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The Countess of Chester Hospital Requires improvement

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Inspection Summary


Overall summary & rating

Requires improvement

Updated 29 June 2016

The Countess of Chester Hospital is part of The Countess of Chester Hospital NHS Foundation Trust which provides a full range of acute and a number of specialist services including an urgent and emergency care, general and specialist medicine, general and specialist vascular surgery and full consultant led obstetric and paediatric hospital service for women, children and babies.

The Countess of Chester Hospital is situated within the Countess of Chester health park in Cheshire, and provides services to a population of approximately 412,000 residents mainly in Chester and surrounding rural areas, Ellesmere Port, Neston and the Flintshire area.

Over 425,000 patients attend the Trust for treatment every year. The Countess of Chester Hospital has approximately 680 beds.

We carried out this inspection as part of our scheduled program of announced inspections.

We visited the hospital on the 16, 17, 18, 19 February 2016. We also carried out an out-of-hours unannounced visit on 26 February 2016. During this inspection, the team inspected the following core services:

• Urgent and emergency services

• Medical care services (including older people’s care)

• Surgery

• Critical care

• Maternity and gynaecology

• Children and young people

• End of life

• Outpatients and diagnostic services

Overall, we rated Countess of Chester hospital as ‘requires improvement’. We have judged the service as ‘good’ for effective, caring and well led. We found that services were provided by compassionate, caring staff and patients were respected and treated with dignity. However, improvements were needed to ensure that services were safe and responsive to people’s needs.

Our key findings were as follows:

Leadership and Management

  • The hospital was led and managed by an accessible and visible executive team. This team were well known to staff, visited most wards and departments regularly, and responded to issues that staff raised, however some staff on surgical wards did not feel they were as engaged with board members.

  • We saw that the board had taken some steps to improve communication within all staff using a variety of methods of communication including department visits, drop in sessions, newsletters and social media.

  • There was clear leadership and communication in services at a local level, senior managers were visible, approachable, and staff were supported in the workplace. Staff achievements were recognised both informally and though staff recognition awards.

  • There was a positive culture throughout teams in the hospital and staff were committed to being part of the trusts vision and strategy going forward.

Access and Flow

  • The trust had established policies and both internal and external escalation procedures in place to support access and flow across the trust which were co-ordinated though meetings held at various points though the day to assess and prioritise patient movements in the trust. This included a designated hospital team who were responsible for patient flow, and provided senior nurse presence and clinical leadership across the trust out of hours.

  • Access and flow remained a challenge in the emergency department, The trust achieved the 95% four hour target on two occasions between November 2014 and October 2015,

  • There were issues with access and flow across the medical and surgical wards with high bed occupancy rates and delayed discharges due to the complexity of patient’s needs. Some medical patients were being nursed in non-speciality beds. Trust data showed In August 2015 data showed that there were 34 patients in total, which rose to 120 in September and further increased to 130 in October 2015. We observed that this data included those patients who were supported in escalation beds within urgent care.

  • A number of extra beds had been opened to help support flow though the hospital at both Countess of Chester Hospital and Ellesmere Port Hospital, which were focused on intermediate care delivery.

  • At the time of our inspection, there were approximately 100 patients who remained in hospital due to delays in transfers of care. These were due to a variety of reasons including packages of care and decisions about community living arrangements.

  • The trust was working closely with other strategic leaders to plan system delivery, strategy and plans in order to support elective and emergency admissions, attendances and discharges to the hospital. As part of this, the trust had introduced a number of initiatives including a general practitioner admissions unit (GPAU) which opened at the end of the announced aspect of this inspection. During the unannounced inspection, we observed that the general practitioner admissions unit (GPAU) was having a positive impact on flow though the hospital and there had been a reduction in patients who were delayed in being transferred from the hospital.

  • Medical services met the national 18-week referral to treatment time targets in all specialities from September 2014 to September 2015.

  • The maternity service had closed six times during 2015 due to staff activity. This had been managed safely through the escalation policy, which involved working with other local maternity services and emergency ambulance services.

  • In January 2016, the trust achieved the referral to treatment (RTT) targets, of 95%, in all areas and specialities with the exception of ear, nose and throat at 94%.

