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Provider: Countess of Chester Hospital NHS Foundation Trust Good

Inspection Summary


Overall summary & rating

Good

Updated 29 June 2016

The Countess of Chester NHS Foundation Trust serves a population of approximately 445,000 people in and around Western Cheshire, Ellesmere Port, Neston and North Wales.

The Trust was one of the first 10 in the country to gain foundation status in 2004. In 2010, Ellesmere Port Hospital came under the management of the Countess of Chester Hospital NHS Foundation Trust.

Over 425,000 patients attend the Trust for treatment every year.

The Trust provides a full range of acute and a number of specialist services including an urgent and emergency care, general and specialist medicine, general and specialist vascular surgery and full consultant led obstetric and paediatric hospital service for women, children and babies at the Countess of Chester Hospital. In Ellesmere Port Hospital the trust provides medical care services, rehabilitation and intermediate care to patients over 65 years age. It has 56 beds over three wards.

We carried out this inspection as part of our scheduled program of announced inspections.

We visited the hospital on the 16, 17, 18, 19 February 2016. We also carried out an out-of-hours unannounced visit on 26 February 2016. As part of this inspection, the team inspected the following core services:

• Urgent and emergency services

• Medical care services (including older people’s care)

• Surgery

• Critical care

• Maternity and gynaecology

• Children and young people

• End of life

• Outpatients and diagnostic services

Overall, we rated the trust as good.

We have rated the Countess of Chester Hospital as ‘good’ for effective, caring and well led. However, improvements were needed to ensure that services were safe and responsive to people’s needs.

We rated Ellesmere Port Hospital as good for all key questions safe, effective, caring, responsive and well-led.

Our key findings were as follows:

Leadership

The Trust was led and managed by an accessible and visible executive team. The team were well known to staff and were regular visitors to wards and departments through the monthly executive walkabouts. Staff were also invited to attend a monthly open forum where they were able to meet with the Executive Team to ask questions, raise issues and discuss the trusts plans for the future.

It was evident that the executive and non-executive directors had taken steps to improve communication with staff using a variety of communication methods including the above and the use of newsletters and good use of social media. However some staff working in surgical services felt that their engagement with Board members could be improved and felt disconnected from the senior team.

There was good leadership and communication in services at a local level; senior managers were visible and approachable. Staff felt well supported and were positive about managers who were seen as knowledgeable and supportive.

The trust had introduced a series of ‘masterclasses’ to support leadership development. In addition there were plans in place to provide coaching and mentoring opportunities as well as support for front line, middle managers and team leaders through leadership development programmes.

Culture

There was a very positive culture throughout the trust. Staff felt well supported, able to raise concerns and develop professionally. Staff were proud of their services and proud of the trust.

There were improving levels of staff engagement. Staff were well motivated and committed to providing high quality services and experiences for patients.

There was a range of reward and recognition schemes that were valued by staff. Staff were encouraged to be proud of their service and their achievements. The trust had recently expanded the ‘celebration of achievement awards’ so that they were more wide ranging and inclusive.

Strategy

The trust had a vision and strategy with clear aims and objectives. The vision was underpinned by the trust core values, Safe, Kind, and Effective.

The trusts long term strategy was based on three key programmes:

  • The ‘West Cheshire Way’ included working with local healthcare and other related partners to drive service re-design and integrate care for the residents of Western Cheshire. The trust was adopting the approach of an Accountable Care Provider organisation.

  • Integrated Specialist Services providing the right services to meet the needs of patients, either as part of clinical network or as a specialist centre in its own right.

  • The’ Countess 20:20’ programme that was aimed at reviewing the core services provided to ensure the delivery of good outcomes and high quality services for patients.

Work was in progress to implement the programmes based the ‘Model Hospital’ initiative. Staff were sighted on the strategy and plans and there were regular communications with staff to keep them informed of progress in this regard.

Equality and diversity

The Trust had a very positive and inclusive approach to equality and diversity and we found the leadership in this important area of organisational culture to be committed and proactive in relation to providing an inclusive workplace.

Equality and diversity training was part of the mandatory training programme and over 95% of staff had received E&D training.

There was a range of diversity awareness raising events coupled with celebratory events. Staff were positive about the trusts approach and felt that the trust was a good place to work where diversity was encouraged and supported appropriately.

We analysed data from the NHS Staff survey regarding questions relating to the Workforce Race Equality Standard (WRES). The results for the trust were positive results across all indicators.

The trust also undertakes a “full census” approach to its staff survey which is the preferred approach rather than using a basic sample group. We considered this to be an example of good practice.

Governance and risk management

The trust had a well-developed approach to governance and risk management.

Governance was well managed and board assurance sought through a divisional governance structure that was well embedded and understood.

There was a robust committee structure in place that supported challenge and review of performance, risk and quality.

The Board Assurance Framework was aligned to trust priorities and linked appropriately to risk registers that were regularly reviewed.

There were divisional and service specific monthly governance meetings were performance, risks and learning was discussed and shared. Quality and performance were monitored through service specific and divisional dashboards.

Mortality rates

Mortality and morbidity reviews were held in accordance with trust policies and were underpinned by policies and procedures. All cases were reviewed and appropriate changes made to help to promote the safety of patients. Key learning Information was cascaded to staff appropriately.

The Summary Hospital-level Mortality Indicator (SHMI) is a set of data indicators, which is used to measure mortality outcomes at trust level across the NHS in England using a standard and transparent methodology. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die based on average England figures, given the characteristics of the patients treated at the hospital. Between August 2014 and July 2015 the trust score was 103, which was within the national average.

Nurse and Midwifery Staffing

The trust had established process in place to assess nurse staffing levels that included the use of an evidence based tool.

The trust undertook biannual nurse staffing establishment reviews as part of mandatory requirements and set key objectives though this work to support safer staffing. Data provided as part of this review in January 2016 identified that over-all the trust had maintained over 95% of staffing levels planned against actual levels for nine months. However the trust recognised that there had been a reliance on bank and agency staff to achieve this and that this was not a sustainable position for the future.

Consequently, the trust continued to actively recruit nurses both locally and from overseas. At the time of our inspection the trust has successfully recruited 20 – 30 registered nurses from Spain.

The trust was also in the early stages of using a workload management tool (NHPPD) from the recently published Lord Carter model hospital review. The trust was also piloting a national activity monitoring tool, to gain robust data on required nurse staffing levels going forward.

However, nurse and midwifery staffing levels, although improved, remained a challenge for the trust and there were times when wards and departments were not fully staffed to meet the needs of patients. This was a particular issue in surgical services at Countess Of Chester Hospital.

Medical Staffing

At the time of our inspection there were sufficient numbers of consultants and medical staff to provide patients with appropriate care and treatment.

Locum doctors were used to cover existing vacancies and for staff during leave. Where locum doctors were used, they were subject to recruitment checks and induction training to ensure they understood the trusts policies and procedures.

Trust data at the time of inspection showed a turnover rate of 17.7% and a sickness rate of 0.41% for medical staff.

A shortage of a paediatric consultant was recorded on the divisional risk register on 21/10/15 however; approval had been obtained to increase medical staffing in this area and work was underway to address the shortfall.

The number of palliative care consultants was below the recommended staffing levels outlined by the Association for Palliative Medicine of Great Britain and Ireland, and the National Council for Palliative Care guidance, which states there should be a minimum of one WTE consultant per 250 beds.

The trusts medical staffing information confirmed 60 hours consultant cover for the delivery suite. This meant the service met the recommendation in the safer childbirth best practice guidelines.

Interventional radiologists worked on a rota system. There were seven consultants covering 24 hours per day, seven days a week. The trust had recently recruited three interventional radiologists to manage the increasing workload.

Safeguarding

Staff in all service areas were able to identify and escalate issues of abuse and neglect. Practice was supported by regular and ongoing staff training. However there were service areas where we found that the numbers of staff attending safeguarding training was below the trusts set target of 80%.

Staff had access to advice and guidance so that safeguarding issues were escalated and managed appropriately and promptly.

The trust had in place a safeguarding strategy board who met to discuss safeguarding issues, reports and incidents. This group had the responsibility to develop strategies and ensure action plans were implemented to improve safeguarding practice across the trust. The work of the safeguarding board was over seen by the trust board.

At the time of our inspection there was not a safeguarding adult and learning disability coordinator in place to take the strategic and operational lead for Safeguarding Adults, however an appointment had been made and the trust were being supported by the lead from the local clinical commissioning group in the interim.

Staff had access to a named doctor and named nurse along with five other staff who acted as points of contacts for advice and guidance in relation to safeguarding.

In children’s services there was a multi- agency approach with links to local authority Child Protection Teams.

Access and Flow

The trust had established policies and both internal and external escalation procedures in place to support patient access and flow across the trust. This included a designated hospital team based at Countess of Chester Hospital who were responsible for patient flow and provided senior nurse presence and clinical leadership across the trust out of hours.

Access and flow remained a significant challenge in the emergency department. Waiting times in the ED Department regularly breached the 95% target for admitting, transferring or discharging patients within four hours of their arrival in ED. Between April 2015 and January 2016 performance varied from 76-93%, except for July and August 2105 when the 95% target was reached

There were also significant issues with access and flow across the medical and surgical wards with high bed occupancy rates and substantial numbers of delayed discharges.

