The Countess of Chester 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 inadequate. At this assessment the rating has stayed the same. This meant people were not always cared for safely.

Patients were frequently treated in unsuitable and unsafe areas, including corridors, with little privacy or dignity. Staff did not always have the training and resources needed to manage risks effectively, particularly for patients with mental health needs. Infection control was poor, with visibly dirty environments and outdated or unsafe equipment. Medicines were not always stored, administered or recorded properly. Staffing levels had improved, however did not always meet the standards.

We found the service had a good learning culture and although training figures were below required compliance staff responded appropriately to safeguarding concerns.

This service scored 34 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We reviewed investigation reports for incidents which demonstrated a good level of family and patient involvement in the investigation of incidents. Families and patients were given the opportunity to ask questions as part of the investigation, and these were investigated and reported on.

Leaders could articulate the themes and trends of incidents in the department, the action they had taken to address these, and the methods used for feeding back to staff.

Staff told us they were encouraged to report concerns and incidents and had regular feedback when they do report incidents. Staff felt well supported by senior staff and that the trust would take action to ensure that incidents and near misses reported would not happen again.

The service had the relevant policies and procedures in place to learn from incidents and near misses and this learning was shared with staff. Safety incidents were investigated as an opportunity to put things right, learn and improve. Managers kept staff aware of safety incidents and complaints, with learning shared through daily safety huddles. Lessons were learned, resulting in changes that improved care for others.

The service had regular simulation training sessions for staff on various trauma and emergency scenarios.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong. The departments compliance with duty of candour was 87.5% for the previous 3 months incidents resulting in moderate harm and above.

The service did not work well with people and health system partners to establish and maintain safe systems of care.

Between September 2024 and January 2025 more ambulances took longer than 60 minutes to receive a handover when compared to the Integrated Care System (ICS, North-West region and England statistics. Whilst patients are held in ambulances, they are unable to be effectively treated, and the incident data showed several occurrences of delays to treatment for sepsis and hyperkalaemia. This also put patients at risk who were waiting in the community for ambulance services.

Feedback from partners also said that patients would sometimes be held in ambulances for prolonged periods of time due to limited capacity in the ED and had been episodes where patients had deteriorated whilst waiting in ambulances. Partners gave feedback that there had recently been an increased focus on reducing tolerance for very long waiting patients in ED which had led to reduction in waiting times.

The department operated a rapid assessment and treatment system in majors; however, leaders told us that during times of increased pressure this system would stop, and the cubicles would be occupied by patients. This posed an increased risk to critically ill patients and increased length of stays in ED.

Patients could be streamed internally to the urgent treatment centre and the same day emergency care (SDEC). SDEC's purpose was to divert attendances away from the emergency department, to reduce pressure on the department and give patients appropriate care in a timely manner. However, on our visit to the emergency department we saw that due to patients being "bedded" in SDEC overnight because of overcrowding in ED, the SDEC was unable to operate. This meant patients were sent back to ED, compounding the pressures on the department further.

Staff did not always make sure there was continuity of care, including when people moved between different services. The trust had a guideline for specialty acceptance and transfer which set a clear point of when a team became responsible for a patient's care and treatment when a specialty referral was made. This was good practice; however, staff were unaware of this policy. We saw a patient who had results indicating they were critically unwell; staff had not escalated them for over 24 hours as they were unsure of who had responsibility for them. We raised this immediately with clinical staff and the medical director and this was addressed.

The trust had a standard operating procedure for caring for patients in non-clinical areas such as corridors in ED, however this procedure only briefly outlined exclusion criteria for this area which was patients who were on oxygen. This meant high risk patients could be placed on the corridor inappropriately and we observed a patient on oxygen being cared for on this corridor.

People's feedback showed dissatisfaction with waiting times and mixed comments around being kept up to date with waiting times and treatment.

SDEC and the Urgent Treatment Centre (UTC) had standard operating procedures in place that detailed which patients were or weren't appropriate to be streamed to these areas, however staff told us that this was not always followed, and acutely unwell patients were sometimes sent inappropriately.

