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Provider: Countess of Chester Hospital NHS Foundation Trust Requires improvement


Inspection carried out on 13 Nov to 13 Dec 2018

During a routine inspection

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.

CQC inspections of services

Inspection carried out on February 2016

During a routine inspection

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:


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.


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.


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.


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

Intelligent Monitoring

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