  • All three cancer wait measures (patients seen within two weeks, 31 day wait and 62 day wait) were generally better than the England average from 2013/14 to 2015/16, although October and November 2015 were below the target of 85% for 62-day wait at 77% and 79.8% for the planned care division.

Cleanliness and Infection control

  • Clinical areas at the point of care were visibly clean; however, we did identify some cleanliness issues in urgent and emergency services, outpatients and in non clinical areas specifically related to an area within maternity services.

  • The trust had infection prevention and control policies in place, which were accessible to staff and staff were knowledgeable on preventing infection.

  • There was enough personal protective equipment available, which was accessible for staff and staff used this appropriately.

  • Staff generally followed good practice guidance in relation to the control and prevention of infection in line with trust policies and procedures.

  • Between April 2015 to December 2015, there were two cases of MRSA bacteraemia reported across the trust. Lessons from all cases were disseminated to staff for learning across directorates.

  • The hospital undertook early screening for infections including MRSA during patient admissions and preoperative assessments. This meant that staff could identify and isolate patients early to help prevent the spread of infection.

Nurse Staffing

  • The trust had established process in place to assess nurse staffing levels, which included using an evidence based tool. The trust was also in the early stages of using a workload management tool (NHPPD) from the recently published Lord Carter model hospital review. The hospital was also piloting an national activity monitoring tool, to gain robust data on required nurse staffing levels going forward.

  • The trust undertook biannual nurse staffing establishment reviews as part of mandatory requirements. As part of this, key objectives were set though this work to support safer staffing. Data provided as part of this review in January 2016 identified that over-all the trust had maintained over 95% of staffing levels planned against actual levels for nine months, however there was the recognition that additional nurse recruitment was required.

  • There were a number of initiatives in place to support recruitment, notably the trust had recently appointed 20 – 30 registered nurses from Spain.

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

  • However, nurse-staffing levels, although improved, remained a challenge across most areas. Staffing levels were maintained by staff regularly working extra shifts and with the use of bank or agency staff. Inductions were in place for new staff in order to mitigate the risk of using staff that were not familiar with the hospital.

Medical Staffing

  • Medical treatment was delivered by skilled and committed medical staff.

  • The information we reviewed showed that medical staffing was generally sufficient at the time of the inspection.

  • Data from January 2016 showed minimal use of locum cover.

  • Trust data at the time of inspection showed a turnover rate of 17.7% and a sickness rate of 0.41% for medical staff.

  • A shortage of a paediatric consultant was recorded on the divisional risk register on 21/10/15 however; approval had been obtained to increase medical staffing in this area.

  • The number of palliative care consultants was below the recommended staffing levels outlined by the Association for Palliative Medicine of Great Britain and Ireland, and the National Council for Palliative Care guidance, which states there should be a minimum of one WTE consultant per 250 beds.

  • The trusts medical staffing information confirmed 60 hours consultant cover for the delivery suite. This meant the service met the recommendation in the safer childbirth best practice guidelines.

  • Interventional radiologists worked on a rota system. There were seven consultants covering 24 hours per day, seven days a week. The trust had recently recruited three interventional radiologists to manage the increasing workload.

Mortality Rates

  • Mortality and morbidity reviews were held in accordance with trust policies and were underpinned by policies and procedures. All cases were reviewed and appropriate changes made to help to promote the safety of patients. Key learning Information was cascaded to staff appropriately.

  • The Summary Hospital-level Mortality Indicator (SHMI) is a set of data indicators, which is used to measure mortality outcomes at trust level across the NHS in England using a standard and transparent methodology. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die based on average England figures, given the characteristics of the patients treated at the hospital. Between August 2014 and July 2015 the trust score was 103, which was slightly higher than the national average.

  • Notably the hospital had achieved a ‘A’ rating for the Senital Stroke National Audit Programme (SSNAP) in 2014, which was a significant improvement from an “E” rating in 2013. The stroke service had been recognised regionally for using innovation to improve outcomes for patients.