Leaders met throughout the day to discuss patient flow issues such as risks relating to ambulance waits and long wait patients in ED. The systems implemented by the trust ensured that leaders at all levels were sighted on performance and risk within the department which was an improvement from our previous inspection.

Triage times for physical health attendances were mostly in line with the NHS England target time of 15 minutes, with an average of 16 minutes for adults for the last 12 months and 13 minutes for children and young people. Information on triage times for mental health attendance is reported under the equity in access quality statement.

Not all staff had training on how to recognise and report abuse, however those we spoke with understood how to protect people from abuse. The service worked well with other agencies to safeguard people.

Most staff had completed level 1 safeguarding in both children and adults with compliance rates 100% and 96% for this level. However, levels 2 and 3 training had lower compliance below the target compliance rate of 90% ranging from 73% to 88.4%.

Not all medical staff had completed safeguarding training, with 84% for level 2 in both adult and paediatric services and level 3 at 77% for adults and 81% for paediatrics, all below the 90% target.

However, nursing staff were mostly trained with compliance levels of 92-93% in all levels.

Staff knew how to report safeguarding concerns. We reviewed the care of a patient presenting with significant harm. During our observation, staff demonstrated sensitivity and professional curiosity, correctly identifying and reporting safeguarding concerns.

Staff had access to relevant partner organisations’ records for safeguarding children and young people.

The service did not work well with people to understand and manage risks. Staff did not always provide care, to meet people’s needs, that was safe and supportive.

Our assessment found that staff were not always appropriately and consistently assessing and managing risk to patients, including the management of mental health needs.

Staff assessed the risks of mental health at triage, but did not formulate and record a risk management plan including the required level of observation and/or the placement of the patient within the department. Staff did not always document observations in line with patients’ care plans. We found these issues during our previous inspection and told the trust it must act. The trust had failed to make the improvements required.

The trust relied on a third-party independent provider to support observations of patients with mental health risks.

Patient records, feedback from staff and leaders and incident data showed that the third-party provider was routinely unavailable to support observations, frequently discontinued observations with little to no notice and were generally unreliable.

We observed a staff member employed by this service using their mobile phone and placing themselves away from the patient behind a door where constant observations could not be maintained for a period of 15 minutes. Incident data also showed an incident where ED staff had found the third-party provider staff asleep whilst on continuous observations.

We observed 3 patients that were deemed to require constant observation to manage their risks. Nursing notes indicated the third-party provider was not available to support observations, however the risk management plan had not been revised. The records showed no evidence of how staff managed the risk to the patient presented by their mental health. We observed that 1 patient had presented following a suicide attempt with a ligature and had not had a ligature risk assessment completed and was unobserved in an area where ligatures were accessible.

The reliance on this service to support observations and failure to reassess the risks to patients when this service wasn’t available put patients at increased risk of self-harm and suicide.

We observed a medical handover; this handover was an improvement from our previous inspection however did not include all the patients that were in the department, risking patients deteriorating without oversight.

Not all medical staff attended the handover due to differing shifts and there was no documentation of the handover for those coming in later. We observed a medic in Resus who had come in for a later shift and was unaware of what the patients were there for. We saw 1 patient that had a trauma pneumothorax which is a life-threatening medical emergency and should be treated as quickly as possible. They had required a chest drain to be inserted 12 hours earlier, but this had not been handed over causing further delays.

Leaders told us that restrictive practice was not common and that any use of restraint would be incident reported and monitored. We saw evidence that restraint was incident reported.

Partners shared feedback about positive engagement related to hyperacute stroke care risks. Partners also said that the department communicated incidents and learning well.

We observed that the nursing handovers had improved from our last inspection with clear processes for staff to share information between shifts.

The service did not always detect and control potential risks in the care environment. Staff did not make sure that equipment, facilities and technology supported the delivery of safe care.

The service still did not meet national guidance on resuscitation capacity within the department. The department had three resuscitation cubicles which was insufficient spaces for Resus based on the number of patients that attend the department. This had been raised as an issue on the last inspection of this service. However, the service had plans to increase the capacity of Resus.

