Fairfield General Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.

We assessed 8 quality statements.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement.

This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

Temporary escalation space (TES) processes were not consistently followed, and staff were sometimes unclear about required risk assessments. The service did not always ensure equipment, facilities and technology supported the delivery of safe care. The service did not always manage medicines and treatments safely or in a way that met people’s needs, capacity and preferences. Staff did not always follow guidance on hand hygiene and use of personal protective equipment.

The service did not have enough qualified, skilled and experienced staff to provide safe care and treatment. Not all staff had completed required mandatory training, including sepsis and life support training.

However, most staff felt confident reporting incidents, staff we spoke with understood how to recognise and report safeguarding concerns. Most wards were clean, organised and free from clutter.

We have not awarded this service a score for Safe.

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

We scored the service as 2. The evidence showed some shortfalls. Processes for investigating and responding to incidents were not always timely and actions were not always achieved to embed good practice.

Staff we spoke with could tell us about the process for reporting incidents and felt confident to raise concerns and report incidents. They told us they received feedback and learning about incidents and safety events through debriefs, ‘themes of the week’, emails, multidisciplinary (MDT) meetings, and handovers. Staff were able to provide examples of incidents which had occurred recently on their ward and what actions had been taken.

The medical division had no never events reported in the previous 12 months. Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. The last reported never event for the medical division was reported in May 2024 and involved the misplacement of a nasogastric (NG) tube.

Actions had been taken across the trust to minimise risk, but at the time of our assessment, not all medical staff were compliant with NG tube mandatory training. Training data showed that nursing staff had met the trust target of 90% compliance for both digital and practical training for NG tube insertion and management. However, compliance for medical staff was 87% for digital training and 68% for practical training. Improvement was still needed, to fully embed learning across the division.

Actions that had been completed included the implementation of a new trust wide NG tube insertion and management policy. Another action was to communicate via 'themes of the week' to inform all wards that NG feeds must only be re-started by registered nurses. Nursing staff we spoke with were aware of this and could describe the changes that had been made to NG practice.

Staff and leaders understood duty of candour (DoC). DoC is the legal obligation for healthcare services and professionals to be open and honest with patients about any incidents that affect their care and treatment. Staff gave examples of when they had apologised to patients and families when an incident had occurred leading to unintended harm.

The service had a trust wide policy for DoC that was comprehensive and in date. The policy outlined clear timescales for verbal and written notifications (stage 1) and for making contact to meet with the relevant person to share investigation findings (stage 2). We reviewed DoC compliance data from January 2024 to January 2025 for 35 safety incidents. The data showed that appropriate stages had been followed but was not always timely and in line with trust guidance, particularly for stage 2. Compliance with verbal and written notifications (stage 1) was 89% and 91% respectively. For stage 2, compliance with the 3‑day target was 32%, and 68% took four days or longer.

From January to December 2025, there had been 1627 incidents reported in relation to medical care. The most common theme across the different medical wards was reporting falls and medicine related incidents.

The division regularly reviewed and investigated incident data in line with good practice and Patient Safety Incident Response Framework (PSIRF) guidance. The trust had a comprehensive patient safety incident response policy in place. The process for reporting and triaging incidents included targets, for example incidents should be reported and triaged within 24 hours. The divisional governance team participated in daily meetings to triage incidents and determine the required level of investigation. For example, immediate learning review (ILR), patient safety review (PSR) or a full patient safety incident investigation (PSII).

We observed the most recent investigation reports from 3 medical wards and where applicable DoC had been completed with the patient’s families within 10 days. They all showed the incidents had been appropriately investigated and action plans were put in place to aid learning and improvement.

Meeting minutes from the experience and standards group meeting (December 2025) highlighted concerns with reduced operational management and governance staff capacity. Leaders recognised how this would likely impact incident investigations.

At the time of our assessment, the medical division had 173 open incidents, of which 30 were overdue. We were told that all overdue incidents had named investigators, and the divisional governance team maintained regular engagement with investigators to support the completion of investigations. Overdue incidents were also discussed at weekly safety summits with senior oversight from the care organisation director of nursing, medical director and divisional directors.

Patient deaths were reviewed and shared with staff as part of routine mortality and morbidity reviews to aid learning and improvement.

We scored the service as 2. The evidence showed some shortfalls. Processes for investigating and responding to incidents were not always timely and actions were not always achieved to embed good practice.

The trust had a full capacity protocol and documented procedures relating to the use of temporary escalation spaces, and expansion of some wards to support the management of patient flow in times of high demand.

The documentation outlined how capacity could be created for an additional 24 beds across 5 medical wards and a further 8 beds could be opened within the surgery division if required. This was approved at director level, nursing care would be provided by the existing surgical nursing workforce, and medical oversight was managed by general medical team.