Nutrition and Hydration

  • Patients had access to food and drink whilst in emergency assessment unit (EAU) and staff offered refreshments throughout the department.
  • We found that there were policies and procedures in place to support patients nutritional and hydration needs. Patients nutritional needs were risk assessed and results were acted upon appropriately.
  • Most patients were supported with hydration; however, we observed that within surgical wards, there was no clear system in place to identify patient in need of assistance with eating and drinking. We found that most patients received assistance with eating and drinking as needed.
  • Patients we spoke with said they were happy with the standard and choice of food available. The menus were comprehensive and there was a wide variety for patients to choose from.
  • Staff and patients had access to specialist nutritional advice from the dietician team who responded promptly to patient referrals.
  • There was an infant feeding team and ‘Bosom buddy’ volunteers to provide breast-feeding support. Mothers with babies on the neonatal unit were encouraged and supported to express milk for their babies.
  • Women on the maternity and gynaecology units were provided with snacks, meals and drinks while on the unit, fluid balance charts were completed so that oral intake could be monitored when required and when intravenous fluids were administered.
  • The trust were rolling out care and comfort worker roles to work across the wards to assist patients with nutrition and hydration.

We saw several areas of outstanding practice including:

  • The sentinel stroke national audit programme (SSNAP) latest audit results rated the trust overall as a grade ‘B’ which was an improvement from the previous audit results when the trust was rated as a grade ‘E’.
  • The trust were rolling out care and comfort worker roles to work across the wards to assist patients with nutrition and hydration.
  • We observed a theatre morning briefing which included all staff within the theatre areas. This briefing ensured that all staff were aware of theatre wide issues and safety concerns and also ensured that staff felt they were part of the wider theatre team.

However, there were also areas where the trust needs to make improvements.

Importantly, the trust must:

  • Ensure that adequate numbers of suitably qualified staff are deployed to all areas within the surgical services to ensure safe patient care.
  • Ensure that patients placed in areas outside their speciality meet the trusts criteria and ensure that there is suitably qualified staff to meet their needs.
  • Ensure that patients nutritional and hydration needs are met at all times.
  • Ensure that all staff are able to understand and apply the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.
  • Ensure that there are sufficient staff trained in adult and children’s safeguarding procedures in the accident and emergency department.
  • Ensure there are sufficient numbers of suitably qualified and skilled staff on medical wards.
  • Ensure that all medications are stored in a secure environment at all times.
  • Ensure staffing levels are maintained in accordance with national professional standards on the neonatal unit and paediatric ward.
  • Ensure that there is one nurse on duty on the children’s ward trained in Advanced Paediatric Life Support on each shift.
  • Improve the waiting times for reporting of radiology investigations.

In addition the trust should:

In urgent and emergency care services :

  • The trust should review medical record storage to ensure that records are accessible for staff easily, but mitigate the risks of the public being able to access records.

  • The trust should ensure all premises and equipment used by the service provider are clean.

  • The trust should review processes to improve access and flow through the accident and emergency department.

  • The trust should review processes of managing patients own medications in accident and emergency areas.

In medical care services :

  • The trust should ensure the electronic paper records system is robust and staff are sufficiently trained and competent in using and understanding the system.

  • The trust should ensure all patients’ records are secure.

  • The trust should ensure at all patients and staff across the trust have access to dementia services.

  • The trust should ensure that all staff receive mandatory training including mental capacity act training.

  • The trust should consider that basic monitoring equipment (blood pressure machine) is available in the discharge lounge.

In surgery :

  • The trust should ensure that all staff receive the adequate level of safeguarding training.
  • The trust should ensure that all staff are treated with dignity and respect during their course of employment.
  • The trust should ensure that staff are able and feel comfortable to raise concerns.
  • Staffing levels on some wards were below 95% of the planned target with levels less 90% on some occasions. Staff worked extra shifts and agency staff were used on a regular basis to ensure patient safety. At night the staff skill mix on the wards was not always sufficient to meet the needs of the patients as staff with specialised competencies for their area of work would be moved to support ward areas that required additional staff.

In critical care:

  • Ensure that all critical care staff are aware of Duty of Candour regulations and their responsibilities within this.

