Fairfield General Hospital

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

We assessed 6 quality statements.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good.

Teams worked well together across wards and services, with effective MDT meetings, safety huddles, board rounds and coordinated discharge planning.

Most patients felt involved in decisions about their care, and records showed clear, appropriate consent processes, including for patients with reduced capacity. The service showed improvements in some national audits, outcomes and patient flow.

Most patients received timely and appropriate risk assessments on admission.

However, care was not always adapted accordingly and in a timely way. Although audits were completed, action plans were often incomplete and lacked clear ownership or timescales.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

We scored the service as 2. The evidence showed some shortfalls. The service assessed and reviewed people’s health, care, wellbeing and communication needs. However, information was not always shared effectively, and care was not always adapted accordingly or in a timely way.

Upon admission to the wards, staff carried out risk assessments to assess patients’ needs and risks. The risk assessments included falls, pressure ulcers, venous thromboembolism (VTE), nutrition and cognitive delirium. Patients at high risk were placed on clinical care pathways and care plans were put in place to ensure they received the right level of care. We reviewed 24 patient records and observed that most risk assessments for these areas had been completed electronically and had been updated. However, we found minor gaps in moving and handling and malnutrition universal screening tool (MUST) risk assessments.

Staff completed fluid balance charts and food charts to document a patient's fluid and food input and output within a 24-hour period. This information was used to inform clinical decisions. Patient records we reviewed showed that fluid balance charts had been fully completed and were up to date. However, we observed that some patients were inappropriately positioned to eat meals, for example lying down or not being moved into chairs if they were able to sit up. One patient reported that staff were not always available to provide assistance with meals and a family member said when visiting the patient, the food was left untouched and cold.

Although we found that staff mostly assessed patients’ needs appropriately, gaps in staffing and workload pressures impacted on their ability to adapt care accordingly and in a timely way. We observed delays in the administration of prescribed thickened fluids used for swallow assessment and rehabilitation. When we raised this with staff, they told us that this was because there were not enough staff to do this.

We also found that documentation used to monitor patients’ needs was not always up to date or accurate. For example, 2 patients were incorrectly recorded as having urinary catheters on the nursing handover document. In addition, although patients requiring assistance with meals were correctly identified as needing red trays on the nursing handover, this information had not been transferred to the housekeeping handover. This meant there was a risk that patients may not receive the nutritional support they required.

We escalated these concerns to managers and senior leaders at the time of the assessment. In response, they told us they would reinforce expectations about effective communication during bedside handovers and add nutrition and hydration information to the housekeeper huddle agenda.

Patient feedback about their pain relief requests were mixed. Some patients advised they had waited too long for pain relief, while other patients had no concerns and said staff were very responsive.

We looked at patient records for a patient living with dementia. They were clear and comprehensive, included Mental Capacity Act (MCA) assessments, Deprivation of Liberty Safeguards (DoLS) information, and a completed ‘this is me’ document. The patient was on enhanced patient observation (EPO), and associated documentation was fully completed. Evidence showed the patient had been reviewed by physiotherapy and occupational therapy on the first day of admission. Staff kept both the patient and their relative updated with the care plan, and a doctor attended during our assessment.

We scored the service as 2. The evidence showed some shortfalls. Not all systems and processes were in line with legislation and current evidence-based good practice and standards.

Policies and clinical guidelines were available in both paper and electronic formats to support staff in delivering care. Staff demonstrated how they accessed policies through the trust’s policy hub on the intranet. They told us that updates to policies or changes in practice were routinely shared through team huddles, and practice‑based educators provided training where required. Staff were able to give recent examples of guidance and practice being updated and implemented.

However, staff did not always access the most up-to-date policies and guidance on the intranet. The trust had shared a policy and guidance that were beyond their intended review dates in error; however, these documents were confirmed to be current on the intranet.

