• Hospital
  • NHS hospital

Cannock Chase Hospital

Overall: Good read more about inspection ratings

Brunswick Road, Cannock, Staffordshire, WS11 5XY (01543) 572757

Provided and run by:
The Royal Wolverhampton NHS Trust

Important: This service was previously managed by a different provider - see old profile
Important: The provider of this service has requested a review of one or more of the ratings.

All Inspections

5th AUGUST 2019 TO 20TH SEPTEMBER 2019

During a routine inspection

Outpatients has previously been inspected and rated alongside diagnostics. This is the first time this core service has been inspected alone. We rated it as good because:

We rated safe, effective, caring, responsive and well led as good.

24 July 2018

During an inspection looking at part of the service

The Royal Wolverhampton NHS Trust (RWT) is a large tertiary, acute, community and primary care provider, with 808 beds available across its three sites.

The trust three main hospital sites are New Cross Hospital, Cannock Chase Hospital and West Park Hospital.

The trust provides urgent care, medical care, surgery, children and young people services, maternity services, outpatients, diagnostic services, end of life and critical care services. The trust serves a population of over 450,000 across Wolverhampton and surroundings areas.

In addition, the trust manages nine GP practices in and around the Wolverhampton area.

The RWT provides medical care across two sites:

  • Cannock Chase Hospital

  • New Cross Hospital.

At New Cross Hospital there are 432 medical beds across 20 wards and other reporting units: This includes Cardiology, Elderly care, Renal, Diabetes, Stroke, Cancer, Neurology, Respiratory and Gastroenterology.

At Cannock Chase Hospital there are 27 beds located on Fairoak ward, a care of the elderly and rehabilitation ward.

The trust (New Cross Hospital and Cannock Hospital) had 59,533 medical admissions from April 2017 to March 2018. Emergency admissions accounted for 18,253, 907 were elective, and the remaining 40,363 were day case.

Admissions for the top three medical specialties were:

  • General medicine: 28,754

  • Clinical haematology: 8,297

  • Clinical oncology (previously radiotherapy): 8,254

Inspection of the medical services at New Cross Hospital, took place in February 2018.

The trust consists of three hospital sites and includes several GP practices.

New Cross Hospital provides a range of services including Emergency care, Medical Care, surgery, outpatients and diagnostics services , maternity, and critical care services. Other services including specialist care are also provided at the hospital. There are specialist facilities for cardiac and stroke patients provided by the regional heart and lung centre.

Cannock Chase Hospital provides medical care, surgical services and a range of outpatient services and diagnostic services.

Rehabilitation and community inpatient services are provided at West Park Hospital.

This inspection was focussed on the care of the elderly ward at Cannock Chase Hospital.This was due to be inspected as part of the Royal Wolverhampton NHS Trust inspection that took place in February 2018, however was excluded due to an infection prevention and control concern causing the ward to be closed to visitors. A report for the February 2018inspection can be found on the CQC website.The medical ward at Cannock Chase Hospital is known as Fairoak Ward, it has 27 beds split between both male and female patients. The beds are in bays containing four beds and allocated as single sex areas, there are three single occupancy rooms.

The ward accommodates elderly care patients and those in need of rehabilitation. Referrals are generally made from within the trusts two other locations, New Cross Hospital and West Park Hospital.

We visited the Fairoak Ward at Cannock Chase Hospital, unannounced, on 24 July 2018.

We spoke with 13 members of the medical team including a consultant and junior doctors, a matron, nurses, health care assistants, physiotherapists and members of the domestic staff team.

We spoke with 11 patients and 4 visitors.

We looked at the records for 11 patients in total.

Our key findings were as follows:

  • We saw improvements in processes to protect patients from harm compared with the previous inspection.

  • Staff understood the procedure to raise concerns, reports incidents and near misses and told us they were supported to do so.

  • Areas were clean and regular audits were carried out. Action plans were put in place to make improvements where required.

  • Patient notes were multi-disciplinary and had name and date stamps throughout all entries, indicating which member of staff had seen the patient.

  • The trust had been working to improve the implementation of the sepsis pathway since the last inspection. On this inspection we found that management of sepsis had improved.

  • The ward carried out various local audits, including auditing their own documentation to check that care plans were being completed correctly.

