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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of regulation for safe care and treatment, premises and equipment and staffing.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The trust had established arrangements for managing patient safety incidents. Medical care wards had not reported a Never Event for over 24 months. A review of incidents for the six months prior to assessment identified 1,665 incidents, of which 97% were categorised as low or no harm, demonstrating active reporting and monitoring processes. The most frequently reported adverse events were abuse towards staff, followed by falls, staffing concerns and skin integrity issues.

Ward 45 recorded the highest number of incidents, with approximately 50% relating to abuse towards staff and security responses, reflecting the ward’s gastroenterology case mix and higher prevalence of alcohol withdrawal.

There was evidence that changes had been made as a result of incident learning. The trust implemented actions to reduce violence and aggression, including updated policies, staff training in prevention and de-escalation, risk assessment of higher risk patients and enhanced staff support. Progress was monitored through a trust wide steering group and remained a corporate quality priority.

Staff used an online electronic incident reporting system, supported by trust wide processes that encouraged reporting and enabled monitoring of themes and trends. Incidents were reviewed daily by senior nursing and executive teams, with divisional risk leads confirming harm grading, allocating investigations and agreeing learning responses. Weekly divisional and patient safety oversight meetings monitored investigation progress and ensured learning was identified and shared. Learning from incidents was disseminated through a range of forums including the Clinical Governance Forum, daily huddles, weekly learning bulletins, specialty meetings and resident doctor forums. For those unable to attend, sessions were recorded and ward managers provided safety briefings to ensure learning reached all teams.

The trust had implemented the Patient Safety Incident Response Framework (PSIRF) system in February 2024.

At the time of our assessment, the trust met verbal compliance with duty of candour (100%). Of those identified for written duty of candour; 42% were complete and 58% on track for planned completion following the initial learning response.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The trust held daily meetings to manage patient flow and overall pressure across the hospital. These meetings reviewed bed availability, patients discharged, long stay patients, and those ready to leave but awaiting care elsewhere. Updates were provided from various areas, including Same Day Emergency Care (SDEC), the Acute Medical Unit, and other wards, covering patient movements, specialist reviews, emergency department (ED) activity, and home discharges. Managers also reported on staffing levels, ICU capacity, maternity and children’s services, discharge support, infection control, portering, and pharmacy.

Meetings were scheduled regularly throughout the day, with additional sessions if pressures were particularly high. Actions included reviewing long stay and mental health patients, arranging community support, updating discharge plans, and ensuring timely specialist reviews and tests.

High dependency units such as the Respiratory Unit, Coronary Care Unit, and stroke unit had strict admission criteria to ensure the right patient accessed the right bed to maintain patient safety, while admission decisions for general wards relied on clinical judgment. Patient placement and flow were regularly monitored to meet national standards.

The SDEC unit was led by a senior ward manager and operated 27 escalation beds to help reduce crowding in the Emergency Department (ED). The unit supported patients from both medical and surgical specialties, as well as children and maternity services, and accepted referrals from the ED, GPs, and ambulance crews. Between May and October 2025, SDEC saw 1,397 patients, of whom 30–35% were subsequently admitted to hospital.

From July 2025, the SDEC Frailty service could accommodate up to six patients overnight, with space for a further five patients in a designated corridor area. The unit contained 18 recliners and 18 cubicles. We were advised by the trust the additional capacity did not disrupt the routine activity of the SDEC area. The trust also reported that using the escalation area in this way helped reduce discharge delays, improve ambulance handover times, decrease ED crowding day and night, improve waiting times, protect elective care, and enhance patient dignity compared with previous corridor care. We observed that corridor beds had limited access to bathroom facilities, which was adequate for up to five patients but insufficient for any additional escalated patients. The use of SDEC as a bedded area was not in line with national guidance.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. They did not always share concerns quickly and appropriately.

The Safeguarding and Complex Care team supported staff to prevent harm, abuse, and neglect and to protect people at risk through the delivery of training, the provision of safeguarding supervision and advice, partnership working, and support to trust divisions. The team worked closely with internal and external partners, including Local Authority Social Care and local safeguarding boards.