The adult observation practice standard (NEWS) policy was out of date by many years, with an intended review date of April 2020. Senior leaders told us that this was being replaced with a new ‘observation policy for patients 16 years and over’ and had been delayed for various administrative reasons.

The endoscopy service had not been awarded Joint Advisory Group on Gastrointestinal Endoscopy (JAG) accreditation when it was last assessed in September 2024. A follow-up review identified clinical leadership gaps including in key roles such as endoscopy lead, training lead and trainee experience. Leaders told us that over the last 12 months, progress had been made with recruitment to these roles and other speciality leadership positions. The service had planned to request a new JAG assessment in April 2026.

The pathways and guidelines we reviewed were in line with national guidance, including NICE‑aligned pathways for chest imaging, stroke and transient ischaemic attack.

The acute respiratory care unit (ARCU) and the acute medical unit (AMU) provided non‑invasive ventilation (NIV) in line with an in‑date Acute NIV policy, which reflected national guidance on safe prescribing, initiation and monitoring. Staffing levels were adjusted to facilitate a 1:2 nurse to service user ratio, in line with British Thoracic Society (BTS) guidelines. However, staff told us that on ARCU they were not always able to meet the 1:2 nurse‑to‑patient ratio due to staffing gaps, and that these risks were escalated.

On ARCU, patient acuity was reviewed 3 times a day and there was an escalation process to flag concerns around patient acuity (including out of hours, weekends and bank holidays). Staff told us that enhanced respiratory care patients were reviewed daily by a respiratory consultant and by the on-call registrar at weekends.

Competency training data for the ARCU showed that most competencies had high completion rates and most nursing staff were RAG rated green. However, not all staff were up to date with tracheostomy practical or cannulation.

The division had oversight arrangements in place to ensure services reviewed and completed NICE baseline assessments as required. Leaders told us that there were no outstanding or overdue NICE baseline assessments to be completed for the division.

We saw evidence that where services were unable to fully meet NICE recommendations, the associated risks had been appropriately recorded on the divisional risk register. In certain areas, services had audited their compliance against NICE guidance and could demonstrate improvements because of this, such as in the prescription of medication to treat hyperparathyroidism.

The trust had policies and procedures in place to support patients with eating disorders which referenced national guidelines and best practice. Staff told us they felt well supported through training and management when caring for patients with eating disorders.

We reviewed results for the nutrition and hydration questions from quality matron checks completed between November 2025 and December 2025 across 9 medical wards. For most wards, most of the questions had been RAG rated green (90% target). For the remaining wards, 69% to 83% of questions met the target.

Most patients and relatives we spoke with said their nutrition and hydration needs were met. Wards had protected mealtimes, which allowed nurses, HCA’s and sometimes volunteers to be available to support patients.

We scored the service as 3. The evidence showed a good standard. The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Stakeholders, partners and patients described a welcoming and collaborative culture, with strong multidisciplinary team (MDT) working across the medical division. Effective coordination between ward teams, the transfer of care team and specialist services supported safe and well‑planned discharges. Structured discussions took place ahead of specialist assessments, helping reduce repetition for patients and carers.

Patient records we looked at showed evidence of good MDT working, including documented family meetings, board rounds and walk‑rounds. Staff attended routine multidisciplinary meetings and daily safety huddles to review deteriorating patients and identify those medically fit for discharge, alongside participation in hospital‑level and trust‑wide meetings.

Handover processes supported continuity of care, and nursing staff reported positive working relationships with consultants, doctors and advanced clinical practitioners. We observed generally effective handovers with good patient knowledge, although this was not consistent across all wards and some inaccuracies were identified.

Staff described effective cross‑department working to meet individual needs. For example, care was adapted for outpatients with complex mobility needs through advance planning and coordination between teams. Discharge planning was well coordinated, with the transfer of care team attending wards daily and progress monitored through huddles and board rounds. Staff at all levels described positive teamwork across nursing, medical, AHP and pharmacy teams.

