The Countess of Chester Hospital

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• 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

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question requires improvement. At this assessment the rating changed to good.

This meant the service was consistently managed and well-led. There had been significant changes to leadership within the service. We found there were improvements in the leadership for the oversight of medicine.

We have not awarded this service a score for Well-led.

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

We scored the service as 3. The evidence showed a good standard. The service 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.

Over the past year, the trust had refreshed its strategy and approach to working with partners and other organisations. Each division had assessed its strengths, weaknesses, opportunities, and risks and considered what it aimed to achieve over the next year and the following five years. While the overall business plan was developed separately, divisions had focused on addressing immediate challenges. Staff across services collaborated, shared their expertise, prepared strategy documents, and presented them to teams throughout the trust. Specialist teams ensured their work aligned with the trust’s overarching goals and often partnered with external organisations to deliver projects.

The trust’s strategy and culture were shaped by staff, patients, and partners, supporting people and families throughout their lives. It reflected the trust’s values of being Safe, Kind, and Effective. The trust had 2 core plans, Improving Lives for clinical care and Transforming Care Together for services, which were designed to work together and reflect national health priorities. Leaders told us staff were encouraged to think ahead, solve long term problems, and enhance patient care.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience, and credibility to lead effectively. They did so with integrity, openness, and honesty.

The medical wards were part of the urgent care division at the trust. This included urgent and emergency care services and inpatient medical wards. There was a leadership team for the urgent care division that included nursing, operational and medical leaders.

Divisional leaders conducted walk arounds and listening events, while matrons held clinics and team sessions to engage staff directly. They rotated through each other’s areas weekly and incorporated staff survey feedback into listening events where appropriate. Leadership was reinforced through formal escalation routes via clinical leads to the divisional committee, which met every two months.

Clinical Directors, serving as full time on-call consultants, worked closely with clinical leads and prioritised solution focused approaches over fact finding. They told us they maintained strong, approachable relationships through frequent direct engagement.

The trust had daily ward meetings and regular executive led forums.

The Trust actively developed ward level leaders through away days, peer reviews, and workforce development initiatives. Heads of nursing met daily with leadership and weekly for broader updates, using multiple communication channels to remain connected with their teams. The trust had implemented a 15 steps programme to review services and promote leadership visibility.

Since our previous assessment, one-to-one meetings had been held with every consultant to listen to concerns, review the implementation of changes, assess teamwork, and address variations in practice.

Leadership presence had been consistent: offices were located near clinical areas, divisional meetings were held regularly, and presentations from consultants and junior doctors were carefully structured. Formal mechanisms ensured that raised issues were addressed. Leaders described themselves as fully integrated within teams, maintaining credibility, approachability, and active involvement across all areas of responsibility.

Staff reported that while morale within individual ward teams was generally good, overall morale towards the trust was low. Frustration was expressed over frequent relocations.

Staff told us that they felt the Senior Leadership Team was not easily approachable regardless of visibility on the wards.

At matron level and above, some staff perceived limited responsiveness to concerns about burnout and the psychological impact of managing challenging patients. Support from matrons and senior leadership was often seen as limited, and many staff were unfamiliar with the senior leadership team.

SDEC operated in a high pressure environment with an established hierarchy. Operational management was effective, and front line staff were supported, maintaining a clear line of sight to their direct managers. The team included two Band 8a managers and one operational manager, who oversaw staffing, equipment issues, ambulance handovers, and represented the service at trust capacity meetings. Service managers covered acute medicine and SDEC. Several listening events were held with SDEC staff, ensuring transparency and oversight. Wider divisional discussions, including endoscopy and genitourinary services, ensured that UEC did not operate in isolation.

Leaders emphasised that visibility was central to nursing leadership, with key focus areas including infection prevention and control, patient experience, and quality dashboards. Leaders reported that these initiatives facilitated open communication, rapid responses, and tangible improvements, often captured through ‘You Said, We Listened’ feedback.

Full time consultants shared leadership responsibilities across stroke services and covered night shifts, embedding themselves with colleagues and maintaining credibility as leaders who understood frontline challenges. Their leadership activities included regular meetings with clinical leads and other consultants, participation in divisional transparency initiatives such as winter planning, and active engagement in meetings, attending and contributing without leading.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The Freedom to Speak Up (FTSU) process was embedded within the organisation, with quarterly pulse surveys and annual staff survey checkpoints used to monitor staff confidence and engagement. The FTSU policy was last reviewed in October 2023 and was considered appropriate. It outlined how staff could raise concerns, who to approach, and the actions taken following escalation. FTSU Champions were in place across medical care services to provide staff support.

FTSU training was at 96.9% at the time of assessment, which was above the trust target.