  • Senior service leaders regularly reviewed the effectiveness of care and treatment through local and national audit.

  • Staff were supported to undertake professional development training to enhance their knowledge and skills and were well supported with their training and development.

  • Patient information huddles were held each day on each ward so that information could be shared with all relevant staff involved in the care and treatment of the patient.

  • Nursing and medical staff ensured that patients received timely pain relief.

  • Patients’ nutritional needs were assessed and care plans developed.

  • Staff understood their roles and responsibilities under the Mental Capacity Act 2005.

  • We observed both nursing and medical staff interacting with patients with dignity and respect.

  • Patients told us they felt involved in their care and they were given enough information.

  • Staff supported patients’ emotional needs and responded to their care and treatment in different ways and according to their social, religious and spiritual needs.

  • Families were encouraged to be part of the rehabilitation process and could support patients whilst on the ward.

  • There was a robust discharge procedure which used a checklist to aid staff in monitoring discharges.

  • Relatives of patients were included in the planning of care and the consultant or a senior member of staff would try to see relatives or loved ones, within 48 hours of an admission to the ward.

  • Patients told us the therapy was “brilliant” and that there was a range of activities to suit individual needs.

  • Staff told us complaints management had improved and they received feedback from complaints across the trust and discussed these at team meetings.

  • Training and development for staff was a priority for the trust and we saw examples where staff had been involved in developing training.

  • There was a local vision and strategy for medicine which was linked to the trust’s overall vision.

  • Nursing forums had been introduced throughout the trust to allow staff to discuss issues openly and offer views on potential solutions.

  • Shared governance meetings were held monthly where staff sent a representative from the ward to attend.

  • The Fairoak Ward team were shortlisted for the “enhancing patient dignity” category at the 2018 nursing times awards.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • review security arrangements around the access to the ward.

In addition the trust should:

  • ensure it continues to work to reduce the number of patients sustaining falls.

  • review training schedules and prioritise basic life support and tissue viability and pressure injury management training.

Professor Edward Baker

Chief Inspector of Hospitals

20 Feb 2018 to 22 Mar 2018

During a routine inspection

Our rating of this hospital stayed the same. We took into account the current ratings of services not inspected at this time.

We rated the hospital as requires improvement because:

  • We found that some infection prevention and control processes were not robust. One theatre was closed due to its unsatisfactory condition. There were loose tiles in the theatre and an unsatisfactory seal on the doors, which compromised the air pressure control.
  • We also saw theatre staff wearing gowns and hats that had been used in theatre. This contradicted policy for standards of dress at work.
  • There were inconsistencies around the world health organisation checklists, with some staff not completing some stages. We found that staff were not always following the correct protocol for taking time out of the theatre environment.


  • Staff told us that they were fully supported by their managers and were proud to work at the trust. They subscribed to the trusts visions and values and demonstrated good care and support to the patients.
  • Staff knew how to access relevant information to perform their duties. There were regular meetings where learning from incidents would be discussed and staff were confident and competent in reporting incidents.

02 - 05 June 2015

During a routine inspection

We undertook this inspection 02 to 05 June 2015. It was an announced comprehensive inspection. This trust had been inspected in the first wave of the comprehensive programme November 2013. Our rationale for undertaking this inspection was to rate the trust because the initial inspections did not receive a rating. In addition to this the trust had taken over services from the dissolved Mid Staffordshire NHS Trust, which included Cannock Chase Hospital. The trust had previously stated its intention to become a Foundation trust, but had had to postpone the application a number of times. Allowing them to address current matters such as the integration of new services appropriately.

Within Cannock Chase Hospital there are services which are offered to the public by other providers, we did not inspect those. All services offered by the Royal Wolverhampton Trust at Cannock Chase hospital were inspected.

We found this location to require improvement. The integration process started 01 November 2014 and we have endeavoured to ensure our inspection is confined to post that date. We recognise that the integration of the service is more than a contract and date, it involves staff and users and we saw there were some teething issues which still required input to resolve.

We saw that some of the processes did not support good patient outcomes namely in the  Medical rehabilitation ward and Outpatients and diagnostics.