Mental health liaison support was accessible, with clear referral information available on wards. Therapy services were available seven days a week, though weekend and bank holiday provision was limited to priority services, and dietetic input was restricted at these times.

The service worked collaboratively with GPs through clear referral guidance and advice pathways, and with local support organisations, including carers’ services, home‑from‑hospital support and hospice services, to support patients and carers in hospital and at home.

Processes were in place to support discharge planning, with progress monitored through daily huddles and board rounds. We observed effective board round meetings that were multidisciplinary including consultants, allied health professionals, pharmacy and the transfer of care team.

We scored the service as 3. The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

Patients we spoke with felt staff supported them to manage their own health, care and wellbeing needs. The service had relevant information promoting healthy lifestyles and support on the wards and units. Information leaflets were readily available for patients.

Staff assessed each patient’s health when admitted and provided support for any individual needs to help them live a healthier lifestyle. For example, staff supported people to engage with smoking‑cessation services, alcohol and drug recovery programmes, and mental health support services.

Patients identified with weight concerns were referred to dietitians or signposted to specialist support services.

We scored the service as 2. The evidence showed some shortfalls. The service routinely monitored people’s care and treatment to continuously improve it. However, action plans were incomplete and lacked evidence that identified issues had been addressed.

The division took part in relevant national clinical audits. Performance was variable, with some audit outcomes worse than the national average, while others met or performed better than the national average. Improvements were seen in some areas compared with previous years. However, the service did not share associated action plans for most of the audits, which meant it was unclear how improvements were being acted upon.

The 2024 National Audit of Dementia showed that 100% of patients had an initial delirium assessment carried out which was better than the national average of 92%. However, only 10.9% of patients had a discharge plan initiated within 24 hours, which was worse than the national average of 89%. Leaders told us that significant changes had been made to improve discharge planning and care for patients with dementia. This included a reconfiguration of wards, including ward 18 (acute medical and dementia) to enable better use of space, the introduction of an activity room, and more dementia‑friendly care. Leaders reported that these changes had improved patient experience and were expected to reduce length of stay.

Leaders described improvements on ward 24 (discharge unit), including innovative therapy‑led models of care, stronger substantive staffing, and recognised quality achievements, which they said had contributed positively to patient outcomes and system‑wide flow.

The 2024 COPD audit (covering admissions from April 2022 to March 2023) showed the service performed better than expected in 2 of 6 metrics, relating to oxygen use at target saturations and non‑invasive ventilation. However, performance was worse than expected in 4 metrics and remained below national standards, with no improvement since the 2023 audit. Although an action plan was developed in November 2023, only 2 of 6 actions had been implemented by January 2026.

Senior leaders told us that improvement was limited by insufficient COPD and asthma nursing resources. While 3 additional respiratory consultants were expected to support improvement, leaders noted that many audit measures relied on nursing‑led interventions. Leaders also reported that community COPD referral pathways had improved over the past year.

The service participated in the quarterly Sentinel Stroke National Audit programme (SSNAP). In the April 2025 to June 2025 quarterly results, the hospital scored an overall SSNAP level of C for both patient-centred and team-centred results (scored from A to E).

National audits that showed improvement included the national heart failure audit (NHFA) 2024/2025, which captured data on clinical indicators linked to improved outcomes for patients with heart failure. Although 8 out of 17 metrics were worse than the national average, most metrics had improved from the previous year.

The national audit of cardiac rehabilitation (NACR) 2024, showed that all metrics had met or were better than the national standards. Performance had remained consistent when compared to the previous 3 years.

Data from the national audit of percutaneous coronary interventions (NAPCI) 2024/2025 and the national audit of cardiac rhythm (NACRM) showed that most metrics were better than the national average and had improved when compared to the previous year.

The myocardial ischaemia national audit project (MINAP) 2024/2025 showed that approximately half of the measures performed better than the national average, with most indicators demonstrating improvement compared with the previous year.

For the integrated specialist survey (ISS) national diabetes audit (NDA) 2024, most metrics had met or were better than the national standards. Performance had remained consistent when compared to the previous year.