The service also used up to 15 temporary escalation spaces (TES) across some of the medical wards to move patients from the emergency department (ED). A temporary escalation space is when a temporary additional bed, or chair, is placed in a dedicated space until a bed becomes available. Medical wards included ward 2 (integrated cardiology unit), ward 8 (endocrinology), ward 18 (acute medical and dementia), the acute medical unit (AMU) and acute respiratory care unit (ARCU). Leaders told us TES spaces were used to support flow through the hospital and balance the risks of crowding in the ED.

Following our assessments at one of the trust’s other hospital sites, the trust had updated trust policies and processes related to the use of TES spaces. This included the use of environmental risk assessments to ensure TES spaces were suitable in terms of environmental risks, infection prevention and control and privacy and dignity. The procedures also outlined the use of patient risk assessments and inclusion and exclusion criteria to ensure patients were suitable and safe to be placed in a TES space.

However, we found staff did not always follow these processes and were unsure when risk assessments should be completed. On ward 18, the ward manager told us that a patient had been risk assessed as suitable for a TES space in a chair; however, the information did not accurately reflect the patient’s clinical condition. They told us that a bed was subsequently created in the ward activity area, which was not a designated TES space and had not been risk assessed. The ward manager had reported this as an incident.

We reviewed data provided by the service which indicated only 3 medical staff had completed training related to the procedures for the use of TES spaces for most of the relevant wards.

The service had a wide range of clinical pathways, standard operating procedures (SOP) and policies across the medical specialities to support referrals, speciality in-reach and senior review. They were comprehensive, clearly structured and aligned with national guidance. However, during our assessment we found that staff did not always access the most up-to-date policies and guidance on the intranet.

The service had a detailed Acute Coronary Syndromes (ACS) guideline that provided clear, evidence‑based guidance on assessing and treating adults presenting with suspected heart attacks. There was also a structured Primary Percutaneous Coronary Intervention (PCI) assessment checklist to help identify patients who may be experiencing a major heart attack and require rapid transfer to a specialist centre.

The service had a lung cancer pathway and a daily triage system for suspected lung cancer cases. The service also had a suspected lung cancer booking policy with clear booking rules, clinic codes and pathways to support the timeliness of assessments.

The service had a trust‑wide frailty identification and management guideline that supported the safe and consistent assessment of older people living with frailty.

Referrals to medical specialities were reviewed by senior clinicians to avoid inappropriate admissions to medical wards and delays. For example, there was a structured triage process for respiratory referrals that included a daily review of referrals by a respiratory consultant and managed according to clinical need.

The service had standards and policies in place for when critically ill patients required a transfer to another department within the hospital or to another NHS hospital. The policies were comprehensive, in date and in line with national guidance. Staff told us that the critical care team was very responsive and typically attended within 5 minutes.

From September 2025, the service had improved access to gastroenterology reviews through the recruitment of an onsite in‑reach gastroenterology consultant Monday to Friday. This meant patients could be assessed more quickly and managed without the need to be transferred to another local hospital. We saw evidence of this in patient records in the AMU and staff spoke positively about the new process. When transfers were required, the onsite consultant or registrar liaised with the receiving hospital’s in‑reach team and tracked patients so they could be prioritised safely and appropriately.

We scored the service as 2. The evidence showed some shortfalls. Medical staff did not always keep up to date with safeguarding training and internal audits showed safeguarding processes were not consistently followed across medical wards.

Nursing and medical staff received mandatory safeguarding training specific for their role. We identified a regulatory breach in safeguarding training compliance during our previous inspection in August 2022. Training compliance for medical staff had been 59% for adult and children’s safeguarding training and 75% for nursing staff.

We found improvements had been made during this inspection, particularly for nursing staff. We reviewed training compliance data for nursing staff across 10 medical wards and specialities including respiratory, stroke, cardiology, endoscopy and care of the elderly. Data showed nursing staff had met the 90% trust target for all levels of adults and children’s safeguarding training.

However, medical staff did not always keep up to date with safeguarding training. We looked at training compliance data for medical staff across the different specialities and levels (junior, middle grade and consultant levels). Data showed compliance with safeguarding adults levels 1 and 2 was 92% and met the trust target of 90%. Compliance with safeguarding adults level 3 was 86%, safeguarding children level 1 and 2 was 87%. However, compliance with safeguarding children level 3 was 78%.

Internal audits demonstrated that safeguarding processes were not always followed as expected. The division carried out inpatient assessment and accreditation system audits for each of the medical wards. The audits were scored as red, amber or green and corresponded to a compliance score. At the time of our assessment, out of the 9 medical wards, 3 had been rated red (less than 60%) and 6 were rated amber (60-80%) for the safeguarding element.

We observed that all wards had an associated action plan in place to drive improvement for the safeguarding metric. Practice based educators (PBEs) and safeguarding link nurses were available to support staff with training needs and we saw evidence of additional training and learning shared with staff.