All staff were required to follow the trust’s Safeguarding Adults at risk policy, which we reviewed and found to be in date. The trust advised that staff were expected to prevent and respond to safeguarding concerns, adhere to professional and trust standards, and maintain mandatory safeguarding training. Clinical staff were also required to be familiar with the local multi-agency safeguarding adults’ policies and procedures.

The trust target for mandatory training compliance was 90%. Trust wide data showed staff compliance for adults and children safeguarding was above 90% for levels 1 and 2. Level 3 safeguarding training was slightly below the trust target, at 88% for the trust.

However, when figures were broken down by staff group, medical and dental staff were slightly below target for level 2 at 86.6% and below target for level 3 at 73.1% for adults. Medical and dental staff did not meet target for level 2 or level 3 child safeguarding training with compliance at 85.1% and 76% respectively. Shortfalls in this training present a risk, as staff may be unable to identify adults and children at risk of, or suffering, significant harm. This was a breach of staffing.

Nursing staff met compliance targets for level 2 and 3 in both adult and children safeguarding training.

All staff we spoke with were able to provide good examples of safeguarding processes, procedures, and situations when referrals were made for patients thought to be at risk of harm.

We reviewed a sample of safeguarding investigations, outcomes and action plans and found them detailed and appropriate.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Patients using the service reported that their family, friends, and carers were appropriately involved in assessments and decisions regarding their care. Patients across all wards reported that their pain needs were consistently addressed as required.

Staff reported that patients with higher needs were cared for in specific areas with enhanced supervision. Any changes to care were clearly explained to patients. Assessments were conducted at the bedside with patients and their families to ensure a comprehensive understanding of individual needs. Care planning was personalised, aiming to support patients in returning to their normal baseline.

Medical care audits were undertaken for the National Early Warning Score 2 (NEWS2). NEWS is a standardised system for identifying acutely ill patients. The trust showed high completion rates in the urgent care division: 90.4% in August, 91.9% in September, and 91.1% in October.

Compliance with falls risk assessments within 6 hours of admission consistently exceeded the 90% target, while compliance with falls prevention measures was strong at 93%. The trust had identified further improvement areas and was working to address these, including cognitive assessments, lying and standing blood pressure checks, and completion of bed rails assessments. Actions underway included updating cognitive assessments on the electronic system, uploading bed rails assessments, enhanced monitoring, reconditioning programmes, and replacing caffeinated drinks with decaffeinated alternatives.

Hospital acquired pressure ulcer (HAPU) rates on medical wards remained stable and within expected ranges. Most HAPUs were category 2, with the highest numbers reported in the respiratory ward, Ward 33, and Ward 44. Compliance with Braden assessments within six hours of admission consistently exceeded 90%. Of all reported HAPUs, 10% involved lapses in care that may have contributed to their development, while 90% were considered unavoidable. Compliance with prevention measures was 92%, with improvement themes including clearer documentation, heel offloading, and recording evidence of TED (Thrombo–Embolus Deterrent) stockings being removed.

VTE compliance was monitored using a live dashboard built by business intelligence, drawing data directly from the electronic patient record. Between January and August 2025, compliance across AMU, medical wards, the respiratory unit (48/49), cardiology, and the modular ward ranged from 84% to 91%. This was below the 95% national standard. September and October data were unavailable due to pending coding prior to validation.

We scored the service as 1. The evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

Ward environments were generally clean and tidy. However, some storage and dirty utility rooms were cluttered and left unsecured

The route from ED to SDEC and Urgent Treatment Centre (UTC) was long and poorly signposted, and outdated internal signage caused confusion. In SDEC triage, beds did not fit cubicle spaces. Busy reception areas also created confidentiality risks due to visible computer screens.

Fire warden checks on Ward 50 repeatedly identified an obstructed fire exit, with no recorded action taken.