A number of extra beds had been provided to help support flow though the hospital at both Countess of Chester Hospital and Ellesmere Port Hospital. Discharge planning was well understood and supported by a trust wide discharge team.

However, at the time of our inspection, there were approximately 100 patients who remained in hospital due to delays in transfers of care. These were due to a variety of reasons, predominantly the availability of packages of care and decisions and delays in relation to community living arrangements.

The trust was very aware of its challenges in this regard and was working closely with other strategic leaders to plan system delivery, strategy and plans in order to support elective and emergency admissions, attendances and discharges to and from the hospitals.

The trust had introduced a number of initiatives including a general practitioner admissions unit (GPAU) that had recently opened. By the time of our unannounced inspection in March 2016 we found that that the general practitioner admissions unit (GPAU) was already having a positive impact on flow though the hospital and there had been a reduction in patients who were delayed in being suitably transferred.

Medical services met the national 18-week referral to treatment time targets in all specialities from September 2014 to September 2015.

In January 2016, the trust achieved the referral to treatment (RTT) targets, of 95%, in all areas and specialities with the exception of ear, nose and throat at 94%.

All three cancer wait measures (patients seen within two weeks, 31 day wait and 62 day wait) were generally better than the England average from 2013/14 to 2015/16, although October and November 2015 were below the target of 85% for 62-day wait at 77% and 79.8% for the planned care division.

Cleanliness and Infection control

Clinical areas at the point of care were visibly clean; however, we did identify some cleanliness issues in none-clinical areas in urgent and emergency services, outpatients and in none clinical areas specifically related to an area within maternity services.

The trust had infection prevention and control policies in place that were accessible to staff and staff were knowledgeable in respect of good practice to prevent and control infection. Staff followed good practice guidance appropriately.

Between April 2015 to December 2015, there were two cases of MRSA bacteraemia reported across the trust. Lessons learnt from these cases were disseminated to staff across all divisions.

The trust also carried out early screening for infections including MRSA during patient admissions and preoperative assessments. This meant that staff could identify and isolate patients early to help prevent the spread of infection.

Infection rates were in line with national averages.

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

Importantly, the trust must:

  • The trust must ensure that adequate numbers of suitably qualified staff are deployed to all areas within the surgical services to ensure safe patient care.
  • The trust must ensure that patients place in areas outside their speciality meet the trusts criteria and ensure that there is suitably qualified staff to meet their needs.
  • The trust must ensure that patients nutritional and hydration needs are met at all times.
  • The trust must ensure that all staff are able to understand and apply the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards.
  • The trust must ensure that there are sufficient staff trained in adult and children’s safeguarding procedures in the emergency department.
  • The trust must ensure there are sufficient numbers of suitably qualified and skilled staff on medical wards.
  • The trust should ensure that all medications are stored in a secure environment at all times.
  • The service must ensure staffing levels are maintained in accordance with national professional standards on the neonatal unit and children's ward.
  • The service must ensure that there is one nurse on duty on the children’s ward trained in Advanced Paediatric Life Support on each shift.
  • The trust must improve the waiting times for reporting of radiology investigations.
  • Undertake robust risk-assessment for the women and children’s building so that the risks associated with baby abduction are minimised.
  • Must deploy sufficient clinical and midwifery staff with the appropriate skills at all times of the day and night to meet the needs of patients using the service.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 29 June 2016

The trust had robust systems in place to protect patients from avoidable harm. Hospital acquired harms such as pressure ulcers and falls were within the national averages.

Staff were aware of current infection prevention and control guidelines and were supported by staff training and the adequate provision of facilities and equipment to manage infection risks in all services.

Infection rates were within the England average.

Mortality and morbidity reviews were held in accordance with trust policies and procedures. Deaths were reviewed and learning opportunities shared and applied to improve patient outcomes and reduce incidents of avoidable death.

There was a positive incident reporting culture and staff were confident and competent in raising matters of concern, incidents were subject to investigation and feedback was used to underpin practice changes to avoid reoccurrence.

However, there had been four Never Events between Nov 2014 and Oct 2015 Three Surgical – wrong site surgery and one Maternity/Obstetric incident;

(A never event is a serious, wholly preventable patient safety incident that should not occur if the available preventative measures have been implemented).

All of the incidents had been subject to investigation and actions planned to improve practice. However, we found that the learning from these events was not systematically shared across the trust.

There had been no further Never Events in analysis up to January 2016.

Staff in all service areas were able to identify and escalate issues of abuse and neglect. Practice was supported by regular and ongoing staff training. Although in some services safeguarding training rates were below the trusts target of 80%. Staff had access to advice and guidance so that safeguarding issues were escalated and managed appropriately and promptly.

Nurse Staffing levels were determined using a recognised tool and were regularly reviewed. However nurse staffing levels, although improved, remained a challenge. There were still nursing vacancies across a number of services. The trust was actively recruiting nursing staff including nurses from overseas to address the shortfalls.

 In the interim, staffing levels were maintained by staff working additional shifts and the use of bank and agency staff. However, there were occasions when the staffing levels on some wards were below the required level.

Incident reporting

  • There were robust systems for reporting actual and near miss incidents. Staff were familiar with and encouraged and supported to use the trust’s procedures for reporting incidents.

  • The executive serious incident panel met on a regular basis and reviewed incident trends and any individual incidents that resulted in moderate harm or greater.

  • The level of investigation would be determined and those that were considered a NPSA (national patient safety agency) level one or two were reported to StEIS (Strategic Executive Information System).

  • The Trust has a higher rate of incident reporting than the England average based on the October 15 data. Most of the incidents reported are low or no harm; this demonstrates a good incident reporting culture.

  • There had been Four Never Events between Nov 2014 and Oct 2015 (Never events are serious, wholly preventable patient safety incidents, which should not occur if the available preventative measures are implemented).

  • Three Surgical – wrong site surgery and one Maternity/Obstetric incident;

  • No further Never Events in analysis up to January 2016.

  • 76 STEIS incidents reported – 49% were pressure ulcers. A further 67 incidents were reported up to January 2016.

  • 48% of incidents reported were in medicine (32). Followed by Surgery (10).

  • All of the incidents had been subject to robust investigations and root cause analysis. However, learning from the never events was not systematically shared, consequently opportunities for learning may have been lost.

  • The trust supports the Speak Out Safely campaign aimed at making it safe for staff to raise concerns about patient care and safety. This assisted in creating a culture in which staff were well supported if they speak up when they see poor practice or poor standards of care.

Duty of Candour

  • The trust had good systems in place to fulfil its obligations in relation to the Duty of Candour Regulations.
  • The incident reporting system identified incidents that had led to serious or moderate harm to patients and prompted staff to apply duty of candour.
  • Staff were aware of the duty of candour requirements. Staff had access to the policy and could demonstrate incidents that would require a duty of candour response.

  • Duty of candour was included in mandatory training and a leaflet was given to staff as part of induction training. Duty of candour requirements were clearly articulated in the policy for investigating incidents.

  • There was evidence that the trust was candid and appropriate with patients and those close to them when incidents of harm occurred. Actions were planned and taken to prevent reoccurrence.

Safeguarding

  • Staff in all service areas were able to identify and escalate issues of abuse and neglect. Practice was supported by regular and ongoing staff training. However there were service areas where we found that the numbers of staff attending safeguarding training was below the trusts set target of 80%.

  • Staff had access to advice and guidance so that safeguarding issues were escalated and managed appropriately and promptly.

  • The trust had in place a safeguarding strategy board who met to discuss safeguarding issues, reports and incidents. This group had the responsibility to develop strategies and ensure action plans were implemented to improve safeguarding practice across the trust. The work of the safeguarding board was over seen by the trust board.

  • At the time of our inspection there was not a safeguarding adult and learning disability coordinator in place to take the strategic and operational lead for Safeguarding Adults, however an appointment had been made and the trust were being supported by the lead from the local clinical commissioning group in the interim.

  • Staff had access to a named doctor and named nurse along with five other staff who acted as points of contacts for advice and guidance in relation to safeguarding.

  • In children’s services there was a multi- agency approach with links to local authority Child Protection Teams.

Nurse and Midwifery Staffing

  • The trust had established process in place to assess nurse staffing levels that included the use of evidence based tool.

  • The trust reviewed the nurse staffing twice a year. Data provided as part of our inspection in January 2016 indicatedthat over-all the trust had maintained over 95% of staffing levels planned against actual levels for nine months, however the trust recognised that there had been a reliance on bank and agency staff to achieve this and that this was not a sustainable position for the future.

  • Consequently, the trust continued to actively recruit nurses both locally and from overseas. At the time of our inspection the trust has successfully recruited 20 – 30 registered nurses from Spain.

  • The trust was also in the early stages of using a workload management tool (NHPPD) from the recently published Lord Carter model hospital review. The trust was also piloting a national activity monitoring tool, to gain robust data on required nurse staffing levels going forward.

  • In surgical services staffing in the ward areas was not always sufficient at times and was not always planned to ensure that the skill mix was appropriate for the patient groups who were being cared for. . This was reflected in the average fill rates for shifts on the surgical ward areas.

