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  • SERVICE PROVIDER

East Cheshire NHS Trust

This is an organisation that runs the health and social care services we inspect

Overall: Good read more about inspection ratings

All Inspections

25 June to 27 June 2019 and 02 July to 04 July 2019

During a routine inspection

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

  • We rated effective, caring, responsive and well-led as good, and safe as requires improvement. We rated 12 of the trust’s 13 services as good and one as requires improvement. In rating the trust, we took into account the current ratings of the six services not inspected this time.
  • We rated well-led for the trust overall as good.
  • Services we inspected had enough staff to care for patients and keep them safe. Most staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The trust controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They mostly managed medicines well. The trust managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment and gave patients enough to eat and drink. Managers monitored the effectiveness of most of the services and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. They provided emotional support to patients, families and carers to minimise their distress. They understood patients’ personal, cultural and religious needs. Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment.
  • Services were planned and provided care in a way that met the needs of local people and the communities served. The trust also worked with others in the wider system and local organisations to deliver care. The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers. The trust treated concerns and complaints seriously, investigated them and shared lessons learned with staff.
  • Leaders ran most services well and supported staff to develop their skills. Staff understood the trust’s vision and values, and how to apply them in their work. Most staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The services engaged well with patients to manage services and staff were committed to improving services continually.

However:

  • Within urgent and emergency care and outpatient services, patients could not always access services when needed and receive treatment within agreed timeframes and national expectations.
  • Within the community inpatients service, people could not always access the service when they needed it and criteria for admission to intermediate care were not formally agreed. The adaptations of the environment and facilities for people living with dementia were limited within the community inpatients services.
  • Within the complex care team in the children’s community service, the service had not met their responsibilities regarding legal and appropriate consent to care and treatment when patients had reached the age of 16. There had been gaps in the leadership teams and governance processes were not well understood in community children’s services.

25 June to 27 June 2019 and 02 July to 04 July 2019

During an inspection of Community dental services

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

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them.
  • Staff provided good care and treatment. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

  • During the inspection we noted not all medical emergency medicines and equipment were available. Immediate action was taken to address this.
  • A dental specific sharps risk assessment had not been carried out.
  • An audit of antimicrobial prescribing had not been carried out.

25 June to 27 June 2019 and 02 July to 04 July 2019

During an inspection of Community health inpatient services

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

  • Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service. The service had enough staff to keep people safe.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

  • People could not always access the service when they needed it and criteria for admission to intermediate care were not formally agreed.
  • Optimal staffing levels were not always achieved as staff were moved when demands for staff elsewhere in the trust increased.

25 June to 27 June 2019 and 02 July to 04 July 2019

During an inspection of Community health services for children, young people and families


Our rating of community health services for children and young people stayed the same. We rated it as requires improvement because:

Some groups of staff were unaware of the systems in place to respond to the potential risks of patients with sepsis.

Not all records were up to date and easily available to all staff providing care.

The arrangements for monitoring patient outcomes were not consistent. Staff appraisal rates in some teams did not meet trust targets. Arrangements to make sure that some children, young people could make legally informed decisions about their care and treatment were not effective. Transition arrangements of children and young people were not suitably planned or monitored to meet individual need.

Information was not always in formats that met individual needs.

There was a lack of a clear vision and strategy to ensure that all staff felt connected with the trust and ensure that the service was monitored. Leaders were not consistently visible in the service.

There was limited engagement with patients, staff, equality groups, the public and local organisations to plan and manage services.

However;

Managers and staff understood how to protect patients from harm and abuse and how to report any safety incidents. Environments and equipment were clean and well maintained. Staffing levels were monitored and adjusted to meet patient’s needs. Medicines were managed safely.

Managers held meetings with staff to provide support and development. There was good team working both within the service and externally with partners.

Staff treated children, young people and their families with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Emotional support was provided as needed.

Leaders supported staff to develop their personal skills and take on more senior roles. Staff were focused on the needs of patients receiving care. Staff within local teams were clear about their roles and accountabilities and had regular opportunities to meet.

9 January 2018

During a routine inspection

Our rating of the trust improved. We rated it as good because:

  • We rated effective, caring, responsive and well led as good. We rated safe as requires improvement. Our rating for the trust took into account the current ratings of services not inspected this time.
  • Our decisions on overall ratings take into account factors including the relative size of services and we use our professional judgement to reach a fair and balanced rating.