  • Ensure that there are robust procedures in place to monitor impact and reduce the numbers of patients that are delayed in being discharged from the critical care unit.

  • Ensure that there are robust procedures in place to monitor impact and reduce delays of patients waiting to be admitted to the critical care unit.

  • Consider supporting critical care patients who have been discharged from hospital to identify any psychological support that may be needed.

  • Ensure that the critical care unit achieves 50% of nursing staff have a specialist critical care qualification.

In maternity and gynaecology :

  • The trust should ensure that all areas, all fridges and equipment are clean and checked as required.
  • The trust should ensure robust systems are in place to evaluate and improve their practice in respect of incidents and all investigations relating to the safety of the service.
  • The service should review procedures for evacuation from the birth pool and consider regular drills including practising removing women from the pool.
  • Undertake robust risk assessment for the women and children’s building so that the risks associated with baby safety are maximised.
  • The provider should provide staff with opportunity to and need for staff to receive yearly individual appraisals.
  • The provider should consider producing regular updates specifically about the stages maternity and gynaecology audits have reached.
  • The provider should consider ways of supporting women to feel confident in choosing a birth plan which does not require intervention unless necessary.

Children and young people’s services:

  • The trust should take steps to ensure that resuscitation equipment is checked in line with trust policy.
  • The trust should ensure that the door to the kitchen on the children’s ward is locked and access restricted as appropriate.
  • Consideration should be given in relation to safe storage of records on the children’s ward. The notes trolley and storage cupboard should be kept locked to ensure safe storage.
  • The trust should ensure controlled medicines are checked daily in line with trust policy.
  • Consideration should be given to the introduction of a routine nutritional assessment tool for all patients on the children’s ward.
  • The trust should ensure staff attend mandatory and safeguarding training as required for their role.
  • Consideration should be given for the development of a winter management plan.

End of Life:

  • Ensure the roll out of the Care and Communication documentation across the trust.

  • Ensure all staff have appropriate End of Life training and support.

  • Evaluate and improve their practice in respect of the quality of people’s experience.

  • Ensure all staff are aware of the vision and strategy for end of life services.

In outpatients and diagnostic imaging services:

  • The trust should improve the waiting times for reporting of radiology investigations.

  • The trust should ensure staff are assured that equipment has been maintained safely.

  • The trust should consider the layout of the waiting area to provide privacy for patients when confirming confidential details.

  • The trust should consider improving the environment for children in the outpatients department as it is not child-friendly.

  • The trust should ensure that all resuscitation equipment is checked and positioned appropriately in order that it is available in an emergency.

  • The trust should ensure all equipment and clinical areas are free from dust.

  • The trust should ensure that all guidelines are clear and followed using national guidance for best practice.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 29 June 2016

Effective

Good

Updated 29 June 2016

Caring

Good

Updated 29 June 2016

Responsive

Requires improvement

Updated 29 June 2016

Well-led

Good

Updated 29 June 2016

Checks on specific services

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.

Medical care (including older people’s care)

Good

Updated 29 June 2016

We rated medical care as good because:

  • Incidents and complaints were reported via an electronic system and staff could access the system.

  • Most staff reported receiving feedback and learning from incidents and complaints.

  • Risk registers were in place; however, action plans with timelines were not documented, however risks identified in this division were reflected in trust wide initiatives in place to mitigate risks.

  • Wards were visibly clean, staff followed good hygiene practices.

  • There were good systems for handling and disposing of medicines.

  • Equipment was available and serviced as required.

  • Staffing across medical services was on the risk register and actions had been taken including recruitment overseas and regular monitoring of staffing levels during the day to help mitigate the risk. The trust biannual review stated that overall the trust had maintained over 95% of the planned staffing levels.

  • The trust had identified this as an area for improvement and a pilot of a new roster was commencing in April 2016. The trust were also undertaking a number of initiatives relating to measuring patient acuity to help plan staffing.

  • Patients risk assessments were completed and staff implemented measures to reduce risks.

  • Staff were aware of the trusts values and vision. Staff enjoyed working at the hospital, felt well supported by their managers and worked collaboratively together to ensure patient were cared for.