  • Data provided by the trust showed that over a two month period the average fill rate for shifts fell below 80% in relation to registered nurses on three out of seven surgical wards. This rate was also below 90% on an additional three wards over a two month period. This means that on six out of seven surgical wards over a two month period there were less than 90% of the registered nursing staff required on duty.

  • In the maternity service the number of midwives employed did not meet best practice guidance. The maternity service had closed six times during 2015 due to staff shortages. This had been managed through the service escalation policy which involved working with other local maternity services and emergency ambulance services.
  • However, the trust had systems in place to review midwifery staffing levels using national guidance (National Institute of Clinical Excellence: Safe Midwifery staffing for Maternity units 2015 NG4) and were in the process of employing additional midwives following the most recent review in January 2016. The active recruitment of midwives was ongoing at the time of our inspection.

  • Nurse and midwifery staffing levels, although improved, remained a challenge for the trust and there were times when wards and departments were not fully staffed to meet the needs of patients.

Medical Staffing

  • At the time of our inspection there were sufficient numbers of consultants and medical staff to provide patients with appropriate care and treatment.

  • Locum doctors were used to cover existing vacancies and for staff during leave. Where locum doctors were used, they were subject to recruitment checks and induction training to ensure they understood the trusts policies and procedures.

  • Trust data at the time of inspection showed a turnover rate of 17.7% and a sickness rate of 0.41% for medical staff.

  • A shortage of a paediatric consultant was recorded on the divisional risk register on 21/10/15 however; approval had been obtained to increase medical staffing in this area and work was underway to address the shortfall.

  • The number of palliative care consultants was below the recommended staffing levels outlined by the Association for Palliative Medicine of Great Britain and Ireland, and the National Council for Palliative Care guidance, which states there should be a minimum of one WTE consultant per 250 beds.

  • The trusts medical staffing information confirmed 60 hours consultant cover for the delivery suite. This meant the service met the recommendation in the safer childbirth best practice guidelines.

  • Interventional radiologists worked on a rota system. There were seven consultants covering 24 hours per day, seven days a week. The trust had recently recruited three interventional radiologists to manage the increasing workload.

Control and prevention of Infection.

  • The trust had infection prevention and control policies and procedures in place which were accessible to all staff across both hospital sites.

  • Staff followed good practice guidance in relation to the control and prevention of infection in line with trust policies and procedures.

  • Good practice was supported by a specialist control of infection team.

  • Between August 14 and August 15 there were overall low numbers of MRSA, MSSA and C.Diff. incidents, although MSSA and C.Diff infections were above the England average for six to seven months out of the year.

Assessing and responding to risk

  • The trust had implemented a modified early warning score system (MEWS) to alert staff if a patient’s condition was deteriorating. This was a basic set of observations such as respiratory rate, temperature, blood pressure and pain score used to alert staff to any changes in a patient’s condition and secure prompt medical attention.

  • MEWS audits were regularly undertaken. Audits highlighted good practice and where improvements were identified action plans were implemented and re-audits carried out to ensure improvements had been made.

Effective

Good

Updated 29 June 2016

Care and treatment was evidence-based and the policies and procedures, assessment tools and pathways followed recognisable and approved guidelines such as the National Institute for Health and Care Excellence (NICE).

Clinical pathways were used to ensure appropriate and timely care for patients in accordance with nationally recognised standards.

Patient outcomes were, in the main, in line with or better than the England average.

There was effective use of clinical audit to monitor and improve performance. Where audits highlighted areas for improvement the trust developed, implemented and monitored robust action plans to secure improvement.

Notably the Countess of Chester hospital had achieved an ‘A’ rating for the Sential Stroke National Audit Programme (SSNAP) in 2014, which was a significant improvement from an “E” rating in 2013.

The stroke service had been recognised regionally for using innovation to improve outcomes for patients.

Multi-disciplinary team work was well established and was focused on securing the best outcomes for patients.

Staff in all professional disciplines and service areas worked well together for the benefit of patients.

Staff had appropriate skills and knowledge to seek consent from patients or their representatives. There was a trust-wide safeguarding team that provided support and guidance for staff for mental capacity assessments, best interest meetings and deprivation of liberties safeguards.

Evidence based care and treatment

  • Care and treatment was evidence-based and the policies and procedures, assessment tools and pathways followed recognisable and approved guidelines such as the National Institute for Health and Care Excellence (NICE).

  • Clinical pathways were used to ensure appropriate and timely care for patients in accordance with nationally recognised standards.

  • Patient outcomes were, in the main, in line with or better than the England average.

  • There was effective use of clinical audit to monitor and improve performance.Where audits highlighted areas for improvement the trust developed, implemented and monitored robust action plans to secure improvement.

Patient outcomes

  • Unplanned re-attendance rates to ED within 7 days were better than the England average between October 2013 and September 2015.

  • The Royal College of Emergency Medicine (RCEM) consultant sign-off audit shows three indicators were about the same as other trusts and one was below the England average. New electronic records had improved compliance and improvements reflected in audits.

  • The risk of readmission across the hospital for all elective and non-elective admissions was generally lower than the England average however there was increased risk of readmission in elective clinical haematology, respiratory medicine and non-elective geriatric medicine.

  • The average length of stay (LOS) at the Countess of Chester hospital for all non-elective and elective admissions was longer than the England average aside from cardiology which was six days shorter.

  • The trust took part in the National Diabetes Inpatient Audit in September 2015. Data showed that there was a higher diabetes prevalence of 38% compared to a national average of 17%. The trust performed within range for four indicators and better than the England average in 14 out of 18 indicators, for example diabetic foot assessment within 24 hours (69%) compared to the England average (29%).

  • Patients admitted with active foot disease who were seen by the multi-disciplinary team within 24hrs (93%) compared to and England average of 58%. Emergency admissions for patients with diabetes was slightly higher (88%) compared to an England average (86%) and patients with active foot disease were more likely to get admitted than the national average.

  • The sentinel stroke national audit programme (SSNAP) is a programme of work that aims to improve the quality of stroke care by auditing stroke services against evidence-based standards. The latest audit results for April to June 2015 rated the hospital overall as a grade ‘A’. This had improved from a grade ‘D’ in July – December 2014 with particularly good performances in discharge processes.

  • The trust implemented actions in 2014 following the National Clinical Audit and Patient Outcomes Programme ‘NCAPOP’included appointing a cardiology specialist nurse, redrafting of the category two chest pain pathway and redefining the acute medical ward with cardiology monitored beds which was proven effective as demonstrated in the MINAP results.

  • The myocardial ischaemia national audit project (MINAP) is a national clinical audit of the management of heart attacks. The MINAP audit 2013/14 showed that the trust was higher than average for two of the three Nstemi indicators.

  • The heart failure audit in 2015 showed the trust is better than the England average for all in hospital and discharge indicators apart from cardiology follow-up.

  • The surgical services participated in a number of national clinical audits including the national hip replacement audit, national bowel cancer audit and the national emergency laparotomy audit.

  • The national hip fracture audit measures a set of outcomes for patients who have suffered a hip fracture and been admitted to hospital. The service performed better than the England average for four of the nine outcomes measured in the national hip fracture audit. The service performed worse in five of the nine outcomes measured; these outcomes were the number of patients developing pressure ulcers and the total length of stay for patient who suffered a hip fracture.

  • However there were a number of audits in progress during the time of the inspection to address this issue. These were detailed in the orthopaedic audit plan.

  • The national bowel cancer audit measures a number of outcomes, which give an indication of how well patients with bowel cancer are treated. The service performed better than the England average for all the indicators measured.

  • The national emergency laparotomy audit (NELA) report from 2014 showed that eight out of the 28 standards were available at the Hospital. The audit highlighted that the hospital did not have 20 of the 28 required standards these included a dedicated surgical assessment unit and did not have key policies related to the care of emergency general surgery patients. Senior managers had reviewed the findings of this audit and had implemented an action plan to address the issues identified.

  • Performance reported outcomes measures (PROMs) data between April 2014 and March 2015 showed that the percentage of patients with improved outcomes following groin hernia, hip replacement, knee replacement and varicose vein procedures was either similar to or slightly better than the England average.

  • Data on hospital episode statistics June 2014 to May 2015 showed the number of patients who were readmitted to this hospital after discharge following elective and non-elective surgery was similar or lower than the England average for all specialties except ENT where readmission rates were slightly worse.

  • The Critical Care service submitted performance information to the intensive care national audit and research (ICNARC) data base, so the trust was able to bench mark its performance and effectiveness alongside other similar specialist trusts. The trust compared well against similar units. There were some issues in relation to timely discharge from Critical Care that was, in the main, linked to bed pressures in the hospital.

  • The trust contributed data to the Royal College of Obstetricians and Gynaecologists (RCOG) clinical indicators reported in August 2015. RCOG results indicated the trust performed in line with the national average for:- normal vaginal deliveries; overall numbers of induced labours; numbers of planned and emergency caesarean sections; numbers of deliveries involving instruments and numbers of 3rd and 4th degree tears.

  • In children’s services, Data confirmed that 98% of children were screened on time for Retinopathy of Prematurity (ROP). ROP is an eye condition that can affect babies born weighing under 1501g or 32 weeks gestation and action plans were developed to address areas of improvement.

