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 inadequate. At this assessment the rating has changed to requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was a risk that people could be harmed, but we saw improvements had been made.

The service was still in breach of legal regulation in relation to safe care and treatment, staffing and premises and equipment.

We identified risks, including poor infection prevention and control practices, low compliance with safeguarding training and inconsistent processes for streaming patients from the ED. The service did not have enough staff, with breaches in paediatric nurse and consultant requirements with a heavy reliance on temporary staff. Environmental risks were not always identified or fully addressed including the storage of chemical substances and adherence to national guidance for resuscitation areas.

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

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.

Staff understood how to report incidents, and most staff we spoke to felt they received feedback or that action was taken following incidents.

In the 6 months prior to our assessment, 1,041 incidents were reported in ED and 31 in the Urgent Treatment Centre (UTC). Within ED there had been one never event, and three Patient Safety Incident Investigations (PSIIs) were being completed at the time of our inspection.

The service had effective processes, policies and procedures to monitor and learn from incidents and near misses, and this learning was shared with staff. Patient safety events were investigated appropriately and followed the Patient Safety Incident Response Framework (PSIRF), which is a mandatory framework within the NHS in England for how health services respond to and learn from patient safety incidents. Learning responses demonstrated a good level of family and patient involvement, and people were given opportunities to ask questions as part of the investigation. Safety incidents were viewed as opportunities to put things right, learn and improve.

Leaders could describe the themes and trends of incidents in the department, the actions they had taken to address these, and the methods used for providing feedback to staff.

Some staff told us they did not always learn about the actions taken in response to incidents, particularly in the UTC. Leaders had commissioned specific reviews into emerging themes from incidents, but the actions taken were not always communicated to staff working in the UTC department.

The Duty of Candour (DoC) requires registered providers to act in an open and transparent way with people receiving care or treatment from them. We requested evidence of occasions when DoC had been completed. The service’s compliance with verbal DoC was 100%, and 89% for written DoC for incidents in the last six months that resulted in moderate harm or above.

We scored the service as 1. The evidence showed significant shortfalls. The service did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services

Patients arriving at the ED could be streamed internally to the UTC, SDEC, GP out-of-hours services, or the frailty services. The streaming process was designed to standardise and optimise patient flow by ensuring people were directed to the most appropriate care setting as early as possible. Information provided by the trust showed that approximately 30% of patients attending the ED were streamed to the UTC.

Staff told us the systems and processes in place for streaming patients to UTC were not safe. We observed patients being streamed to the UTC whose presenting issues were outside of the service’s inclusion criteria. We asked staff in different roles about the streaming process to UTC. All staff gave us conflicting answers or were unsure of the process. Staff did not have a consistent understanding of who was responsible for making streaming decisions. As a result, people were being inappropriately streamed to the UTC when it may not have been the correct place for their care or treatment. This exposed people to the risk of unsafe care and improper treatment. This was a breach of safe care and treatment.

Staff told us when patients were referred to the UTC outside of the defined criteria it was difficult to transfer their care back to ED. Data collected by the trust showed only 1.4% of patients were sent back to the ED in the 3 months prior to our inspection. Staff told us this occurred because of the challenges with patients being accepted back into the ED. As a result, patients continued to be treated in UTC despite this not always being the most appropriate setting.

Following our inspection the service reviewed incidents that had been reported relating to the transfer of patients to UTC. Of 14 incidents reported in November 2025, no incidents related in patient harm and only 2 patients were found to be not appropriate for UTC. They found that no incidents resulted in patient harm and the correct process for returning to ED was adhered for most patients.

Following our feedback the service also made changes to streaming processes and oversight to strengthen assurance regarding the effectiveness and safety. This included updating the patient inclusion criteria and improving the documentation process when transferring patients. The service was working with NHS Emergency Care Improvement Support Team (ECIST) to improve governance and oversight mechanisms to support more consistent and safe decision-making. However, following the initial action we continued to receive anonymous feedback from staff that the issues had not been addressed.

Children were seen in a dedicated Paediatric ED which had separate waiting and treatment areas designed to be child friendly. However, due to ongoing building work children were booked in at a shared reception and were required to wait in the adult waiting area. This was a temporary measure due to ongoing building improvement works within the ED.