9 January 2018

During an inspection of Community end of life care

We rated the service overall as good because:

  • The trust had a dedicated specialist palliative care team who provided support to community staff and patients at the end of their life.
  • Care and support was given in a respectful and compassionate way. Staff within the specialist palliative care team worked hard to support staff to ensure patients received the care and treatment they required.
  • Managers planned and provided services in a way that met the needs of local people. They worked with local organisations and made changes to improve services and support patients more effectively.
  • Staff were competent, knowledgeable and responded to patients and their loved ones’ needs. The majority of the team had completed mandatory training and all staff had received annual appraisals.
  • The specialist palliative care team worked as an integrated team with hospital and community providers to promote continuity and consistency in patient care. The team also participated in local and national groups to share information and learn from peers.
  • Staff knew what incidents to report and how to report them and managers were involved in investigating incidents and they shared any lessons learned.
  • Staff across the service understood how to protect patients from abuse and how to assess patients’ capacity to make decisions about their care.
  • The team attended daily board rounds and multidisciplinary team meetings across secondary and primary care in order to provide knowledge, support, input and consistency into patients’ palliative and end of life care.
  • Medicines were managed and prescribed appropriately and equipment was available to patients at the end of their life. Equipment was mostly well maintained.
  • Managers supported all staff through regular appraisals and supervision. New staff received a package of support including a mentor, induction, and list of competencies, which was flexible according to their previous experience and training.

However,

  • End of life care plans reflected National Institute for Health and Clinical Excellence guidelines however these were not used consistently in the community..
  • The service relied upon other organisations to collate and measure patient outcomes and although this was shared we did not see any service specific action plans to address areas for improvement.
  • Although the majority of staff had received training on safeguarding, the Mental Capacity Act, and Deprivation of Liberty Safeguards the trust provided no evidence that two members of staff had attended or were going to attend level 2 training in adults safeguarding.
  • Specialist palliative care services were not available seven days a week although community staff had support from a local hospice telephone advisory line or GP service at weekends and out of hours.
  • Some staff felt the senior managers and executive team were not all visible within their service.

9 January 2018

During an inspection of Community health services for adults

Our rating of this service improved. We rated it as good because:

  • The community adult’s service had made a number of improvements since our last inspection.
  • There were sufficient numbers of staff across the community adults service to keep people safe, although caseloads varied by team. Staff were competent in their roles.
  • Completion rates for mandatory and safeguarding training were high across the service’s range of specialisms. Staff were able to identify and knew how to report safeguarding concerns and incidents. There was governance oversight of incidents and complaints and learning emerging from these was shared with staff and teams across the service.
  • Care and treatment provided was evidence based and we saw evidence of effective multidisciplinary working within the teams. This included specialisms working together to identify potential risks to patients and to avoid the development of a frailty ‘wrap around’ care service to keep people safe in their own homes or care homes and to avoid admission to hospital.

  • The service collected data in all its specialisms on patient outcome measures. Results showed that the majority of patients achieved positive outcomes from the care and treatment provided to them.
  • Staff were kind and compassionate in the care and treatment provided to their patients. Staff involved people in decisions and ensured people understood the care and treatment provided to them, and supported people emotionally when appropriate.
  • The service worked with local commissioners, GP and other stakeholders in planning the services offered to people, and also took into account individuals’ needs. People were able to access the service when they needed to and waiting times were within local and nationally agreed targets.
  • The service’s leaders understood the challenges the service faced, and had a vision and plans for the future development of the service to integrate further with primary and secondary medical services in the area.
  • The culture within the service and engagement with staff and the public had improved since our last inspection. Innovation, improvement and learning was supported by the trust.

However:

  • Patient treatment plans developed in the electronic ‘paper light’ working environment were not of sufficient detail or quality to enable staff to adequately plan individualised patient treatment and care goals, to assess progress against these, or to reasonably mitigate the risks to the health and safety of patients receiving care and treatment. This meant there was an over-reliance on staff knowledge of individual patients to mitigate any ongoing or developing risks to patients.

9 - 12 December 2014

During a routine inspection

We inspected East Cheshire NHS Trust as part of our new comprehensive inspection programme.

