Source · CQC inspection
Ellesmere Port Hospital
Provider Countess of Chester Hospital NHS Foundation Trust
Type NHS Healthcare Organisation
Region North West
Last inspected 14 Feb 2024
Overall rating: Requires Improvement View full CQC report
Domain ratings
Safe
Requires Improvement
Effective
Requires Improvement
Caring
Good
Responsive
Requires Improvement
Well-led
Requires Improvement
Earlier inspection findings
Must-do actions (56)
Must-do action 1 of 56
Must do
Well-led
The trust must assess, monitor, and drive improvement in the quality and safety of the services provided, including the quality of the experience for people using the service in line with the regulations
Must-do action 2 of 56
Must do
Well-led
The trust must ensure risks in services are appropriately recorded, assessed, escalated to the trust’s board where required, and regularly reviewed.
Must-do action 3 of 56
Must do
Well-led
The trust must ensure effective action is taken to address risks in services including areas of low compliance highlighted through internal governance systems.
Must-do action 4 of 56
Must do
Well-led
The trust must ensure risks on the risk register are regularly reviewed.
Must-do action 5 of 56
Must do
Responsive
The trust must ensure patients waiting to receive treatment after a referral are clinically reviewed and validated.
Must-do action 6 of 56
Must do
Well-led
The trust must implement effective systems to comply with the requirements of CQC registration. The system must ensure services are provided from locations which have appropriately added to the trust’s registration.
Must-do action 7 of 56
Must do
Well-led
The trust must ensure strategies designed to support the delivery of the trust’s new overall strategy are completed, implemented, and monitored to ensure their effectiveness.
Must-do action 8 of 56
Must do
Well-led
The trust must ensure staff feedback is captured and responded to appropriately to identify risks and drive improvement in services.
Must-do action 9 of 56
Must do
Safe
The trust must implement an effective system to ensure the assessment, prevention and management of infection prevention and control in the physical environment, this is recorded, monitored, and audited with actions taken to improve compliance.
Must-do action 10 of 56
Must do
Well-led
The trust must ensure there is effective oversight of the quality and safety of care provided to patients with mental health needs.
Must-do action 11 of 56
Must do
Safe
The trust must implement an effective system to identify, report and learn from incidents involving the use of restrictive interventions including restraint and rapid tranquilisation.
Must-do action 12 of 56
Must do
Caring
The trust must ensure staff undertake thorough assessments for patients who have a learning disability, care needs are assessed and planned to meet their individual needs.
Must-do action 13 of 56
Must do
Safe
The trust must ensure service user records are audited appropriately to evidence ongoing compliance with the requirements of the Mental Capacity Act 2005 and to identify missed opportunities to safeguard service users.
Must-do action 14 of 56
Must do
Well-led
The trust must implement an effective system to ensure that medical, nursing and midwifery staff have the skills, knowledge, experience, and appraisal to care for and meet the needs of patients within their service area.
Must-do action 15 of 56
Must do
Safe
The trust must ensure that staff receive appropriate training, supervision and appraisals, this must include but not be limited to training in life support training, as is necessary to enable staff to carry out the duties they are employed to perform.
Must-do action 16 of 56
Must do
Safe
The trust must ensure that staff are assessing the risk of, and preventing, detecting and controlling the spread of infections, including those that are healthcare associated.
Must-do action 17 of 56
Must do
Safe
The trust must ensure that fire exits are clear from obstruction and well maintained.
Must-do action 18 of 56
Must do
Safe
The trust must ensure there are effective systems in place for the safe management, storage, and monitoring of medicines. The system must ensure the safe administration of medicines.
Must-do action 19 of 56
Must do
Caring
The trust must seek to eliminate mixed sex accommodation breaches and must identify and report mixed sex accommodation breaches appropriately for all inpatient settings
Must-do action 20 of 56
Must do
Responsive
The trust must ensure that effective and timely care is provided; to improve patient access and flow through the hospital to safe discharge or transfer to other appropriate services.
Must-do action 21 of 56
Must do
Safe
The trust must ensure the risks presented by gaps in the out of hours stroke service are effectively assessed and mitigated.
Must-do action 22 of 56
Must do
Well-led
The trust must ensure that staff receive conflict resolution training in a timely manner, as is necessary to enable them to carry out the duties they are employed to perform.