Since our last assessment the trust acted to improve fire safety although some concerns remained. We saw reports showing that the trust had made improvements to risk assessments, and evacuation arrangements. During our review of evidence, we saw that evacuation procedures had been updated where exits were previously restricted, and staff training and drills had taken place. Fire exits were alarmed, most doors had compliant hold open devices, and trained fire wardens were in place. External feedback and an independent audit rated fire safety management as comprehensive, and investments had been made in fire safety infrastructure.

However, at the time of the assessment defects were found in 13 fire doors (e.g. missing smoke brushes and intumescent strips). We saw some exits remained partially obstructed and we escalated this at the time, requesting beds and mattresses blocking fire doors to be removed. This was a breach of the regulations related premises and equipment.

Equipment was PAT tested, and emergency trolleys were appropriately stocked.

On the modular ward, patient overflow led to a bed being placed without privacy curtains. Unsecured oxygen cylinders were observed in a stroke unit corridor.

Overall, fire safety concerns were a repeated breach across 3 inspections. The trust was previously requested to ensure that fire exits were clear from obstruction and well maintained. In addition, there were ongoing risks related to maintenance, privacy, and environmental safety that required action resulting in a breach of premises and equipment regulation.

We scored the service as 2. The evidence showed some shortfalls. The service made sure there were enough qualified, skilled, and experienced staff across most services. However, compliance with some statutory and mandatory training was below the trust threshold.

Gaps in the staffing of the out-of-hour stroke service remained although some mitigation were in place. Workforce pressures were most evident among healthcare support workers, who had higher sickness rates and lower fill rates. Not all staff had the required mandatory training to provide safe care. This was a breach of safe staffing regulation.

A review of the Same Day Emergency Care (SDEC) unit in 2024 had identified Emergency Care Intensive Support Team (ECIST)/NHS England benchmarks of 8 registered nurses and 6 healthcare support workers per shift. A mitigated model of 7 registered nurses and 5 healthcare support workers was implemented, supported by 3 Whole Time Equivalent (WTE) Acute Medical Unit (AMU) staff and 3 WTE Nursing Associates. Safe staffing was maintained, with vacancy fill rates above 100% (RNs 132%, HCSWs 107%). However, SDEC also operated as an unfunded escalation area, with sufficient staff due to increased reliance on temporary staff. Registered nurse sickness remained low (3.8%) but was higher for healthcare support workers (10.6%).

The fill rate percentage for medical staffing across UEC and Medical Care over the last three months were 89%. This was based on a total of 1,201 filled shifts out of 1,345 total shifts (including 144 unfilled shifts). Fill levels were maintained through a combination of local bank usage and use to the DIT bank across both areas. (The DIT Collaborative Bank is an NHS initiative that allows doctors in training to book and work bank shifts across multiple trusts without additional recruitment checks, enhancing workforce flexibility and patient care).

Percentage of shifts filled by locum doctors broken down to medical care and UEC was 41%

Turnover rate across medical care and UEC nursing staff was 5.3% and medical staff was 21.7%

Medical ward nurse staffing was generally stable across most bands, with Band 7 at 97.6% and Band 6 slightly above establishment at 104.1%, although Stroke services were notably lower at 66%. The Stroke service had relocated to a larger ward and expanded both its bed capacity and nursing establishment. Consequently, a 66% fill rate represented a shortfall of only 1 WTE post.

Band 5 staffing was at 100%, but variation existed across wards, as 8 out of 11 were operating above their established levels. Band 4 staffing was fully established at 100%, while Band 3 was slightly below at 94.1%, indicating a small shortfall at this level. Overall, staffing was largely on target, with some variation across specific areas and bands.

SDEC nurse staffing by band was recorded as follows: Band 7 accounted for 33.3%, Band 6 was at 127%, and Band 5 stood at 114.2%. Band 4, which included Nursing Associates, was significantly higher at 296%, while Band 3 was at 80% and Band 2 measured 103.1%.

Appraisal rate for medical staff across UEC and medical care was 74.4% and Nursing and midwifery was 83%.

