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Fairfield General Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 12 August 2016

Fairfield General Hospital is one of the locations providing inpatient care as part of The Pennine Acute NHS Trust. It provides a range of hospital services including emergency care, critical care, a comprehensive range of elective and non-elective general medicine (including elderly care) and surgery, and a range of outpatient and diagnostic imaging services.

The Pennine Acute NHS Trust provides services for around 820,000 people in and around the north east of Greater Manchester in Bury, Prestwich, North Manchester, Middleton, Heywood, Oldham, Rochdale and parts of East Lancashire. There are approximately 1191 inpatient beds across the Trust with The Fairfield General Hospital having approximately 236 inpatient beds.

We carried out an announced inspection of The Fairfield General Hospital between the 23 to the 3rd March 2016 as part of our comprehensive inspection of The Pennine Acute Trust.

Overall, we rated The Fairfield General Hospital as Requiring improvement. We found that the services were provided by dedicated, caring staff, and patients were treated with dignity and respect. However, improvements were needed to ensure that all services were safe, effective, well led and responsive to people’s needs.

Leadership and Management

  • There was clear leadership and communication in services at a local level, senior managers were visible, approachable, and staff were supported in the workplace.
  • There was a positive culture throughout teams in the hospital and staff were committed to being part of the trusts vision and strategy going forward.
  • Managers also engaged with staff via team briefs, newsletters and through other general information and correspondence that was displayed on notice boards and in staff rooms.
  • Staff reported there was clear visibility of members of the trust board throughout the service. Staff could explain the leadership structure within the trust and the executive team were accessible to staff.
  • We observed there was currently no trustwide clinical lead in Pathology Services, however recruitment was underway.

Access and Flow

  • Access and flow remained a challenge in the emergency department. Records showed that between April 2015 and February 2016, the department achieved the 95% target in only five weeks during this period. The monthly percentage of patients seen within four hours of arrival ranged between 74.35% and 97.12%, with an overall average of 84.61% of patients seen within four hours during this period.
  • The average time to treatment was consistently worse than the 60 minute Department of Health standard between October 2015 and February 2016.
  • Between October 2015 and December 2015, the average occupancy rate at the hospital was 94%,
  • There were challenges with access and flow across medical ward which resulted in patients being moved multiple times, of which some were undertaken outside of normal working hours. In the period November 2014 to October 2015, 45% of patients experienced multiple ward moves during their stay. Information provided by the trust showed that between April 2015 and September 2015, the number of patients on medical wards that were transferred to another ward after 10pm at night was high for the emergency admissions unit which averaged around 126 a month.
  • Some medical patients were being nursed in non-speciality beds but to access and flow pressures. Between November 2014 and October 2015 there had been 173 outliers at the hospital.
  • The hospital met the 18 week referral times for 95.6% of patients as at 11 February 2016 and this included medical treatment, which was better than the national target of 92%.
  • Access and flow challenges impacted upon patients being delayed from being discharged from critical care. Between January and June 2015, 55 patients had experienced delays, however most delays were less than 24 hours.
  • There were processes in place to support patients reaching the end of life bring transferred to their preferred place of care within 24 hours, including a rapid transfer arrangements.
  • Though it was reported that the numbers of patients waiting longer than 18 weeks from referral to treatment (RTT) was consistently better than the England average and the cancer waiting times for the trust were consistently better than the England average we have subsequently learned that data collection in the department is not reliable and are not assured that targets are truly at that level. Work is being undertaken with the trust to clarify the current position.

Cleanliness and Infection control

  • The trust had infection prevention and control policies in place, which were accessible to staff and staff were knowledgeable on preventing infection.
  • Clinical areas were visibly clean, and there were were processes in place to maintain standards of cleanliness.
  • There was enough personal protective equipment available, which was accessible for staff and staff used this appropriately.
  • Staff generally followed good practice guidance in relation to the control and prevention of infection in line with trust policies and procedures.
  • Between April 2015 to December 2015, there were no case of MRSA bacteraemia reported across the hospital.

