Countess of Chester Hospital maternity services rated 'inadequate' in critical CQC inspection report

The surprise inspection by the Care Quality Commission focused on acute services at the hospital in February and March this year, when the hospital was still battling the Omicron wave of Covid.

The 112-page report, published today (Wednesday, June 15) on the CQC website, said staff morale at the Countess of Chester Hospital Trust was the lowest nationally, waiting times had soared as more patients were referred to the hospital, and lessons were not properly learned when serious incidents took place.

Staff shortages, particularly in midwifery, and the roll-out of a problematic electronic patient record system in July 2021 had resulted in failings.

Inspectors gave an 'inadequate' rating to how well the trust was led.

However, throughout all areas of the hospital inspected, staff were commended for being caring and kind, with positive patient feedback, resulting in a 'good' rating for caring services.

The hospital trust received an overall 'requires improvement' rating, and CQC served the trust with two warning notices, meaning the trust needed to make significant improvements in the quality and safety of healthcare provided in maternity services and significant improvements in governance systems relating to referral to treatment processes, implementation of the electronic patient record system and around the management of incidents, complaints and patient deaths.

The trust must take action to bring services into line with 34 legal requirements.

Inspectors noted that, in the maternity services between April and November 2021, five patients experienced a major post-partum haemorrhage, where each had lost more than two litres of blood and required an unplanned hysterectomy.

Countess of Chester Hospital's Women & Children's Building, maternity unit.

In one such case, a staff member highlighted there were no hysterectomy kit or staff trained in its use present in the theatre, and both staff and this equipment had to be requested from main theatres, leading to a delay in carrying out the lifesaving procedure. No learning was highlighted following the incident.

Inspectors said two of the incidents were not reported as serious and where there was learning identified, action plans were not being completed in a timely way.

They added: "The service had not consistently reported incidents to external stakeholders. The Care Quality Commission were only made aware when a whistleblower contacted us."

Inspectors noted there were not enough maternity staff and in the 12 months prior to the inspection, the service was closed for a total of 144 hours and 35 minutes.

Inspectors said: "Thirty-three women had to be diverted to other maternity units for some or all aspects of their care. Of these, 13 women birthed their baby in a maternity unit not of their choosing. The main reasons cited...were short staffing.

"Women did not receive 1:1 care when in established labour. The service relied on staff submitting an incident form to report that the service had been too busy for them to provide safe care. Midwives in differing clinical areas told us they frequently worked over their contracted hours and missed breaks which they were not paid for."

In addition, midwives felt they were not valued by all the leadership team, and that had resulted in many leaving to work elsewhere.

However, the observed rate for perinatal mortality at Countess of Chester – any in-hospital death within seven days of birth – had been better than expected between September 2020 and March 2021, showing an improvement following a peak during June-August 2020).

For waiting times, the monthly average proportion of patients waiting less than 18 weeks from referral to treatment was 44% in January 2022. The trust consistently performed worse for the 18-week waiting time standard when compared with national averages and to other Cheshire/Mersey trusts.

Performance in relation to cancer care between April and December 2021 was below target in all areas except one. The 14-day standard for cancer treatments for the proportion of patients seen by a specialist within two weeks of an urgent GP referral was significantly below the national target of 93%, being just over 60% in January 2022. The 14-day standard for referral for symptomatic breast cancer measured 13%.

The previous recovery plans developed during 2020/2021 had not led to sufficient improvement in referral to treatment waiting times. The main focus was on reducing 104-week waits from over 800 patients in March to zero by the end of June. The trust had 60% of Cheshire and Mersey region’s 104-week waits.

The trust had had reported no 12-hour breaches (ie, patients waiting more than 12 hours from decision to admit to admission) from January 2020 until August 2021. But there had been a worsening trend since October 2021, and there were 461 breaches in February 2022.

However, inspectors noted: "The increased size of the ambulance handover area since our last inspection had made a difference to the times for ambulance handovers and minimised patients being held on a corridor awaiting assessment. Patients arriving by ambulance were very rarely held on a corridor because there was no capacity."

Criticism also fell on a new electronic patient record (EPR) system launched in July 2021.

