East Cheshire NHS Trust

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 as requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

The service managed patient safety incidents well, staff understood what to report and how to report incidents. Managers investigated incidents, and when learning was identified, it was cascaded to teams and shared with the service.

Staffing was a known concern within the community services, and was on the risk register, the risks and mitigations had been identified. Processes were in place to mitigate staffing gaps, ensuring care and treatment was still delivered in times of reduced capacity.

Records were comprehensive, and staff worked collaboratively with other teams and external services where additional support for patients had been identified. Staff had training to recognise abuse, and were confident in reporting safeguarding concerns, they worked well with the trust’s internal safeguarding team, and outside agencies.

Premises where patients received care were accessible and suitable to the needs of the patients.

However, the staff mandatory training compliance rates were low for the core training modules and infection prevention control across all bands of staff, meaning staff did not have all training required for their roles.

Risk assessments were not always completed or a clear rationale recorded for why risk assessments were not required for specific service users.

Environmental issues were identified in the clinic area of one location, including the sink not meeting infection prevention control standards, and there were large rips in the vinyl covering of chairs which meant they could not be cleaned effectively.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

Staff we spoke to knew the process for reporting incidents and there was a drive within the service for staff to report all incidents.

Managers had a good oversight of incidents through the Safety Quality and Standards meeting and lessons learned were shared with the teams and wider service. This learning was shared with teams through regular team meetings, hand over meetings and newsletters.

Following serious incidents staff were supported, received debriefs.

We observed how staff discussed patients in handovers and multi-disciplinary team meetings (MDT), discussions were open, friendly and supportive, and advice and learning was shared as group.

In the 12 months prior to our inspection (1 August 2024 until 31 July 2025), the service reported 896 adverse incidents. Incidents covered a range of categories including medication, infection control, falls, IT, staffing and tissue viability. Where appropriate, incidents were escalated to Patient Safety Incident Investigations (PSII) and learning was identified.

Staff understood the duty of candour. They were open and transparent and gave patients and families an explanation if and when things went wrong. There was evidence of lessons learnt following the outcome of investigations.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

We reviewed 22 care records in total. We found that records were comprehensive, there was evidence of risk assessments being completed, and there was a holistic approach to assessments.

The records showed that staff identified where patients required additional support from other community and social care services. We observed staff within the Knutsford District Nursing and a local hospice service discussing a patient who would benefit from the additional support. We observed effective joint working between these two organisations. Staff demonstrated a positive understanding of partner services within the local area.

We scored the service as 3. The evidence showed a good standard. 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, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff were trained in safeguarding; admin staff were trained with safeguarding adults level 1. Safeguarding adults level 2 was completed by band 3-8a staff, completion rates were over 85% for each band. Band 6-8b and consultants were trained in safeguarding adults level 3.

Staff were also trained in safeguarding children, all admin staff had completed level 1 training, and 90% of Bands 4-7 staff, and all band 3, 8a and 8b staff had completed safeguarding children level 2

Staff were confident in recognising safeguarding concerns and knew how to make a safeguarding alert through the trust’s internal process and the local authority’s process. Staff had close links with the trust’s safeguarding team, who also provided support and training to teams. During handovers safeguarding was considered and discussed openly with the team, this ensured all staff were aware but also enabled staff to access support from the team.

Staff could give examples of when they had raised safeguarding concerns and were confident with identifying abuse.

Staff understood the Mental Capacity Act 2005 (MCA), and completion of consent training which included MCA and Deprivation of Liberty Safeguards (DoLS) was at 90% and above. We saw that staff completed capacity assessments when appropriate and detailed these in care and treatment records.

We scored the service as 2. The evidence showed some shortfalls. The service worked with people to understand and manage risks by thinking holistically. They did not always provide care to meet people’s needs that was safe and supportive.

Staff completed comprehensive risk assessments for most patients, however when we reviewed the records for virtual wards, we found that 4 out of 5 records did not have a pressure risk assessment in place, despite it being part of the standard assessment. This meant patients were potentially at-risk of developing pressure sores, as there was also no documentation to say the patient did not require a pressure risk assessment.

This was raised with the trust during the onsite inspection. Leaders confirmed that, in the trust’s caseload management tool, a pressure ulcer risk assessment should be completed alongside a full skin inspection. The trust noted that if this is not completed for any reason, such as patients on the virtual ward potentially being more mobile, then there should be clear documentation of this decision within the patient’s record. The trust recognised that the caseload management tool did not include the role of specialist teams, so for patients who may have been receiving district nursing care as well, the role of pressure sore management was not clearly identified. To address this, the trust adapted the caseload management tool to include specialist teams and this was due to be signed off through the trust’s governance processes, but it was not in place at the time of our inspection.

Staff used recognised tools to assess the risk to people, such as the Malnutrition Universal Screening Tool (MUST) and the Pressure Ulcer Risk Primary or Secondary Evaluation Tool (PURPOSE-T) which were used to monitor patients for deterioration.

Where appropriate, staff assessed patients at risk of physical deterioration using the national early warning score tool (NEWS2), which enabled them to monitor and then escalate patients when required.

Records showed that staff obtained consent as part of the initial assessments for all patients.

Patients were able to give feedback on their care through surveys and felt confident to raise concerns directly with the teams they were under. Patients and carers felt the communication on actions, and how staff managed risk was effective.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

All premises where patients received care were safe, and suitable to meet the needs of patients and their families. The clinic rooms were accessible and there were appropriate adjustments in place such as lifts and double wide doors where required.

Safety checks for equipment were carried out centrally to ensure it was properly maintained and calibrated.