We observed a patient being cared for in a small corridor between main ED corridor, Resus and Majors areas which had not been designated as an escalation space or risk assessed as such. This was between 2 fire doors blocking the fire evacuation route and had no call bell. The corridor was busy due to its location between departments and with the relatives' room next to it. There was a glove dispenser above the bed and the door release button next to it. This area was inadequate for patient care as it did not have the necessary functions and was not dignified which will be covered in the responsive section. We raised this at the time of the inspection and immediate action was taken to remove this area from use.

We found that not all electrical equipment in the department had portable appliance testing (PAT) test stickers on, some that did were dated as far back as being due for retest in 2022. We found 2 extension cords that were several years past their test date and 1 with damaged insulation exposing the wires which is a danger of electrocution and fire. We noted that these were being used for the escalation bed in the small corridor space. This meant the equipment presented a fire risk whilst the bed blocked the fire exit.

Not all medical devices had service date stickers on meaning staff were unable to know if these were within date or not before use. Some of the equipment that did have stickers on were out-of-date and were not listed as being in the ED in the records so were not being tested or serviced.

We found stock that was out-of-date across the service including blood sample bottles, needles and bottles of liquid nutrition. This was raised and was addressed overnight. However, we identified issues with out-of-date equipment in our previous inspection and so this is a repeated breach of regulation.

We observed that the ED had 2 sets of emergency call bell systems in place with 1 no longer functional. Not all old emergency call bells had signs over advising not in service, which posed a risk as the incorrect one could be pulled in an emergency, and no one would respond.

We found a cupboard unlocked with the door open that contained cleaning chemicals that should be stored securely in line with regulations. We raised this at the time of inspection and action was taken to ensure the lock on the cupboard was fixed and was something that had been reported to maintenance prior to our visit.

The service did not make sure there were enough qualified, skilled and experienced staff. Leaders and staff told us, and we observed that the trust was not able to consistently maintain staffing in line with the requirements for Resus. The NICE guidance states for the resuscitation area there is 1 registered nurse to 2 cubicles in the Resuscitation area; meeting nurse-to-patient ratios for major trauma and cardiac arrest which require 2 registered nurses to 1 patient and priority ambulance calls requiring 1 registered nurse to 1 patient. We saw 1 registered nurse for 4 patients in Resus, 1 required assistance with a chest drain insertion which meant the other 3 patients did not have any staff monitoring or supporting them. Following our visit and in response to the concerns we raised, the trust told us the service now allocated two nurses to Resus to ensure nurse to patient ratios were maintained in line with national guidance.

Not all staff had competed mandatory level 2 resuscitation training, with medical staff compliance rates 77% for adults and 73% for paediatrics. Nursing staffing was also below target at 87% for adults and 86% for paediatrics.

For mandatory training on managing the deteriorating patient including sepsis compliance was also below the trust's target of 90% with medical staffing at 77%, UTC 71.4% and ED nursing staffing just under at 89.4%. Low training compliance puts patients at increased risk as staff may not have the skills and competencies to respond to emergency situations.

People told us that they did not think there were enough staff, and that staff were doing their best but were distracted as they were so busy. In Healthwatch feedback staff were described to be 'run ragged'. However, people told us they felt confident in staff's competency. This was also reflected in the 2024 patient experience survey with 94% of patients voting they had confidence and trust in the staff in ED.

Data showed there were higher numbers of admissions per consultant whole time equivalent (WTE) and all staff WTE compared to the England average for this trust, however, staff told us that staffing levels had improved since our previous inspection and the only area that was left consistently short was Resus.

The service was below establishment by 4 WTE career grade medical staff and 4 medical trainees. Vacancy rates by percentage were not provided. The service had 1 more consultant grade doctor than budget establishment.

The service had 6% vacancies for registered nurses and healthcare assistants.

The average sickness absence rate for medical staffing was 5.5% and for nursing staff 8.2%.

