Fairfield General Hospital

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• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.

At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement. This meant people’s needs were not always met.

The service did not always have sufficient capacity to treat the number of people arriving in the emergency department and routinely nursed patients on the corridor, which negatively impacted on their overall care experience. The service did not make sure that people could access the care, support and treatment they needed when they needed it.

However, the service provided relevant information and made it easy for patients to give feedback about their experiences.

We have not awarded this service a score for Responsive.

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

We scored the service as 3. The evidence showed a good standard. The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Staff told us they discussed patients’ clinical and personal needs as part of the nursing assessments and used this information to deliver person-centred care. Most patients told us their needs and preferences were taken into account by staff.

We observed positive interactions between staff and patients. In most cases, we saw staff demonstrate a good understanding of their needs and provided appropriate care and treatment.

Psychiatric liaison staff completed assessments in parallel to emergency department members of staff. We saw examples of good practice. For example, a patient known to the home treatment team was assessed directly by them in the ED having been brought in on a section 136 as opposed to being assessed by the mental health liaison team. This meant their needs could be more effectively assessed by professionals who know them best.

The trust had a dedicated nurse for adults and children at risk who worked alongside a mental health liaison practitioner to support patients with mental health needs who attended the ED on a frequent basis. Together they would develop trauma informed, person-centred care plans, consult with professionals involved in the care and assess patients together to ensure better outcomes for them. Staff directed patients to other resources in the community where appropriate.

We looked at a selection of care records for children and patients with mental health needs in the emergency department and for patients living with dementia or a learning disability in the frailty SDEC. The records we looked at showed care plans had been put in place, with involvement from patients or their relatives and carers. Staff were able to give examples of reasonable adjustments made to accommodate patient’s with specific needs.

Most staff had received training in dementia awareness and learning disabilities and autism. We saw limited use of hospital passports for patients living with dementia or a learning disability within the emergency department. Staff told us they were not always able to complete hospital passport records because most patients were only present in the department for a limited period of time. Staff told us they discussed and recorded information about patients’ individual needs in the daily notes. We saw evidence of this in the care records we looked at. We also saw some examples of completed hospital passports in use within the frailty SDEC.

The paediatric ED area provided a secure, segregated and child-friendly environment. This included toys and play equipment and a sensory mobile unit to calm children whilst they waited to be seen. There was a designated resuscitation bay for children in the emergency department. The medical SDEC had an ear, nose and throat (ENT) assessment room and was managed by ENT medical staff from the division of medicine. Staff told us any children requiring ENT support were assessed and treated in the paediatric ED area to maintain segregation.

We also observed the mental health room in the ED to have a mural painted on one wall depicting trees.

We scored the service as 2. The evidence showed some shortfalls. The service did not always have sufficient capacity to treat the number of patients arriving in the emergency department and routinely nursed patients on the corridor.

The service had a full capacity protocol and escalation policy and bed management meetings took place a number of times each day to address and escalate risks that could impact on patient safety, such as low staffing and patient flow and capacity issues. Staff also carried out huddle meetings and held discussions during handovers where specific patient needs were discussed.

The full capacity protocol provided guidance for staff around escalation during periods of high demand. The protocol stated temporary escalation / corridor spaces could be utilised when the department reached operational pressures escalation level (OPEL) 3 and prolonged use of non-designated escalation spaces could be used if the department operated at OPEL 3.5 or above. The department had operated at OPEL 3 during the week of our inspection and managers reported there had not been any instances in the past 12 months where OPEL 4 status had been declared at this hospital.

The service reported the average length of stay for patients nursed on the corridor was 253 minutes between February 2025 and January 2026. Corridor care patients accounted for 14.5% of all ED attendances during this period. The longest stay on the corridor was 94 hours, for a patient with mental health needs, who had two corridor care episodes during one attendance.

We found the emergency department did not have sufficient capacity and cubicle space to treat the number of patients arriving in the department. During the inspection, we saw patients were regularly nursed on corridor. The number of corridor spaces used varied throughout the day. We saw corridor patients were moved to a cubicle once they became available and staff prioritised patients by risk, so an existing cubicle patient with lower acuity could be swapped with a corridor care patient if required.

We found 10 patients were nursed on the corridor on the morning of the second day of our inspection. Staff told us the corridor spaces had been used due to increased demand following an ambulance divert declared by another of the trust’s hospitals. We saw all 10 patients had been admitted to the wards, moved to cubicles or transferred out to other hospitals by 11am.

