Fairfield General Hospital

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

We assessed 7 quality statements

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service did not always have effective governance arrangements, with outdated policies and audit action plans that lacked clear accountability, timescales and evidence of completion. Leaders did not always act on identified risks in a timely way and did not always use risk registers effectively.

Leaders did not always turn escalation, challenge and assurance into timely, sustained improvement. Repeated issues in safety, responsiveness and quality showed that learning and oversight did not consistently result in embedded change.

However, the service had a shared vision, strategy and culture. Leaders were visible and engaged with staff. Most staff felt valued and respected and were supported to speak up or raise concerns. Partners and stakeholders reported that leaders and the management team worked in an open and collaborative way with system partners.

We have not awarded this service a score for Well-led.

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

We scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Most staff we spoke with were positive about the culture and reported that teams worked effectively together. Most staff felt respected and valued by their managers. Staff we spoke with were passionate and dedicated to providing the best possible care and treatment to patients.

The trusts vision for the next 5 to 10 years was to be the safest and most effective organisation in the NHS and be the place people want to work, tackling inequalities and improving health outcomes and experiences. The trust had overarching objectives that were aligned to the trusts vision, including improving population health, caring for and inspiring people and improving quality and performance.

Throughout January and February 2026, the trust had started to engage with staff, patients and system partners to help develop the new 10-year strategy. This included the development of a new vision, mission and objectives for the trust.

The medical division had its own objectives from 2024 – 2026. This included: improving population health and working with partners, caring for and inspiring our people, improving quality, improving performance, supporting social and economic development and financial sustainability.

The medical division had key priorities that included violence prevention and reduction and staff wellbeing, improving emergency department and hospital flow, improving stroke flow and reducing length of stay, and creating a sustainable workforce.

The medicine division had an annual plan that outlined its priorities for the year, and the actions required to deliver them. The aims included reducing length of stay, improving weekend cover, reducing waiting times and improved patient experience.

Performance against priorities was monitored through directorate review meetings with individual directorate teams, alongside monthly divisional reviews where key priorities and risks were discussed.

The service monitored improvements that had been made from 2024 – 2026 against the priorities and objectives. The service shared improvements that had had been made such as expanding its workforce including additional consultants across respiratory, geriatrics and stroke services and increased medical cover at weekends on AMU. Improvements were also noted for length of stay, mandatory training, appraisals and in staff surveys for management metrics.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The medical division was overseen by a leadership team consisting of a divisional director of nursing, a divisional clinical director for unscheduled care, and a managing director of medicine. They were supported by an assistant director of nursing for respiratory and stroke services and reported to the director of nursing.

Most staff told us they felt well supported by both managers and senior leaders. They spoke positively about their colleagues and team working. Despite frustrations around staffing and workload they reported feeling motivated to provide the best care to patients. Students and healthcare assistants said they received good support from nurses in higher bands.

Staff we spoke with told us that senior leaders were visible and regularly attended morning handovers, safety huddles and walk arounds.

Staff told us that consultants were supportive. Medical staff said they received good support from medical directors and described senior leaders as approachable and responsive.

Partners and stakeholders spoke positively about the skills, knowledge, experience and credibility of the leadership team.

At speciality level we saw the cardiology directorate had held a leader’s session in February 2025 to explore how high‑performing teams are created through strong leadership, shared accountability and clear communication. Cardiology away days had been introduced as a direct action from the leader’s session and the service shared evidence from an away day delivered in May 2025.

Senior leaders told us they had supported the development of these sessions in line with staff requests and as part of the wider response to the cardiology staff survey results. A leaders’ forum was also established to strengthen communication, collaboration, and shared ownership of improvement actions. Leaders told us that these sessions were well attended, and actions had been taken forward to support ongoing improvement across the directorate.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

There were processes and systems in place so that staff were supported to raise concerns.

There was a freedom to speak up (FTSU) policy which was in date and had been reviewed in June 2025. It included links to resources and contact details, along with guidance on how to raise a concern, should staff need to do so.

