation equipment.

  • Any prescribed medications were stored in locked cupboards and there was no controlled drugs or intravenous fluids stored in outpatients at COCH. Patients’ records were maintained on paper and via electronic systems, although; plans for changes in electronic systems were in place.

  • Staff had received mandatory training, although some groups were not up-to-date with safeguarding requirements. There was some staff shortages identified, although recruitment processes were in progress.

  • There was a caring culture embedded in all areas visited and from all members of staff we met. We observed good, compassionate care being delivered.

  • Reception staff were polite and helpful. Patients and their relatives were very positive about the staff in outpatients and radiology. They said they were supportive and communicated well. We observed respectful interactions between staff and patients.

  • Staff actively involved those close to patients with initiatives in place to support relatives of patients who attended regularly.

  • There was specialist staff in clinics with good multidisciplinary working, although not all had been appraised annually.

  • Services were available seven days a week.

  • Consent for procedures was obtained although by different clinicians.

  • There were audit plans in place and good use of the WHO safety checklist, for radiological interventions, was observed.

  • The outpatient and diagnostic services were available at both Countess of Chester Hospital (COCH) and Ellesmere Port Hospital (EPH). The main activity was at COCH with a small department at EPH for routine care of patients in the local area.

  • Targets of referral to treatment targets were within national guidelines, however; there was a wide variation in waiting times for individual consultants. Extra clinics were arranged, out of hours and at weekends to manage the demands of the local population.

  • There was support for patients with individual needs including visually impaired, hearing impaired, learning disability or dementia.

  • There was evidence of learning from complaints and how changes had been implemented.

  • There was a clear vision and strategy for the future.

  • The management teams were stable and committed to patient well-being in both out patients and diagnostics despite challenges.

  • There were governance processes embedded with action plans in progress to improve services. Waiting list initiatives took place to meet demands of the local population.

  • There were regular meetings, at all levels. Staff felt supported by their line managers and there was good team working in the departments.

  • There were several innovations taking place with plans to increase services.

  • Radiology trust guidelines and standard operating procedures were in place although not always clear and robust. There had been recent reviews of procedures.

  • There were delays in reporting in radiology, which meant there could be delays in treatment. The trust had responded to increased demand by outsourcing x-ray reporting.

However,

  • There was dust found on some medical equipment.

  • In the nuclear medicine department of radiology, we observed that a prescribed medication was not always signed as administered.

  • There were delays in reporting in radiology, which meant there could be delays in treatment. The trust had responded to increased demand by outsourcing x-ray reporting.

Surgery

Requires improvement

Updated 17 May 2019

Our rating of this service went down. We rated it as requires improvement because:

  • Nurse staffing on surgical wards was not always sufficient to meet the needs of patients because there was insufficient flexibility in the staffing to deal with unexpected demands in the service or higher acuity of patients. This led to an increase in avoidable incidents, caused delays in care and contributed to morale issues and high staff turnover. The division used high levels of bank and agency staff to supplement permanent staff and moved staff around to fill gaps in staffing levels.
  • Staff in theatres did not always comply with the World Health Organisation (WHO) surgical safety checklist as there were omissions and inconsistencies in its application.
  • There were not enough staff that had the recommended levels of children and young persons’ safeguarding training on the Jubilee Ward.
  • The service did not always implement measures to reduce the risk for some patients. The service did not always highlight patients’ individual risk effectively to alert other staff to those risks.
  • The service did not effectively demonstrate a robust approach response to sepsis identification and treatment. Not all staff had received training and processes were not embedded. It was not always clear how sepsis fitted with early warning scores processes.
  • Patient records were not stored in a way that prevented unauthorised access.
  • Some fire escapes had been blocked by patient beds, furniture, equipment or items stored in front of them.