Staff were aware of the whistleblowing process and the role of the Freedom to Speak Up Guardian. However, two members of staff reported that, after raising concerns through the Freedom to Speak Up process, they felt that limited action had been taken.

Local stakeholders advised that students felt able to raise and escalate concerns about safe systems of care. These included the whistleblowing policy and access to speak up guardians. When concerns were raised, the stakeholder felt able to work in collaboration with trust representatives to review the placement offer and the educational audit. Practice education facilitators (PEF) were said to be open and transparent.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

We received limited evidence showing the trust’s commitment to workforce equality, diversity and inclusion at service level. At senior leadership level, there was no ethnic minority representation on the trust board or among executive members, highlighting a significant disparity between workforce diversity and leadership representation.

The trust adhered to its Equality, Diversity, and Inclusion (EDI) policy and monitored progress through the WRES framework. Leaders reported that EDI principles were fully embedded across the organisation. Ward teams actively celebrated cultural and ethnic events, while staff forums supported LGBTQ+ colleagues and accommodated religious and spiritual needs. The multi-faith centre provided a dedicated space for reflection, and concerns were addressed through formal processes such as Freedom to Speak Up, with oversight at senior leadership meetings.

Stakeholders advised that a diverse range of students within the trust felt supported with reasonable adjustments and that the trust were accepting of the diverse student population. Feedback from students did not indicate any concerns.

The trust maintained a wide range of support groups for both staff and patients, including networks for Black, Asian, and Minority Ethnic (BAME) staff, women, LGBTQ+ colleagues, and enabled groups focused on enhancing abilities and supporting disabilities. Additional groups supported carers, faith and belief communities, and armed forces members. Patient engagement and EDI groups ensured that patients, families, and representatives were actively involved in shaping services.

Staff also had access to education and training on care, compassion, and cultural competence. EDI principles were integrated into everyday practice across the organisation rather than confined to individual divisions. Through these ongoing initiatives, the trust continued to review, strengthen, and promote an inclusive organisational culture that supported equity, diversity, and inclusion.

Overall, the Trust’s 2023/24 WRES results indicate some improvement in race equality; however, disparities remain in recruitment outcomes, workplace experience, and perceptions of career progression for ethnic minority staff. Despite a diverse workforce, the absence of ethnic minority representation at Board and Executive level highlights a continued gap between representation and leadership. While EDI initiatives are embedded across the organisation, the findings suggest that meaningful equality in experience and progression has yet to be fully achieved.

We scored the service as 3. The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The trust had established governance arrangements to provide clinical, operational, and quality oversight while reducing the risk of siloed working.

Medical governance was delivered through monthly specialty and unit meetings, chaired by medical leads with nursing and operational leadership in attendance. Meetings followed agreed agendas covering quality, safety, finance, and operational performance. Multidisciplinary quality governance groups and divisional operational forums within Medicine and UEC provided regular input into executive operational and performance meetings.

Key risks were reviewed at quarterly risk committee meetings, ensuring board level oversight. Locally, weekly meetings examined incidents, emerging themes, learning, and operational issues, with escalation where required. Weekly trust level incident review meetings, led by the Medical Director, monitored incident closure and learning, linked to appraisal processes, and ensured mechanisms for shared learning across services.

Nursing governance was supported by daily safety and governance meetings, reviewing incidents from the previous 24 hours and identifying moderate harm events. Issues were discussed with matrons and heads of department in line with PSIRF principles. Weekly patient safety oversight meetings reviewed the quality of investigations, learning, and escalation to formal patient safety forums. Service managers contributed to complaint review and learning.

Operational governance included daily meetings attended by executive, clinical, and operational leaders to support situational awareness and escalation. Serious incidents were shared across relevant forums, with updates provided through safety and governance meetings. Daily ward managers’ meetings, attended by pharmacy and therapy teams, enabled the sharing of operational issues and learning. Monthly operational management boards allowed divisional clinical and operational leads to present risks, performance, and improvement actions to the executive team.

The risk register was actively used to identify, monitor, and mitigate risks. All staff could submit risks via the digital incident reporting system, promoting open reporting. Risks were reviewed by the triumvirate and specialty leads, with further information requested where required. Risks were discussed routinely at daily operational meetings, on the shop floor, and at quarterly risk meetings. Executive oversight was maintained through consistent feedback and a robust check and challenge process, providing assurance.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The Trust worked closely with patients, families, and local communities to improve services, using feedback to make care safer, more dignified, and compassionate. Initiatives included hospital tours for patients with learning disabilities, the Patient Advice and Liaison Service (PALS), listening groups, follow-up calls after discharge, educational events, quiet and multifaith spaces, and opportunities for patients to develop new skills. Leaders told us a new needs based system for managing waiting lists was piloted and well received.