Specialist equipment was ordered through an external contractor; staff told us that there were no issues with accessing the equipment as required. Staff told us that if equipment was ordered before 4pm, they could receive it the same day.

Staff were aware of personal safety protocols when working alone in the community.

However, at Knutsford and District Community Hospital, we found a resuscitation trolley with out-of-date equipment. We raised this with the trust who removed and replaced the equipment while we were onsite. They also confirmed that the trolley was due to be decommissioned and replaced by the end of October.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met people’s individual needs.

Staffing levels were raised as a concern throughout the community service by staff and was on the trust risk register, as well as risks for individual teams such Bollington, Disley, Poynton care community, Urgent Community Response Therapy Team, and Chelford, Handforth, Alderley Edge, Wilmslow care community. Vacancy rates varied between teams, but the most significantly affected teams were Bollington, Disley, Poynton care community, which was at 36.1%, community therapies at 17.63% and virtual wards at 17.96%.

The trust risk register detailed the risk, including how they would be mitigated along with frequent reviews of actions and impact. As part of the mitigation the trust had an agreement to block book agency staff to maintain safe staffing levels across the service. Agency staff had an induction checklist, to be completed as part of their first shift. Additional mitigation included senior management oversight at daily meetings to move staff to support gaps where possible, and the trust had a recruitment task and finish group. During our inspection we did not see staffing levels adversely impact on the delivery of patient care and treatment.

The service also had a demand and capacity standard operating procedure (SOP). The SOP was implemented with the intention of providing a framework for caseloads to be managed in times of high pressure and reduced capacity and had been enacted across the adult community services. Team leaders met daily to review staffing and once a week the meeting would look at staffing for the week ahead. The caseloads were managed through a RAG rating system in line with Nursing Caseload Priority Categories Guideline, with the virtual wards having a similar priority RAG rating system.

During our inspection, we found that virtual wards had adequate consultant cover during the week, and during the weekends staff had access to hospital out of hours consultant or GP out of hours. However, staff told is that there was a lack of consistency, because consultants worked on a two-week rota. This was also reflected in patient feedback.

We also found that the lack of safer staffing tool for Allied Health Professions (AHP) meant it was difficult for managers to access back fill when a staff member left or moved teams. Currently there is no national AHP staffing tool available, however, a job planning tool had been developed by the service and was being trialled in musculoskeletal health to establish capacity and demand. AHP staff also told us there was some confusion with management, as they currently sat under the care communities but received all clinical management from the AHP leaders.

Staff told us they had access to flexible working arrangements, and managers could give examples of how agile working and compressed hours were used to good effect without impacting on patient care. This ensured staff had a good work/life balance.

Staff received additional specialist training for their roles, such as Oliver McGowan training in learning disability and autism, syringe driver training, aseptic non touch technique and blood gases.

Staff completed mandatory training; however, completion rates varied between training modules. Completion of the Core Skills Training Framework was between 45% and 65% for band 3 – band 8a staff. Completion rates were below 85% for most bands in infection prevention control level 2, mask fit testing, medical gases and Medicines Management Awareness.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading promptly.

The clinical areas did not always have suitable facilities to ensure infection prevention and control (IPC). In the Hand Therapies clinic in Macclesfield District General Hospital, the chairs had rips in the vinyl covering meaning that they could not be appropriately cleaned. This was a concern as patients with open wounds attended the clinic. In the same clinic, the sink did not meet IPC standards, as it was not elbow-operated or non-touch, meaning staff had to turn the taps off with paper towels once they had washed their hands. The varnish on the sink’s base was also worn away, which meant the sink could not be wiped clean. These concerns were raised with the trust during the inspection, and the chairs with ripped coverings were removed from the clinics.

Across the community services, there was no audit programme in place to ensure that staff maintained appropriate standards of cleanliness and infection control.

Completion rates for mask fit testing were low, the highest level of completion was for Band 5s at 40%, this meant staff could not be assured that there would be a tight seal when using the equipment, risking the wearer from exposure to infection. Overall completion rates for IPC level 2 training were 72% and above.

However, other clinic rooms were kept clean and had suitable furnishings for the treatment. There were examination couches and appropriate equipment in clinic rooms, which we observed staff clean between appointments. Staff had access to disposable gloves, aprons, masks and sanitizing liquid gel.

We observed staff in clinics and during home visits practice good infection control procedures, and where appropriate used personal protective equipment (PPE) such as gloves and aprons. Staff received infection prevention control (IPC) training level 1 and 2 as part of their mandatory training.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Medications were prescribed through GPs, and staff linked in with GPs where necessary, for example, in the daily Knutsford GP huddle call we observed district nursing staff raise concerns regarding a patient needing an urgent prescription, which the GP was able to prescribe immediately on the call.

We observed staff discussing medication with patients, including if they were having any side effects. Staff also confirmed with patients if they had any allergies. For example, in clinics we observed staff asking patients if they had a latex allergy at the beginning of appointments.

Staff knew how to check and replace anaphylaxis kits. Staff advised that they were responsible for requesting replacements when the kit reached its expiry date. We saw a tracking report that detailed each pack and the staff member it had been signed out by, all anaphylaxis kits were within date.

Patients told us that they were involved in decisions about their care and treatment and staff discussed options available to them, and their risks and benefits. One patient told us they felt more involved in decisions about care through the virtual ward.

Staff told us they had support from the pharmacy department when needed and were competent to administer medicines within the areas they worked. However, the completion rates for medicine management awareness for band 5-8a were between 72% and 79%.