  • The rate of multiple (two or more) emergency admissions within 12 months (July 2014 to June 2015) among children and young people aged 1-17 years with asthma was 16.5% compared to the England average of 16.8%.

  • Children and young people aged 1-17 years admitted on two or more occasions with diabetes was 18.8% compared to the England average of 13.6% between July 2014 and June 2015. However, data from the diabetes specialist nurse indicated that between October 2015 and January 2016 only two patients had been admitted to the children’s unit with diabetic ketoacidosis (DKA).

  • The hospital took part in the National Paediatric Diabetes Audit. This identified that in the period 2013/14 the percentage of children with controlled diabetes was 22.2% compared to the England average of 18.5%.

  • A child health audit programme was in place to monitor compliance to clinical care pathways for example the guidelines for the management of patients with deliberate self-harm.

  • Admission of term infants to the neonatal unit was audited monthly and discussed at the Clinical Incident group to identify any trends.

Multidisciplinary working

  • Multidisciplinary team work was very well established and focused on the securing good outcomes for patients.

  • Staff across all disciplines worked well together for the benefit of patients.

  • There were mechanisms in place such as combined ward rounds and regular MDT meetings that supported all professional disciplines to positively contribute to the care and treatment of patients.

  • There was also good evidence of multi-disciplinary working around the discharge of patients involving medical, nursing and allied health professional staff.

Nutrition and Hydration

  • There were policies and procedures in place to support patients nutritional and hydration needs. Patients nutritional needs were risk assessed and managed appropriately.

  • Patients with specialist needs in relation to eating and drinking were supported by dieticians and the speech and language therapy team.

  • Patients confirmed that they were happy with the standard and choice of food available. The menus were comprehensive and there was a wide variety of food for patients to choose from.

  • There was an infant feeding team and ‘Bosom buddy’ volunteers to provide breast-feeding support. Mothers with babies on the neonatal unit were encouraged and supported to express milk for their babies.

  • The trust was implementing ‘care and comfort’ worker roles to work across the wards to assist patients with nutrition and hydration in a sensitive and personalised way.

Consent, Mental Capacity Act and Deprivation of Liberty Safeguards

  • Staff had the appropriate skills and knowledge to seek consent from patients. Staff were able to clearly articulate how they sought informed verbal and written consent before providing care or treatment.

  • Senior staff had knowledge and understanding of the procedures relating to the Deprivation of Liberty Safeguards (DOLS). DOLS are part of the Mental Capacity Act (2005). They aim to make sure that people in hospital are looked after in a way that does not inappropriately restrict their freedom and are only done when it is in the best interest of the person and there is no other way to look after them. This includes people who may lack capacity.

  • Senior Staff would complete all assessments as required.

  • Front line staff had a good understanding of the legal requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

  • Staff gave us examples of when patients lacked the capacity to make their own decisions and how this would be managed.

  • A trust-wide safeguarding team provided support and guidance for staff in relation to any issues regarding mental capacity assessments and deprivation of liberty safeguards during working hours.

Evidence based care and treatment

  • Care and treatment was evidence-based and the policies and procedures, assessment tools and pathways followed recognisable and approved guidelines such as the National Institute for Health and Care Excellence (NICE).

  • Clinical pathways were used to ensure appropriate and timely care for patients in accordance with nationally recognised standards.

  • Patient outcomes were, in the main, in line with or better than the England average.

  • There was effective use of clinical audit to monitor and improve performance.Where audits highlighted areas for improvement the trust developed, implemented and monitored robust action plans to secure improvement.

  • Unplanned re-attendance rates to ED within 7 days were better than the England average between October 2013 and September 2015.

  • The Royal College of Emergency Medicine (RCEM) consultant sign-off audit shows three indicators were about the same as other trusts and one was below the England average. New electronic records had improved compliance and improvements reflected in audits.

  • The risk of readmission across the hospital for all elective and non-elective admissions was generally lower than the England average however there was increased risk of readmission in elective clinical haematology, respiratory medicine and non-elective geriatric medicine.

  • The average length of stay (LOS) at the Countess of Chester hospital for all non-elective and elective admissions was longer than the England average aside from cardiology which was six days shorter.

  • The trust took part in the National Diabetes Inpatient Audit in September 2015. Data showed that there was a higher diabetes prevalence of 38% compared to a national average of 17%. The trust performed within range for four indicators and better than the England average in 14 out of 18 indicators, for example diabetic foot assessment within 24 hours (69%) compared to the England average (29%).

  • Patients admitted with active foot disease who were seen by the multi-disciplinary team within 24hrs (93%) compared to and England average of 58%. Emergency admissions for patient with diabetes was slightly higher (88%) compared to an England average (86%) and patients with active foot disease were more likely to get admitted than the national average.

  • The sentinel stroke national audit programme (SSNAP) is a programme of work that aims to improve the quality of stroke care by auditing stroke services against evidence-based standards. The latest audit results for April to June 2015 rated the hospital overall as a grade ‘A’. This had improved from a grade ‘D’ in July – December 2014 with particularly good performances in discharge processes.

  • The trust implemented actions in 2014 following the National Clinical Audit and Patient Outcomes Programme ‘NCAPOP’included appointing a cardiology specialist nurse, redrafting of the category two chest pain pathway and redefining the acute medical ward with cardiology monitored beds which was proven effective as demonstrated in the MINAP results.

  • The myocardial ischaemia national audit project (MINAP) is a national clinical audit of the management of heart attacks. The MINAP audit 2013/14 showed that the trust was higher than average for two of the three Nstemi indicators.

  • The heart failure audit in 2015 showed the trust is better than the England average for all in hospital and discharge indicators apart from cardiology follow-up.

  • The surgical services participated in a number of national clinical audits including the national hip replacement audit, national bowel cancer audit and the national emergency laparotomy audit.

  • The national hip fracture audit measures a set of outcomes for patients who have suffered a hip fracture and been admitted to hospital. The service performed better than the England average for four of the nine outcomes measured in the national hip fracture audit. The service performed worse in five of the nine outcomes measured; these outcomes were the number of patients developing pressure ulcers and the total length of stay for patient who suffered a hip fracture.

  • However there were a number of audits in progress during the time of the inspection to address this issue. These were detailed in the orthopaedic audit plan.

  • The national bowel cancer audit measures a number of outcomes, which give an indication of how well patients with bowel cancer are treated. The service performed better than the England average for all the indicators measured.

  • The national emergency laparotomy audit (NELA) report from 2014 showed that eight out of the 28 standards were available at the Hospital. The audit highlighted that the hospital did not have 20 of the 28 required standards these included a dedicated surgical assessment unit and did not have key policies related to the care of emergency general surgery patients. Senior managers had reviewed the findings of this audit and had implemented an action plan to address the issues identified.

  • Performance reported outcomes measures (PROMs) data between April 2014 and March 2015 showed that the percentage of patients with improved outcomes following groin hernia, hip replacement, knee replacement and varicose vein procedures was either similar to or slightly better than the England average.

  • Data on hospital episode statistics June 2014 to May 2015 showed the number of patients who were readmitted to this hospital after discharge following elective and non-elective surgery was similar or lower than the England average for all specialties except ENT where readmission rates were slightly worse.
  • The Critical Care service submitted performance information to the intensive care national audit and research (ICNARC) data base, so the trust was able to bench mark its performance and effectiveness alongside other similar specialist trusts. The trust compared well against similar units. There were some issues in relation to timely discharge from Critical Care that was, in the main, linked to bed pressures in the hospital.
  • The trust contributed data to the Royal College of Obstetricians and Gynaecologists (RCOG) clinical indicators reported in August 2015. RCOG results indicated the trust performed in line with the national average for:- normal vaginal deliveries; overall numbers of induced labours; numbers of planned and emergency caesarean sections; numbers of deliveries involving instruments and numbers of 3rd and 4th degree tears.
  • In children’s services, Data confirmed that 98% of children were screened on time for Retinopathy of Prematurity (ROP). ROP is an eye condition that can affect babies born weighing under 1501g or 32 weeks gestation and action plans were developed to address areas of improvement.

  • The rate of multiple (two or more) emergency admissions within 12 months (July 2014 to June 2015) among children and young people aged 1-17 years with asthma was 16.5% compared to the England average of 16.8%.

  • Children and young people aged 1-17 years admitted on two or more occasions with diabetes was 18.8% compared to the England average of 13.6% between July 2014 and June 2015. However, data from the diabetes specialist nurse indicated that between October 2015 and January 2016 only two patients had been admitted to the children’s unit with diabetic ketoacidosis (DKA).

  • The hospital took part in the National Paediatric Diabetes Audit. This identified that in the period 2013/14 the percentage of children with controlled diabetes was 22.2% compared to the England average of 18.5%.

  • A child health audit programme was in place to monitor compliance to clinical care pathways for example the guidelines for the management of patients with deliberate self-harm.

  • Admission of term infants to the neonatal unit was audited monthly and discussed at the Clinical Incident group to identify any trends.

  • Multidisciplinary team work was very well established and focused on the securing good outcomes for patients.

  • Staff across all disciplines worked well together for the benefit of patients.

  • There were mechanisms in place such as combined ward rounds and regular MDT meetings that supported all professional disciplines to positively contribute to the care and treatment of patients.

  • There was also good evidence of multi-disciplinary working around the discharge of patients involving medical, nursing and allied health professional staff.