Nurse Staffing

  • The trust undertook biannual nurse staffing establishment reviews as part of mandatory requirements. As part of this, key objectives were set though this work to support safer staffing.
  • We found that there were not always sufficient numbers of trained nursing staff in the emergency department to meet patients’ needs, as the existing establishment did not always have the flexibility to cope with the number of patients attending the department.
  • Nurse staffing levels on medical wards overall met the needs of patients; however, there had been a reliance on temporary staff on the some of the wards.
  • There had been a decrease within the specialist palliative care team which meant patients did not have appropriate access to specialist care and treatment from this team on Mondays or at weekends.
  • Staffing information was available for patients and the public on a boards at the entrance to wards..
  • Pressures in nurse staffing meant that the critical care unit did not always meet the standard set by the Intensive Care Society for supernumerary shift co-ordinators at band 6/7.

Mortality Rates

  • Mortality and morbidity meetings were held on a monthly basis. Meeting minutes showed that actions and learning were identified but it wasn’t always clear who was responsible for their implementation or the timeframe that it would be expected in.
  • 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 on the basis of average England figures, given the characteristics of the patients treated at the hospital. The risk score is the ratio between the actual and expected number of adverse outcomes. A score of 100 would mean that the number of adverse outcomes is as expected compared to England. A score of over 100 means more adverse (worse) outcomes than expected and a score of less than 100 means less adverse (better) outcomes than expected. In September 2014 the hospital score was 106.8. Actions had been put in place to improve the outcome for patients. These included review of the care pathway and further end of life training for staff.
  • Within critical care, mortality and length of stay for ventilated admissions and patients with severe sepis was higher than in similar units.

Nutrition and Hydration

  • Patients had access to food and drink whilst in emergency and outpatient departments.
  • We found that there were policies and procedures in place to support patients nutritional and hydration needs. Patients nutritional needs were risk assessed and results were acted upon appropriately.
  • Patient received assessments of their nutritional requirements using the malnutrition universal screening tool (MUST), which highlighted if they were at risk of dehydration or malnutrition. However, audits undertaken across medical wards showed that this assessment was not always completed.
  • A variety of food choices was available to patients. Special diets, for example diabetic, gluten free, renal, soft textured and allergy diets were available.

There were also areas of poor practice where the trust needs to make improvements.

Importantly, the hospital must:

Emergency and Urgent Care

  • Take appropriate actions to improve nursing and medical staffing levels.
  • Take appropriate actions so that patients attending the department are assessed and treated in a timely manner.

Medical Services

  • Ensure that records are kept secure at all times so that they are only accessed by authorised people.
  • Ensure that all staff are aware of the procedures for capacity assessments and these are completed where necessary
  • Ensure that assessments of patient’s nutrition and hydration needs are fully completed and patient’s receive appropriate support where necessary
  • Ensure that the discharge lounge and ambulatory care unit is fit for purpose and patients supported to have conversations about their care where they cannot be overheard.

End of life care

  • Ensure that the DNACPR procedure is always completed in accordance with the accepted legal requirement to either gain the patient’s consent, or where a patient lacks capacity, following a discussion with the patient’s family.

  • Ensure that where a patient lacks capacity to make a decision about DNACPR, a mental capacity assessment has been carried out.

  • Ensure that it takes action to ensure the DNACPR documentation is always completed in line with its own policy.

In addition the hospital should:

Emergency and Urgent Care

  • Consider improving mandatory training compliance.
  • Consider improving the processes for reviewing and managing key risks to the services.
  • Consider taking appropriate actions to improve the processes for monitoring and improving the management of sepsis.