The trust had safeguarding policies in place for adults and children to help staff recognise and report abuse and neglect. These were available on the trust intranet and were in date.

Staff knew how to make a safeguarding referral and could access support and guidance from the hospital’s safeguarding team, which included safeguarding leads for adults and children. The safeguarding leads had completed the higher level of safeguarding training (level 4 or above).

The safeguarding leads attended routine meetings within medical division and were involved in serious incident and patient death reviews. The safeguarding leads also attended routine hospital wide safeguarding steering group meetings and trust-wide safeguarding committee meetings that took place every 3 months to review incidents and identify learning and improvement.

We observed safeguarding information displayed throughout the medical wards with contact details.

The service provided data on safeguarding incidents that had been reported over the previous 6 months. There had been 33 incidents reported of which 8 were reported as moderate or above harm. Leaders told us that these incidents had been reviewed divisionally through the weekly governance oversight meeting and 7 had been downgraded. There was 1 incident confirmed as a severe harm and was in the process of being investigated through a patient safety review. All other incidents were graded as no/low harm and some had specific learning themes identified such as communication failures, discharge related and documentation related.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff utilised the National Early Warning Score (NEWS2) tool to identify deteriorating patients. This was a basic set of observations such as respiratory rate, temperature, blood pressure and pain score used to alert staff to any changes in a patient’s condition. This was supported by an electronic patient tracker system which flagged when observations were due.

We reviewed 16 patient records across 4 medical wards, representing different specialties including respiratory, AMU, general medicine and stroke. These showed mostly good compliance with NEWS2 recordings.

Although the medical records we reviewed demonstrated good compliance with recording NEWS2 observations, audit data revealed inconsistent performance across the medical wards.

We reviewed the most recent NEWS2 audit covering 8 medical wards. The audit looked at patients with NEWS2 scores of 5 or above during June 2025 and focused on patient safety. It assessed whether patients were escalated to the medical team, received timely clinical reviews, and had clear management plans documented. The audit included 109 patients and showed improvement in most areas compared to the previous year’s audit (60 patients).

However, only 1 of the 8 wards met the standard for appropriate escalation to the medical team. Ward scores ranged from 33% to 100%, with an overall average of 71%, which was lower than the July 2024 result of 85%. For patients who were escalated, 4 of the 8 wards met the target for receiving an appropriate clinical review. Scores ranged from 33% to 100%, with an overall average of 82%, an improvement on July 2024 (59%).

Timely completion of clinical reviews averaged 75%, with 4 wards meeting the target. This was better than the July 2024 result of 41%. Management care plans were documented for 97% of patients following clinical review, also an improvement compared to July 2024 (55%). Although the audit was completed in June 2025, there was no evidence of an action plan to address the findings or monitor improvement.

The service had a comprehensive sepsis policy that was in date. Staff understood the importance of recognising the signs of sepsis early and knew how to escalate this. Nursing staff demonstrated good compliance with sepsis training which met or exceeded the trust target of 90%. However, medical staff compliance was 77%.

We observed sepsis information on boards to aid education and awareness. There was a sepsis practitioner and sepsis and deterioration champions available to support patients who needed to be escalated for review.

We requested audit data and any associated action plans around management of sepsis. The service took part in quarterly trust wide inpatient and ED sepsis audits. The most recent audit report included patient admissions from April, May and June 2025. The audit included 42 patients from Fairfield General Hospital and reviewed 8 standards with a target compliance score of 95% and above. The service scored 100% for 4 standards such as ‘NEWS2 recorded within 1 hour of hospital arrival’, ‘microbiology tests and antimicrobials within 3 hours for moderate diagnosis (NEWS 5-6)’ and ‘antimicrobials given within 1 hour for severe diagnosis (NEWS 7+)’. The other 4 standards ranged from 57% (clinical assessment done within 30 minutes for severe diagnosis (NEWS 7+) and 94% (IV fluids given within 1 hour of sepsis diagnosis).

The trust‑wide action plan showed 2 actions with no recorded progress to evidence completion by the December 2025 target date, and neither action had an assigned responsible person. The service did show evidence of an action plan specific to their results from the trust wide audit, such as actions to improve timely clinical assessments within 30 minutes for severe diagnoses.

Performance data for medical care from February 2025 to January 2026 showed that the number of falls fluctuated month to month. The average number of falls a month was 44 with a total of 526. Falls had been discussed in the experience and standards group meeting (October 2025). Meeting minutes had highlighted a gradual increase in falls, although the number of falls with harm had not increased.

Pressure ulcers generally decreased over the previous 12 months. Between January 2025 and June 2025, the average number of pressure ulcers was 9 compared with an average of 5 between July 2025 to December 2025.

There was a low number of avoidable venous thromboembolism (VTEs) in the previous 12 months, with 2 cases identified and none in the previous 6 months.

Most patients told us they felt involved in decisions about their care, and this was reflected in patient records.