  • There were policies and procedures in place to support patients nutritional and hydration needs. Patients nutritional needs were risk assessed and managed appropriately.

  • Patients with specialist needs in relation to eating and drinking were supported by dieticians and the speech and language therapy team.

  • Patients confirmed that they were happy with the standard and choice of food available. The menus were comprehensive and there was a wide variety of food for patients to choose from.

  • There was an infant feeding team and ‘Bosom buddy’ volunteers to provide breast-feeding support. Mothers with babies on the neonatal unit were encouraged and supported to express milk for their babies.
  • The trust was implementing ‘care and comfort’ worker roles to work across the wards to assist patients with nutrition and hydration in a sensitive and personalised way.

Consent, Mental Capacity Act and Deprivation of Liberty Safeguards

  • Staff had the appropriate skills and knowledge to seek consent from patients. Staff were able to clearly articulate how they sought informed verbal and written consent before providing care or treatment.

  • Senior staff had knowledge and understanding of the procedures relating to the Deprivation of Liberty Safeguards (DOLS). DOLS are part of the Mental Capacity Act (2005). They aim to make sure that people in hospital are looked after in a way that does not inappropriately restrict their freedom and are only done when it is in the best interest of the person and there is no other way to look after them. This includes people who may lack capacity.

  • Senior Staff would complete all assessments as required.

  • Front line staff had a good understanding of the legal requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

  • Staff gave us examples of when patients lacked the capacity to make their own decisions and how this would be managed.

  • A trust-wide safeguarding team provided support and guidance for staff in relation to any issues regarding mental capacity assessments and deprivation of liberties safeguards during working hours.

Evidence based care and treatment

  • Care and treatment was evidence-based and the policies and procedures, assessment tools and pathways followed recognisable and approved guidelines such as the National Institute for Health and Care Excellence (NICE).

  • Clinical pathways were used to ensure appropriate and timely care for patients in accordance with nationally recognised standards.

  • Patient outcomes were, in the main, in line with or better than the England average.

  • There was effective use of clinical audit to monitor and improve performance.Where audits highlighted areas for improvement the trust developed, implemented and monitored robust action plans to secure improvement.

  • Unplanned re-attendance rates to ED within 7 days were better than the England average between October 2013 and September 2015.

  • The Royal College of Emergency Medicine (RCEM) consultant sign-off audit shows three indicators were about the same as other trusts and one was below the England average. New electronic records had improved compliance and improvements reflected in audits.

  • The risk of readmission across the hospital for all elective and non-elective admissions was generally lower than the England average however there was increased risk of readmission in elective clinical haematology, respiratory medicine and non-elective geriatric medicine.

  • The average length of stay (LOS) at the Countess of Chester hospital for all non-elective and elective admissions was longer than the England average aside from cardiology which was six days shorter.

  • The trust took part in the National Diabetes Inpatient Audit in September 2015. Data showed that there was a higher diabetes prevalence of 38% compared to a national average of 17%. The trust performed within range for four indicators and better than the England average in 14 out of 18 indicators, for example diabetic foot assessment within 24 hours (69%) compared to the England average (29%).

  • Patients admitted with active foot disease who were seen by the multi-disciplinary team within 24hrs (93%) compared to and England average of 58%. Emergency admissions for patient with diabetes was slightly higher (88%) compared to an England average (86%) and patients with active foot disease were more likely to get admitted than the national average.

  • The sentinel stroke national audit programme (SSNAP) is a programme of work that aims to improve the quality of stroke care by auditing stroke services against evidence-based standards. The latest audit results for April to June 2015 rated the hospital overall as a grade ‘A’. This had improved from a grade ‘D’ in July – December 2014 with particularly good performances in discharge processes.

  • The trust implemented actions in 2014 following the National Clinical Audit and Patient Outcomes Programme ‘NCAPOP’included appointing a cardiology specialist nurse, redrafting of the category two chest pain pathway and redefining the acute medical ward with cardiology monitored beds which was proven effective as demonstrated in the MINAP results.

  • The myocardial ischaemia national audit project (MINAP) is a national clinical audit of the management of heart attacks. The MINAP audit 2013/14 showed that the trust was higher than average for two of the three Nstemi indicators.

  • The heart failure audit in 2015 showed the trust is better than the England average for all in hospital and discharge indicators apart from cardiology follow-up.

  • The surgical services participated in a number of national clinical audits including the national hip replacement audit, national bowel cancer audit and the national emergency laparotomy audit.

  • The national hip fracture audit measures a set of outcomes for patients who have suffered a hip fracture and been admitted to hospital. The service performed better than the England average for four of the nine outcomes measured in the national hip fracture audit. The service performed worse in five of the nine outcomes measured; these outcomes were the number of patients developing pressure ulcers and the total length of stay for patient who suffered a hip fracture.

  • However there were a number of audits in progress during the time of the inspection to address this issue. These were detailed in the orthopaedic audit plan.

  • The national bowel cancer audit measures a number of outcomes, which give an indication of how well patients with bowel cancer are treated. The service performed better than the England average for all the indicators measured.

  • The national emergency laparotomy audit (NELA) report from 2014 showed that eight out of the 28 standards were available at the Hospital. The audit highlighted that the hospital did not have 20 of the 28 required standards these included a dedicated surgical assessment unit and did not have key policies related to the care of emergency general surgery patients. Senior managers had reviewed the findings of this audit and had implemented an action plan to address the issues identified.

  • Performance reported outcomes measures (PROMs) data between April 2014 and March 2015 showed that the percentage of patients with improved outcomes following groin hernia, hip replacement, knee replacement and varicose vein procedures was either similar to or slightly better than the England average.

  • Data on hospital episode statistics June 2014 to May 2015 showed the number of patients who were readmitted to this hospital after discharge following elective and non-elective surgery was similar or lower than the England average for all specialties except ENT where readmission rates were slightly worse.
  • The Critical Care service submitted performance information to the intensive care national audit and research (ICNARC) data base, so the trust was able to bench mark its performance and effectiveness alongside other similar specialist trusts. The trust compared well against similar units. There were some issues in relation to timely discharge from Critical Care that was, in the main, linked to bed pressures in the hospital.
  • The trust contributed data to the Royal College of Obstetricians and Gynaecologists (RCOG) clinical indicators reported in August 2015. RCOG results indicated the trust performed in line with the national average for:- normal vaginal deliveries; overall numbers of induced labours; numbers of planned and emergency caesarean sections; numbers of deliveries involving instruments and numbers of 3rd and 4th degree tears.
  • In children’s services, Data confirmed that 98% of children were screened on time for Retinopathy of Prematurity (ROP). ROP is an eye condition that can affect babies born weighing under 1501g or 32 weeks gestation and action plans were developed to address areas of improvement.

  • The rate of multiple (two or more) emergency admissions within 12 months (July 2014 to June 2015) among children and young people aged 1-17 years with asthma was 16.5% compared to the England average of 16.8%.

  • Children and young people aged 1-17 years admitted on two or more occasions with diabetes was 18.8% compared to the England average of 13.6% between July 2014 and June 2015. However, data from the diabetes specialist nurse indicated that between October 2015 and January 2016 only two patients had been admitted to the children’s unit with diabetic ketoacidosis (DKA).

  • The hospital took part in the National Paediatric Diabetes Audit. This identified that in the period 2013/14 the percentage of children with controlled diabetes was 22.2% compared to the England average of 18.5%.

  • A child health audit programme was in place to monitor compliance to clinical care pathways for example the guidelines for the management of patients with deliberate self-harm.

  • Admission of term infants to the neonatal unit was audited monthly and discussed at the Clinical Incident group to identify any trends.

  • Multidisciplinary team work was very well established and focused on the securing good outcomes for patients.

  • Staff across all disciplines worked well together for the benefit of patients.

  • There were mechanisms in place such as combined ward rounds and regular MDT meetings that supported all professional disciplines to positively contribute to the care and treatment of patients.

  • There was also good evidence of multi-disciplinary working around the discharge of patients involving medical, nursing and allied health professional staff.

  • There were policies and procedures in place to support patients nutritional and hydration needs. Patients nutritional needs were risk assessed and managed appropriately.

  • Patients with specialist needs in relation to eating and drinking were supported by dieticians and the speech and language therapy team.

  • Patients confirmed that they were happy with the standard and choice of food available. The menus were comprehensive and there was a wide variety of food for patients to choose from.

  • There was an infant feeding team and ‘Bosom buddy’ volunteers to provide breast-feeding support. Mothers with babies on the neonatal unit were encouraged and supported to express milk for their babies.

  • The trust was implementing ‘care and comfort’ worker roles to work across the wards to assist patients with nutrition and hydration in a sensitive and personalised way.

Consent, Mental Capacity Act and Deprivation of Liberty Safeguards

  • Staff had the appropriate skills and knowledge to seek consent from patients. Staff were able to clearly articulate how they sought informed verbal and written consent before providing care or treatment.

  • Senior staff had knowledge and understanding of the procedures relating to the Deprivation of Liberty Safeguards (DOLS). DOLS are part of the Mental Capacity Act (2005). They aim to make sure that people in hospital are looked after in a way that does not inappropriately restrict their freedom and are only done when it is in the best interest of the person and there is no other way to look after them. This includes people who may lack capacity.