Medical Services

  • Consider that rooms used to care for patients who have an infection are managed appropriately
  • Consider that patients are discharged as soon as they are fit to do so.
  • Consider that patients are not moved ward more than is necessary during their admission and are cared for on a ward suited to meet their needs.
  • Consider implementing formal procedures for the supervision of staff to enable them to carry out the duties they are employed to perform.
  • Consider that patient pain is consistently recorded
  • Consider that all staff seek consent for the use of bedrails and if they lack capacity apply the Mental Capacity Act (2005) principals and this is reflected in procedures.

Surgical Services

  • Consider embedding a recognised early warning system which gives clear and unambiguous guidance on escalation procedures and care for the deteriorating patient.

  • Consider the recording and disposal of controlled drugs where the whole of one vial is not prescribed, is in line with trust and Royal Pharmaceutical Society of Great Britain guidance.

  • Consider implementing a pracise where no arrest trolleys are padlocked, but that they are sealed with unique reference number tags as per trust policy.

  • Consider ensuring doctors’ handwriting is legible, particularly on important documents such as consent forms and the detailing of side effects of surgery.

  • Consider that in the anaesthesia and surgery divisionthey are compliant with all elements of the NICE clinical guidance 83 concerning the rehabilitation of critically ill patients.

  • Consider that they take steps to improve compliance with the recommendations of the British Orthopaedic Association standards for Trauma (BOAST) to prevent patients waiting longer than 72 hours before seeing an orthopaedic specialist.

  • Consider that the division take steps to address their very high readmission rates.
  • Consider ensuring they work towards compliance with all of the recommendations of the Faculty of Pain Medicine’s Core Standards for Pain Management (2015).

  • Consider taking steps to improve theatre utilisation.

End of Life care

  • Consider a full review of the staffing requirements to introduce seven day specialist palliative care services at the hospital.
  • Consider how to respond to the complex symptom control needs of EOL patients out of hours.
  • Consider how to provide training to middle grade doctors about the complex symptom control needs of EOL patients.
  • Consider whether the current SPCT staffing levels are sufficient to meet the current demands on the service.
  • Consider how to involve SPCT in the service developments required to implement the EOL strategy.
  • Consider the level of support and education required from EOLC facilitation team for FGH to embed the use of the IPOC documentation across all its wards.
  • Consider how to develop a sensitive tool to ascertain when incidents occur related to EOL issues.
  • Consider how to provide SPCT staff with feedback from incidents submitted to enable action to be taken to prevent such incidents reoccurring.

Outpatients and Diagnostics

  • Consider changing the way that patient records are being scanned onto the EVOLVE system so that historic records are prepped and scanned on demand in advance of patient attendance at an outpatient clinic. This system has been seen working well in other trusts and ensures that “active” patient notes are prioritised.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 12 August 2016

Effective

Requires improvement

Updated 12 August 2016

Caring

Good

Updated 12 August 2016

Responsive

Requires improvement

Updated 12 August 2016

Well-led

Requires improvement

Updated 12 August 2016

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 12 August 2016

We judged medical services at Fairfield General Hospital as requires improvement overall because:

  • We found standards in record keeping required improvement and records were left unsecured on the acute medical unit and ward 21.
  • It was unclear if resuscitation equipment was always being checked which meant that emergency equipment might not be available when needed.
  • Training levels in medicines management was low
  • Staff were not always following trust policies and procedures in relation to assessing patients for capacity and in the completion of capacity assessments. Nursing staff were unclear about the procedures to follow when reaching decisions about using bed rails which are a form of restraint.
  • We found there was insufficient bed capacity on occasions on the medical wards to meet the needs of people within the hospital .
  • Some risks on the risk register had been there since 2011. It was unclear if all risks were managed in effective timely way to lower the risk. It was unclear if learning was shared wider across other service areas. There were times when complaints took a long time to resolve.