The service completed a “recognising end of life” audit in 2024 involving 14 patients. Only 2 of 6 measures met the 95% target. While NEWS documentation and communication with relatives achieved 100% compliance, 14% of patients were not informed of their end‑of‑life status, and recognition was delayed for 43%. An action plan was in place, with most actions completed, and a re‑audit planned for February 2026 using a larger sample.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Most patients we spoke with told us they had not experienced any issues with equipment used to support their care or treatment. However, we received feedback from a patient that call bells were left out of reach or hard to reach for patients who were less mobile. We escalated this to management at the time of our assessment and immediate action was taken to remind staff through ‘themes of the week’ to ensure that call bells were returned to an accessible position.

We observed that a fire door on the AMU was being kept open to allow staff to maintain visibility of patients on the other side of the door. We raised concerns with ward staff, and the following day the fire door had been closed and staffing arrangements adjusted to ensure appropriate observation.

On Ward 21 (female stroke rehab unit), from our observations of the environment, staff feedback and review of the fire risk assessments, we shared concerns with managers and leaders about the 8 additional patients on the ward due to opening escalation beds on the ward. We received staff feedback regarding the lack of fire evacuation practice and staffing capacity. Fire risk assessments had been completed to account for the extra patients, but it was unclear if the actions had been completed to mitigate any risks.

We asked for urgent assurances that there was a robust assessment of the fire risk and that any potential risks had robust mitigations and action plans in place. This included a request for evidence of a robust evacuation plan for patients which the ward manager and ward staff have sufficient awareness of.

Immediate action was taken and a multidisciplinary team including the group fire safety manager, health and safety advisor, associate director of governance, and ward manager reviewed the fire safety arrangements. Actions from 2023 had been completed but not formally updated and were subsequently amended to reflect completion. The May 2025 action plan was updated to show progress, with all evacuation‑related actions either completed or assigned clear timescales.

An additional action was for the trained fire marshals to undertake practical mock evacuation exercises, due to commence within 3 weeks. The fire safety review concluded that, with existing compartmentation, fire strategy, equipment, staffing levels and high compliance with mandatory fire training, the ward could safely manage an increased patient capacity within current procedures.

We also asked for assurance that other risks such as staffing and mixed sexed accommodation associated with the increase of patients had been appropriately identified and mitigated. Leaders told us that staffing increases followed the bed escalation plan, implemented in October 2024. The trust accepted that this put significant pressure on nurse staffing, rehab resources, and environment. During our assessment, a risk was recorded on the risk register, along with actions taken to reduce the risk associated with opening additional beds. These new actions were added to the controls that were already in place.

Existing risk‑reduction measures included clear admission criteria and bay tagging to ensure male patients were not placed in female‑designated areas. Separate male and female bathrooms were also provided. Additional actions included daily ward reviews when the eight extra beds were in use.

All medical wards we visited had sufficient shower and bathroom facilities with emergency pull cords available. Most pull cords were in working order; however, we observed one broken cord, which we escalated to staff at the time.

Toilets were clearly identified for different genders. Most ward areas were free from clutter, and we saw that equipment and consumable items were stored appropriately.

However, on ward 21, the activity/family room was cluttered and was being used for storage, including rehabilitation gym equipment. This was because the room normally used as the rehabilitation gym was being used to accommodate additional patients. Staff reported that when the gym was unavailable, therapy sessions were delivered at the bedside. They said that the ward environment and large beds significantly restricted space and made it difficult to manoeuvre around patients.

Staff told us that they had completed competency training for using standard and specialist equipment.

Some staff reported concerns that some equipment such as Electrocardiogram (ECG) and bladder scanners had to be shared between wards. Staff reported that an incident had been raised in relation to insufficient ECG equipment and was under review by the finance team. The trust advised that this was due to the volume of equipment, along with the cost per machine and ongoing maintenance.

On ward 21, staff reported that there were insufficient electrical plug sockets which meant they had to alternate the plugging in of equipment which was essential to the treatment of patients. This had been on the divisional risk register as a moderate risk since 2022 for both ward 20 and ward 21. At the time of our assessment, estates had completed a review and were awaiting installation dates for 2 extra sockets per bedspace.

Staff told us they were not aware of how frequently security codes for medication storage and door access were changed. We raised this with managers during our assessment, and some codes were in the process of being updated.

Staff had access to equipment and consumables they needed; however, we found some expired consumables which was escalated to staff and was removed.

We checked equipment across some of the medical wards and the service due date stickers showed that they were mostly in date. We identified some equipment with expired service dates showing on stickers and escalated this to staff at the time.

We reviewed current data on medical devices across the medical division, including compliance with required safety checks. Medical device compliance varied significantly across wards. Several wards showed high compliance ranging from 96% to 100%. However, on the cardiology day case unit and the integrated cardiology unit, compliance was 20% and 36% respectively. The acute stroke unit and AMU had 60% compliance. Leaders told us that following our assessment, actions had been taken to complete the servicing of outstanding equipment with a planned completion date by the end of February 2026.