The AMU ran 49 funded beds plus 3 escalation beds. Staffing increased slightly but remained below budget, with vacancy fill at 97.9% (RNs) and 85.2% (HCSWs). Registered nurse sickness was low, while healthcare support worker sickness remained higher. Some safety indicators improved (pressure ulcers, C. difficile), though medication errors and falls increased.

In October 2025, 218 incidents referenced staffing or skill mix issues, largely involving delays in care. Most resulted in no harm, and none caused severe harm. Staff reported inequitable workforce distribution, with resources often redirected to ED and SDEC, and described workload pressures as unsustainable.

The Stroke Patient Thrombolysis Standard Operating Procedure (SOP) was updated in 2025 and was scheduled for review in February 2028. The SOP was comprehensive and included detailed guidance, with key information clearly highlighted in red, such as emergency contact numbers and references to both local stroke management guidelines and the more comprehensive 2023 Royal College of Physicians (RCP) Stroke Guidelines.

Since the last inspection, the trust had invested in and expanded the substantive establishment of the Stroke Coordinator team to 5.0 WTE Band 6 posts. This ensured sufficient staffing to support a permanent rota from 08:00 to midnight on a seven-day basis. To achieve full 24/7 coverage, a further 1.0 WTE Band 6 post had been identified as required. In preparation, the trust had updated the job description and all associated recruitment documentation to reflect this requirement. A consultation process with the existing 5.0 WTE staff was also underway to ensure alignment with the revised job descriptions and working hours. These actions were intended to support the implementation of a 24/7 rota and mitigate associated service risks.

Teaching sessions for Emergency Medicine Registrars on acute stroke management, including extended time windows for thrombolysis and thrombectomy, were delivered on two occasions in January 2024. Induction sessions for new doctors rotating into the Emergency Medicine Department, covering Stroke Services within the trust, were delivered in May 2025. Plans were in place to deliver additional sessions, including simulation-based training for stroke emergencies. Furthermore, Emergency Medicine Registrars had undertaken shadowing opportunities with the Stroke Coordinator team, with additional sessions planned.

The division maintained oversight of stroke patient breaches through a fortnightly Stroke Breach Meeting. This forum identified patients who had breached Sentinel Stroke National Audit Programme (SSNAP) targets, facilitated the identification of learning points, and explored underlying causes, including recurring themes and trends. Learning outcomes were regularly communicated to the Emergency Medicine Stroke Lead and were subsequently acted upon.

Since the introduction of the “to midnight” Stroke Coordinator service on 12 July 2024, no incidents had resulted in significant harm. At the time of reporting, two incidents remained under investigation by the multidisciplinary team (MDT); both had been assessed as resulting in no harm and were in the final stages of review prior to closure. The division had been progressing towards the implementation of a 24/7 Stroke Coordinator service and was actively undertaking preparatory work to support this. The absence of a full 24/7 service remained on the risk register and continued to be identified as a key priority for the division.

We found that 91.8% of registered nursing and midwifery staff and 83.5% medical and dental staff had completed their mandatory training trust wide against a compliance rate of 90%. Role specific competency training was delivered to 320 staff across medical specialties. We did not receive a breakdown by division.

The data provided an overview of mandatory training compliance across the trust, not by division, resulting in an overall compliance rate of 90.31% (all staff). This indicated that, overall, compliance was strong, with the majority of staff having completed their required training. Several areas demonstrated particularly high performance, including Fire Safety (94.6%), Moving and Handling Level 1 (95.2%), Infection Prevention Level 1 (93.9%), and Preventing Radicalisation training (93%), suggesting that these subjects were well embedded and effectively managed.

However, the data also highlighted some areas of concern where compliance fell below the expected 90% threshold. Most notably, Resuscitation Level 1 had a significantly lower compliance rate of 77.4%, with additional resuscitation modules (adult and paediatric) also below target at around 85%. NHS Conflict Resolution (85.1%) and Information Governance (86.6%) similarly fell short, alongside Safeguarding Adults Level 3 (87.9%), Infection Prevention Level 2 (88.3%), and Safeguarding Children Level 3 (88.3%). These gaps were particularly important as several related to critical clinical skills and patient safety.