  • Senior Staff would complete all assessments as required.

  • Front line staff had a good understanding of the legal requirements of the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards.

  • Staff gave us examples of when patients lacked the capacity to make their own decisions and how this would be managed.

  • A trust-wide safeguarding team provided support and guidance for staff in relation to any issues regarding mental capacity assessments and deprivation of liberties safeguards during working hours.

Caring

Good

Updated 29 June 2016

Care and treatment was delivered by caring, dedicated and compassionate staff.

Staff in all disciplines treated patients and those close to them with dignity and respect.

Patients were very positive about their interactions with staff and found them to be open, friendly and helpful.

We saw many good examples of staff providing care in an individualised and person centred way.

There was a positive, caring culture and staff and managers worked well together to review and improve patient’s experiences.

Staff involved patients and those close to them in the planning of their care and treatment.

Patients felt included and valued by the staff team. We found that staff were committed to including and responding to patients individual needs and preferences

Patients and those close to them understood their treatment and the choices available to them.

Meeting people’s emotional needs was recognised as important by staff and they were sensitive and compassionate in supporting patients and those close to them during difficult and stressful periods.

Compassionate care

  • Care and treatment was delivered by caring, dedicated and compassionate staff. There were positive examples of staff displaying a caring and compassionate approach to patients.

  • Staff at all grades treated patients and those close to them with dignity and respect.

  • Patients were very positive about their interactions with staff and found them to be open, friendly and helpful.

  • The NHS Friends and Family Test (FTT) is a satisfaction survey that measures patients’ satisfaction with the healthcare they have received. In the FFT the trust are consistently higher than the England average for those who would recommend the trust between November 14 to October 15 aside from a 3% decrease below the average in February 15.

Understanding and involvement of patients and those close to them

  • Staff respected and understood the patients’ rights to make choices about their care.

  • Patients and those close to them and received information about care and treatment in a manner they understood.Patients felt involved the planning of their care and treatment and felt valued by the staff team.

  • In Children’s services patients and parents told us they felt fully informed about their care planning, that staff spent time explaining what was happening and provided information that was easy to understand. Parents stated ‘they will explain as many times as needed until you understand’.

  • Patients and parents felt involved in their care and were confident that they were taught skills required before discharge, for example parents on the neonatal unit had been taught how to administer medicines and had received a resuscitation demonstration.

  • A variety of leaflets were available for parents on the neonatal unit covering a variety of topics including discharge from hospital.

  • Parents were encouraged to stay with their children on the children’s ward and there were chairs at the bedside that converted to beds and parents had access to Christopher Wing. This was a residential facility next to the children’s unit that had bedrooms, a kitchen, sitting room and shower room and was originally opened with donations from a family whose child had passed away

Emotional support

  • Meeting people’s emotional needs was recognised as important by all staff

  • Staff were sensitive and compassionate in supporting patients and those close to them during difficult and stressful periods.

  • Counselling and individualised support packages were available for patients and staff who had suffered a traumatic event.

  • Multi faith spiritual leaders were available 24 hours a day for patients requiring spiritual support.

  • Patients in the maternity and children’s services were particularly positive about the emotional support offered to them and their families by staff.

  • Chaplaincy services were available on request. A chaplaincy team member told us that they were able to offer spiritual support to patients of all or no faith as they had developed close links with local churches and members of various congregations.

  • There was a bereavement office that issued death certificates and provided relatives with information about support services available to them including what to do following a death.

  • Prior to our inspection we had received positive feedback from families regarding the bereavement service. This feedback detailed the kindness and support people had received from the bereavement team.

Responsive

Requires improvement

Updated 29 June 2016

The Trust had a strong approach to strategic planning. Services were planned to meet the needs of the local population and included national initiatives and priorities.

As a result of the increased number of emergency admissions and increased demand for services there was continual pressure on the availability of acute beds in the Countess of Chester Hospital.

The trust was working closely with strategic leaders to plan system delivery, strategy and plans to support elective and emergency admissions, attendances and discharges across the trust.

In addition, the trust had established policies and internal and external escalation procedures in place to support access and flow across both sites to assess and prioritise patient movement. This approach included a designated hospital team that was responsible for patient flow, and provided senior nurse presence and clinical leadership across the trust out of hours.

Never the less, access and flow remained a challenge in the emergency department. Waiting times in the A&E department regularly breached the 95% national target for admitting, transferring or discharging patients within four hours of their arrival in A&E.

There were also concerns about patient access and flow across the medical and surgical wards with high bed occupancy rates and significant numbers of delayed discharges.

A number of extra beds had been opened to help support flow though the hospital at both Countess of Chester Hospital and Ellesmere Port Hospital, which were focused on intermediate care delivery.

The trust had recently introduced a number of initiatives including a general practitioner admissions unit (GPAU) that opened during our inspection. At the time of our unannounced inspection we found that the GPAU was having a positive impact on flow though the hospital and there had already been a reduction in patients who were delayed in being transferred.

In addition, the trust was working closely with other organisations and had implemented the ‘discharge to assess’ project to improve care, reduce acute admission times for elderly patients and assist in patient flow.

Medical services were involved several service development and transformational initiatives jointly with the clinical commissioning group (CCG) such as frailty services.

Despite the bed pressures, the trust continued to perform well in relation to Referral to Treatment Times; Medical services met the national 18-week referral to treatment time targets in all specialities from September 2014 to September 2015.

In January 2016, the trust achieved the referral to treatment (RTT) targets, of 95%, in all areas and specialities with the exception of ear, nose and throat at 94%.

All three cancer wait measures (patients seen within two weeks, 31 day wait and 62 day wait) were generally better than the England average from 2013/14 to 2015/16, although October and November 2015 were below the target of 85% for 62-day wait at 77% and 79.8% for the planned care division.

There was a red flag system included in the electronic patient record for patients with dementia and learning disabilities. This would act as a reminder to staff to make reasonable adjustments for these patient and to also ensure’ health passports’ were in place to support the determination of the patients specific needs so that they could be met in a sensitive and person centred way.

The trust had implemented a number of initiatives to respond to patient’s individual needs and circumstances that enabled an individualised and sensitive approach to care delivery.

The trust also provided access to interpreters for patients whose first language was not English and patient information leaflets were available in a number of languages and braille.

In maternity services there were dedicated midwives who could support and meet the needs of women whose circumstances made them or their babies vulnerable.

Service planning and delivery to meet the needs of local people

  • < >he Trust had a strong approach to strategic planning. Services were planned to meet the needs of the local population and included national initiatives and priorities.

    As a result of the increased number of emergency admissions and increased demand for services there was continual pressure on the availability of acute beds in the Countess of Chester Hospital.

  • The trust was working closely with strategic leaders to plan system delivery, strategy and plans to support elective and emergency admissions, attendances and discharges across the trust.

  • In addition, the trust was working closely with other organisations and had implemented the ‘discharge to assess’ project to improve care, reduce acute admission times for elderly patients and assist in patient flow.

  • Medical services were involved several service development and transformational initiatives jointly with the clinical commissioning group (CCG) such as frailty services.

Meeting people's individual needs

  • The trust had implemented a number of initiatives to respond to patient’s individual needs and circumstances that enabled an individualised and sensitive approach to care delivery including;

  • A red flag on the electronic patient record for patients with learning disabilities and patients living with dementia. This acted as a reminder to staff to make reasonable adjustments to meet the patents individualised needs.

  • Staff also had access to a learning disabilities coordinator who was able to support staff in providing sensitive and appropriate care for this group of patients.

  • Staff were also able to make reasonable adjustments for patients who had visual or hearing impairments. Documentation was accessible in electronic format along with text and email messaging to support personalised assessment.

  • There was a wide range of specialist nurses and teams for example diabetic, tissue viability and dementia who offered specialist advice to staff caring for people with these conditions.

  • Staff had access to three NHS Framework approved interpretation and translation provider organisations for patients whose first language was not English

  • Information boards and a range of leaflets were available so that patients were informed about services and treatment options. These could be provided languages other than English if required.

  • There was a wide range of specialist nurses and teams for example diabetic, tissue viability and dementia who offered specialist advice to staff caring for people with these conditions. .

  • Specialist nurses could also offer support and guidance for patients and those close to them about living with and managing long term conditions.

  • In the maternity service, there were specialist midwives who supported patients with complex needs such as diabetes, learning disabilities and mental illness.

  • In children and young people’s services inpatients on the children’s unit for more than seven days had a play specialist assessment completed and a play plan drawn up to ensure their developmental progress was supported during their admission to hospital.

  • There were formal transition processes in place for children moving in to adult services so that transition could be managed in a sensitive and seamless way.

Dementia

  • The trust was active in providing appropriate and personalised services for patients living with dementia and had signed up to the dementia friendly charter that supported staff to create dementia friendly patient environments.

  • There were designated dementia champions and data provided by the trust indicated that over 5000 people had attended the Dementia awareness sessions that incorporated the ‘dementia friends’ initiative.

  • Staff had access to dementia training and there were designated link nurses who supported their colleagues in meeting patient’s needs in a sensitive and personalised way.

  • The wards used the ‘this is me’ documentation for carers to record information about patients living with dementia so that their individual needs could be met appropriately.