The designated mental health room was often busy, due to patients with mental health needs having long waits to access beds. In these instances, psychiatric liaison members of staff used other rooms in the department, such as other bays. One patient, for example, had been assessed on the corridor on the morning of our visit, however he had been moved into the mental health bay by the end of the morning.

The ED staff and psychiatric liaison team had clear processes to escalate when a person requiring an inpatient mental health admission remained in the department. These included escalating to senior managers when a person had been in the department more than 12 hours.

Whilst we did not identify any serious harm incidents relating to corridor care, the extended use of temporary escalation spaces negatively impacted on patient’s experience.

The hospital worked in partnership with an external primary care service that was located near the entrance to the emergency department and provided pre-emergency department front door streaming services.

A nurse from the external primary care service assessed patients on arrival to the emergency department to determine if they needed emergency care or if their condition can be managed without admission to the emergency department. Patients presenting with minor ailments, such as minor respiratory conditions could be given self-care advice or streamed to the urgent treatment centre (UTC) or same day emergency care (SDEC) ward at the hospital or deflected to external services such as local integrated community services, pharmacy services, GP’s and dental providers.

There had been 48,577 attendances at the urgent primary care front door streaming service, of which 19,460 patients had been streamed or deflected between January 2025 and December 2025. This accounted for 40% of all attendances during this period. Most of the deflected patients (over 90%) had been referred to the SDEC and UTC at the hospital.

The emergency department implemented the new NHS acuity tool in December 2024, which enabled the early identification of patients who could be deflected away from ED. The hospital commissioned an external review of front door streaming processes in July 2025. This identified duplication in how patients were being streamed at the front door. The review prioritised deflections away from the suite of ED services (including the UTC and SDEC).

The hospital adopted a new GP led model following the external review, where patients would be streamed from the front door to a GP based on site with 2 assessment rooms allocated next to the UTC. The hospital reported the external primary care service was in the process of recruiting a GP to support the new service model, which was expected start in June 2026. The new service was expected to increase GP streaming numbers from 4 patients per day to 20 per day.

Records showed 24,338 patients streamed to UTC between February 2025 and January 2026. There had been 17,316 patient attendances to the SDEC, including 16,188 medical SDEC attendance and 1,128 frailty SDEC attendances. The average length of patient stay was 4.7 hours in the medical SDEC and 7.4 hours in the frailty SDEC.

Staff followed clearly defined inclusion / exclusion criteria to stream eligible patients presenting in the emergency department to the UTC or SDEC. We found staff followed streaming pathways effectively and we did not identify any patients that had been streamed to the UTC or SDEC areas inappropriately. We found the UTC and SDEC areas had sufficient capacity and bed space to meet patient demand.

A number of initiatives had been undertaken to improve and expand the UTC and SDEC services to support emergency department attendances and reduce inpatient admissions. The UTC operated between 8am-10pm but opening hours had been extended to 2am during January 2026 as part of winter pressures planning. Managers told us they were also reviewing the UTC inclusion criteria to determine if they could admit patients to the UTC with conditions currently excluded (such as some types of wounds or limb injuries).

The medical SDEC operated 7 days a week between 8am-12am (midnight). The frailty SDEC did not currently operate on Sundays but managers told us they were reviewing the feasibility of expanding this to a 7 day service.

Staff told us any SDEC patients that had not been discharged the same day were admitted to a ward. They told us there had been rare occasions where the medical SDEC had remained open overnight to accommodate patients that could not be transferred to other wards. The service reported there had not been any reported incidents relating to the extension of SDEC opening hours.

The service had an arrangement with the local NHS ambulance service for the types of patients that could arrive by ambulance which reflected the services provided at the hospital. The hospital did not provide inpatient facilities for children under 16 years of age and the emergency department did not routinely receive ambulance patients less than 16 years of age. There had been 19 instances where children arrived in the emergency department by ambulance between February 2025 and January 2026 and they had been assessed, stabilised and transferred to other hospitals for care and treatment.

Children under 16 of age who self-presented were admitted to a segregated paediatric area within the emergency department, where they were triaged and assessed separately from adult patients.

Stakeholder and service partners, such as mental health, ambulance and children’s services spoke positively about the way care was coordinated when patients transferred between services. Staff in the emergency department had daily engagement with ward staff and we saw consultants from the acute medical unit (AMU) were present in the department on a daily basis to facilitate inpatient admissions.