During our previous assessment in February 2025, we found people being cared for in the ED corridors. At this assessment, the service was no longer using the ED corridors; however, corridors within the Same Day Emergency Care (SDEC) units were being used during periods of increased pressure. The corridors in both areas had been equipped with call bells. SDEC is included in the medical care assessment report which was conducted on the same date.

An electronic patient record (EPR) prompted staff when medication or clinical patient observations were due. However, staff told us due to pressures within the ED they were not always able to complete observations at the required times. Audit results provided by the service showed compliance between June and October 2025 was 84 - 96% against their policy for recording observations.

We scored the service as 2. The evidence showed inconsistencies. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse and discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately. However, training was provided but not all staff completed it to the required level.

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 trust target for mandatory training compliance was 90%. Information provided by the service showed trust compliance for adults and children's safeguarding was above 90% for levels 1 and 2. However, level 3 safeguarding training was below the trust target; training compliance for medical and dental staff was significantly below target at 73.9% for adults and 75.9% for children. Level 3 safeguarding training is the minimum requirement for all registered healthcare professionals who have regular contact with patients and their families or carers. Shortfalls in this training present a risk, as staff may be unable to identify adults and children at risk of, or suffering, significant harm. Safeguarding training compliance had been highlighted at our last assessment of the service. This was a breach of staffing. Oliver McGowan training compliance was 92.4%; medical and dental staff were slightly below the trust training target at 87.3%

We reviewed patient records which demonstrated that appropriate safeguarding information had been recorded and referrals to external agencies had been made where required.

Staff and managers used clear systems, processes and practices to protect people from abuse, neglect and harassment. Safeguarding policies for both adults and children reflected national guidance and best practice and clearly outlined the steps staff should follow. Managers and staff demonstrated a good understanding of their safeguarding responsibilities. The service worked well with other agencies to safeguard people.

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.

We observed delays for patients at triage due to the number of assessments and tasks being completed by a single nurse. This increased the risk to patients in waiting areas and created additional pressure on individual nurses to complete effective and accurate assessments. Staff we spoke to were concerned about the volume of tasks required at triage and the impact this had on the timeliness of patient care. For example, triage nurses were required to complete a 14-step process on the IT system to administer pain relief, which contributed to delays. Staff in various roles told us they were concerned that those working in triage did not always have the appropriate level of support, skills or experience to carry out this process safely. We escalated these concerns to senior leaders and following our inspection changes were made to the processes used when patients arrive. The service had processes in place to ensure staff had appropriate training in Manchester Triage System (MTS) and staff were required to work in ED for 12 months prior to working in triage. Despite the pressure on staff, the service had made significant improvements in the time to triage since our previous assessment of the service.

Since our last assessment the trust had made some improvements to how staff assessed and managed risks for patients presenting with mental health needs. There was further improvement needed to ensure staff responded to mental health risks consistently.

We reviewed 4 records of patients whose primary reason for attending the ED was support with their mental health need. All 4 records showed staff had identified and assessed the level of mental health risk presented by each patient. Three records showed staff had developed plans to safely manage the presenting risks, although in one record the safety plan was not documented until more than 24 hours after the patient had first arrived in the ED. The fourth record identified the patient had lower-level risks in relation to their mental health; however, staff had not made plans to manage these risks safely. Staff used observation, regular (hourly) checks and placement within the department to manage mental health risks. Most records showed mental health rounding had been completed regularly although not always within the recommended hourly intervals.

Evidence provided by the service demonstrated in the 11 weeks prior to our assessment 100% of mental health patients had risk and safety plans completed. Compliance for mental health rounding was mostly above target in the 6 months prior to our assessment. The service also monitored nurses understanding of mental health safety plans and the percentage of patient with nursing evaluations against safety plans which was improving the months leading to our assessment.

We reviewed the divisional risk register which highlighted a moderate risk as the provision of safe care for patients presenting with mental health needs. This risk was being actively managed with improvements to the environment for mental health patients and staff training.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure facilities supported the delivery of safe care.

Since our last assessment, the trust had made changes to increase resuscitation capacity by building an additional patient care bay. However, the service still did not meet national guidance on resuscitation capacity as each bay remained below the recommended size, this had been recognised as an ongoing risk by the trust. Staff were concerned about the lack of 360-degree access and inadequate temperature control in resus bays. We observed a patient receiving emergency treatment and not all staff involved in the care could fit into the designated space. The service was aware of this risk and had taken steps to monitor and improve this, resus facilities were recorded as a risk within the divisional risk register and a risk assessment had been completed.