We carried out an announced inspection of Macclesfield District General Hospital on 10, 11 and 12 December 2014. The announced inspection of community healthcare services also took place at this time and we carried out an announced inspection at Congleton War Memorial Hospital on 11 December 2014.

We undertook an unannounced inspection between 6am and 12.30pm on 22 December 2014 at Macclesfield District General Hospital only. During the unannounced inspection we looked at the management of medicines and checked to see what actions the trust had taken to address concerns we raised during the announced inspection in relation to children’s and young people’s services and surgical services.

Overall, we rated East Cheshire NHS Trust as ‘requires improvement’. We have judged the service as ‘good’ for caring. We found that services were provided by dedicated, caring staff. Patients were treated with dignity and respect and were provided with appropriate emotional support. However, improvements were needed to ensure that services were safe, effective and responsive to people’s needs, and we rated the trust as requires improvement with regard to services being well led.

Our key findings were as follows:

Incidents

  • Systems were in place for reporting and managing incidents. However, these systems were not followed consistently across all services. Incidents were not always reported in line with trust policy, which meant that data provided in relation to incidents may not provide a reliable oversight of incidents occurring in these services.
  • In some services, there was poor understanding of the formal system for deciding the serious nature, or potential outcomes, of an incident or how it should be investigated. This meant that not all incidents with potential risks of harm were formally investigated or recorded or lessons shared.
  • Some staff raised concerns that they were not given feedback on incidents that had been reported.

Safeguarding

  • There was a clear policy in place that was accessible to staff on the intranet. However, there was a lack of clarity relating to the application of the policy.
  • We found that there had been no self-referrals to adult social care in the last 18 months. We found that, when a potential safeguarding concern was identified, the incident would be investigated locally before being entered on the electronic reporting system. Only if the outcome of the investigation substantiated a safeguarding concern would it then be referred to adult social care. This was not in line with best practice.
  • In addition, we were informed of an incident relating to the suspension of a member of staff for potential verbal abuse of a patient, which, on review, had not been reported via the safeguarding process.

Cleanliness and infection control

  • During our inspection we identified concerns with the decontamination and storage of equipment and the maintenance of a safe environment. A number of areas showed signs of ‘wear and tear’ which meant that they could not be cleaned adequately. We raised our concerns immediately with the trust, which addressed the urgent issues.
  • However, we were not satisfied that there were robust arrangements in place for monitoring the patient environment or for identifying and addressing risks in a timely manner. Policies for managing patients in isolation rooms were not always followed. Where risks had been identified, action had not always been taken in a timely way to protect patients from harm.
  • We observed good practice in relation to hand hygiene and ‘bare below the elbow’ guidance and the appropriate use of personal protective equipment.

Medicines management

  • The systems in place for the management, storage, administration, disposal and recording of medication, including controlled drugs and oxygen, were not robust or in line with requirements.
  • Anticipatory prescribing in end of life care was common, in line with best practice. This meant that pain relief and other medication could be started quickly if patients became unwell.

Staffing

  • Overall, medical treatment was delivered by sufficient numbers of skilled and committed medical staff.
  • Care and treatment were delivered by committed and caring staff who worked hard to provide patients with good services.
  • Consultant cover in critical care services was limited due to only six of the nine consultants being trained in intensive care. This meant that only 80% of patients were assessed by a consultant within 12 hours of admission to the critical care unit (CCU) and the provision of two daily ward rounds was not achieved at weekends.
  • A shortfall in the number of junior doctors in urgent and emergency services meant that the trust had to employ locum staff from November 2014 to February 2015 to cover shortages. The trust was also having difficulty recruiting to four additional registrar posts. In addition, there were four vacancies for junior doctors in critical care services. Shortfalls were covered by locum, bank and agency staff.
  • The trust was actively recruiting nursing staff from overseas to try to improve staffing levels. In most areas we found that nurse staffing levels were generally adequate at the time of our inspection. However, appropriate steps had not been taken to ensure that there were sufficient numbers of suitably qualified, skilled and experienced nursing staff working in adult community services to meet the needs of service users. Adult community teams experienced staff shortages and had difficulty in recruiting.
  • We also found that nurse staffing levels within the children’s unit were not always in line with Royal College of Nursing recommendations.
  • The midwife-to-patient ratio averaged at one to 30. This was worse than the recommended number of one to 28. A staffing acuity guideline was in place based on Birth-rate plus. However this did not allow for this assessment to be done daily.