However,

  • There were systems in place to keep people from avoidable harm and staff were aware of how to ensure patients’ were safeguarded from abuse.
  • Incidents were reported by staff through effective systems and lessons were learnt and improvements made from investigations where findings were fed back to staff at a local level.
  • There were safe systems of the handling and disposing of medications.
  • The hospital was clean and staff followed good hygiene practices.
  • The hospital had implemented a number of schemes to help meet people’s individual needs, such as the forget-me-not sticker for people living with dementia or a cognitive impairment and a leaf symbol to indicate that a patient was frail or elderly. This helped alert staff to people’s needs.
  • People were supported to raise a concern or a complaint and lessons were learnt and improvements made.
  • We observed care and found this to be compassionate from all grades of support and clinical staff and patients were involved in their care and treatment.

Urgent and emergency services (A&E)

Requires improvement

Updated 12 August 2016

We judged urgent and emergency services at Fairfield Hospital as requires improvement overall because:

  • Patients attending the department experienced extended delays before they received treatment.
  • The emergency department consistently failed to meet the Department of Health (DH) target to admit or discharge 95% of patients within four hours of arrival
  • The average time to treatment was consistently worse than the 60 minute DH standard between October 2015 and February 2016. 
  • There were six instances where patients had trolley waits of more than 12 hours between November 2015 and February 2016.
  • The department failed to achieve targets for ambulance handover within 15 minutes between April 2015 and January 2016. There were 122 ambulance handovers that took longer than 60 minutes (black breaches)
  • There were vacancies in the medical, nursing and healthcare support worker establishment, which meant the staff did not always have the flexibility to cope with the number of patients attending the department, especially during busy periods. .
  • The main reasons for these delays was due to insufficient bed capacity across the hospital, which meant patients that required admission could not be transferred to the wards in a timely manner.
  • The completion rates for mandatory training in the department were below the trusts expected level of 90%. Complaints were not routinely resolved within the trusts specified timelines.
  • The department last participated in the CEM audit for severe sepsis and septic shock during 2011/12. We did not see any evidence to demonstrate how the department planned to improve compliance against the sepsis audit or how compliance was monitored since this audit.
  •  There was no formal strategy specifically for the service. 
  • The patient satisfaction surveys showed the department scored worse that the England average for the number of patients that would recommend the emergency department to friends and family.

However, : -

  • Patient safety was monitored and incidents were investigated to assist learning and improve care. Patients received care in safe, clean and suitably maintained premises.
  • Care and treatment was provided in line with national clinical guidelines.
  • Patients spoke positively about their care and treatment. There was effective local leadership and staff spoke positively about the support received.

Surgery

Requires improvement

Updated 12 August 2016

We judged surgery at Fairfield General Hospital as requires improvement overall because;

  • The early warning system the hospital had adopted was implemented inconsistently and clear procedures for escalation of concerns for a deteriorating patient were not embedded.
  • The division did not always record and dispose of controlled drugs in line with policy.
  • An emergency trolley was padlocked in theatres, which could prevent quick access to it in an emergency.
  • We found that in four out of ten records that we checked that the doctors’ handwriting was illegible on surgery consent forms.
  • There was no surgical consultant on duty at Fairfield to see medical patients who required a specialist surgical consultation.
  • There were difficulties recruiting surgical doctors. There was a reliance on locum doctors.
  • The division had very high readmission rates, which were significantly higher (worse) than the England average.
  • Theatre utilisation was low at 69.2%.
  • However, we also found that;
  • There was a good culture of reporting incidents and safety issues and that investigations were thorough.
  • We saw evidence of learning when things went wrong and saw implementation of measures to improve quality and safety.
  • We found that staff had the appropriate skills and training to enable them to keep people safe.
  • The environment was clean and hygienic with low levels of healthcare associated infections.
  • Patient outcomes were good and in some areas, the division performed better than other trusts and England averages.
  • Staff were experienced, well trained and competent in their roles.
  • The multidisciplinary team working was good with satisfactory access to a range of specialities.
  • Patients told us staff were kind and respectful and that they were kept informed and involved in the care and treatment they received.
  • The division achieved good friends and family test results.
  • The ward environment was very good for dementia patients and many of the recommendations from dementia best practice guidance had been implemented.
  • Complaints were handled and responded to appropriately and the feedback was used to improve services for patients.
  • The average length of stay for surgical patients at Fairfield was lower than the England average.
  • The surgery and anaesthesia division was well led both on a ward level and at divisional level.
  • Managers were competent and enthusiastic about their service.
  • There was a positive supportive culture throughout the wards and departments.
  • Staff had seen positive changes in the last 12 months and anticipated things would continue to improve.