Our key findings were as follows:

  • Staffing levels were not sufficient to meet the needs of patient in the Minor Injuries Unit (MIU). We also saw that staff on the medical ward were fatigued and felt this was because they were required to cover shift shortfalls via the bank.
  • Surgery services were good on the whole, demonstrating that patient care was safe and effective.
  • The integration process was in progress and we saw where continued work was required. For instance in Surgery there needed to be a process for identifying the best practice and incorporating that into the trust as a whole. Within medicine we saw that the staff felt isolated from the New Cross Site. We also noted that in MIU they did not fully understand how they fitted into the vision of the trust with regard to the Emergency service strategy.
  • The end of life service was meeting the needs of the people and staff. There was complete ‘buy-in’ of the staff with regard to the implementation of the Swan Project.
  • Governance arrangements in Outpatients and diagnostics needed to be strengthened. We saw that appraisals for qualified staff were not undertaken in outpatients. Within diagnostics there were a number of challenges such as the radiation risk assessments being generic and the use of two types of referral form for the same procedures.
  • Care was consistently good throughout the service. We saw that patients we recommend friends and family to use the service. We received good feedback from patients and visitors about the care they had receive in the hospital.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • The trust must put in place effective systems to monitor outcomes for patients.
  • The trust must insure that governance systems improve so that safety issues and shortfalls in risk assessments and protocols are highlighted and addressed.
  • The trust must insure that there is clear ownership of responsibilities to ensure the radiology departments is working within best practice professional guidelines and IR(ME)R regulations.

These represents a breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (Part 3) (as amended) Regulation 17: Good Governance

In addition the trust should:

Minor Injuries Unit

  1. The trust should improve risk management for the MIU including demonstrating how it has assessed and how it safely manages the lack of access to x ray facilities for patients and the lack of privacy at the reception desk.
  2. The trust should improve the uptake of mandatory staff training at the MIU and provide staff with dementia awareness training.
  3. The trust should support the MIU service to participate in appropriate audit activity.
  4. The trust should support the MIU service to monitor outcomes for its patients including those transferred to the ED, and to provide key performance indicators, including waiting times, and other access and flow indicators.
  5. The trust should effectively communicate a clear vision for this service.
  6. The trust should strengthen Governance arrangements to support continuous improvement and manage risk strategically and more effectively.


  1. The trust should ensure that broken equipment is fixed in a timely manner.
  2. The trust should ensure that all equipment such as nutrition feeding equipment pumps are portable appliance tested (PAT).
  3. The trust should ensure that the protocols be documented regarding wound care.


  1. The trust should make sure that all staff is up to date with the requirements of the Mental Capacity Act and Deprivation of Liberty safeguards so that patients are not put at unnecessary risk of staff not acting legally in their best interests.
  2. The trust should have in place a major incident plan for all the services. Staff should be aware of this plan as it relates to their specific service.
  3. The trust should make sure that there are process in place to ensure formal “sign in” takes place in the anaesthetic room.
  4. The hospital should ensure operating lists are published in a timely manner.
  5. The trust must make sure that the integration of the service is undertaken by engaging clinicians at all levels in an inclusive manner.

OPD Diagnostics

  1. The trust should ensure that all staff receives post-incident feedback, shared learning and changes in practice related to incidents.
  2. The trust should ensure that all staff receives safeguarding training in the protection of vulnerable adults and children.
  3. The trust should ensure that the procedure to check whether women were pregnant prior to receiving radiography tests is improved to be in line with professional body guidance.
  4. The trust should ensure that the disabled cubicle in radiography is improved to ensure the call bell and curtain is fit for purpose.
  5. The trust should improve radiation risk assessments to ensure they are fit for purpose.
  6. The trust should standardise radiology referral forms and ensure that they adequately record the information required by IR(ME)R.
  7. The trust should ensure that all staff in outpatients receives their appraisals.
  8. The trust should try to improve waiting times in outpatients and radiology and keep patients informed of delays.
  9. The trust should ensure that appointment letters and patient information leaflets are accessible in languages other than English.
  10. The trust should ensure that there are facilities to provide food and drink to patients in outpatients and radiology.
  11. The trust should ensure that senior management support and empower staff to make changes and drive improvements within both outpatients and radiography.

Professor Sir Mike Richards

Chief Inspector of Hospitals

20 April 2015

During an inspection of this service