Medical wards had resuscitation equipment readily available. There were systems in place to ensure it was checked and ready for use. Records indicated that daily and monthly checks of the equipment had taken place on the wards we visited.

We observed that oxygen cylinders were in date and stored securely.

Staff disposed of clinical waste safely and appropriately. Dirty utility areas were organised and clear from clutter. Sharps bins that were situated in these areas were dated correctly and were not overfilled.

Medical wards were made up of a mix of side rooms and same sex bays. Staff were aware of the need to report breaches of the standards for mixed sex accommodation.

We reviewed health and safety audits completed across the medical division in previous 12 months. Data showed that 8 out of 11 wards were rated good or excellent with scores ranging from 79% to 99%. The other wards with the lowest scores ranged from 56% to 73%. Associated action plans had been completed for all wards with target dates ranging from March 2025 to December 2025. However, none of the actions had completed dates recorded in any of the action plans. This meant there was a lack of assurance that identified risks had been addressed.

Quality matron checks were completed between November 2025 and December 2025 across 9 medical wards and included environmental safety. Questions included fire safety training and fire exits being accessible. The service used a RAG‑rated system to indicate performance, where green showed standards were being met, amber highlighted areas for improvement, and red identified significant concerns requiring action. For 6 of the 9 wards, most of the questions had been RAG rated green (90% target). For the remaining wards, 64% to 82% of questions met the target

We looked at patient feedback data for the medical division between August 2025 and January 2026. The data included responses from 3414 patients and the average score showed that 91% of patients had selected ‘very good’ or ‘good’ for the ‘environment’ metric.

Patient feedback was also gathered through an initiative called ‘observe, listen and act’ (OLA) with a focus on listening and acting on patient experiences. The team included staff from the patient experience team and a volunteer observer. Data from the most recent OLA feedback showed that the average score across the medical wards was 94% for environment.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. Not all staff had completed required mandatory training, including sepsis and life support training.

We identified a regulatory breach relating to staffing and mandatory training at our inspection in August 2022. At this assessment, we found that no significant improvement had been made.

Some patients and relatives told us there were not always enough staff to meet care and treatment needs. Although most shifts had an appropriate skill mix, actual staffing levels did not always match planned levels.

Some staff said staffing shortages and high workloads meant they did not have enough time to provide good care. Newly qualified nurses were given a supernumerary period; however, some reported being counted in staffing numbers when wards were short staffed. Practice‑based educators supported training and staff development but were sometimes required to cover staffing shortfalls, reducing their educator capacity.

Staff told us that when planned staffing levels were not met, it was difficult to maintain safe patient observations due to reduced visibility. Requests for staffing to support enhanced patient observations (such as 1:1 care) were often not met. During our assessment, we saw that not all patients who required 1:1 care received it.

We reviewed staffing-related incident data from January to December 2025. Across the medical division, 82 staffing incidents were reported, with the highest numbers from AMU, the acute stroke unit, and ward 18.

Staffing levels were monitored and escalated daily using site reports with RAG ratings. While examples of these reports were provided, the service did not supply the requested breakdown of staffing escalations for the previous 12 months, limiting our ability to assess their frequency and severity.

A safer staffing review was completed in 2025 using the Safer Nursing Care Tool (SNCT) and Care Hours Per Patient Day (CHPPD). Most wards were within expected standards and RAG rated green. However, 3 wards did not meet SNCT requirements for registered nurses or HCAs.

Staff could raise red flags when staffing risks remained after mitigation. In November 2025, 56 red flags were raised across the medical wards, down from 71 in October. Ward 21 accounted for 34% and ward 20 for 52%, mainly due to escalation beds. Red flags related to registered nurse shortages (16%), poor skill mix (3.5%), and lack of enhanced observation cover (1.7%).

The January 2026 safer staffing report showed safe care compliance of 92–94% between June and November 2025. However, night shift compliance in November 2025 was 87%, below the 90% target. The integrated cardiology unit and ward 20 had the lowest night‑shift compliance (63% and 60%) and were RAG rated red.

Nursing staffing levels

As of January 2026, the medical division employed 176.57 WTE registered nurses. Vacancy levels were low overall, with most specialties fully staffed. There were some unfilled vacancies for band 7 nurses on cardiology and endocrine and diabetes.

From July 2025 to January 2026, sickness and turnover remained low across most specialties. Higher sickness rates were reported for band 6 nurses in endocrine and diabetes and stroke services (20.73% and 11.64% respectively).

Review of planned versus actual staffing between July 2025 and January 2026 showed staffing was generally close to establishment, although persistent shortfalls were identified in the acute respiratory care unit (ARCU), acute medical unit (AMU), and ward 24, which did not consistently meet planned registered nurse staffing levels for day or night shifts during this period.