All staff we asked about FTSU knew how to raise concerns, FTSU posters were present in all areas we visited. Most staff said they felt confident to speak up or use the process. However, 2 members of staff said they were more reluctant to raise concerns using this process in case they were treated unfairly.

The medical division had 3 FTSU cases in the previous 12 months, including 1 anonymous submission. FTSU meetings took place monthly. Leaders told us there were no specific FTSU trends or concerns within the division and reported that the process was working well.

There were systems in place to address concerns about bullying and harassment, including a trust wide policy on tackling workplace bullying and harassment.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. It worked towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff could access trust wide equality, diversity and inclusion (EDI) staff networks. The networks are designed to be a safe forum to support under‑represented staff, promote inclusion, and influence organisational decision‑making.

We looked at Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) 2024/2025 survey results across the medical division at this hospital. Representation of Black, Asian and minority ethnic colleagues across the workforce was higher than the overall trust average. However, for representation of disabled colleagues across workforce, the service was lower than the overall trust average.

The survey results showed Black, Asian and minority ethnic (BAME) staff and those with a disability were more likely to experience harassment, bullying or abuse from managers, other colleagues and patients when compared with white ethnic background and non-disabled colleagues. They were also less likely to feel the organisation acted fairly regarding career progression/promotion. We received similar feedback from a limited number of BAME staff during our assessment.

Overall, 69% of disabled colleagues said their employer had made reasonable adjustments to enable them to carry out their work, which was lower than the trust average (74%).

However, survey responses were more positive in relation to BAME colleagues accessing non-mandatory training and continual professional development (CPD).

There was an associated trust wide equality, equity and inclusion objective tracker 2025-2026 that showed actions had been completed or were in progress. For example, actions included changing the process for requesting and monitoring reasonable adjustments to increase assurance and visibility.

The service provided results from the 2024 NHS Staff Survey, alongside comparisons with the 2023 survey outcomes. The response rate for the medical division was 55%, an increase from 35% in the 2023 NHS Staff Survey and higher than the national average of 50%.

Overall, the results showed improvement across several key areas over the 2-year period. The most improved areas related to work–life balance, flexible working, compassionate leadership and thinking about leaving. The areas with a decline or limited improvement included diversity and equality, inclusion, and autonomy and control. The service had an associated action plan in place to drive further improvements. Some actions had already been completed, and some were still in progress.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

During our previous inspection of medical care in August 2022, we identified 4 regulatory breaches for Regulation 12 (safe care and treatment), Regulation 16 (receiving and acting on complaints), Regulation 17 (good governance) and Regulation 18 (staffing).

We found significant improvements had been made in some areas such as acting on complaints and participation in relevant national audits.

However, at this assessment significant improvements had not been made in relation to other regulatory breaches. The safety and responsive issues we found showed that escalation and challenge did not always translate into timely, sustained change.

The division maintained a structured schedule for both internal and external audits. The schedule clearly outlined the frequency and scope for each audit. However, we found that action plans from national and local audits were not always fully completed or timely. The service did not share associated action plans for most of the national audits, which meant it was unclear how improvements were being acted upon.

Action plans from local audits showed that 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 division acknowledged that there were missing or incomplete audit action plans for some departments. The associate director of governance for the care organisation was working with the clinical audit team to explore ways to improve oversight and engagement with the audit process. The trust was currently taking part in a clinical audit improvement programme which was planned to run for 2 years and had recently secured a new digital system for audit. The new system would allow audit leads to track their progress directly and training for the system was underway.

Oversight and governance of inpatient assessment and accreditation system audits were delivered through the quality, patient experience and clinical effectiveness meetings. Senior leaders produced reports every 3 months to update the board.

Most wards had not shown overall improvement ratings for inpatient assessment and accreditation system audits when compared to previous scores. The data showed that 2 wards experienced a decline in performance, moving from green to amber overall ratings, and that no wards improved from an overall amber rating during this period.

However, minutes from the September 2025 meeting showed that for some wards, within all the metrics assessed there were some increases in green standards and reduction in red standards. It was noted that ward managers would be supported to focus on red areas. The minutes highlighted the need for a different approach collectively to focus on fundamental standards and how best to improve these outcomes. The new deputy chief nurse would be providing direction and ongoing support.