Mortality rates

  • Our ‘intelligent monitoring’ report of July 2014 showed that there was no evidence of risk for summary hospital mortality level indicators or for hospital standardised mortality ratio indicators.

Nutrition and hydration

  • Patients had a choice of nutritious food and an ample supply of drinks during their stay in hospital. Patients with specialist needs in relation to eating and drinking were supported by dieticians and by the speech and language therapy team.
  • The patient records we reviewed included an assessment of patients’ nutritional requirements based on the malnutrition universal screening tool (MUST).
  • Children and young people were offered a choice of meals that were age appropriate and supported individual needs, such as gluten-free and sugar-free. Children told us that they enjoyed the food. Parents told us that the food was good quality and there was a lot of choice, including healthy options.

We saw several areas of outstanding practice including the following:

  • Care planning in the community dental service was found to be outstanding in its care planning and we observed excellent interactions with the diverse and complex needs of patients using the service.
  • A learning disabilities and autism group was in place in the trust and the trust had received an Autism Access Award from the National Autistic Society.
  • The trust's home intravenous therapy service had recently piloted new projects to expand the service into new specialities. For example, cardiology and alcohol management. The team had developed policies and procedures based on best practice from other trusts and in line with national guidance.
  • The Parkinson’s nurses, respiratory nurses, physiotherapists and podiatrists networked in specialist groups. They attended regular update meetings where some would present their work to peers outside the organisation.

We found evidence of breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 [now the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014].The trust must take action to ensure improvements in these areas.

Importantly, the trust must:

  • Ensure that there are suitable arrangements in place to respond appropriately to any allegation of abuse in order to safeguard service users against the risk of abuse.
  • Ensure that there are robust systems in place for the management, storage, administration, disposal and recording of medication, including controlled drugs and oxygen, in line with requirements.
  • Ensure that there are effective processes in place for the decontamination and storage of clean and contaminated equipment and for the monitoring of this, particularly in relation to children’s and young people’s services.
  • Ensure that the environment within the surgical wards and maternity services is well maintained and fit for purpose so that appropriate standards of cleanliness can be maintained.
  • Ensure that there are sufficient numbers of suitably qualified, skilled and experienced nursing and other staff working in adult community services to meet the needs of service users.
  • Ensure that there are effective systems in place to identify, assess and monitor risks relating to the health, safety and welfare of both staff and the people who use services. This includes incident-reporting systems and risk management processes for the maintenance of equipment.
  • Ensure that records contain accurate information in respect of each patient and include appropriate information in relation to the treatment and care provided, particularly with regard to children’s and young people’s services, community healthcare services for adults, pain relief documentation in the emergency department and ‘do not attempt cardio-pulmonary resuscitation’ (DNA CPR) forms.

Professor Sir Mike Richards

Chief Inspector of Hospitals

9 - 12 December 2014

During an inspection of Community health services for adults

East Cheshire NHS Trust provided adult community services across east and south Cheshire and Vale Royal. Services we inspected were provided in people’s own homes, nursing homes, clinics and GP practices.

The trust had taken measures to increase nursing capacity. However, adult community teams experienced staff shortages and had difficulty in recruiting. Community nurses told us that there were limitations when it came to seeing emergency patients due to staffing and time pressures. Staff shortages had compromised the standard of record keeping and of the recording and investigation of incidents.

Training records showed that most community staff had completed appraisals in the last 12 months and mandatory training including training in the Mental Capacity Act 2005. However, several staff, including senior clinical staff, did not know what the term ‘deprivation of liberty’ meant or how to apply the Mental Capacity Act 2005 to their work.

The service did not adequately monitor the quality of service provision to identify or manage risks in order to assure people’s welfare and safety. Incident reporting and investigation were inconsistent across the adult community health services. Community nurses did not always report and investigate incidents in line with the trust’s incident-reporting policy. Evidence of learning from incidents in the community nursing services was also limited.

The vision for the service was unclear and staff felt that the trust was focused on hospital care rather than community services. Although staff knew who the chief executive was, they were unclear on the management structure above their immediate line manager. Most staff was unable to tell us who the director of nursing was. Allied health professionals were unaware of which directorate they came under and some were unaware of who their next-level managers were. There was good local leadership across allied health professionals and specialist nursing teams. However, there was a lack of leadership from immediate line managers within community nursing teams. While some staff told us that the chief executive had liaised with them about the restructuring of the service, some community nursing staff felt that they did not have a voice in the organisation.

