The Countess of Chester Hospital

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question inadequate. At this assessment the rating has changed to requires improvement. We saw some improvement, but the effectiveness of people’s care, treatment and support to achieve good outcomes was inconsistent.

Team collaboration was inconsistent, particularly between the ED and UTC. Monitoring of clinical outcomes was variable, with fluctuating compliance in key indicators and sepsis management fell short of national standards. Assessments of people’s mental capacity were not always carried out in line with the Mental Capacity Act 2005. However, we saw staff worked closely with mental health teams and other specialists, ensuring coordinated care. People were supported to live healthier lives.

The service was in breach of the legal regulation in relation to safe care and treatment and staffing.

We have not awarded this service a score for Effective.

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

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

Data provided by the service showed the average compliance for falls risk assessments completed within the expected time was 70-85% between July and November 2025. People could be at increased risk of falls without timely and documented risk assessments. The average compliance for completing Braden assessments, which score and assess the risk of hospital acquired pressure ulcers (HAPU), was 65-80%. People were at increased risk of developing avoidable pressure damage without timely skin assessments. The trust investigated all of HAPUs weekly, in the 6 months prior to our assessment there was 1 avoidable HAPU. Pain assessment audits were below the trust standards with a compliance of 64.4%. The figures provided included other services in the urgent care division such as the Acute Medical Unit (AMU) and SDEC which have been reported on in our assessment of medical care services.

This was a breach of safe care and treatment.

We reviewed risk assessments in 6 patient records, and all had been completed appropriately.

People using the service told us their family, friends and carers had been appropriately involved in and assessment or decisions about their care.

Staff working in the service completed mental health, learning disabilities and dementia training during induction which the complex care team delivered. Compliance rates were not provided for the service.

Since our last assessment, a bespoke mental health training programme for ED staff had been developed in collaboration with Liaison Psychiatry. Training compliance for nurses was 75% and 81% for support staff. We saw some improvement in the assessment and management of patients presenting with a mental health condition since our previous inspection.

We scored the service as 2. The service showed some shortfalls. The service did not plan always and deliver people’s care and treatment with them. They did not always follow and current evidence-based good practice and standards.

Staff were not always supervised appropriately to provide safe and effective patient care. Staff working in the UTC told us staffing was not planned to ensure the correct level of suitably qualified staff were on shift to provide appropriate clinical supervision. We saw evidence of this on the rota and we raised this concern during our visit. The service acted immediately to review and amend staffing allocations to ensure no trainee or practitioner requiring supervision was working without appropriate supervision. Evidence of a 7-day audit was provided of practitioner documentation, only 2 out of 30 records reviewed did not evidence appropriate supervision had taken place. Appraisal rates for medical and dental staff within the division were 74.44%. This was a breach of staffing.

The services did not always assess people's nutrition and hydration needs effectively. Compliance for completing the Malnutrition Universal Screening Tool (MUST) ranged from 75-85%. MUST is used to identify patients who are malnourished or at risk of malnutrition. This compliance had improved but there remained a risk peoples’ nutritional needs were not being assessed in a timely manner to provide safe care. This was a breach of safe care and treatment.

Most patients we spoke to felt they had been offered enough food and drink, patient records also showed the majority patients had been offered food and drink during their stay. Patient records were clear and contemporaneous.

We reviewed a selection of clinical policies and found these were in line with current guidelines. The department also provided information leaflets for patients, and posters displayed within the service referenced evidence-based guidance.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well across teams and services to support people. They did not always share their assessment of people’s needs when people moved between different services.

Staff told us and we observed that the teams in the ED and UTC did not always work well together. Patients who fell outside of the set referral criteria would be sent to the UTC where staff were not always trained to deal with the higher level of clinical need and did not have the staffing numbers to manage it. Staff told us it was difficult to transfer patients from the UTC back to ED when required. This divide between teams was also observed during our last inspection.

We reviewed the deteriorating patient policy which outlined clear responsibilities and interprofessional standards for patients requiring speciality review. We received mixed feedback from staff about how well specialties worked with the ED department. We observed and staff told us about positive joint working with the paediatric and stroke teams. However, staff told us access to timely surgical review was difficult and time consuming.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment and support. The trust used an electronic patient record (EPR) throughout the hospital. This meant patient information was accessible for all, easy to find and helped facilitate better communication between healthcare professionals.