  • Wards also used the forget-me-not’ scheme that included a discreet flower symbol to act as a visual reminder to staff that patients were living with dementia .This was to ensure that patients received appropriate care, reducing stress for the patient and increasing their safety.

  • The trust had translation and language services available via language line, deafness support and translation. Staff we spoke to had not accessed the services.

  • There were arrangements in place for rapid discharge to ensure patients at end of life died in their preferred place of care.

Access and flow

  • As a result of increasing demand for emergency care , waiting times in the A&E Departmentregularly breached the 95% national target for admitting, transferring or discharging patients within four hours of their arrival in A&E. Between April 2015 and January 2016 performance varied from 76-93%, except for July and August 2105 when the 95% target was reached.

  • There were also delays in ambulance handovers and data confirmed 382 black breaches from May 2014 to November 2015.

  • The number of patients waiting four to12 hours to be admitted was generally higher (worse) than the England average from November 2014 to October 2015 (except in August 2015 when there was a decrease below the average by 2%). Data for October 2015 showed 20% of patients waited four to 12 hours to be admitted compared to the England average of 8%.

  • There were a large number of patients being cared for in non-speciality beds which may not be best suited to meeting their needs (also known as outliers). The patient flow policy states ‘outliers’ should be patients with an imminent discharge date (preferably Data indicated that in August 2015 there were 34 outliers that increased to 120 in September 2015 and 130 in October 2015.

  • A number of extra beds had been opened to help support flow though the hospital at both Countess of Chester Hospital and Ellesmere Port Hospital, which were focused on intermediate care delivery.

  • However, at the time of our inspection, there were approximately 100 patients who remained in hospital due to delays in transfers of care. These were due to a variety of reasons, predominantly the availability of packages of care and decisions and delays in relation to community living arrangements.

  • The trust was very aware of its challenges in this regard and was working closely with other strategic leaders to plan system delivery, strategy and plans in order to support elective and emergency admissions, attendances and discharges to and from the hospitals.

  • The trust had introduced a number of initiatives including a general practitioner admissions unit (GPAU) that had recently opened. By the time of our unannounced inspection in March 2016 we found that that the general practitioner admissions unit (GPAU) was already having a positive impact on flow though the hospital and there had been a reduction in patients who were delayed in being suitably transferred.

  • Medical services met the national 18-week referral to treatment time targets in all specialities from September 2014 to September 2015.

  • In January 2016, the trust achieved the referral to treatment (RTT) targets, of 95%, in all areas and specialities with the exception of ear, nose and throat at 94%.

  • All three cancer wait measures (patients seen within two weeks, 31 day wait and 62 day wait) were generally better than the England average from 2013/14 to 2015/16, although October and November 2015 were below the target of 85% for 62-day wait at 77% and 79.8% for the planned care division.

Learning from complaints and concerns

  • There trust had a formal policy in place for managing concerns and complaints.

  • Staff were aware of the policy and how to access it for reference purposes and guidance.

  • Staff would deal with complaints informally if possible to aid timely resolution for the complainant. Where this was not possible staff referred patients to patient advice and liaison service (PALS) and the formal complaints procedure.

  • Learning from complaints was shared implemented and evaluated. There were examples of practice changes made in response to learning from complaints.

  • There was good board oversight in relation to complaints and performance was regularly monitored.

  • In 2014-15 the Trust acknowledged 93% of all formal complaints within 3 working days, and responded to 69% of all complaints with the agreed timescale.

  • There have been a relatively consistent number of written complaints received by the trust from 2010/11 to 2014/15.

    Service planning and delivery to meet the needs of local people

  • < >he Trust had a strong approach to strategic planning. Services were planned to meet the needs of the local population and included national initiatives and priorities.

    As a result of the increased number of emergency admissions and increased demand for services there was continual pressure on the availability of acute beds in the Countess of Chester Hospital.

  • The trust was working closely with strategic leaders to plan system delivery, strategy and plans to support elective and emergency admissions, attendances and discharges across the trust.

  • In addition, the trust was working closely with other organisations and had implemented the ‘discharge to assess’ project to improve care, reduce acute admission times for elderly patients and assist in patient flow.

  • Medical services were involved several service development and transformational initiatives jointly with the clinical commissioning group (CCG) such as frailty services.

  • Meeting people's individual needs

  • The trust had implemented a number of initiatives to respond to patient’s individual needs and circumstances that enabled an individualised and sensitive approach to care delivery including;

  • A red flag on the electronic patient record for patients with learning disabilities and patients living with dementia. This acted as a reminder to staff to make reasonable adjustments to meet the patents individualised needs.

  • Staff also had access to a learning disabilities coordinator who was able to support staff in providing sensitive and appropriate care for this group of patients.

  • Staff were also able to make reasonable adjustments for patients who had visual or hearing impairments. Documentation was accessible in electronic format along with text and email messaging to support personalised assessment.

  • There was a wide range of specialist nurses and teams for example diabetic, tissue viability and dementia who offered specialist advice to staff caring for people with these conditions.

  • Staff had access to three NHS Framework approved interpretation and translation provider organisations for patients whose first language was not English

  • Information boards and a range of leaflets were available so that patients were informed about services and treatment options. These could be provided languages other than English if required.

  • There was a wide range of specialist nurses and teams for example diabetic, tissue viability and dementia who offered specialist advice to staff caring for people with these conditions. .

  • Specialist nurses could also offer support and guidance for patients and those close to them about living with and managing long term conditions.

  • In the maternity service, there were specialist midwives who supported patients with complex needs such as diabetes, learning disabilities and mental illness.

  • In children and young people’s services inpatients on the children’s unit for more than seven days had a play specialist assessment completed and a play plan drawn up to ensure their developmental progress was supported during their admission to hospital.

  • There were formal transition processes in place for children moving in to adult services so that transition could be managed in a sensitive and seamless way.

  • Dementia

  • The trust was active in providing appropriate and personalised services for patients living with dementia and had signed up to the dementia friendly charter that supported staff to create dementia friendly patient environments.

  • There were designated dementia champions and data provided by the trust indicated that over 5000 people had attended the Dementia awareness sessions that incorporated the ‘dementia friends’ initiative.

  • Staff had access to dementia training and there were designated link nurses who supported their colleagues in meeting patient’s needs in a sensitive and personalised way.

  • The wards used the ‘this is me’ documentation for carers to record information about patients living with dementia so that their individual needs could be met appropriately.

  • Wards also used the forget-me-not’ scheme that included a discreet flower symbol to act as a visual reminder to staff that patients were living with dementia .This was to ensure that patients received appropriate care, reducing stress for the patient and increasing their safety.

  • The trust had translation and language services available via language line, deafness support and translation. Staff we spoke to had not accessed the services.

  • There were arrangements in place for rapid discharge to ensure patients at end of life died in their preferred place of care.

  • Access and flow

  • As a result of increasing demand for emergency care , waiting times in the A&E Departmentregularly breached the 95% national target for admitting, transferring or discharging patients within four hours of their arrival in A&E. Between April 2015 and January 2016 performance varied from 76-93%, except for July and August 2105 when the 95% target was reached.

  • There were also delays in ambulance handovers and data confirmed 382 black breaches from May 2014 to November 2015.

  • The number of patients waiting four to12 hours to be admitted was generally higher (worse) than the England average from November 2014 to October 2015 (except in August 2015 when there was a decrease below the average by 2%). Data for October 2015 showed 20% of patients waited four to 12 hours to be admitted compared to the England average of 8%.

  • There were a large number of patients being cared for in non-speciality beds which may not be best suited to meeting their needs (also known as outliers). The patient flow policy states ‘outliers’ should be patients with an imminent discharge date (preferably Data indicated that in August 2015 there were 34 outliers that increased to 120 in September 2015 and 130 in October 2015.

  • A number of extra beds had been opened to help support flow though the hospital at both Countess of Chester Hospital and Ellesmere Port Hospital, which were focused on intermediate care delivery.

  • However, at the time of our inspection, there were approximately 100 patients who remained in hospital due to delays in transfers of care. These were due to a variety of reasons, predominantly the availability of packages of care and decisions and delays in relation to community living arrangements.

  • The trust was very aware of its challenges in this regard and was working closely with other strategic leaders to plan system delivery, strategy and plans in order to support elective and emergency admissions, attendances and discharges to and from the hospitals.

  • The trust had introduced a number of initiatives including a general practitioner admissions unit (GPAU) that had recently opened. By the time of our unannounced inspection in March 2016 we found that that the general practitioner admissions unit (GPAU) was already having a positive impact on flow though the hospital and there had been a reduction in patients who were delayed in being suitably transferred.

  • Medical services met the national 18-week referral to treatment time targets in all specialities from September 2014 to September 2015.

  • In January 2016, the trust achieved the referral to treatment (RTT) targets, of 95%, in all areas and specialities with the exception of ear, nose and throat at 94%.

  • All three cancer wait measures (patients seen within two weeks, 31 day wait and 62 day wait) were generally better than the England average from 2013/14 to 2015/16, although October and November 2015 were below the target of 85% for 62-day wait at 77% and 79.8% for the planned care division.

  • Learning from complaints and concerns

  • There trust had a formal policy in place for managing concerns and complaints.