Compliance data for deteriorating patient training (including Sepsis training) was recorded as 84.8% for medical and dental staff and 97.8% for nursing and midwifery staff trust wide. Training compliance for Advanced Life Support and Immediate Life Support was 100% for qualified staff trust wide.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

All clinical staff we observed were compliant with Bare Below the Elbows guidance and used gloves appropriately. However, we observed and audit data demonstrated that hand hygiene practices were inconsistent, with the five-step handwashing technique and the use of hand gel between patients not always followed.

Wards were generally clean. Housekeeping staff reported that monthly stock checks were undertaken, with only three expired items identified. However, some staff members were unable to describe cleaning schedules or provide assurance that tasks had been completed.

We observed infection prevention and control (IPC) risks in the Stroke Unit. We saw a staff member use the same cloth across multiple surfaces and a clinical support worker was also seen using a single wipe to clean tray tables for three different patients. Environmental risks included a broken waste bin pedal, a damaged toilet seat cushion, with exposed MDF on a toilet seat.

The Estates team acknowledged there were gaps in their services and explained that domestic services were being restructured to strengthen ward integration, improve training, and enhance supervision, especially given ongoing recruitment difficulties. Despite these challenges, infection rates had decreased.

Mandatory IPC Level 2 training compliance reached 95% in October 2025. The organisational compliance target for training was 90%.

Hand hygiene compliance on medical wards improved from 78% (January–March 2025) to 87% (July–September 2025). Bare Below the Elbows compliance increased from 89% to 95%.

Clinical audits conducted in October 2025 showed compliance rates were below the target in IV lines at 88% and urinary catheters at 86%, while the commode audit was above target at 92.5%

The IPC team assumed responsibility for hand hygiene audits in October 2024. IPC champions were active across more than 40 wards. Of 13 audited areas (July–September 2025), nine met the 90% compliance target. In October 2025, IPC compliance in Same Day Emergency Care (SDEC) was 77%. This is below the trust target of 90%. However, this figure had improved from previously reported compliance of 57% as a result of targeted training.

Cleaning audits indicated that most areas met required standards, although the Acute Medical Unit (AMU) and cardiology wards were slightly below target. Some cross contamination risks were identified and appropriately escalated.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. They did not always involve people in planning.

Clinical pharmacy support was available on the wards Monday to Friday. The pharmacy team supported with medicines reconciliation. National Institute for Health and Care Excellence (NICE) Quality Standard published 2016, recommends service users have their medicines reconciled within 24 hours of admission to hospital. The information provided by the trust showed they were not meeting their targets for medicines reconciliation within 48 hours of admission.

Whilst the pharmacy service dispensed discharge prescriptions in a timely manner, the data provided by the trust showed a high proportion of the discharge prescription required amendments before dispensing.

Nursing staff knew where to find medicine related policies and prescribing information and how to access medicines and pharmacy advice out of hours.

When people had their medicines via a feeding tube, we saw information to support staff to administer the medicines safely.

When people had thickener added to their drinks, to reduce the risk of choking, this was not always stored safely and in line with the National Patient Safety Agency alert dated 2015. We highlighted this to the nursing staff who took prompt action.

We saw that when people were prescribed medicines to manage symptoms of alcohol withdrawal, their health was not always monitored as per the trust guidelines.

The trust provided evidence of audits completed to show service users had their medicines administered as prescribed. However, during the inspection we saw some people did not receive their medicines as prescribed because there was no available stock on the ward and action had not been taken to address this in a timely manner.

Records we reviewed showed the temperature of the medicine’s fridge was monitored, however, if action was taken when it was outside of the normal range, it was not always recorded. We saw the recording of the room temperature where medicines were stored was inconsistent across the wards.

Information provided by the trust showed 85% or more of staff had completed their medicines administration training, with several wards reporting 100% of staff had completed medicines administration training.

We saw evidence the trust acted on patient safety alerts and disseminated information to clinicians when there was a concern around medicine shortages. The trust acted when concerns were raised about controlled drugs.