Inspectors said: "We saw evidence staff underwent e-learning training in the use of the EPR system prior to its launch; however, this training had only been completed by 83% of staff, with a further 10% of staff in training at time of launch.

"Feedback from ward staff...identified there was an inconsistent approach in the level of training and additional support available to staff during and after the EPR system launch and not all staff were confident in using the EPR system effectively.

"We looked at 10 patient records across the medical and surgical wards on 24 February 2022 and found seven of these records did not have complete and up to date patient risk assessments or care plans; such as for patient fall risks, mobility or pressure care.

"14 of the 15 nursing staff we spoke with expressed concern about the manner in which the new EPR was introduced and the impact this had on their ability to complete work efficiently and effectively."

More positively, inspectors said for staff throughout the hospital: "Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs.

"Staff were discreet and responsive when caring for patients. Staff took time to interact with patients and those close to them in a respectful and considerate way. Patients said staff treated them well and with kindness.

"We saw that mental health patients, although they may experience lengthy waits in the department, were treated with kindness and compassion and that staff, including security staff, tried to make them feel at ease.

"Staff provided emotional support to patients, families and carers to minimise their distress. They understood patients' personal, cultural and religious needs. Staff gave patients and those close to them help, emotional support and advice when they needed it.

"We spoke to 12 patients [in the emergency department] who told us that staff treated them with dignity and respect and they had been given pain relief in a timely way. Patients told us that they were well-informed about their care plan and what was happening."

Karen Knapton, CQC’s head of hospital inspection, said: “While we found kind and caring interactions from staff to patients across the services we inspected, the trust has work to do to ensure people consistently receive the safe and effective care they have a right to expect.

“This was particularly evident in its maternity service, which we rated inadequate due to issues including a lack of staff and suitable equipment to keep women and babies safe. The trust didn’t learn from safety incidents to avoid them happening again and while some reviews were taking place, they weren’t effective in ensuring safe care and treatment in this service.

“Medical care, surgery and urgent and emergency care had enough staff, but some lacked the training for their roles, and poor management of patient records increased the risk of people coming to harm.

“We recognise NHS services are under enormous pressure. However, senior leaders must be visible and have good oversight to manage and mitigate challenges and risks – and we found this was lacking at this trust.

“Although they had the necessary skills and abilities, leaders hadn’t successfully captured key information regarding the quality of patient care and emerging risks across the trust. This hindered their ability to develop and implement solutions, as well as target resources to where they were needed.

“Since the inspection, the trust has started to address the issues we raised. It’s also receiving additional support from NHS England and NHS Improvement to make improvements.

“We will continue to monitor the trust closely and will inspect it again. If improvements are not made, or if patients are at immediate risk of harm, we will take further action to hold the trust’s leaders to account and ensure people’s safety.”

In response, a spokesperson for the Countess of Chester Hospital said: "The report recognised positive outcomes in a number of areas, with the CQC noting:

• The Trust’s urgent and emergency services maintained a ‘good’ performance in terms of its provision of effective and caring treatment
• Staff treated patients with compassion and kindness across all the core services inspected
• Staff understood how to protect patients from abuse
• A reduced observed rate for perinatal mortality at the Trust (for September 2020 to March 2021)."

Dr Susan Gilby, Chief Executive at the Trust, said: “The CQC’s report identifies a number of key areas for further improvement and development that are required at the Trust, as well as recognising the work which has taken place to embed a culture of compassionate care and treatment across the Trust’s services.

Dr Susan Gilby of The Countess of Chester Hospital NHS Foundation Trust

“The report illustrates where more progress must still be made to ensure the Trust can provide the highest quality of treatment to the local community, which we are committed to delivering. In our Maternity Department, we have implemented and are continuing to develop measures to ensure we can consistently provide patients with the safe and effective care they have a right to expect.

“Despite unprecedented pressure, the Trust’s urgent and emergency services were able to maintain a ‘good’ performance in terms of its provision of effective and caring treatment, which is a testament to the professionalism and commitment of our staff.

“We are now working hard across the Trust to implement the CQC’s recommendations, so we can continue to make improvements and deliver increasingly high-quality care to our communities in the future.”