Leaders told us that for nurse staffing, agency usage had reduced and mostly consisted of bank staff familiar with the department. Data showed that for December 2024 to February 2025, 24% of shifts were filled by bank and agency staff which was an improvement from the previous inspection, with only 2-5% agency use and bank at 18-20%. Leaders told us that most bank staff were substantive at the trust in their areas.

In the previous 3 months there had been a high percentage of shifts filled by locum doctors at 72.3%. Despite this only 89.1% of medical shifts were filled for ED in the last 3 months.

Leaders and staff told us that the patients on the corridor now had their own allocated nursing establishment each shift. There were now 2 registered children's nurses on each shift.

New staff had an ED specific induction which covered identifying and managing the deteriorating patient, venepuncture and cannulation training. They would be supported by the 2 practice development nurses for ED.

Staff told us about new programmes and improved oversight and resource to support mandatory training, role specific training and opportunities for bespoke training within the department.

The trust had recruitment, capability and disciplinary processes in place.

The service did not assess or manage the risk of infection. Throughout the urgent and emergency care service we saw equipment and the environment was visibly dirty. The waiting room chairs and tables were worn, making them an infection risk as could not be cleaned adequately.

Staff did not detect and control the risk of infection spreading.

The department had low compliance scores for all audits relating to infection prevention and control (IPC). Audits were inconsistent with only some areas audited each month and not all. The audits showed the department did not have effective IPC procedures in place which increased the risk of infection to patients.

Audits showed that between December 2024 and February 2025 that only 47% of commodes were visibly clean on inspection.

The IV line audit for areas in urgent and emergency care the scores were low, at 54.7% for blue majors in December, 41% for red majors in January 2025 and ranged between 33.8% and 54.7% for February across red majors, UTC and ambulatory majors.

Hand hygiene audit compliance between December 2024 and February 2025 was consistently below the trust target ranging from 61% to 74.1%.

The enhanced environmental audit scored 61.7% in December 2024 and 60.5% in January 2025 for ED areas.

For December 2024 and January 2025 no IPC champion audits were undertaken in ED, which demonstrated a lack of monitoring and oversight of IPC in the department.

We requested a copy of the infection prevention and control risk assessment for escalation areas. This was not provided and so we could not be assured that this had been done.

People’s feedback showed that patients had found the ED to be dirty and unclean, including the waiting room toilets and cubicles. We also observed that not all equipment and areas were clean including dressing trolleys, curtain rails and waiting room vents.

The cleanliness of the department was addressed overnight on our inspection following feedback; however, we have raised this issue as a breach of regulation in the 5 inspections of this service undertaken since 2016. The repeated failure to address this area for improvement has led to CQC taking more significant enforcement action following this latest inspection.

Not all staff had completed the relevant mandatory IPC training to their role, with medical staffing compliance rate 78%and nursing staffing compliance just under the 90% target at 89%.

However, we did observe good Aseptic Non-Touch Technique and sterility for an invasive procedure in the department.

Medicine management was not always in line with relevant best practice and professional guidance.

The trust had a policy which permitted staff to use a cubicle in paediatric ED for the purposes of sedation. However, this room did not have the space or necessary equipment to undertake this intervention safely in line with national guidance. The trust had not effectively assessed the risks of carrying out sedation in this area.

An audit on procedural sedation in the ED had shown limited assurance when last completed and was due to be reaudited in May 2025.

Staff did not maintain complete and contemporaneous records of the administration of medicines. We observed a patient being given local anaesthetic for a procedure. This medicine dose was not documented for several hours as being administered until one of our team intervened. Without a complete record of medications administered during an episode of care, there was a risk this patient could therefore have been overdosed. We escalated our concerns during the assessment and ensured staff took immediate action.

We found medicines that were not stored correctly, and fridge temperature checks were not completed consistently. In February 2025 staff had not completed daily fridge checks in Resus for 9 days out of 25. We found similar gaps in fridge checks in other areas of the department including the UTC and majors.

Audit data demonstrated that oxygen therapy compliance had improved and was 82% for November 2024 and 100% for October and December 2024 and January 2025.

Leaders told us pharmacy provision provided to ED had improved medicines arrangements for patients upon discharge and discharge processes.