Managers attended clinical site meetings throughout the day to brief the wider hospital on the status of the department. This included operational concerns, long patient waits and stays in the department and ambulance offloads. Information from these meetings fed into the wider hospital data set collected from other departments and was used to predict upcoming capacity for patients waiting in the ED to be transferred to wards.

Staff shared information about patients at effective handover meetings. The service had separate nursing and medicine handovers, each focused on patient care. Handover processes had improved since our previous assessment.

Feedback from partners was positive. Partners told us the service communicated well and were responsive. There had been a notable improvement in joint working between ED staff and liaison psychiatry services which were provided by another NHS trust.

needs for care and support. Staff assessed each patient’s health requirements when admitted and provided support for any individual needs.

Information was available on the trust website signposting the public to Better Health, an NHS campaign aiming to improve the health of the nation. Through this resource, people could access support with aspects of healthy living including diet, exercise and diabetes prevention.

Patients were provided with information to support their health and wellbeing, helping them maximise independence, choice, and control.

The trust led cardiovascular disease education sessions in partnership with primary care services and had planned mental health education sessions for 2026. Although this was not directly provided by urgent and emergency care staff the aim was to improve outcomes within the community and reduce the need for urgent care.

The trust’s ‘Green Plan 2025–2028’ emphasised improving population health and creating a healthier environment including initiatives to expand healthy food options for staff, patients and visitors.

We scored the service as 1. The evidence showed significant shortfalls. The service did not routinely monitor people’s care and treatment to continuously improve it. They did not ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves.

Since our last assessment, the service had demonstrated improved oversight and compliance against national standards for sepsis. However, further improvement was still required to achieve full compliance with these standards and ensure care is safe and consistent. National guidance requires staff to respond to patients with possible sepsis within specific times including treatment within an hour for patients presenting with highest risks. Internal data provided showed compliance with 3 out of 5 aspects of the national sepsis standard. In the 3 months of data provided, compliance rates for antibiotics given within the required time frame were only 62.3%, which meant there remained a risk people would not receive timely treatment for sepsis.

Audits for June 2025 to August 2025 showed that an average of 78.8% of patients with sepsis as a primary diagnosis received a clinical assessment within the required time frame. Performance had improved month on month, and the service had introduced a sepsis response team to support prompt assessment and treatment of patients presenting with sepsis. Medical, nursing and care assistant staff wore a badge to identify them as being part of this team each day. Staff told us this was a positive initiative but there was not always enough staff to support the additional responsibilities. We observed one staff member handing in their badge to the nurse in charge because they were also working in triage and did not have capacity to undertake the extra role.

The service used recognised tools to support the early detection and response to clinical deterioration. We reviewed the ED audits for National Early Warning Score 2 (NEWS2), a standardised system used to identify acutely ill patients. Between May 2025 and October 2025, the audit showed 85% compliance, meaning there is a risk that deteriorating patients may not always be identified in a timely manner. Both NEWS2 and sepsis compliance required further improvement, this was a breach of safe care and treatment.

We scored the service as 2. The evidence showed some shortfalls. The service did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

Staff within the department told us that all people attending the ED with a mental health condition would have a mental capacity assessment completed. This practice is not in line with the Mental Capacity Act 2005 (MCA) which requires capacity to be assumed unless there is evidence that someone may lack capacity. Capacity assessments should be decision specific, proportionate, and triggered only when there was reason to believe an individual might lack capacity. The trust provided evidence that this was not in line with their policy and there was specific training available for staff. During quarters 1 and 2 of 2025/26, the ED recorded 805 mental health presentations. Over the same period, 524 formal capacity assessments were completed. Across the same period, 161 patients were identified as high-risk at triage and capacity assessment were documented in 121 of these cases. Following our assessment the service was reviewing this process and the number of assessments completed at triage.

The service did not audit consent decisions or documentation in the ED or UTC. We reviewed audits relevant to the MCA and Deprivation of Liberty Safeguards (DoLS) in the urgent care division which provided some assurance that frontline staff are able to appropriately identify a deprivation of liberty, establish a lack of capacity, and make a best interest decision in accordance with statutory guidance. However, these were not specific to the service and therefore did not provide assurance about consent and MCA practice within these services.

We observed good practice of consent taking by clinical staff prior to a procedure or intervention. Information leaflets were available in multiple languages and formats, these were also embedded into consent forms, to support people in making informed decisions about their care.