We scored the service as 3. The evidence showed a good standard. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Staff told us they provided patients with relevant information and discussed this with them, so they were well informed about their care and treatment. Most patients and relatives we spoke with told us staff provided them with the necessary information about their care and treatment and that staff answered any questions they had. Staff could access interpreter and sign language services for patients who needed it when required.

We saw notice boards across the urgent and emergency care services that included information for staff, patients and visitors. Information leaflets were readily available. Information leaflets could be provided in different languages or other formats, such as braille or easy read format, if required. The ED and UTC had a variety of resources to aid communication, such as communication books, picture books and QR codes that could be scanned for information. Information about the urgent and emergency care services was also accessible on the trust’s website.

Most patients told us they had been given relevant information about their care and treatment. However, some patients told us they were not given clear information on waiting times. Staff told us patients were streamed to different parts of the service, which meant they could not always provide accurate information about wait times. We saw information boards and TV monitors that could be used to display waiting time information, but these were not in always in use during the days of our inspection.

Information around performance, safety incidents, audits and complaints was shared with staff during daily huddles and routine staff meetings.

Information such as policies and guidelines were available in paper and electronic format. Paper records were held securely, and electronic records were easily accessible by staff and kept secure with password-protected access. Staff told us they could easily access information such as care records, policies and guidance relevant to their role. The staff we spoke with did not identify any concerns relating to accessing information technology (IT) systems or any connectivity issues.

Most staff (91%) had completed mandatory training in information governance and data security but the trust target of 95% training compliance had not been achieved. There had been no information commissioner’s office (ICO) reportable data breaches relating to the urgent and emergency services in the past 12 months.

We scored the service as 3. The evidence showed a good standard. The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support.

Patients told us they knew how to raise a complaint or concern. Staff understood the policy on complaints and knew how to handle them. They told us information about complaints was discussed and learning shared through daily huddles, handovers and routine staff meetings. Managers told us they reviewed complaints, compliments and feedback from patient surveys to aid learning and improvement.

The complaints policy stated that routine formal complaints would be investigated and responded to within 25 working days, where this was not possible (such as for complex complaint investigations), staff could agree a longer time period with the complainant. The complaints policy included information on how to escalate their concerns internally in the trust or to external organisations such as the Parliamentary and Health Service Ombudsman.

There had been 94 complaints received by the urgent and emergency care services at this hospital between January 2025 and December 2025. The most frequent reasons for complaints related to communication with patients, relatives or carers, delays in treatment and inappropriate or incorrect diagnosis or treatment. Most complaint responses (98%) were completed within the timeframes agreed with the complainant.

Staff across the urgent and emergency services told us they routinely engaged with patients, relatives and carers to gain their feedback. This was done informally through daily engagement and formally through participation in surveys, such as the NHS friends and family test.

Friends and family test survey data between January 2025 and December 2025 showed the urgent and emergency care services achieved compliance between 83% and 100% across all the survey indicators, indicating most patients were positive about their experience of using the services.

The urgent and emergency care services also monitored patient experience as part of the observe, listen and act (OLA) assessments. The emergency department, UTC and SDEC were scored as green during recent assessments in 2025, indicating they had achieved expected compliance against the OLA assessment standards.

The trust scored about the same when compared with other trusts across all survey indicators in the CQC urgent and emergency care survey 2024.

We scored the service as 1. The evidence showed significant shortfalls. The service did not make sure that people could access the care, support and treatment they needed when they needed it.

There had been 86,136 attendances at the urgent and emergency care services at this hospital between February 2025 and January 2026. Of this figure, around 13% were paediatric attendances and 6% were patients with mental health needs. Approximately 24% of all attendances were by ambulance transfer.

There had been an increase in overall attendances during the past 12 months, as well as arrivals by ambulance, compared with the previous year. The urgent and emergency services at this hospital also received a higher proportion of attendances with a mental health condition and patients from higher levels of deprivation compared to national averages.

Patients could access the urgent and emergency care services through a number of routes, including by ambulance transfer or self-attending (walk-in) patients. Patients could also arrive following GP or 111 service referral. The majority of patients attending the service were initially assessed in the emergency department. Staff told some GP referrals or ambulance arrivals could be directly admitted the UTC or SDEC but this was limited in scope and the service planned to make improvements to expand direct referrals to these areas.