Intensive/critical care

Requires improvement

Updated 12 August 2016

We  judged that overall the critical care service at Fairfield Hospital required some improvement.

The was because

  • The nurse staffing failed to meet the standard set by the Intensive Care Society for supernumerary shift co-ordinators at band 6/7.
  • There was no critical care outreach service provided at Fairfield Hospital.
  • The hospital was non-compliant with a number of elements of the NICE clinical guidance around the rehabilitation of critically ill patients.
  • There was a problem with delayed and out of hours discharges from critical care.
  • It was not clear how risks to critical care were being managed.
  • The risk register reported risks that had been identified for a number of years but there was a lack of clarity about mitigating actions, progress and review.

However

  • Critical care services were delivered by caring, compassionate and committed staff.
  • We saw patients, their relatives and friends being treated with dignity and respect.

End of life care

Requires improvement

Updated 12 August 2016

We judged End of life services at FGH require improvement this was because

  •  No specialist palliative care service is provided  after 5.00pm Monday to Friday or at all at the weekends. 
  • There was a lack of training in symptom control for middle grade staff  which compounded the lack of specialist palliative care available to patients out of hours and at the weekend.

  • We observed a number of examples where completion of Do not Attempt Cardiopulmonary Resuscitation (DNACPR) documentation did not conform to the standard set out in the trust policy.

  • The individual plan of care (IOPC) replacing the Liverpool care pathway was not embedded across FGH wards. Staff reported that they did not understand the IPOC documentation, did not feel confident using it and required more training before they would be happy to use it.

  • There was no robust, sustainable strategy proposed to address the risk regarding the lack of a seven day service.

  • Clinicians  believed that managers did not share their passion and commitment to EOL services, because of the reduction in staffing levels and did not feel involved in decisions about the future of services at FGH.

However

  • We observed care being delivered to patients, who were at the their end of life, with kindness, consideration and empathy.

  • We heard from relatives who reported that they and their loved ones were treated with kindness and received professional treatment and care.

  • We also, heard, observed and noted that rapid discharge services were arranged to be highly responsive to the needs and wishes of patients.

Outpatients

Good

Updated 12 August 2016

We judged outpatients and diagnostic imaging services as Good overall this was because

              • Staff were confident about raising incidents and told us that they were encouraged to do so.

            • Staffing levels were appropriate to meet patient needs although increased demand on the Radiology services meant some reporting on diagnostic imaging is outsourced overnight to ensure that turnaround times for reports are within national guidelines.

          • There were appropriate protocols for safeguarding vulnerable adults and children and staff were aware of their roles and responsibilities in regard to safeguarding.

        • The departments inspected were visibly clean and staff followed good practice guidance in relation to the control and prevention of infection.

    • We observed that the equipment used in the care and treatment of patient’s was clean and in good work order.

  • An electronic patient record system allowed the filtering out of relevant information and facilitated information being available to different teams very quickly.
  • Outpatient and diagnostic services were delivered by caring, committed and compassionate staff who treated people with dignity and respect
  • Departmental managers were knowledgeable and supportive and had vision improve their services.
  • Staff in outpatients and diagnostic services, demonstrated good team working (including multidisciplinary working) and were competent and well trained.

However

  • Not all notes had been scanned and paper notes were still in use for some patients.