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 has remained required improvement. This meant the service management and leadership was inconsistent.

There had been significant changes to leadership within the service. We found governance arrangements were not robust with a lack of insight into staffing and repeated failures to fully address known risks and previous regulatory breaches. However, we found leaders were visible and supportive, and there had been a significant improvement in the culture within the service. The service engaged effectively with partners and demonstrated a commitment to continuous improvement aimed at enhancing patient care and system flow.

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

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.

There was a clear trust wide vision and strategy, with defined priorities and objectives for the urgent care division which aligned with the overarching organisational direction.

Leaders and staff described a noticeable improvement in the culture, with many telling us the service “feels the best it has in years.” Staff spoke positively about their work and demonstrated pride in being part of the service.

Within teams, staff worked well together and showed mutual respect. This contributed to an environment focused on delivering high quality care. We observed positive, compassionate interactions between staff, patients and their relatives. However, staff told us, and we observed, that joint working between the ED and the UTC was not always effective, which at times affected the consistency of patient flow and communication.

We scored the service as 2. The evidence showed some shortfalls. Not all leaders understood the context in which the service delivered care, treatment and support.

There had been significant changes to leadership arrangements within the service. Some staff and leaders felt it would take more time fully embed the changes and structures. There was a triumvirate leadership structure at divisional level with medical, nursing, and operational leads.

We found repeated breaches of regulation relating to IPC, safe environments and safeguarding training. The cleanliness of the department had been identified as a breach of regulation in the 6 inspections of this service undertaken since 2016. The continued failure to fully address these issues demonstrated continuing weaknesses in leadership oversight and risk management.

Staff in the ED told us they felt supported and nursing oversight was effective. The department had 2 matrons, a unit manager and team leaders who worked together closely. Feedback about medical leadership was also positive however we were told leadership capacity was sometimes reduced due to clinical demand and workforce restrictions. Operational leaders had a presence in the service to support performance delivery.

We scored the service as 2. The evidence showed some shortfalls. People did not always feel they could speak up and that their voice would be heard.

Staff gave mixed feedback with some stating they did not always feel able to raise concerns or were unsure their concerns would be acted on. Staff did not always feel involved in decision making about the service. We were told that operational changes were implemented quickly, and clinical staff did not always feel well informed or involved in decision making.

The trust had a Freedom to Speak Up (FTSU) policy which provided staff with details of what they could speak up about, who to speak to and what the process would involve if they did. The policy outlined the roles and responsibilities of the FTSU guardian and champions. Staff we spoke to knew how to access the FTSU process, information was displayed within the department and communicated via email.

Senior leaders told us the FTSU process was well embedded within the service; they conducted regular listening events for staff and used quarterly pulse surveys and the annual staff survey to monitor themes in relation to wellbeing and speaking up.

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

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.

The service valued diversity within its workforce and staff described working towards an inclusive and fair culture, with a focus on improving equality and equity for colleagues. The trust had an Equality, Diversity and Inclusion (EDI) Strategy in place for 2023–2026, which set out its organisational commitments and priorities.

Feedback from education partners was positive about the experience and support provided to learners, including those requiring reasonable adjustments. Partners also highlighted the department’s commitment to supporting a diverse student population.

In the division’s most recent staff survey results from 2024 the result for ‘we work flexibly’ was 5.33 out of 10, this was below both the organisation wide result and the national average. The score for ‘we are compassionate and inclusive’ was 6.69 out of 10, this was slightly below the organisation wide result and national average.

Staff had access to a range of relevant training and toolkits including defeating barriers training, unconscious bias training, fair and inclusive recruitment training and active bystander training and a neurodiversity toolkit.