We saw patients arriving by ambulance were triaged and appropriately assessed in the rapid assessment and treatment (RAT) area. Ambulance crews spoke positively about their interactions with staff in the department and they felt handovers were more organised and better coordinated compared to other local hospitals. We saw patients arriving by ambulance were assessed and transferred to other parts of the department. Ambulance crews told us they had not experienced any instances where patients had been held in ambulances for long periods of time. During February 2025 to January 2026, the monthly average time patients spent in the RAT area ranged between 55 and 124 minutes.

We observed patients in the SDEC and UTC areas and saw patients were seen in a timely manner. We saw the longest wait times from arrival to assessment in both areas was approximately 1 hour during our inspection. We also saw patients in the paediatric ED area had been seen and assessed within 1 to 2 hours.

We saw the emergency department was at full capacity on each day during our inspection with over 60 patients in the department at the times we visited. The longest wait time to be seen following triage was 2 to 2.5 hours at the times we visited the department. We saw patients were regularly nursed on the corridor. We saw at least 13 patients had been in the department for over 12 hours during one of the inspection days.

Staff told us patients with mental health needs often spent more than 12 hours in the department. We found a patient with mental health needs had been in the emergency department for over 2 days. The patient had received appropriate care with involvement and oversight from the psychiatric liaison team.

The majority of patients we spoke with during the inspection told us they had experienced long waiting times.

Performance data over the past 12 months prior to our inspection showed patients were not always seen and treated in line with national standards. Whilst the urgent and emergency care services performed better than national and peer averages for the proportion of patients that were treated within 4 hours during the past 12 months, a significant proportion of patients remained in the emergency department for longer than 12 hours since arrival. The service also performed worse than national average for the time taken to triage patients self-presenting or arriving by ambulance. We also identified a regulatory breach around timely access to services during our previous inspection in August 2022.

The revised 2025 NHS target for emergency departments was to admit, transfer or discharge 78% of patients within 4 hours of arrival. During February 2025 to January 2026, the average monthly percentage of patients treated within 4 hours between ranged between 65% and 74% and the NHS target had not been achieved. However, the emergency department performed better than both the national average (between 59% and 64%) and regional peer average (55% to 62%) in each of the 12 months during this period.

During February 2025 to January 2026, 6,842 patients remained in the emergency department over 12 hours. This accounted for 10% of all type 1 (major ED) attendances during this period. There had been a worsening monthly trend over time between October 2025 and January 2026 with an average of 11.8% of patients remaining in the department over 12 hours, compared with an average of 9.2% of patients remaining in the department over 12 hours between February 2026 and September 2026..

The national target was that handovers between ambulance and emergency department staff must take place within 15 minutes with no patients waiting more than 30 minutes. During February 2025 to January 2026, only 50% of ambulance handovers took place within 15 minutes and 15.5% of handovers took longer than 30 minutes (including 4.5% over 61 minutes).

During February 2025 to January 2026, the average monthly triage time for ambulance patients ranged between 11 and 15 minutes. This was worse than the national average during this period (between 8 and 9 minutes). During this period, 57% of ambulance patients were triaged within 15 minutes, 25% within 16 to 30 minutes, 12% within 31 to 60 minutes and 5% over 61 minutes. The average time from arrival to treatment for all patients ranged between 73 to 100 minutes. This was worse than the national average during this period (between 56 and 67 minutes).

During February 2025 to January 2026, there had been 70,803 triage assessments completed for self-presenting (non-ambulance) patients. Records showed 44% of these patients were triaged within 15 minutes, 24% were triaged between 16 to 30 minutes and13% were triaged between 31 to 60 minutes. There had also been 3,441 patients (5%) that were triaged between 61 and 120 minutes and triage assessments took longer than 120 minutes for 995 patients (1.4%) during this period.

There were a number of improvement programmes in place to improve access and flow and improve waiting times across the urgent and emergency care services. This included the implementation of a new GP-led streaming model at the front door, planned changes to expand the scope and operating hours in the UTC and SDEC areas, and planned refurbishment of the emergency department to increase capacity. There was also hospital-wide improvement programme under way which aimed to improve admission avoidance measures and reduce inpatient length of stay that would lead to improvements in access and flow in the emergency department.