  • Staff treated patients and their relatives with respect and dignity and communicated with them effectively. Patients were happy with their care, felt informed, and were involved in care planning.

However,

  • Data provided showed there were occasions when the nurse staffing levels were less than 90 %.

  • There were issues with access and flow across the medical wards with high bed occupancy rates and delayed discharges due to the complexity of patient’s needs. Some patients were being nursed in non-speciality beds and on occasions in mixed sex wards, although this was based on clinical need.

  • There was a risk that personal information was accessible to members of the public as patient’s records were not always stored securely.

  • Monitoring documentation for input and output, bowel charts and cannulation checks were not always consistently completed.

  • On one ward, a large quantity of medication was found in an accessible unlocked cupboard, which was a risk to patients and members of the public.

  • Compliance with mandatory training for the majority of staff was below trust target. The trust target was 95%.

Urgent and emergency services (A&E)

Good

Updated 29 June 2016

We rated emergency and urgent services as good because:

  • Staff were committed and proud of the service they provided.

  • There were staff vacancies and bank and agency staff were successfully used to fill gaps.

  • Medical cover was sufficient and staff worked well together.

  • Staff treated patients and their relatives with respect and dignity and communicated with them well.

  • Patients were involved in care planning and felt informed.

  • Incidents were reported via an electronic system and staff could access the system.

  • Staff reported receiving feedback and learning from incidents.

  • Risk assessments were completed and staff implemented measures to reduce risks.

  • Equipment was available and serviced.

  • Medicines were stored safely.

  • Risk registers were in place.

  • Staff were aware of the trusts values and vision.

  • Staff felt well supported by the multi-disciplinary team and worked collaboratively to ensure patients were cared for.

However,

  • Access and flow was a challenge due to bed capacity, and some patients were in the emergency department for long periods.

  • Four hour targets were not being met, however patients were cared for and their needs met.

  • Clinical areas at the point of care were visibly clean, however, we observed some none clinical storage areas that were dusty.

  • We observed a storeroom with a ladder to an unlocked hatch to the roof space near the resuscitation room, action was taken during the inspection.

  • Two storerooms were found to have doors propped open; the door to the dirty utility was also propped open and the lock was sealed with tape to ensure the door did not lock.

  • There were three tubs of chlorine tablets on the shelf in the dirty utility and access to cleaning materials.

Surgery

Good

Updated 29 June 2016

We rated surgery as good because:

  • We found that staff were aware of how to report incidents and we saw evidence that the service undertook robust and appropriate incident investigations.

  • The uptake levels of mandatory training were high for both nursing and medical staff.

  • Staff were fully aware of how to raise and manage safeguarding issues appropriately.

  • Staff managed medicines well and nurse staffing levels in the theatre areas were sufficient.

  • Patients received surgical care which was evidence based and met national guidelines.

  • Clinical audits were routinely undertaken and action as a result of these was evident.

  • Patients were assessed and provided with appropriate pain relief.

  • Knowledge of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards was good in most areas however, most staff did not receive training in these areas.

  • Staff treated patients with kindness, dignity and respect and patients told us that they were happy with the care they received.

  • The surgical services were responsive to the needs of patients.

  • Information was readily available for patients in a variety of formats, which could be adapted to individual needs.

  • The access and flow within the surgical services was challenging at times, however staff managed this effectively.

  • Patients had timely access to consultant led care. The service was well led and staff respected their local leaders.

  • Staff could not articulate the trusts vision and values; however they were aware of significant work programmes taking place

  • There were robust governance frameworks and managers were clear about their roles and responsibilities.

  • There was clear leadership in the service and senior managers were visible and approachable.

  • We found the culture within the service was open and managers made efforts to engage with staff and the public.

  • We found evidence that the trusts board made attempts to engage with staff through different mediums and had implemented a speak out safely campaign.

However,

  • In some areas we found that the learning from these investigations was not disseminated fully.

  • We found that Nurse staffing levels on the surgical wards were not always sufficient to meet patients needs.

  • Some staff raised concerns about leaders at trust board level, and these concerns included lack of visibility and support and fear of raising concerns.

Intensive/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.

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.

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.

Outpatients

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.