We reviewed the medicine division risk register that showed key risks were identified, they had review dates and control measures in place to mitigate risks. At our previous inspection in 2022, we found that the risk register had a large number of risks on the register which made it difficult to effectively scrutinise and manage. Similarly, at this assessment we found that not all risks had been recorded, updated or made progress in a timely manner. The risk register provided during our assessment did not record an accountable lead, which meant responsibility for managing the risks was unclear. Following our assessment the trust told us that all risks did have assigned owners recorded in a mandatory section.

During our assessment we raised concerns about the care and treatment of patients on ward 21 when escalation beds were used. Ward 21 (16 bedded female rehabilitation ward) could have up to 8 escalation beds added. We asked for urgent assurances that risks surrounding environment, staffing, and mixed sexes had been identified and mitigated.

This risk had not been recorded on the risk register prior to our assessment. Following our assessment, the service added this risk to the register and noted that if ward 21 was escalated to 24 beds (a 50% escalation) then there is a risk that quality, rehabilitation and nursing care could be compromised. The risk had controls in place to mitigate risk with some gaps in controls identified. The risk was scored as high risk.

We also highlighted concerns about patient outcomes in relation to patients’ rehabilitation gym access being impacted by the use of escalation beds. This risk was identified in 2023 and recorded on the risk register as a moderate risk. Controls were implemented to mitigate the risk; however, some gaps in these controls were identified.

The service had identified risks but had not always mitigated them in a timely manner. For example, a risk was recorded on the risk register (February 2021) due to the absence of psychological support provision for stroke patients on ward 21. The service level agreement (SLA) with the partnering mental health service provided support for ward 20 only (male stroke rehabilitation ward). Actions from 2022 to 2025 involved discussions and meetings with system partners around the service level agreement. For example, to explore the potential to support a priority list rather than ward specific support. A formal SLA review was undertaken in December 2025 which was almost 6 years after the risk had been added. At the time of our assessment, an action had been identified for January 2026 to present a proposal for additional workforce capacity to address the risk.

The risk register was not always updated to reflect changes related to risks. For example, a risk relating to the lack of in‑reach provision across some medical specialties had not been updated to reflect the recent recruitment to in‑reach gastroenterology as a mitigating control or completed action.

During our assessment we shared concerns around the process for temporary escalation spaces (TES). We identified different versions of documents in use within the care organisation that differed from the associated policy. The service provided data that showed a risk assessment and several checklists still referenced terminology relevant to the trust’s previous iterations of the procedures relating to TES. Risk assessments were not always being completed and/or were not completed fully. Staff demonstrated variable understanding regarding when the assessments should be completed.

An audit of TES usage conducted between 8 September and 3 October 2025, found inconsistent practice across wards. Some wards had no evidence that risk assessments had been completed and there was inconsistent oversight of the length of time a patient remained in a TES.

During our assessment we found that 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 service had a workforce strategy in place, and several business cases to recruit to key roles across the medical specialties had been submitted and approved. This included a diabetes specialist nurse and an increase in respiratory consultant to deliver 7 day working.

The medical division operated a formal meeting structure to support governance and oversight. Medicine divisional management team (DMT) meetings were held monthly, medicine senior management team (SMT) meetings took place every six weeks, and medicine governance meetings were held weekly.

Regular meetings were in place across the different medical specialties, including cardiology, stroke, dementia, lung cancer, and respiratory. These meetings were then reported into the relevant directorate review meetings which took place every 6 weeks.

Senior leaders attended monthly performance meetings. These were held jointly with another care organisation at the trust. We reviewed meeting minutes from November and January 2026. The December 2025 meeting had been cancelled due to the number of apologies received, associated with the Christmas period. The meetings reviewed performance, risks and capacity pressures across services. They also reviewed delivery against key standards, and where applicable, actions were agreed to address emerging issues.

The division had 8 information governance breaches within the previous 12 months with no specific learning found following investigations. The division had no ICO (information commissioner’s office) reportable incidents in the previous 12 months.

