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.

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.

Governance processes were not always effective in managing risks and performance issues across the service. Whilst leaders understood the key risks to the service, the actions taken to address these risks had not been fully implemented or led to service improvements.

However, leaders engaged with service partners and promoted a work culture based on equality, diversity and inclusion. Staff felt valued and respected and were supported to speak up or raise concerns.

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.

The urgent and emergency care / medicine directorate had developed their own local objectives for 2025/26. These were based on 6 key ambitions: integrating services with system partners, developing the workforce, maintaining good quality and safety measures, improving service recovery and productivity, strengthening partnerships and delivering to agreed financial targets. The directorate’s priorities had incorporated the strategic objectives outlined in the trust’s 10 year strategy (vis10n).

Managers told us progress against the objectives and key priorities was reviewed as part of routine departmental, directorate and divisional meetings. Information about the vision and strategic objectives was displayed in the areas we inspected and staff had a good understanding of these.

The staff we spoke with were highly motivated, patient-focussed and spoke positively about the care they delivered. Staff told us there was a friendly and open culture based on team working. They told us they received regular feedback to aid future learning and that they were supported with their training needs by their line managers.

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 urgent and emergency care services formed part of the emergency and urgent care directorate, which was integrated into the division of medicine. The directorate was overseen by a leadership team consisting of a clinical director, lead nurse and directorate manager. The ED and UTC were managed as a combined department and the SDEC was managed as a separate department within the directorate. The day to day running of the emergency department was overseen by a nurse in charge and emergency physician in charge on each shift.

The departmental and directorate leadership structure was stable and fully established. Most of the divisional and departmental leaders had been in post for a number of years. They had a good understanding of the risks to the services and had clear oversight on quality and safety, governance and performance issues through daily involvement and quality monitoring.

Staff told us they understood their departmental reporting structures clearly and spoke positively about the support they received from line managers. They told us leaders were visible, approachable and provided them with good support and guidance.

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.

The trust’s freedom to speak up (FTSU) and whistle blower policies provided guidance for staff around how to raise concerns internally and externally. Hospital-wide FTSU guardians were also in place.

Staff told us they felt confident they could raise any issues with their managers and that managers listened to them. Staff were aware of the freedom to speak up process and understood how to contact the freedom to speak up guardians if needed.

There had been 1 FTSU case reported in relation to the urgent and emergency care services during the 12 months prior to our inspection and the service reported this had been fully resolved.

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

Staff received training in equality, diversity and human rights and had equality, diversity and inclusion policies in place to provide support and guidance. Managers told us equality, diversity and inclusion was embedded in the culture of the service. They told us they routinely engaged with staff to maintain an inclusive, diverse, and supportive work environment.

Staff told us the service had an inclusive working culture and they were treated with respect and equity. Staff told us managers engaged with them regularly and they felt confident their concerns were listened to. The staff we spoke with told us they had not experienced any instances of unfair treatment, discrimination or harassment.

The Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) 2024 survey results across the urgent and emergency care services at this hospital showed the services had a more diverse workforce compared to 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. However, survey responses were more positive in relation to the likelihood of being appointed from shortlisting and the likelihood of accessing non-mandatory training and continual professional development (CPD).

The 2024 NHS staff survey responses showed the urgent and emergency care service performed better when compared to the trust average for key indicators relating to staff engagement, development opportunities and raising and acting on patient safety concerns. The survey also showed the urgent and emergency care service performed worse than trust average in indicators relating to teamwork, reward and recognition and experiencing bullying and harassment from patients, visitors and members of the public.

A further staff survey relating to violence and aggression in the emergency department at this hospital was undertaken in April 2025. The survey results (based on 60 responses) showed 90% of staff had experienced verbal abuse and 33% had experienced physical abuse during work in the past 12 months.

The service reported they had focused on the survey indicators around staff experiencing violence and aggression in the workplace as an area they could make a big difference that could affect other aspects of the survey result rather than lots of smaller projects.

Actions undertaken to reduce violence and aggression against staff included the establishment of the violence and aggression reduction team (VAART) in partnership with the Police and other stakeholders, encouraging staff to report violence and aggression incidents to the Police, supporting staff with debriefs and senior nurse contacts, investment in body worn cameras, appointment of a police liaison officer based at the hospital 3 days per week and 6-monthly staff surveys to gauge improvements.

The urgent and emergency care services had also implemented the safe haven initiative, which focused on reducing violence and aggression through training and partnership working and also undertook regular VAART meetings to support the reduction of violence and aggression against staff.

The service reported a psychometric profile survey was developed in March 2025 to support development, working preferences and communication styles. An emergency department staff survey undertaken between June and August 2025 showed a staff wellbeing score of 3.1 out of 5 and most respondents (92%) knew how to access support and raise concerns.

Staff engagement also took place through daily discussions, team meetings, senior leadership walk rounds, newsletters and through other general information and correspondence that was displayed on notice boards and in staff rooms.

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.

We found the governance processes were not always effective in managing risks and performance issues across the urgent and emergency care services.