During January to December 2025, the average monthly percentage of unplanned reattendances to the urgent and emergency care services ranged between 10.1% and 12.7% and performance was consistently worse than national averages during this period. There had been a worsening monthly trend from June 2025 to December 2025.

The hospital reported there had been an increase in patients attending the ED and UTC for wound care that would ordinarily be managed within community teams. This included repeat attendances for wound care due to patients being unable to access community services. The hospital reported they worked in collaboration with community teams to monitor and identify improvements in order to reduce wound care reattendances at the hospital.

There had been 3,056 instances where patients left the urgent and emergency care services without being seen between February 2025 and January 2026. This included 367 patients in the UTC. Incident records showed staff took appropriate actions where patients absconded or left without being seen, in line with trust policies.

The missing and absconded patient policy provided guidance for staff around managing patients who left the service without being seen. Patients who left without being seen or absconded were initially contacted by a senior nurse to check safety and identify the reasons why they left the service. Patients identified at high risk were reported to the Police.

The hospital reported that staff completed the ED mental health risk of absconding triage assessment to identify patients at risk. Staff also followed the risk, assessment, vulnerability and emergency (RAVE) framework to evaluate risks relating to absconding patients and to determine if / when to involve the Police.

We scored the service as 2. The evidence showed some shortfalls. Whilst staff and leaders listened to information about people who are most likely to experience inequality in experience or outcomes, people’s care was not always tailored in response to this.

We looked at data around incidents, feedback from patients and complaints, and this did not identify any disparity in care experiences, adverse outcomes or inequalities for people with protected characteristics. However, we found patients attending the department experienced long waits and some patients were nursed on the ED corridor for long periods during busy periods, which had a negative impact on their experience of using the services.

Staff followed the trust’s equality policy, which outlined a commitment to recognise diversity, promote equal opportunities and support human rights in the provision of health services. New and existing policies and procedures included equality impact assessments.

Staff were able to describe the processes for embedding equity including how they ensured they did not discriminate, including on the grounds of protected characteristics under the Equality Act, when making care and treatment decisions. Most patients we spoke with told us their needs and preferences were assessed, and they had been treated with equality and in a non-discriminatory way.

Care records showed staff completed risk assessments on admission to identify and manage risks around ethnicity, lifestyle choices (such as smoking and drinking) and social and economic factors.

Most staff across the urgent and emergency care services had completed mandatory training in equality, diversity and human rights and training compliance was better the than the hospital’s 90% target. Staff were able to give examples of how they respected the individual wishes of people with protected characteristics, such as those with a disability or mental health needs and patients with communication or language difficulties.

We scored the service as 3. The evidence showed a good standard. People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Staff told us they planned and discussed care and treatment plans, including transfer or discharge arrangements, on admission to the service. Care records included transfer checklists and staff completed these for patients admitted to the hospital’s wards or transferred to other external healthcare providers. Most patients told us staff kept them informed about their care and treatment, including when they were likely to be discharged, admitted or transferred out of the hospital.

Staff completed discharge planning at an early stage and care records included discharge checklists. Our observations and discussions with patients and relatives did not identify any significant issues or delays around patient discharges from the emergency department, UTC or SDEC areas. Patients could also be discharged from ward 24 (discharge lounge).

A discharge to general practitioner (GP) audit was undertaken in 2025 (based on a sample of 40 records coded as GP follow up). The audit reviewed discharge information benchmarked against RCEM guidance and showed 80% of discharge records were complete and provided good information. Learning from the audit had been shared with staff to raise awareness and aid learning and improvement.

Most patients attended the urgent and emergency care service as a single episode of care, however staff told us some patients (such as those awaiting diagnostic scans or results) could be discharged home where it was safe to do so and attend the SDEC the next day rather than being admitted as an inpatient overnight.

Staff told us they could seek advice and guidance from the hospital’s specialist palliative care team, including for bereavement and counselling support. A multi-faith chaplaincy service was available for spiritual or religious support to patients and relatives of all faiths and beliefs.

Staff utilised advanced care plans for palliative and end of life care patients and followed the Swan model of care is to promote dignity, respect and compassion at the end of life. Staff were able to give examples of how they were able to facilitate the prompt discharge of patients who wished to receive their end of life care away from a hospital.

We looked at 3 care records for patients where do not attempt cardiopulmonary resuscitation (DNACPR) decisions had been made. These were all current, complete and showed involvement from the patient or their relatives or carers had been documented.