Bank and agency usage between July 2025 and January 2026 was low overall but higher in areas with sustained staffing gaps, particularly ARCU, AMU, the acute stroke unit, and the discharge lounge.

Safer staffing data for November 2025, showed that day and night shift fill rates generally met the 90% target. However, when additional duties such as escalation beds and enhanced therapeutic observation care were included, day shift fill rates reduced, and not all wards met the target.

Health care assistants (HCAs)

Leaders told us that as of January 2026, there were 20.45 (WTE) vacant HCA (band 3) posts. Vacancy levels varied across specialties and bands. For example, general and specialist medicine recorded the highest vacancy level in the division, with band 3 consistently at 75% since July 2025. However, care of the elderly showed an over‑establishment position for band 3. Band 3 vacancies across other specialties ranged from 0% to 37% and band 2 vacancies ranged from 0% to 47%.

HCA sickness rates were generally low across the division, with several specialties reporting no sickness. Higher sickness levels were limited to a small number of areas, including endocrine and diabetes and care of the elderly, which exceeded the trust target of 5%.

From July 2025 to January 2026, HCA turnover remained low, with most specialties reporting 0% turnover.

Review of planned versus actual HCA staffing between July 2025 and January 2026 showed that most wards met or exceeded planned establishment on day and night shifts. However, the cardiology day case unit and ward 24 experienced shortfalls on day shifts during this period.

Bank and agency usage for HCAs between July 2025 and January 2026 was higher at night than during the day and was greatest in AMU, ARCU, and the ward 24, although some wards showed a downward trend over time.

Safer staffing data for November 2025, showed that HCA day and night shift fill rates met the 90% target. However, when additional duties such as escalation beds and enhanced therapeutic observation care (ETOC) were included, fill rates reduced, and not all wards met the target on day shifts.

Allied health professionals (AHP)

Staffing data for AHPs was RAG rated. We looked at staffing data from May to December 2025 and found that physiotherapy staffing was consistently rated green (compliant) throughout this period. Dietetics and occupational therapy did not consistently meet staffing requirements, and speech and language therapy experienced the most frequent and sustained shortfalls.

In December 2025, sickness rates for physiotherapy and speech and language therapy were 3%, below the trust target of 5% and reduced compared with the previous 6 months. However, occupational therapy and dietetics sickness rates were higher, at 8% and 15% respectively, and had increased over the same period.

Between May and December 2025, AHP turnover remained above the trust target. However, leaders reported ongoing improvement through actions including expanding apprenticeship routes, strengthening career development opportunities, responding to staff feedback, and proactive recruitment into key roles.

Medical staff

Across the medical division, the total medical staffing workforce was 104.43 whole time equivalent (WTE). This included general and specialist medicine, cardiology, care of the elderly, endocrine and diabetes, respiratory, and stroke services.

Leaders told us that the service had reduced their locum medical workforce from 65 to 3 in the last year and that medical recruitment was supported through established trust wide vacancy panels.

We reviewed vacancy data between July 2025 and January 2026, as provided by the service, and found that medical staff vacancy levels had generally increased across the medical division. Vacancies varied across the division, with some specialties showing significant gaps while others operated above establishment.

As of January 2026, the highest medical staffing vacancies were found in general and specialist medicine, stroke, and endocrine and diabetes. These specialties had unfilled senior or specialty doctor posts.

The lowest vacancy levels were recorded in respiratory, care of the elderly, and cardiology, where several posts were fully staffed or over‑established.

We reviewed sickness and turnover data provided by the service, but figures for medical staff were not included.

The biggest gaps in medical staffing were within the registrar workforce. The service provided data showing the number of unfilled medical shifts between July and December 2025. There was a total of 262 unfilled shifts over the 6-month period. Unfilled shifts had reduced for consultants, FY1 and FY2 doctors and speciality doctors. However, there had been a significant increase in unfilled shifts for lower specialty registrars and higher specialty registrars.

The service did not always manage to fill staffing gaps. In December 2025, a large proportion of these shifts were covered by locum doctors.

The service provided data on locum cover between July and December 2025. Use of locum consultants and lower specialty registrars remained high, although some reduction was seen over time.

Locum consultant shifts decreased from 168 in July 2025 to 92 per month by December 2025. Locum shifts for lower specialty registrars also reduced, from 190 to 125 shifts per month.

Use of locum FY2 doctors increased from 5 to 25 shifts per month in November 2025, before falling to 9 shifts in December 2025. Locum use for specialty doctors increased from 9 to 29 shifts per month, and for higher specialty registrars from 16 to 44 shifts per month.

The lowest locum usage was for FY1 doctors, which reduced from 10 to 3 shifts per month over the same period.