Staff told us that the combination of paper‑based documentation and multiple electronic systems was burdensome. They described duplication of work, with some assessments completed on paper before being entered into electronic systems, and reliance on handover sheets from the morning safety huddle due to information being recorded across different locations and formats.

The service undertook medical records and documentation audits. We reviewed the record-keeping audit report dated April 2025. The report summarised the findings from a retrospective case note review of 60 patient records from all wards for patients admitted in December 2024.

The audit reviewed 10 metrics, with compliance ranging from 18% to 100% against a 95% target. Overall performance averaged 66%, a decline from 69% the previous year. Recording order and legibility scored highest, while deletions or alterations, date and time entries, and recording frequency scored lowest. Although improvement actions were identified, the service did not provide evidence of completed action plans.

Electronic records were easily accessible by staff and kept secure with password-protected access. However, staff told us that NHS Professionals bank staff (NHSP) and students used the same generic username and password to access online records. This meant access to patient records could not always be attributed to individual users, which limited auditability and information governance assurance.

Paper records were not always held securely. We saw some instances where medical notes were left unattended on a trolley and not locked away.

There was a comprehensive and in date information governance policy. Training data showed that nursing staff had met the target of 95% training compliance. However, compliance for medical staff was 78%.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Staff across the medical division shared good practice and worked collaboratively with system partners to support service improvement. For example, cardiology delivery group meetings took place every 2 months.

Partners and stakeholders told us that leaders and the management team worked in an open, transparent, and collaborative way with system partners. This was supported by a clear leadership strategy that promoted inclusive working and positive contribution to local integrated teams and governance arrangements, including shared prioritisation and resource allocation.

They also described strong clinical leadership links with community and primary care teams, supporting better integration, continuity of care, and joint working, including collaborative work with mental health services, primary and community services.

The trust worked in collaboration with Healthwatch, which supported independent surveys for trust-based services.

We observed monthly newsletters from various medical wards that shared important information including lessons learnt, training, social events and policy updates. Newsletters also promoted the trusts support programme for staff called ‘SCARF’ (Support, Care, Assist, Recognise, Family). This helped staff look after their physical, emotional, and psychological wellbeing and to make it easier for staff to find access to practical resources and information. Staff we spoke with had heard of the SCARF programme and knew how to access it if they needed to.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

Staff participated in a number of quality improvement (QI) projects aimed at improving the delivery of care and patient experience and outcomes. We saw examples of improvements made in relation to days kept away from home (DKAFH). There had been an increase in the number of patients returning to their usual place of residence, since the QI work began.

The service had taken an innovative approach to enhanced therapeutic observation and care (ETOC) on ward 24 (discharge unit) for patients who were medically optimised for discharge but may require on-going rehab, care packages or 24-hour care. The initiative called ‘at a glance’ was an approach where all staff on the ward were responsible for “glancing” on the patient and recording this on a corresponding form. The approach supported patients to be more independent, build on their strengths and increase the chance of going home.

As a result of this, ward 24 had significantly reduced their usage of ETOC and had reduced the number of assaults on staff. Based on average pathway waiting times, an estimated 549.5 inpatient bed days were saved, reducing the time patients spent waiting in hospital. There had also been a 27% reduction in falls, year on year.

The ‘at a glance’ initiative and DKAFH collaborative had been presented and shared with other NHS trusts and the improvements had been widely recognised by system partners.

The service had a QI project that focused on improving the management of nasogastric (NG) tubes following a number of never event incidents across the trust. Changes included a new policy, improved training compliance and improved local safety standards. Across all pilot wards there has been a 32% reduction in incidents with harm. Other projects included a focus on board round standards, with the aim of developing an agreed set of trust‑wide standards from July 2026 to improve consistency and reduce variation in practice.

In December 2025, the nursing quality and development team celebrated the 10th cohort of the Fundamentals of Care programme. Since February 2023, the programme had supported 170 healthcare support workers across the local area to help build confidence and skills across key areas of patient care. Feedback on the programme had been consistently positive, with evaluation showing improved knowledge and staff recommending the training.