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Provider: Countess of Chester Hospital NHS Foundation Trust Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 17 May 2019

Our rating of the trust went down. We rated it as requires improvement because:

  • We rated safe, effective, responsive and well led as requires improvement. We rated caring as good.
  • At this inspection, we inspected three core services and rated all of them as requires improvement. All three services had previously been rated as good.
  • In rating the trust, we took into account the current ratings of the services not inspected this time.
  • We rated well-led for the trust overall as requires improvement.
  • The trust was rated as requires improvement for Use of resources.
  • Overall this gives a combined rating of requires improvement.
Inspection areas

Safe

Requires improvement

Updated 17 May 2019

Our rating of safe went down. We rated it as requires improvement because:

  • The trust did not effectively demonstrate a consistent approach to sepsis identification and treatment. We found that all staff had not received sepsis training and processes for the rapid identification and treatment of sepsis were not embedded. Documents we reviewed did not support staff to safely identify sepsis patients. The trust had developed an action plan to improve this.
  • The surgical services did not have enough nursing staff, with the right mix of qualification and skills, to keep patients safe and provide the right care and treatment. The urgent and emergency care department did not have sufficient paediatric nurses to meet the Royal College of Paediatric Child Health standard of two children’s nurses per shift in an emergency department treating children.
  • Best practice was not always followed when storing medicines. Across the medical wards and urgent and emergency care we saw that fridge and room temperatures were not monitored and medicines were found to be out of date.
  • Staff in the medical wards did not always escalate patients appropriately following deterioration in their national early warning score.
  • The national audit of inpatient falls 2017 showed that the trust did not meet the national aspirational standards. Patients at risk of falls were not always assessed or managed in a timely manner across the areas we inspected.
  • The trust failed to achieve its targets for healthcare-acquired infections. The processes for cleanliness of the environment, isolation of patients and availability of hand washing facilities was not in line with infection control code of practice guidelines.

However:

  • Staff understood their role in recognising and preventing potential abuse. There were systems in place to ensure that patients were appropriately protected.
  • Another trust provided a mental health liaison service. The management team monitored compliance with Psychiatric Liaison Accreditation Network (PLAN) quality standards.

Effective

Requires improvement

Updated 17 May 2019

Our rating of effective went down. We rated it as requires improvement because:

  • The trust did not always ensure that care and treatment followed national guidance and evidence in order to achieve positive outcomes for patients.
  • Not all patients had comprehensive assessments and plans to meet their specific needs. Expected outcomes for patients were not fully identified and risks to patients were not always mitigated.
  • The outcomes of people’s care and treatment were not always monitored regularly. Participation in external audits and benchmarking was limited.
  • Information was not always available to staff, that was clear, accurate and up to date. This meant that information was not always shared with those involved in the care of patients in a manner that supported and met patients’ needs.
  • Staff we spoke with told us they were not always supported to maintain or further develop their skills and experience.
  • Patients consent to care and treatment was not always obtained in line with legislation and guidance, including the Mental Capacity Act 2005 and the Children’s Acts 1989 and 2004.
  • The trust had not fully embedded the updated national early warning scores (NEWS2) which determined the condition of a patient and prompts critical care intervention. Staff we spoke with said they not received training relating to this.
  • Staff appraisal rates had improved since the last inspection but not to the expected levels in all areas we inspected.

However:

  • There were a number of initiatives to try and reduce the number of patients requiring emergency transfer to hospital.
  • The trust achieved a grade A rating (best) in the latest Sentinel Stroke National Audit Programme (SSNAP).

Caring

Good

Updated 17 May 2019

Our rating of caring stayed the same. We rated it as good because:

  • There was a strong, person-centred culture, the staff we met were highly motivated and driven. The relationships between people who used the service, their families and staff was valued and promoted by leaders.
  • Patients’ personal, cultural, social and religious needs were understood and arrangements were in place to meet their individual needs. We saw several examples of how staff had been creative to overcome obstacles to delivering care.
  • People’s personal preferences were reflected in how care was delivered.
  • We noted that staff had a good rapport with their patients and those close to them.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • Staff provided information to patients in a way that they could understand. Patients were supported to understand their condition, care, treatment and advice.
  • Peoples emotional needs were important to staff and were central to their care and treatment.

Responsive

Requires improvement

Updated 17 May 2019

Our rating of responsive stayed the same. We rated it as requires improvement because:

  • Patients’ needs were not consistently met through the way services were organised and delivered. Signage across the medical wards did not meet the requirements for patients living with dementia, or patients with sight, or reading problems.
  • In urgent and emergency care we found that children were not always segregated appropriately from adults. The children’s waiting area was opposite the room used for patients attending with mental health issues. Patient’s privacy and dignity was not always maintained in the ambulance hand-over area.
  • The trust consistently failed to meet the target for urgent and emergency care four hour wait standards between September 2017 and August 2018.
  • The average length of stay for medical elective patients was worse than the England average From June 2017 to May 2018.
  • Sufficient beds for patients were not always available. During our inspection we found patients in beds in the middle of some wards without appropriate access to call bells and the ability to screen off the bed for privacy. This meant that patients’ privacy and dignity was not maintained at all times.
  • Information leaflets regarding the services, patient rights and help and support resources were only displayed in English and one size print format across all services.

However:

  • The complaints process was easy to access and all complaints were taken seriously and dealt with in an open and transparent way.

Well-led

Requires improvement

Updated 17 May 2019

Our rating of well-led went down. We rated it as requires improvement because:

  • We rated all three of the core services reviewed at this inspection as requires improvement for well-led. We considered the previous ratings of services that we did not inspect this time within the overall rating for this key question.
  • We identified that some improvements had been made since our last inspection in February 2016. However, we found several areas for improvement from the previous inspection that had not improved. We also found that monitoring systems had not been embedded to ensure areas of concern had been fully addressed and monitored for improvement.
  • There was no clear strategic objective in place to lead the organisation. This meant that there was no robust and realistic strategy for achieving trust priorities and developing good quality, sustainable care.
  • Staff did not always feel actively engaged or empowered. We received mixed comments from some staff groups in relation to the level of engagement and support they received from senior management.
  • The trust board had undergone changes in its representation including the chief executive and medical director. Leadership changes were recognised by the board and staff as vital in bringing about service improvement plans and to improve the quality of the service delivery. However, at the time of our inspection these improvements were not yet defined or fully embedded.

However:

  • Changes in senior leadership such as the appointment of the interim chief executive and interim medical director had led to recognition that improvements were required.
  • Staff were positive about the support they received from their local departmental team leaders.
  • The trust was compliant with the fit and proper person’s requirement which ensures that directors of NHS providers are fit and proper to carry out this important role.