The division undertook audits as part of the trust’s inpatient assessment and accreditation system. The audits measured the quality of nursing care across 14 standards. Areas included patient safety, infection control, safeguarding, person centred care and several other key care standards.

We looked at the overall ratings from assessments (dated July 2024 to July 2025) across 9 medical wards and found that most wards were not compliant with the expected standards. For example, only 2 wards had been RAG rated green, and most were rated amber. Improvements had been noted in some wards, with an increase in green standards and a reduction in red standards.

The service shared associated action plans which had appropriate and detailed actions. However, they demonstrated a limited assurance that actions were being actively monitored, progressed and closed in a timely way. Most actions had remained ‘in progress’ for extended periods without evidence of updates. Some action plans had missing information such as blank action status fields and no completion dates.

The inpatient assessment and accreditation system audits had been paused across the trust since October 2025. The medical division had started to pilot the new quality assurance assessment (QAA) in November 2025.

Length of stay (LOS) was monitored and discussed monthly at directorate level alongside weekly LOS reviews. Between 2023 and 2025, average LOS reduced overall from 50.9 days to 42.6 days, which showed an improvement of 8.3 days. Reductions were seen across most specialties, including gastroenterology (−6.9 days), general medicine (−0.8 days) and geriatric medicine (−0.6 days), while respiratory medicine remained unchanged. In 2025, the net bed availability gain was reported to be 15,899 days.

We scored the service as 3. The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Most patients we spoke to told us their treatment plan had been explained to them in a way they could understand so they could make informed decisions about whether to proceed with treatment.

Patient records showed that consent forms were clear and legible, avoided abbreviations, were fully completed and risks and benefits had been explained to patient. We observed staff seeking verbal consent before providing care or treatment.

When patients had reduced capacity, we saw evidence that adjustments were made to improve communication and understanding. This included the use of hearing aids, interpreters, family support, adjusting the time of day, using a quiet place and changing the wording of questions.

Staff received training in the MCA and Deprivation of Liberty Safeguards (DoLs). This was included in the safeguarding training. Compliance rates are reported under the safeguarding quality statement.

The trust completed an annual audit for patients with ‘do not attempt cardiopulmonary resuscitation’ (DNACPR) documentation in place. We reviewed data taken from 100 cases in 2024 that were audited for the Bury care organisation. Data showed a decline in performance from 2024 compared to the previous year. Audit data showed that out of 19 metrics only 7 met the trust target of >95% and 13 metrics had decreased from 2023. A trust‑wide action plan was in place to drive improvement, with target completion dates set for December 2025. As of January 2026, the actions were recorded as on track.

We reviewed 24 patient records and found patients had DNACPR documentation where appropriate, they were up to date, signed and completed. The service also had a DNACPR policy in place that was comprehensive and in date.

The trust completed an audit which measured how compliant staff were with the Mental Capacity Act 2005 (MCA). The audit reviewed 5 standards against a trust target of 95%. We reviewed audit data for the Bury care organisation (12 patients) between July and September 2025. Compliance had improved for all 5 standards when compared to the previous audit (April to June 2025). Only 2 out of 5 standards had met the 95% target. Compliance for the remaining 3 standards ranged from 67% to 92%.

However, we reviewed 24 patient records and found that where applicable, MCA assessments and best interest meetings had been completed, and were comprehensive and appropriate.

Records also showed that Deprivation of Liberty Safeguards (DoLS) decision-making processes and approval were in line with the legal requirements. There was appropriate documentation DoLS had been removed if no longer appropriate.

The service used a trust wide policy for MCA and best interest decisions which was in date. However, the trust wide policy for DoLS had passed the review date of August 2025.

Nursing staff could give examples when DoLS would be appropriate and how they would identify and escalate. Staff told us they could escalate concerns to the safeguarding team and senior nurses to get accurate advice on MCA and DoLS.