Community input and health data helped the trust understand local needs and plan services effectively. Programmes such as Community Home First, virtual wards, and rapid response teams supported patients to recover safely at home, with assistance from care coordinators and local charities. Shared digital patient records enabled staff to coordinate care and follow up more efficiently. Public engagement events and patient feedback also contributed to improvements in outpatient services. The Trust played an active role in wider local health initiatives, including mental health and healthy weight programmes.

Staff wellbeing was supported through dedicated hubs, leadership and development programmes, wellness spaces, professional networks, and pastoral and multifaith services, helping staff deliver safe, effective, and compassionate care.

Leaders told us that partnerships were central to the Trust’s approach. Learning was shared with other services and local health boards. Integrated services, such as the heart failure virtual ward and Hospital at Home, provided coordinated care, reduced pressure on hospital beds, and supported earlier patient discharge.

A Patient Flow Steering Group, chaired by an executive director, brought together local partners and staff to oversee patient flow, identify pressures, and plan joint action. Collaborative efforts also improved care in areas such as cardiology, bowel cancer, and discharge processes, creating a more joined up health system.

Stakeholder feedback highlighted positive working relationships in relation to safe systems, pathways, and transitions; how staff, teams, and services work together; kindness, compassion, and dignity; and care provision, integration, and continuity.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome, and quality of life for people. They actively contribute to safe, effective practice and research.

The trust provided an example of a quality improvement in stroke services. A review carried out of 48 patients referred for a bubble echocardiogram in 2023, using NHS England guidelines for closing a patent foramen ovale (PFO), which is a small hole in the heart. Staff in the Stroke Department attended a training session, the referral form was updated, and all referrals were carefully checked. Another 50 referrals from 2024 were reviewed to assess the impact of these changes. In 2023, 44% of patients had a heart shunt, 43% were referred for closure, and 56% of those referred had the procedure. After introducing formal checks in 2024, 24% of referrals were rejected, 21% of patients had a PFO, and all three referred for closure were accepted. Overall, appropriate referrals increased from 69% to 92%, acceptance for closure went from 54% to 100%, and waiting times dropped from 16 weeks to 10 weeks.

A four day wellbeing programme was delivered for all Respiratory Unit staff. The sessions focused on emotional resilience, mindfulness, team building, and the PERMA (positive emotions, engagement, relationships, meaning, and accomplishment) model of wellbeing, which considers positive emotions, engagement, relationships, meaning, and accomplishment. Staff also received practical support such as hand massages and wellbeing goodie bags containing information and sample products.

Several staff completed the ACORN programme and launched projects to improve care. These included introducing a new chart for teaching non-invasive ventilation on the ward, creating a tracheostomy trolley checklist that was rolled out to another ward, and improving waste segregation with new bin stickers, which early results showed increased compliance. The ward corridor learning board continued to provide educational information for staff and visitors, covering topics such as tissue donation, oxygen use, fall prevention, nutrition, mouth care, and pressure ulcer prevention.

After a serious hospital-acquired pressure ulcer, a ward introduced a bell that rang every two hours to remind staff to help patients move or reposition. Staff actively supported patients with movement activities and explained the benefits, helping the ward achieve 120 days without another pressure ulcer. Ward 51 introduced the “Legs 11” initiative, carrying out focused pressure area checks at 11am and 11pm, adjusting mattresses, repositioning patients, and ensuring heels were fully supported. This practice became routine, and the ward achieved 110 days without a pressure ulcer. Ward 33 saw an increase in heel and foot pressure ulcers, with 10 cases over six months. In response, the ward implemented “CPR for Feet,” supported by the Tissue Viability Nurse, who provided education, practical guidance, trialled protective boots, and introduced charts showing when the next repositioning was due. Since July, only 1 heel or foot pressure ulcer occurred.

Ward 50 delivered a programme during Dementia Action Week to improve the experience of patients living with dementia. Activities included a sing along supported by the chaplain, with a Bluetooth speaker for patients who could not attend, afternoon treats of cakes and biscuits, therapy led activities such as hand massages, and a sponsored walk to continue fundraising efforts.

On the Acute Stroke Unit, nursing assistants completed enhanced stroke therapy training, which enabled them to support patients using specialist handling and therapeutic techniques. The ward also participated in a continence improvement trial, with staff trained as Continence Champions to support product trials and provide feedback.

A ward manager told us they had completed a senior leadership apprenticeship through the NHS Leadership Academy, gaining experience in divisional work and developing leadership skills.

A study was underway, examining how non-invasive wearable technology that used neuromuscular electrostimulation, and intermittent pneumatic compression devices, affected blood flow in the brain during the first 36 hours after an ischemic stroke.