Community services for adults were unable to provide us with a clear overview of what their performance indicators were and what the outcomes were for patients. Podiatrists and physiotherapists told us that they were meeting their targets but did not have evidence of this. Staff had limited access to the trust’s intelligence data or any information the trust gathered. This meant that services and the trust did not have robust oversight of the quality of services provided.

Community services delivered evidence-based practice in line with national guidance. Staff worked within their scope of practice and in accordance with the recommendations of their professional governing bodies. Across all services, care and treatment of patients were delivered with empathy and compassion. We observed staff interacting with patients in a professional and respectful manner. Staff promoted and maintained the dignity of patients when they delivered care in various community settings, such as community clinics and patients’ own homes. Staff were aware of the need to be sensitive to people’s religious and cultural needs. All teams were aware of the demographics in their area and how they needed to adapt the way they worked to meet the needs of patients.

9 - 12 December 2014

During an inspection of Community health services for children, young people and families

We found mixed evidence of staff engagement with the trust board. We were told by community staff that the trust was focused on Macclesfield District General Hospital and they felt separate from the acute trust. We were told that senior managers were not visible.

Management and team leader posts had been condensed, making visibility across the whole district challenging.

The trust had restructured services in order to meet the needs of the population, but the changed structures had not been embedded at the time of the inspection. There was little evidence that children, young people and families had been involved in decisions about the service redesign.

There were systems in place for reporting and investigating incidents and there was evidence that learning from incidents occurred. Safeguarding arrangements were embedded in practice and staff were well supported with regular safeguarding supervision.

The clinics we visited were clean and well maintained and staff followed infection control procedures. Staff were passionate about providing person-centred care and understood the importance of engaging with families in order to understand their situation and the support they required.

Staff aimed to assess and deliver treatment in line with current legislation, standards and evidence-based practice. We found that staff numbers were sufficient to deliver the Healthy Child Programme but this was new to teams as they were becoming fully staffed following significant recruitment.

9 - 12 December 2014

During an inspection of Community health inpatient services

There were processes in place for reporting and learning from incidents. Staff were clear about what incidents to report and how to do this. Managers were confident that incidents were being reported appropriately. Staff knew how to raise a safeguarding alert and were familiar with the Mental Capacity Act and deprivation of liberty safeguards. Staff had access to training and felt well supported. They had annual appraisals that identified training needs.

There were good joint working arrangements in place and team members were respected and listened to. Patients were treated respectfully, with sensitivity and patience, and were involved in the planning of their care and discharge. Services were responsive to the individual needs of the patients they were caring for.

Staff generally felt well connected to the trust and were clear about the purpose of the services they provided. External organisations had been used to help staff teams improve the quality of services they provided and we saw examples of local initiatives that had led to an improved service for patients.

Total staffing numbers were adequate at the time of our inspection but staff skill mix and registered nurse staff numbers was not always in line with the trust’s planned figures. Bank and agency staff were used to cover staff vacancies and there were processes in place to ensure continuity of care as much as possible.

11 December 2014

During an inspection of Community dental services

East Cheshire NHS Trust provides a range of specialised dental services for people with complex or special needs, vulnerable people and those who find it difficult to access general dental services because of their particular needs.

The community dental service had systems and processes in place to keep patients and staff safe. There were robust processes to identify and manage potential risks to patients, including the use of effective infection control measures. Each clinic was clean and well maintained.

Patients told us that they were treated with dignity and respect when accessing and receiving treatment. Patients and their representatives spoke highly of the care provided and said that care was delivered by staff who were compassionate and understanding of their needs. There was good collaborative working between the service and other healthcare services to ensure good patient outcomes.

Initiatives had been established to improve the service and to use the resources effectively. Staff we spoke with felt supported in their roles and that their managers were approachable and accessible.

Use of resources

These reports look at how NHS hospital trusts use resources, and give recommendations for improvement where needed. They are based on assessments carried out by NHS Improvement, alongside scheduled inspections led by CQC. We’re currently piloting how we work together to confirm the findings of these assessments and present the reports and ratings alongside our other inspection information. The Use of Resources reports include a ‘shadow’ (indicative) rating for the trust’s use of resources.

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up. Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.