During our previous inspection in August 2022, we identified 5 regulatory breaches across the urgent and emergency care services at this hospital. We found improvements had been made in relation to 2 of the 5 breaches from the previous inspection. This related to improving quality monitoring processes and around safe environments and mental health facilities in the emergency department.

We found significant improvements had not been made in relation to 3 of the 5 regulatory breaches during this inspection. This included shortfalls in staffing levels, staff training compliance and around timely access to treatment. We saw evidence actions plans had been put in place to improve compliance. This included refurbishment plans to expand the emergency department, proposals to improve front door streaming to reduce unnecessary admissions and approved funding to increase paediatric nurse staffing. However, these actions were in progress and had not yet been fully implemented or embedded.

During this inspection, we identified shortfalls around managing patients nursed on the corridor in the emergency department. Staff practice around the use of temporary escalation spaces (TES) did not always reflect trust policies, which meant the way patients were identified for TES and the documentation used by staff differed from trust-wide processes. We also identified shortfalls around infection prevention and control compliance and around the management of sepsis.

The systems and processes around use of patient records were not standardised across the hospital. The urgent and emergency care services mostly used paper-based patient records, with some information (such as patient triage) recorded electronically. A separate electronic patient record system was used in other parts of the hospital, such as the inpatient wards. This meant staff had to access multiple systems to access patient information. There was a long-term plan to implement a trust-wide electronic patient record system to improve this.

Leaders understood the key risks affecting the service, including demand, flow, staffing and corridor care. However, the actions taken to address these risks had not been fully implemented or embedded at the time of our inspection. As a result, leadership oversight did not consistently provide sufficient assurance that agreed processes, such as corridor care guidance, infection prevention and control expectations and sepsis pathways, were being followed reliably across all shifts.

The routine use of corridor care, alongside variation in policy adherence and documentation, created a risk that poor practice could become normalised and reduced assurance that care remained consistently safe, person-centred and in-line with trust policies.

The safety and responsive issues we found, particularly around corridor care practice and variable adherence to agreed processes, showed that escalation and challenge did not always translate into timely, sustained change.

There were routine departmental, directorate and divisional governance meetings in place to discuss clinical safety, operational performance, governance and risks across the urgent and emergency care services. Recent meeting minutes showed key discussions took place around performance, risk, governance, audit findings and incidents. Action logs were in place for key performance indicators and progress against planned actions was reviewed at subsequent meetings.

Staff told us information on performance, risks and governance was discussed during daily handovers, safety huddles and during routine team meetings.

Managers maintained departmental and directorate risk registers that fed into divisional and hospital-wide risk registers. The risk registers showed that key risks were identified, and control measures were put in place to mitigate risks. Risks had a review date and an accountable staff member (such as nursing or clinical leads) responsible for managing that risk. Staff were aware of how to record and escalate key risks on the risk registers.

We found most risk assessments relating to key process and health and safety risks were complete and up to date and these were accessible to staff in paper and electronic format. Risk assessments relating to managing violence and aggression, use of restraint and managing mental health and suicidal patients and children attending the department were also in place.

Routine audit and monitoring of key processes took place to monitor performance against safety standards and organisational objectives. Information relating to performance against key quality, safety and performance objectives was monitored and cascaded to staff through team meetings, huddles, performance dashboards and newsletters. Staff told us their performance was routinely monitored and they received feedback following audits to aid learning and improvement.

Audit findings showed mixed compliance in several areas and observations indicated variation in the consistent application of policy, particularly during periods of high demand. This reduced assurance that learning was being translated into reliable, standardised practice.

The urgent and emergency services planned to replace the monthly quality assurance review (QAR) process with the hospital quality assurance audit (QAA) process to align audit processes with other parts of the trust.

The inpatient assessment and accreditation system (IPAAS) ward accreditation process was in place to assess the quality of care delivered. The most recent accreditation showed the emergency department had achieved amber (partial compliance) status and action plans were in place to improve compliance.

Managers were aware of their responsibility to report notifiable incidents. There was a system in place to ensure safety alerts relating to safety, medicines and medical devices were cascaded to staff and responded to in a timely manner.

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.

Staff in the urgent and emergency services worked closely with stakeholders, service partners and commissioners to plan and deliver services. Staff had regular engagement and participated in meetings with safeguarding leads, community services, mental health liaison, alcohol liaison, ambulance services and children’s services to support seamless and coordinated care for patients.

Stakeholders and partners told us they worked collaboratively the urgent and emergency care services to ensure there was effective communication and shared learning, continuous improvement and effective joint working across the services.

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.

Staff told us there was a culture of learning and improvement across the service. They told us routine audits took place to monitor compliance and learning was shared through daily huddles and routine meetings. We saw evidence of learning and improvement resulting from findings from audits, incidents and complaints and this had been cascaded to staff to improve services.

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 and innovations made to reduce overcrowding in the ED and to improve UTC and SDEC frailty SDEC services and pathways to reduce hospital admissions and improve access and flow.

There were plans to further expand and streamline services through the expansion of operating hours for the UTC and SDEC services, implementation of a GP-led pre-emergency department streaming service in the UTC and refurbishment plans to extend the size and capacity of the emergency department.