  • Staff were aware of the policy and how to access it for reference purposes and guidance.

  • Staff would deal with complaints informally if possible to aid timely resolution for the complainant. Where this was not possible staff referred patients to patient advice and liaison service (PALS) and the formal complaints procedure.

  • Learning from complaints was shared implemented and evaluated. There were examples of practice changes made in response to learning from complaints.

  • There was good board oversight in relation to complaints and performance was regularly monitored.

  • In 2014-15 the Trust acknowledged 93% of all formal complaints within 3 working days, and responded to 69% of all complaints with the agreed timescale.

  • There have been a relatively consistent number of written complaints received by the trust from 2010/11 to 2014/15.

Well-led

Good

Updated 29 June 2016

The trust had a vision and strategy with clear aims and objectives. The vision was underpinned by the trust core values, Safe, Kind, and Effective.

The Trust was led and managed by an accessible and visible executive team. The team were well known to staff and were regular visitors to wards and departments through the monthly executive walkabouts. Staff were also invited to attend a monthly open forum where they were able to meet with the Executive Team to ask questions, raise issues and discuss the trusts plans for the future.

There was good leadership and communication in services at a local level; senior managers were visible and approachable. Staff felt well supported and were positive about managers who were seen as knowledgeable and supportive.

There was a very positive culture throughout the trust. Staff felt well supported, able to raise concerns and develop professionally. Staff were proud of their services and proud of the trust.

There were improving levels of staff engagement. Although some staff in surgical services felt that their engagement with the board and senior team would benefit from improvement.

Staff were well motivated and committed to providing high quality services and experiences for patients.

The Trust had a very positive and inclusive approach to equality and diversity and we found the leadership in this important area of organisational culture to be committed and proactive in relation to providing an inclusive workplace.

The trust had a well-developed approach to governance and risk management.

Governance was well managed and board assurance sought through a divisional governance structure that was well embedded and understood.

There was a robust committee structure in place that supported challenge and review of performance, risk and quality.

Vision and strategy

The Trust long term strategy was based on three key programmes:

  • ‘West Cheshire Way’ working with local healthcare and other related partners to drive service re-designs and integrate care for the residents of Western Cheshire. The trust was adopting the approach of an Accountable Care Provider organisation.

  • Integrated Specialist Services providing the right services to meet the needs of patients, either as part of clinical network or as a specialist centre in its own right.

  • The ‘Countess 20:20’ programme that was aimed at reviewing the core services provided to ensure the delivery of good outcomes and high quality services for patients.

The three programmes of work were supported by a series of enablers:

  • Technology making best use of medical and information technology available.

  • Clinically led to make themselves the most clinically led and engaged organisation in the NHS.

  • Research, Education & Innovation to utilise the learning and creativity that exists within our organisation to ensure the delivery of quality outcomes, efficiency and sustainability.

Work was in progress to implement the programmes based the ‘Model Hospital’ initiative. Staff were sighted on the strategy and plans and there were regular communications with staff to keep them informed of progress in this regard.

Leadership

  • The Trust was led and managed by an accessible and visible executive team. The team were well known to staff and were regular visitors to wards and departments through the monthly executive walkabouts. Staff were also invited to attend a monthly open forum where they were able to meet with the Executive Team to ask questions, raise issues and discuss the trusts plans for the future.

  • There was good leadership and communication in services at a local level; senior managers were visible and approachable. Staff felt well supported and were positive about managers who were seen as knowledgeable and supportive.

  • The trust had introduced a series of ‘masterclasses’ to support leadership development. In addition there were plans in place to provide coaching and mentoring opportunities as well as support for front line, middle managers and team leaders through leadership development programmes.

Culture

  • There was a very positive culture throughout the trust. Staff felt well supported, able to raise concerns and develop professionally. Staff were proud of their services and proud of the trust.

  • There were improving levels of staff engagement. Staff were well motivated and committed to providing high quality services and experiences for patients.

  • There was a range of reward and recognition schemes that were valued by staff. Staff were encouraged to be proud of their service and its achievements.The trust had recently expanded the ‘celebration of achievement awards’ so that they were more wide ranging and inclusive.

Equality and diversity

  • The Trust had a very positive and inclusive approach to equality and diversity and we found the leadership in this important area of organisational culture to be committed and proactive in relation to providing an inclusive workplace.

  • Equality and diversity training was part of the mandatory training programme and over 95% of staff had received E&D training.

  • There was a range of diversity awareness raising events coupled with celebratory events. Staff were positive about the trusts approach and felt that the trust was a good place to work where diversity was encouraged and supported appropriately.

  • We analysed data from the NHS Staff survey regarding questions relating to the Workforce Race Equality Standard (WRES). The results for the trust were positive results across the board.

  • The trust also undertakes a “full census” approach to its staff survey which is the preferred approach rather than using a basic sample group. We considered this to be an example of good practice.

Governance and risk management

  • The trust had a well-developed approach to governance and risk management.

  • Governance was well managed and board assurance sought through a divisional governance structure that was well embedded and understood.

  • There was a robust committee structure in place that supported challenge and review of performance, risk and quality.

  • There were clearly set out the roles and responsibilities for risk management. There was a clear governance reporting structure

  • The Board Assurance Framework (BAF) was aligned to trust priorities and linked appropriately to risk registers that were regularly reviewed.

  • From our review of the BAF, risk registers, governance and committee structures it was evident that risk and performance issues were escalated to relevant committees and onwards to the board through clear reporting structures and processes.

  • There were divisional and service specific monthly governance meetings were performance, risks and learning was discussed and shared. Staff had access to robust data to support good performance management, the mitigation of risks and securing and improving service quality.

  • Quality and performance were monitored through service specific and divisional dashboards.

Fit and Proper Persons

  • The trust was appropriately prepared to meet the requirements of the Fit and Proper Persons regulation (FPPR). This regulation ensures that directors of NHS providers are fit and proper to carry out this important role.

  • We reviewed a number of records relating to senior appointments and found that they were robust and included checks on applicants/appointees criminal record, financial background, identity, employment history, professional registration and qualification checks.

  • It was part of the trust’s approach to conduct a check with any and all relevant professional bodies and undertake due diligence checks for all senior appointments.

Public engagement

  • Patients were encouraged and had access to a range of opportunities to give feedback about their care or experience including bedside TV screens, the NHS friends and family test, inpatient experience survey and via social media. All feedback mechanisms could be accessed via the trusts website.

  • The trust had attended health and well-being forums which gave members of the DSN, , Lesbian, Gay, Bisexual, and Transsexual people and the Older Peoples Network an opportunity to give feedback to the trust about their care and experiences along with any recommendations for improvement.

  • There was an active Volunteers Scheme that enabled local people to make a positive contribution to the work of the trust and support positive patient experience.

  • The trust were active members of support groups for patients such as a ‘drop in’ with the respiratory team at the Countess of Chester hospital or Age UK with the healthy ageing team at Ellesmere Port hospital.

  • In children’s and young people’s services ,parents and patients were involved with the babygrow fundraising appeal and parents were represented on the neonatal project board that encouraged and supported parentsto review designs and plans for the planned neonatal unit and contribute their views and ideas.

  • Annual board reports, accounts and minutes were accessible to the public via the trust website. Annual members and board of directors meetings were advertised on the intranet with dates for the public to attend for the rest of the year.

  • There was a range of public information leaflets displayed throughout the trust that gave the public information about the services provided and plans for the future.

Staff engagement

  • It was evident that the executive and non-executive director’s had taken steps to improve communication with staff using a variety of communication methods. Staff reported that they felt the Senior Team was more visible and that engagement with them had improved.

  • There was a range of fora for staff engagement that included a clinical workforce & leadership development programme, the ‘You Said, We listened’ programme, regular newsletters and the good use of social media.

  • There were also regular Executive Team walkabouts and a monthly open forum where staff could meet with the senior team to ask questions, raise issues and make a contribution to the future development of services.

  • However some staff working in surgical services felt that their engagement with Board members could be improved and felt disconnected from the senior team.

  • The trust had three negative findings, two positive findings and the remaining 26 questions were within expectations for the NHS Staff survey

  • Throughout the entire reporting period of January 12 to January 16 the trusts staff sickness levels have been lower than the England average.

  • The trust performed within expectations for 14 questions in the GMC survey. They scored worse than expected for Feedback Report

Innovation, improvement and sustainability

  • The trust was a Vanguard site andworked in partnership with DH developing the ‘Model Hospital’ concept which supported the capacity and flow work stream within the Trust’s ‘High Quality Costs Care Costs Less’ programme.

  • The trust was progressing a joint venture with the University of Chester to develop a Centre for Integrated Healthcare Science at Bache Hall that included new undergraduate and postgraduate medical education schemes.

  • It was envisaged that this venture would also increase the trusts research and development capacity and capability.

  • The Stroke service were recently awarded the innovative Team of the Year 2015 award by North West Coast Research and Innovation Awards for the work the team had undertaken to develop a robust auditing tool.

  • To meet the needs of the increasing elderly population and to assist in patient flow the trust had introduced the GP to clinician screen and was working collaboratively with other agencies in delivering the discharge to assess (DTA) project which included introduction of frailty ward at the Countess of Chester Hospital and the GP led ward at Ellesmere Port hospital.