The Countess of Chester Hospital

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

The service’s culture did not ensure staff consistently modelled positive or professional behaviours, with instances of inappropriate behaviour not in line with the trust’s vision and strategy. Leadership at departmental level lacked clarity and consistent visibility, and appraisal compliance was below target. Governance and accountability were weak, with repeated failures to address known risks, regulatory breaches, and poor audit outcomes in areas such as cleanliness, equipment maintenance, and sepsis care. Staff experiences with raising concerns were mixed.

However, we found executive leaders were visible and supportive, and staff development was encouraged through various training and progression opportunities. The service demonstrated a strong commitment to diversity and inclusion, supported by high training compliance and strategic oversight. The service mostly engaged effectively with partners and showed a commitment to continuous improvement through innovative initiatives aimed at enhancing patient care and system flow.

The service was in breach of legal regulation in relation to the governance of the service.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff did not always demonstrate a positive and professional culture within the department. There were 2 examples during our assessment where staff used language that was not in keeping with professional standards and was inappropriate in a clinical setting. One instance involved unprofessional language from staff in the presence of patients and their loved ones.

We escalated this at the time of inspection, and this was dealt with by senior leaders.

We heard from managers who told us addressing culture within the department was one of their top priorities following themes identified from complaints.

The 2024 staff survey results for the urgent care division were similar to the 2023 results with the division scoring slightly lower than the overall organisation and the national benchmark for most categories.

The trust had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Managers supported staff to develop through appraisals of their work. However, compliance levels were below the trust target of 90%. For ED medical staff, compliance was 58% and for nursing staff was 75%. The UTC compliance rate was 62.5%.

Staff gave mixed feedback on support from leaders, varying by the level of leadership. They felt supported by the executive leadership team saying that the chief executive officer and the chief operating officer were visible in the department but said that senior and departmental leaders were not as visible.

There was a leadership structure for the division however this was not clear for staff about who had responsibilities and ownership of issues or areas of the service.

Leaders had the skills, knowledge, experience and credibility to lead effectively. The department had a new matron in post who had progressed within the department to that role. Staff felt that this was positive and felt supported.

The trust had a "Talent and Succession Planning Strategy". The trust provided access for staff to a wide range of continuing personal development including internal and external leadership and management offers, apprenticeships for all levels and access to higher education programmes of study.

Staff told us that they had used the trust's internal transfer process to move into roles in ED to develop their practice.

The division displayed FTSU information so that staff knew how to raise concerns, however, staff gave mixed feedback with some stating they did not always feel that they could raise their concerns or that their concerns would be acted on and others feeling that their concerns and incidents were learnt from.

The trust’s staff survey results showed an improvement from 2023 on percentage of staff that felt secure to raise concerns about unsafe practice with 66.2% stating they agreed and strongly agreed with the statement, which was similar to the national average.

Leaders told us staff were encouraged to raise concerns via various channels including the intranet, posters and via meetings. The FTSU process was explained to new members of staff on their induction.

The trust had developed a freedom to speak up strategy in January 2025. The trust had a freedom to speak up policy in place which gave staff details on how to raise a concern and get advice and support.

The service valued diversity in their workforce. Staff work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff had training in equality, diversity and human rights with a compliance rate of 93.9% across the service. Staff survey results showed the division scored slightly lower than the trust overall for the people promise elements: “we are compassionate and inclusive” and “we each have a voice that counts”.

The trust had an equality, diversity and inclusion committee that set objectives with staff, patients and partners. The trust also had an equality, diversity and inclusion strategy for 2023 to 2026.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. Leaders did not always act on the best information about risk, performance and outcomes.

Since our previous inspection the service had not embedded and sustained improvements within the department or addressed breaches of regulation identified in previous inspections.

Following our inspection in 2023, the trust was told it must ensure that patients identified with a mental health condition are cared for in a safe ligature free environment with appropriate risk assessments completed. We found this was a repeated breach of regulation during this inspection.

We told the trust it must ensure that patients are cared for in areas where dignity and respect are not compromised. We again saw the normalisation of corridor care which compromised patient’s safety, privacy and dignity.

We identified poor practice in relation to cleanliness of the department in each of the 5 inspections between 2016 and 2025. We escalated cleanliness and out of date equipment as a concern during our inspection and this was addressed. However, processes had not operated effectively to ensure the department was consistently clean. The service had not acted on cleanliness audits which showed the department consistently performed below the required standards.

We had told the trust it must implement an effective system to ensure the assessment, prevention and management of infection prevention and control in the physical environment is recorded, monitored, and audited with actions taken to improve compliance. IPC audits continue to show poor performance in adherence to IPC standards.

The service had not improved sepsis performance by the time of our most recent inspection. Sepsis performance had been consistently below national standards and identified as an area for improvement by us in 2018, 2022 and 2023.

We had told the trust it must ensure that there is sufficient equipment that is maintained to keep patients safe. We again found equipment which had not been maintained or checked to ensure it was safe for use. This demonstrated a lack of sufficient oversight of the devices in use in the department to ensure they were safe.

We had told the trust it must be assured that medicines are being stored securely and administered safely as per manufacturing guidance. We again found examples where patients had not received medicines within required timescales and where patients were administered medicines without appropriate records.

The service had not acted on audits showing consistently poor performance within the department. Audit data showed, nutrition scores were rated as red signifying low compliance in five of the six months between October 2024 and February 2025. No compliance data was gathered in October 2024 and February 2025. Compliance was less than 10% in December 2024 and January 2025.

Average compliance with monthly audits between March 2024 and February 2025 in Braden Scores, nutrition and falls was 49%, 50% and 6% respectively.

The department had a falls cross chart; however, we identified that there were serious harm falls incidents missing from this as no falls had been recorded on the chart between July 2024 and January 2025.

The service did not have effective systems to ensure patients receive care without delay when compared to national and regional performance.

Patient’s confidential information was not always secure.

The service did have a business continuity plan for the ED covering loss of premises, supply issues, heating and electrical failing.

The trust took immediate action to address several of the concerns we raised during our inspection. Our concerns included breaches of regulation which had been identified in multiple inspections of the service since 2016. Whilst we were satisfied that the trust acted to mitigate risk in response to our feedback, we remained concerned that the trust was not able to embed and sustain improvement within the service. This prompted our enforcement action.

Action was taken to address the concerns we raised at the time of the inspection quickly. However, the trust had a history of acting on concerns during the inspection but being unable to sustain this.

Feedback from partners was mixed with some concerns around communication, however for the most part evidenced collaborative working, with initiatives demonstrating a shared understanding of local health and care needs, leading to the implementation of new frameworks and care pathways to benefit patients. Partners told us that the service understood their duty to collaborate and work in partnership and endeavoured to do this.

Leaders told us they were involved in regional improvement programmes and regularly engaged with partners through various forums. Dedicated meetings were held with partners to review performance and identify opportunities for improvement. However, improvements to the levels of patients with no criteria to reside had not improved despite this work.

There was further work needed to improve relationships with other local providers including mental health services.

The service provided examples of improvement to systems to manage flow. Since our previous inspection we saw a more system wide approach to managing and improving flow through the ED and the rest of the system.

The service gave examples of areas of improvement work in the division such as trialling a "Corridor watch" staff member to ensure constant staff presence in the corridor and ongoing building work developing a dedicated area for patients attending with mental health needs. The service had plans to increase the capacity of resus.

However, given the number of areas where the service continued to breach regulations, including some which had been raised across multiple assessments and inspections, the service did not evidence a commitment to continuous improvement.