There were 6 staff networks within the trust. These included Black and Asian Minority Ethnic (BAME) Lesbian, Gay, Bisexual, Trans, Questioning/Queer Plus (LGBTQ+) and Enhancing Abilities and Leveraging Disabilities (ENABLED). Staff networks provide protected spaces where people can be open, supported and inclusive. The ‘NHS People Plan’ requires boards of local NHS institutions to recognise the expertise of staff networks. The trust had established the Staff Networks Working Group (SNWG) to improve planning and coordination of network events and activities.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The division had governance arrangements in place to provide clinical, operational, and quality oversight. However, at divisional level the same leadership team oversaw a large portfolio of services which contributed to a complex governance structure.

Since our previous assessment, the service had made improvements within the department to address some areas of concern. However, the trust's governance systems did not always operate effectively to identify and address risk within services or areas requiring improvement. We found areas requiring significant improvement relating to staffing and the UTC which had not been identified or addressed through the trust's governance processes.

The service participated in national audits including the RCEM audits of care of the elderly and time critical medication. However, audit evidence showed that of 11 active national and local audits results for 8 were overdue. We reviewed 4 audit reports which assessed areas of clinical practice against national guidelines, 3 of the 4 provided assurance to standards or demonstrated improvement. An audit looking at the documentation of point of care ultrasound scans resulted in a finding of “very limited assurance.”

RCEM guidance outlines high risk patient groups who should be reviewed by a consultant before being discharged from ED. Staff within the department were concerned this was not taking place consistently due to staffing and ineffective processes. When we requested further information, the service was unable to provide evidence that consultant sign-off was taking place as required. RCEM sign-off audit data was overdue with an end date of 2023. Consultant sign-off is a critical element of patient discharge to ensure patients are safe and receive appropriate clinical assessment and have a follow-up plan before leaving the ED.

In the 6 months prior to our inspection the service had 4 incidents relating to information governance. None of these incidents were reportable to the Information Commissioner's Office (ICO).

The service had 5 clinical policies and procedures out of date for review in October 2025. There was a risk these documents were not in line with current best practice.

We reviewed the risk register for the urgent care division and found that of the high risks listed only 1 was related to the ED or UTC. This was the risk to patient safety due to lack of adherence to NHSE 4-hour ED standard. There were other risks recorded as lower risk including resuscitation capacity however, leaders had not identified all risks impacting on the service and added further risks to the register following our inspection.

The trust took immediate action to address several of the concerns we raised during our inspection. Whilst we were satisfied that the trust acted to mitigate risks in response to our feedback, we remained concerned that the trust could not fully identify and address areas requiring improvement within the service. This is a breach of good governance regulation.

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.

Feedback from partners was mostly positive and evidenced collaborative working, with initiatives demonstrating a shared understanding of local health and care needs. This led to the implementation of new frameworks and care pathways designed to benefit patients. Partners told us the service understood their duty to collaborate and to work in partnership and endeavoured to do this.

We saw evidence that leaders were involved in regional improvement programmes and regularly engaged with partners through a range of forums. Relationships with other local providers including mental health services had significantly improved since our previous assessment of the service.

Working in partnership with the local ambulance trust, in June 2025 the ‘Call before convey scheme’ showed a 64% deflection rate from ED. Of 33 calls, 12 patients were conveyed to ED, whilst the remaining patients were redirected to alternative services, including hospital at home, GPs or care homes. The service also met with GP groups and other partners to review missed opportunities for both ambulance‑conveyed and walk‑in patients and to identify further improvements.

We scored the service as 2. The evidence showed some shortfalls. The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The service provided examples of improvement work in the division, including initiatives related to medicines management and sepsis performance. Since our previous assessment we saw a more system wide approach to managing and improving flow through the ED and the rest of the system. However, given the number of areas where the service continued to breach regulations, including issues which had been raised across multiple assessments and inspections, the service did not evidence sufficient commitment to continuous improvement or innovation.

The service identified learning from deaths as an area requiring improvement. At the time of our assessment, actions were being taken to improve awareness of escalations from the Medical Examiner, strengthen learning from deaths and mortality review oversight. The most recent Summary Hospital-level Mortality Indicator (SHMI) was within the expected range. SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number expected to die based on average figures for England.