Training

Staff received mandatory training and required learning on a rolling programme in areas such as infection control, sepsis, information governance, learning disability and autism training. Practice educators and managers monitored staff training; however, levels of compliance varied across different staff groups and medical specialties.

Overall compliance for mandatory training for the medical division was 96%. This included nursing staff, additional clinical services, admin, estates and allied health professionals.

We reviewed training compliance data for nursing staff across 10 medical wards and specialities including respiratory, stroke, cardiology, endoscopy and care of the elderly. Training modules that met and/or exceeded the trust target of 90% included falls awareness, intravenous (IV) therapy, malnutrition universal screening tool (MUST), pressure ulcer prevention, safe use of insulin, sepsis, blood transfusion theory and competence training.

Compliance with basic life support training was 96% and exceeded the trust target of 90%. However, immediate life support training compliance was 87%, and advanced life support compliance ranged between 67% and 71%.

Medical staff did not always keep up to date with mandatory training and role-specific training. We looked at mandatory training compliance data for medical staff across different specialities. This included cardiology, care of the elderly, medical evaluation unit, endocrinology/diabetes, respiratory and general medicine (junior, middle grade and consultant levels). The overall average compliance of these medical staff groups was 86% and had not met the trust training target of 90%. Compliance varied across specialities and medical grades. For example, 73% (general medicine middle/senior level), 75% (general medicine consultant level), 88% (cardiology), 92% (general medicine junior level) and 94% (respiratory).

Compliance with life support training was below the trust target for medical staff. Compliance rates across the specialities were 82% for adult basic life support and 71% for advanced life support training. General medicine junior level staff were required to complete adult immediate life support training and compliance was 50%.

Other modules that were below the trust target were sepsis training (77%), blood transfusion competency assessment (72%), blood transfusion theory (81%) and safe use of insulin (74%).

Medical staff were given study days to focus on continuing professional development. For example, away days, conferences and training courses specific to their medical speciality.

We reviewed job specific competency training data for nursing staff across various medical wards. Compliance was sometimes RAG rated with green (training in date) amber (approaching expiry) and red (training out of date). We saw that compliance with competency training was mixed and varied between specialties.

Data from the endocrinology and diabetes ward showed that most staff had completed most competencies. For example, all HCAs and all registered nurses had completed blood glucose monitoring and ketones training. However, only 57% of registered nurses had completed cannulation training.

Data for the acute stroke unit showed that 100% of nursing staff had completed competencies such as glucometer and manual observations. However, some competencies showed that most staff had not yet completed the training. For example, ECG training was 22% (band 5 nurses), 45% (band 6 nurses) and 50% (band 7 nurses). The trust advised that this training was non-essential.

For the cardiology day case unit, some cardiology specific competencies ranged from 94% to 100% compliance, while others ranged from 46% to 77%. On the coronary care unit, cardiology specific competencies compliance ranged from 31% to 81%.

Appraisal compliance for medical care staff ranged from 71% (AMU) and 100% (Ward 2 and Endoscopy). The average overall compliance was 90% and 87% for doctors.

We scored the service as 2. The evidence showed some shortfalls. The service assessed and managed the risk of infection. However, staff did not always follow guidance around hand hygiene and use of personal protective equipment. Routine audits showed poor staff compliance in some infection control standards

We observed that patients with infection risks were appropriately isolated in single side rooms. An orange triangle symbol was displayed on the door to discreetly alert staff and support effective infection control measures.

We observed most staff followed hand hygiene and 'bare below the elbow' guidance. However, we saw instances of poor hand hygiene and inappropriate personal protective equipment (PPE) practice when moving between clinical and utility areas and between attending to patients. We also observed some instances of inadequate hand hygiene and PPE use when entering and leaving isolation side rooms. We raised this with staff during our assessment.

The wards we visited were visibly clean and free from odour. There was sufficient hand wash sinks and hand gels. Hand towels and soap dispensers were adequately stocked. PPE and hand sanitisers were readily available across all wards.

We observed that equipment was clearly labelled to indicate it had been cleaned. Staff routinely used ‘I am clean’ stickers to support this process. However, we saw some disposable curtains on the wards we visited that had not been replaced within the last 6 months in line with national guidance.

Staff completed infection prevention and control (IPC) training as part of mandatory requirements with a trust target of 90%. We reviewed training compliance data for nursing staff across 10 medical wards and specialities including respiratory, stroke, cardiology, endoscopy and care of the elderly. Overall compliance was 100% for IPC level 1 and 95% for IPC level 2.

We looked at IPC training compliance data for medical staff across different specialities. This included cardiology, care of the elderly, medical evaluation unit, endocrinology/diabetes, respiratory and general medicine (junior, middle grade and consultant levels). The overall compliance of these medical staff groups was 95% for IPC level 1 and 85% for IPC level 2 which had not met the trust target.