However:

  • Staff recognised incidents and knew how to report them. Managers investigated incidents in a timely way, lessons and learning were shared and this led to positive changes in practice. Staff were aware of incidents and knew were familiar with changes that came from them.
  • Staff demonstrated compassion and kindness as they undertook their work and in delivering care and treatment of their patients. Patients, families and carers gave positive feedback about their care, staff involved patients and those close to them in decisions about their care and treatment. Patients had time to ask questions, have them answered and were asked their opinions.
  • Staff knew how to deal with complaints and concerns and complaints were acknowledged, investigated and responded to in an appropriate way. Lessons were learned and changes implemented based on complaints and patient feedback. The service recognised the cultural and religious needs of patients and their families. Interpreters and translation services were available and leaflets were available in a range of languages. Spiritual support was available and staff were respectful of the cultural needs of patients and their families.

Urgent and emergency services

Requires improvement

Updated 17 May 2019

Our rating of this service went down. We rated it as requires improvement because:

  • There was a lack of cleaning rotas for the department. Domestic staff did not evidence that cleaning schedules had been followed and completed and there was no evidence to say that specific areas of the department, or the toys in the children’s waiting area had been cleaned.
  • The children’s waiting area was diagonally opposite the room used for patients attending with mental health issues, leaving children potentially exposed to distressed and agitated patients.
  • There was no emergency call bell in the ambulance hand-over area.
  • There was no sink for hand washing within the ambulance hand-over area and only one electrical socket, when there could be up to three patients on trolleys in this area at any one time.
  • The resuscitation trolleys within the department did not have evidence of daily checks being completed. One of the trolleys had 53 days out of a three-month period where it had not been checked and documentation for the checks that had been done was disorderly and incomplete.
  • The service only had a total of three children’s nurses, so were unable to meet the Royal College of Paediatric Child Health standard of two children’s nurses per shift in an emergency department treating children.
  • Although the service participated in the Royal College of Emergency Medicine (RCEM) audits between 2016-2017, the department failed to meet any of the national standards for the audits in: moderate and acute severe asthma, consultant sign off and severe sepsis and septic shock.
  • There was an issue with the privacy and dignity of patients within the ambulance hand-over area, as when there was more than one patient waiting in the area, any other patients and their carers/relatives could hear conversations regarding other patients. This was also evident for those waiting on ambulance trolleys, who were also able to hear other hand overs and histories being taken on poorly patients. There was only one curtain inside the ambulance hand-over area, but there could be up to three patients within that area at any one time, which meant that privacy and dignity could not be maintained for all patients and this also left the risk of children being next to adult patients within the same area.
  • Not all the staff we spoke with reported a very approachable, open and honest culture where leaders were easily accessible and supportive, as during the inspection, we were told about some issues of bullying.
  • Whilst speaking with staff, we asked about the trust’s Freedom to Speak Up Guardian/Champion and if they knew who this was and how to contact them. Out of all the staff we spoke with, none were aware of who this was and what this role entailed.

However:

  • Staff knew how to keep people safe from abuse and worked well with other agencies to do so.
  • Staff used personal protective equipment when delivering patient care and we saw staff observing the arms ‘bare below elbow’ policy.
  • Improvements had been made to the rooms used for patients presenting with mental health issues, to reduce ligature points.
  • All patients arriving at the department were seen and triaged by a clinically trained practitioner.
  • We saw evidence of National Early Warning Scores (NEWS) being used appropriately with each patient and action being taken when scores became high.
  • There was an effective multidisciplinary team working environment within the service, particularly within the emergency multi-disciplinary unit, which operated Monday to Friday 9am until 5pm.
  • The department could access mental health services for patients requiring a mental health assessment 24-hours a day seven-days a week from a local mental health trust.
  • Throughout our inspection, we saw all staff interacting with patients, carers and family members in a very caring, polite and friendly manner. All the people we spoke with during the inspection were happy with the care and treatment provided by the service.
  • During inspection we spoke to eight patients and carers. All of them reported the care to be good and the staff to be very kind and supportive and could not do enough to help.
  • The department employed a mental health coordinator to work with all patients in the department experiencing mental distress. The department had introduced a bereavement re-call service, which was for any relative or carer to be invited to the department to speak with senior staff, if their loved one had died within the department. We saw enthusiasm and a real sense of team working from speaking to staff. All the staff we spoke with regardless of role, were open, honest and very helpful.