Must-do action 23 of 56
Must do
Well-led
The trust must ensure there is effective action to address low compliance and areas for improvement in quality and safety identified through internal audits.
Must-do action 24 of 56
Must do
Caring
The trust must ensure that patients are cared for in areas where dignity and respect are not compromised.
Must-do action 25 of 56
Must do
Safe
The trust must ensure that nurse staffing levels, are safe for the numbers of patients in the department.
Must-do action 26 of 56
Must do
Safe
The trust must ensure that medical staffing levels, with the right qualifications and competencies, are safe for the numbers of patients in the department.
Must-do action 27 of 56
Must do
Safe
The trust must ensure that the service meets infection, prevention and control standards and that staff adhere to those standards.
Must-do action 28 of 56
Must do
Safe
The trust must ensure that there is sufficient equipment that is maintained to keep patients safe.
Must-do action 29 of 56
Must do
Safe
The trust must ensure that doors to clinical rooms where hazardous substances are stored are kept secure and accessible only to staff.
Must-do action 30 of 56
Must do
Safe
The trust must be assured that medicines are being stored securely and administered safely as per manufacturing guidance.
Must-do action 31 of 56
Must do
Safe
The trust must ensure that oxygen is prescribed as required by national guidelines.
Must-do action 32 of 56
Must do
Safe
The trust must ensure that patients identified with a mental health condition are cared for in a safe ligature free environment and have appropriate risk assessments completed.
Must-do action 33 of 56
Must do
Well-led
The trust must ensure that there is effective oversight of checks to maintain patient safety.
Must-do action 34 of 56
Must do
Well-led
The trust must ensure there is effective action taken and evidenced in response to risks, issues and low compliance with audits
Must-do action 35 of 56
Must do
Safe
The trust must ensure that there are sufficient numbers of qualified staff that have completed mandatory training requirements including safeguarding.
Must-do action 36 of 56
Must do
Well-led
The trust must ensure that all staff receive an annual appraisal.
Must-do action 37 of 56
Must do
Safe
The trust must ensure doors are not left unlocked and accessible to patients or members of the public.
Must-do action 38 of 56
Must do
Safe
The trust must ensure that the assessment of risk, preventing, detecting, and controlling the spread of, infections, including those that are healthcare associated is managed in line with trust and national guidance.
Must-do action 39 of 56
Must do
Safe
The trust must ensure the maternity theatre, birthing rooms and room 15 are serviced, maintained, and fit for purpose in line with best practice guidance.
Must-do action 40 of 56
Must do
Safe
The trust must ensure that a robust system is in place to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users.
Must-do action 41 of 56
Must do
Well-led
The trust must ensure patient records are complete, contemporaneous and securely stored.
Must-do action 42 of 56
Must do
Responsive
The trust must ensure waiting times and other key metrics are in line with national standards.
Must-do action 43 of 56
Must do
Effective
The trust must ensure that policies and procedures are reviewed and follow national guidance.
Must-do action 44 of 56
Must do
Safe
The trust must ensure that mandatory training (including safeguarding) compliance meet the trust target.
Must-do action 45 of 56
Must do
Safe
The trust must ensure premises and environment are safe and secure. This includes but is not limited to ensuring storeroom doors are not left open or unlocked and COSHH cleaning chemicals and oxygen cylinders are safely stored.
Must-do action 46 of 56
Must do
Safe
The trust must ensure the premises and environment are clean and maintained to prevent the spread of infection. This includes but is not limited to repairs to flooring, walls and doorframes, plumbing/drainage, and food storage within patient’s fridges.
Must-do action 47 of 56
Must do
Caring
The trust must ensure that appropriate nutritional risk assessments are completed for anyone with specific dietary requirements or anyone with social, religious, or cultural needs.
Must-do action 48 of 56
Must do
Safe
The trust must ensure that a robust system is in place to assess, monitor and mitigate the risks relating to the health, safety, and welfare of service users.
Must-do action 49 of 56
Must do
Responsive
The trust must assess, monitor and improve the quality of the services provided and ensure waiting times and other key metrics are in line with national standards.
Must-do action 50 of 56
Must do
Well-led
The trust must assess and manage the risks relating to the electronic patient records system and transcription services. The trust must improve the quality of the services provided and ensure this did not impact on delays to patients care and treatment.