The division completed IPC and environmental audits and scheduled re‑audits based on the results. The audits covered 15 areas including patient areas, general environment and hand hygiene. The target compliance rate was 90%. Metrics were rated red, amber or green, and aligned to a corresponding compliance score.

We reviewed audit data for 8 wards over the previous 12 months including specialities such as stroke, respiratory, the AMU and cardiology. Data showed performance was mixed, and most actions plans were incomplete. Across all 15 metrics, only 2 out of the 8 medical wards had met the overall compliance target of 90%. Compliance scores ranged from 72% to 92% and the combined average score was 84.5%.

It was not evident from the action plans that concerns identified in the audit were being addressed in a timely manner. Actions plans showed that issues identified had actions assigned to domestic services and were completed in a timely manner. However, most issues assigned to ward managers had no actions identified and were still blank 7 months after the audit had been undertaken. Start dates, progress and review dates were mainly blank.

Senior leaders acknowledged gaps in action plans for some wards and departments. They told us that the associate director of governance had been working with the clinical audit team to strengthen oversight and improve engagement with the audit process.

The service had appropriate IPC policies in place including decontamination of reusable medical devices. There was a cleaning policy in place which outlined guidance for hand hygiene, the use of PPE and the cleaning of equipment. The medical wards used standardised daily cleaning schedules and checklists with clear instructions on where to clean.

Staff attended daily safety huddles with IPC as a standing agenda item. The service had an IPC lead to offer support and advise on infection risks, outbreaks, and how to manage them safely. The lead was involved in audits, training and risk assessments.

Medical wards were visibly clean, and we observed cleaning staff on the wards during our assessment. Cleaning records were up to date and demonstrated areas had been cleaned regularly.

Wards had noticeboards which displayed IPC best practice information, data including infection rates and audit compliance data.

The service monitored key metrics in relation to infection rates, including Methicillin-Resistant Staphylococcus aureus (MRSA), E. Coli and Clostridioides Difficile Infections (CDI). The medical division had 11 healthcare acquired CDIs between January and December 2025 and most wards ranged from 0 to 1. There were also low rates of Escherichia coli (E. coli), Klebsiella and Methicillin-Sensitive Staphylococcus aureus (MSSA) which ranged from 2 to 5 cases over the 11 months.

The highest number of infections recorded was COVID‑19 (58 cases), with 38% occurring on a single ward. The service had identified key themes for any outbreaks and took appropriate actions in line with policies to control the outbreaks.

We reviewed weekly environmental audits from July to December 2025 across the medical wards. Audits included areas such as domestic, estates, clinical and porters areas. Compliance against the trust target was high across all wards in most areas, and scores ranged from 91% to 100%. Associated actions plans were in place to drive improvement, and we saw evidence of this in subsequent audit scores.

We spoke with patients and relatives about the cleanliness of the wards. No patients or relatives we spoke with had any concerns regarding infection prevention and control.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

There was a clinical pharmacy service available that supported the acute medical unit 7 days a week, however other medical wards did not receive a pharmacy service daily on weekdays. There was a clear process for staff to obtain medicines and advice outside of these hours.

The pharmacy team supported medicines reconciliation and discharge prescriptions for people going home with medicines. The NICE standard recommends that people have their medicines reconciled within 24 hours of admission to hospital however the local target was 50%. Audits showed that in November and December 2025 over 80% of people had their medicines reconciled within 24 hours of admission and 95% within 72 hours.

Wards used multiple electronic systems and paper records to document a person’s medicines and related care notes. This meant that information was stored in multiple places and for one person this meant that staff had not recorded contemporaneously an administration of a medicine. We saw for another person that the allergies listed on the electronic medicines administration record (EPMA) did not contain the same allergies as those recorded on a paper chart. This placed people at risk of receiving duplicate doses of a medicine or a medicine they are allergic too.

The EPMA system used for prescribing and recording of administration of medicines did not always contain all the information that prescribers would require to ensure medicines were prescribed safely, for example we saw that people’s weights were not always documented on the EPMA system.

Medicines were not always stored securely as we found on one ward that cupboards had been left unlocked and there was no restriction on which staff could access the room. Medicines were secured immediately by staff when we reported this. Devices used to administer medicines that are for single patient use were not always labelled as such and there was a risk these could be used for multiple people. We found evidence of expired medicines in cupboards on one ward.

We found that for people prescribed medicines to be given via a feeding tube there was not always instructions from a pharmacist that would support staff to do this in a safe way. Records did not always reflect the correct route that medicines should be given however this was rectified by the ward when we reported this.

For people prescribed thickener powder to be used in drinks to prevent choking and aspiration staff did not always follow trust policy to ensure that the use was recorded on a record chart.

Staff across the service had received medicines training and data showed that nursing staff across medical wards had all completed medicines training, however on 2 wards the practical assessment had not been completed by all staff, with completion rates of 87% and 95%.

The service had no reported incidents of using rapid tranquilisation in the last 12 months.