The limited space within the resuscitation area risked compromising how staff could respond effectively to multiple emergency situations at the same time.

We found a storage room door not locked and contained cleaning chemicals which should be stored securely in line with regulations. We raised this at the time of inspection and action was taken to repair the lock. The secure storage of chemicals had been identified as an issue on the last inspection of this service.

These concerns were a breach of premises and equipment.

The trust had improved the environment used to provide care for patients with a mental health need. The Milbrook Suite, located within the ED, had been purpose-built to provide a safer environment. The Millbrook Suite was a quieter and more private area, with a significant reduction in the number of fixed ligature points compared to the wider ED, alongside improved facilities to support the safe observation of patients. The Millbrook Suite did not meet the standards set by the Psychiatric Liaison Accreditation Network (PLAN). However, it represented a significant improvement in facilities for patients with mental health needs since our last assessment.

We looked at a sample of clinical stock and medical equipment and found the items were within expiry dates and had been appropriately serviced and maintained. Evidence reviewed showed effective systems and processes were in place to monitor equipment. This was an improvement from our previous inspection in February 2025. Resuscitation trolleys in the ED and the UTC were maintained by the service. Audit results showed over 90% compliance with the required resuscitation trolley checks.

At the time of our assessment, construction work was ongoing to redevelop the ED and appropriate risk assessments had been completed. However, there were limited signs directing people to other departments from ED, especially to the UTC and SDEC. We observed people using the service getting lost as they attempted to navigate the building work.

People using the service told us they felt there was not enough space. Staff told us the building work had significantly reduced the size of the waiting rooms and created a more constrained environment. There was a secondary waiting room for patients who had been triaged to use in times of increased pressure. We saw evidence that the service recognised the risks associated with the ongoing building work which was a temporary measure to improve the ED environment.

We scored the service as 1. The evidence showed significant shortfalls. The service did not make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support supervision.

The Royal College of Emergency Medicine (RCEM) workforce recommendations outline the number of consultants and senior decision makers required to provide safe and effective patient care in emergency medicine. The Countess of Chester is a medium sized ED with recommended whole time equivalent (WTE) consultant staffing of between 18-25 consultants. At the time of our assessment the service was funded for 14 WTE consultants and associate specialists. The service recognised this was below RCEM guidelines and previously implemented changes to provide additional middle grade clinicians out of hours. However, consultants told us this was insufficient and recommended recruiting additional resources to meet current demand.

Staff told us the shortage of consultants was impacting timely patient care and the level of support available for resident doctors. We reviewed staffing rotas which showed in the week prior to our assessment consultants were covering additional night shifts on 3 out of 7 nights. Staff told us consultants were regularly covering additional shifts which posed a risk of burnout within the workforce.

In the previous 3 months there had been a high percentage of shifts filled by locum doctors at 34.65%. Most shifts were filled by doctors who worked regularly in the service and 96.7% of medical staff shifts had been filled during the same period.

Medical staffing in the service was below establishment by 6.8 WTE in the 3 months prior to our assessment. Since the assessment recruitment has taken place to fill 1 vacancy. Leaders told us they were aware of staff concerns and were listening but did not feel the locum use to be a risk to patient safety due to 55% of shifts being filled by regular staff.

An average of 93.4% of shifts for nursing and allied health staff had been filled in the previous 3 months in the ED and UTC. No agency staff were used to fill shifts, however 17.8% of shifts in ED and 22.6% of shifts in UTC had been filled by bank staff. Most bank shifts were filled by regular staff working additional shifts who were familiar with the department.

In the Urgent Care Division, the medical and dental rolling 3-month average absence rate was 15.4% with specialty registrars having the highest absence rate within the staff group. For nursing and midwifery staff the 3-month average absence rate was 4.1%.

There had been 21 staffing related incidents reported in the ED in the 6 months prior to our assessment. The top themes were delays to commencing care, assessments and treatment and lack of timely liaison psychiatry. There was 1 moderate harm incident related to a shortfall in resident doctors, all other incidents were reported as low or no harm.

Trust wide mandatory training compliance was mostly within the trust target of 90%. However, service level training compliance was not provided. Not all staff had completed level 1 resuscitation training with trust wide compliance at 77.4%. Medical and dental staff compliance for deteriorating patient and sepsis training was 84.8%.