Must-do action 51 of 56
Must do
Safe
The trust must ensure that staff receive appropriate training, supervision and appraisals, this must include but not be limited to training in life support training, as is necessary to enable staff to carry out the duties they are employed to perform.
Must-do action 52 of 56
Must do
Safe
The trust must ensure there are effective systems in place for the safe management, storage, and monitoring of medicines. The system must ensure the safe administration of medicines including medicines administered covertly.
Must-do action 53 of 56
Must do
Safe
The trust must ensure that fire exits are clear from obstruction and well maintained.
Must-do action 54 of 56
Must do
Responsive
The trust must ensure that effective and timely care is provided; to improve patient access and flow through the hospital to safe discharge or transfer to other appropriate services.
Must-do action 55 of 56
Must do
Effective
The trust must ensure there is effective data collection and analysis in relation to patient outcomes, including relevant clinical audits to drive improvement in patient care.
Must-do action 56 of 56
Must do
Well-led
The trust must ensure there is effective action to address low compliance and areas for improvement in quality and safety identified through internal audits.
Should-do actions (23)
Should-do action 1 of 23
Should do
Responsive
The trust should implement effective systems to identify and plan services to address health inequalities.
Should-do action 2 of 23
Should do
Well-led
The trust should improve the visibility of senior leadership in all services and particularly in urgent and emergency care services.
Should-do action 3 of 23
Should do
Responsive
The trust should implement effective patient engagement in the development of the trust’s services.
Should-do action 4 of 23
Should do
Safe
The trust should ensure that the premises are safe to use for their intended purpose and are used in a safe way.
Should-do action 5 of 23
Should do
Safe
The trust should ensure that there are sufficient numbers of nursing staff that can meet peoples care and treatment needs and keep them safe from avoidable harm.
Should-do action 6 of 23
Should do
Safe
The trust should review the prescribing of medicines that control distressed behaviour to ensure the policy is followed and monitoring is completed.
Should-do action 7 of 23
Should do
Safe
The trust should ensure when peoples medicines are given covertly, the covert administration care plan is completed, reviewed and updated regularly.
Should-do action 8 of 23
Should do
Caring
The trust should ensure that reasonable adjustments are in place to meet the needs of patients living with complex needs such as dementia and learning disabilities.
Should-do action 9 of 23
Should do
Responsive
The trust should ensure that health promotion and information is available in all areas in the department and in languages other than English.
Should-do action 10 of 23
Should do
Safe
The trust should ensure that all doors leading to the children’s area are secure.
Should-do action 11 of 23
Should do
Effective
The trust should ensure that the nationally recognised screening tool to monitor patients at risk of malnutrition is included in the audit programme for nutrition.
Should-do action 12 of 23
Should do
Well-led
The trust should ensure it maintains local oversight of the quality of responses to complaints.
Should-do action 13 of 23
Should do
Caring
The service should ensure that patients’ privacy, dignity and confidentiality is maintained in the reception area.
Should-do action 14 of 23
Should do
Safe
The trust should ensure that patient identifiable details are kept confidential when displayed or stored in public areas.
Should-do action 15 of 23
Should do
Safe
The trust should ensure that medicines are being stored securely.
Should-do action 16 of 23
Should do
Effective
The trust should continue to embed the changes made to the post-operative care of women and birthing people following obstetrics surgery.
Should-do action 17 of 23
Should do
Responsive
The trust should continue to embed the changes made to the triage systems and processes.
Should-do action 18 of 23
Should do
Safe
The trust should ensure all medicines are stored securely at all times.
Should-do action 19 of 23
Should do
Safe
The trust should ensure resuscitation equipment is checked in line with trust policy.
Should-do action 20 of 23
Should do
Responsive
The trust should ensure that information for children, young people and families is available in languages other than English, in child friendly versions, and in alternative formats.
Should-do action 21 of 23
Should do
Effective
The trust should ensure staff improve the compliance of completing the sepsis screening tool on the electronic patient record.
Should-do action 22 of 23
Should do
Safe
The trust should ensure that the premises are safe to use for their intended purpose and are used in a safe way.
Should-do action 23 of 23
Should do
Safe
The trust should ensure that there are sufficient numbers of nursing staff that can meet peoples care and treatment needs and keep them safe from avoidable harm.