The service did not meet the requirements of “Facing the Future: Standards for Children in Emergency Care Settings” from the Royal College of Paediatrics and Child Health (RCPCH). RCPCH recommends every emergency department treating children must be staffed by 2 registered children's nurses who must possess recognisable post-registration trauma and emergency training. Evidence reviewed showed that there were not sufficient staff with the right training, skills and competencies to meet these standards. We reviewed staffing rosters and found in a 10-day period prior to our assessment 9 days had not been staffed in line with the standards. Adult registered nurses had been regularly working as the second nurse within the department. Some of these staff had completed Advanced Paediatric Life Support (APLS) or Paediatric Immediate Life Support (PILS), however the service did not have systems in place to make sure adult nurses had completed all additional training before working in the children’s ED. Following our inspection the trust changed the staffing model to always provide 2 registered children’s nurses and planned to recruit additional children’s nurses.

Most people we spoke to using the service told us told us they did not feel there was enough staff.

The service was in breach of staffing, the evidence demonstrated there was not always enough qualified, skilled and experienced staff to provide safe and effective care.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection.

Since our last assessment, there were improvements in the cleanliness of the environment. However, throughout the urgent and emergency care service we continued to see equipment that was visibly dirty and some areas that required further and more consistent cleaning. We observed staff were not always adhering to infection prevention and control precautions in relation to hand hygiene which put people at increased risk of infection. A door in the paediatric waiting room had a cleaning sticker dated 8 days prior to our assessment. The sticker remained in place during the first day of our visit despite the service’s cleaning schedule requiring doors to be cleaned daily.

The trust target for hand hygiene compliance was 90%. Evidence reviewed showed that between May and June 2025 compliance was consistently observed to be below the expected target level of 90%, ranging between 67%-76%. Following targeted improvement compliance had improved and in October compliance was above 90%. Staff adherence to ‘bare below the elbows’ practice in the ED was 89% compliance between July and September 2025 which had improved. During our assessment we observed staff being prompted by leaders to adhere to ‘bare below the elbows’ practice.

Environmental cleanliness audits were undertaken in line with the national cleaning standards. The service was in breach of safe care and treatment.

The trust had invested in hand hygiene technology by purchasing a hand scanner. The device is a training aid to assess hand hygiene technique by scanning an individual’s application of hand sanitiser. The device was being used as part of a rolling programme of hand hygiene roadshows which commenced in October 2025 beginning with the ED.

The service had clear roles, responsibilities and procedures for IPC, which were aligned with national guidance. The domestic services provision within the service had been increased since our last inspection. A dedicated rapid response team, responsible for the immediate cleaning and preparation of bed spaces and clinical areas following patient discharge or transfer had been introduced with positive impact.

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.

Clinical pharmacy support was available in the department Monday to Friday. The pharmacy team supported with the completion of drug histories and medicines reconciliations for service users. A process was in place to identify service users who were taking a medicine classed as a ‘critical’ medicine; a critical medicine is a medicine that should not be omitted or delayed. There was also a process to identify service users who had certain medical conditions or who were being treated with certain antimicrobial medicines to ensure they were prioritised by the pharmacy team.

We saw clinicians requested the pharmacy team to counsel service users on the use of their new medicines. A system was in place for the mental health clinicians from another NHS Trust to review and prescribe medicines for service users who were admitted to the department.

We saw 1 service user had been given a medicine to control or restrain their behaviour. We found staff had not monitored and observed the service user’s health in line with the trust policy after the medicine was given. When service users were prescribed an antimicrobial to treat an infection, it was not always highlighted to be given outside of the regular medicine administration round. There was a risk the service user would not be given their antimicrobial in a timely manner.

The Trust did not provide assurance that pharmacy staffing levels had been assessed against the ‘Pharmacists & Pharmacy Services in the Emergency Department’ standard.

We saw medicines were not always stored securely, this was highlighted at the time of the inspection and action was taken to rectify the issue to ensure medicines were stored securely.

Nursing staff could describe the process to follow if there was a medicine related incident or error. The nursing staff told us any medicines incidents were discussed with staff to share lessons learnt and training was completed.

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

There was a process for writing and issuing prescriptions that service users could take to a local community pharmacy to obtain their medicines. Controlled stationery was managed appropriately. We saw records showed the temperature of the medicine’s fridge was outside of the normal range. The records did not detail what action had been taken to ensure the medicines within the fridge were still safe to use.