Our rating of services improved. We rated it them as good because:

A summary of our findings about this location appears in the overall summary.

Our inspection focussed on the Accident and Emergency (A&E) at Fairfield General Hospital.

We found that patients were assessed by a triage nurse when they arrived at A&E. Their clinical need was then prioritised. Staff usually asked patients for their verbal consent before carrying out any procedure or treatment.

Patients were cared for in a clean, hygienic environment. They were protected from the risk of infection because appropriate guidance had been followed. All equipment was visibly clean.

The A&E department was very busy. We saw that most shifts were fully staffed although staff sometimes worked extra hours or did not take breaks. The number of staff required was monitored by the trust and was due to increase the week following our inspection.

There was an effective system in place to identify, assess and manage risks to the health, safety and welfare of patients and others. Patient questionnaire responses were collated and the results of the NHS friends and family test was monitored to check the satisfaction of patients.

The patients we spoke with were positive about the service they received. Comments of the patient questionnaire from August 2013 were also mainly positive. Comments included “The staff are good, they asked for consent and provided me with a chaperone when I was examined”, “I personally can’t fault any of the staff and the care is excellent” and “The staff are professional”.

During this inspection we visited Ward 6 (Cardio Respiratory Ward), Ward 7 (Emergency Admissions Unit) and Ward 21 (Care of the Elderly). We spoke with three ward managers, a pharmacist, a pharmacy technician and six nurses. We also spoke with four patients and looked at the medication records of six patients.

In the records we looked at medication had always been available. We saw there was a system in place to access medication at all times, including when the pharmacy was closed. All the staff we spoke with were aware of the system.

Medication was stored securely. Where medication needed to be stored in a refrigerator the temperature was checked daily to make sure it was safe.

Formal checks of medication records were carried out monthly by ward managers. Pharmacists also brought any errors in medication records to the attention of ward managers so they could be addressed with staff immediately.

Patients told us they had their medication explained to them, and their regular medication was given to them at the correct times.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

We visited the Accident and Emergency department at Fairfield General Hospital. The patients we spoke with said they were happy with the service the received. One patient who had been brought to hospital in an ambulance said that they had been seen more or less straight away and doctors had explained what they thought was wrong. Patients told us “I have been here a couple of times before. I have no concerns about this visit or previous ones”, and “The level of care has been very good. Staff put me at ease”. One patient was waiting to see a specialist and said they would have liked to see the specialist quicker, but knew they were busy elsewhere in the hospital.

During our visit on 19 January 2011 we interviewed 5 patients at Fairfield General Hospital. People told us that they were always kept informed about their care and treatment, and that permission was always asked for before procedures were carried out. We were told that choices regarding treatment were not always available but patients thought this was appropriate.

People told us that they were happy with the care they received. We heard that staff were very highly thought of, took the time to explain everything to patients, and treated people with respect.

We heard that availability of food outside mealtimes was variable, and we also heard that some patients did not like the food. We were told that discharge was discussed with patients and in some cases choices regarding discharge were given.

Fairfield General Hospital is one of the locations providing inpatient care as part of The Pennine Acute NHS Trust. It provides a range of hospital services including emergency care, critical care, a comprehensive range of elective and non-elective general medicine (including elderly care) and surgery, and a range of outpatient and diagnostic imaging services.

The Pennine Acute NHS Trust provides services for around 820,000 people in and around the north east of Greater Manchester in Bury, Prestwich, North Manchester, Middleton, Heywood, Oldham, Rochdale and parts of East Lancashire. There are approximately 1191 inpatient beds across the Trust with The Fairfield General Hospital having approximately 236 inpatient beds.

We carried out an announced inspection of The Fairfield General Hospital between the 23 to the 3rd March 2016 as part of our comprehensive inspection of The Pennine Acute Trust.

Overall, we rated The Fairfield General Hospital as Requiring improvement. We found that the services were provided by dedicated, caring staff, and patients were treated with dignity and respect. However, improvements were needed to ensure that all services were safe, effective, well led and responsive to people’s needs.

Leadership and Management

• There was clear leadership and communication in services at a local level, senior managers were visible, approachable, and staff were supported in the workplace.
• There was a positive culture throughout teams in the hospital and staff were committed to being part of the trusts vision and strategy going forward.
• Managers also engaged with staff via team briefs, newsletters and through other general information and correspondence that was displayed on notice boards and in staff rooms.
• Staff reported there was clear visibility of members of the trust board throughout the service. Staff could explain the leadership structure within the trust and the executive team were accessible to staff.
• We observed there was currently no trustwide clinical lead in Pathology Services, however recruitment was underway.

Access and Flow

• Access and flow remained a challenge in the emergency department. Records showed that between April 2015 and February 2016, the department achieved the 95% target in only five weeks during this period. The monthly percentage of patients seen within four hours of arrival ranged between 74.35% and 97.12%, with an overall average of 84.61% of patients seen within four hours during this period.
• The average time to treatment was consistently worse than the 60 minute Department of Health standard between October 2015 and February 2016.
• Between October 2015 and December 2015, the average occupancy rate at the hospital was 94%,
• There were challenges with access and flow across medical ward which resulted in patients being moved multiple times, of which some were undertaken outside of normal working hours. In the period November 2014 to October 2015, 45% of patients experienced multiple ward moves during their stay. Information provided by the trust showed that between April 2015 and September 2015, the number of patients on medical wards that were transferred to another ward after 10pm at night was high for the emergency admissions unit which averaged around 126 a month.
• Some medical patients were being nursed in non-speciality beds but to access and flow pressures. Between November 2014 and October 2015 there had been 173 outliers at the hospital.
• The hospital met the 18 week referral times for 95.6% of patients as at 11 February 2016 and this included medical treatment, which was better than the national target of 92%.
• Access and flow challenges impacted upon patients being delayed from being discharged from critical care. Between January and June 2015, 55 patients had experienced delays, however most delays were less than 24 hours.
• There were processes in place to support patients reaching the end of life bring transferred to their preferred place of care within 24 hours, including a rapid transfer arrangements.
• Though it was reported that the numbers of patients waiting longer than 18 weeks from referral to treatment (RTT) was consistently better than the England average and the cancer waiting times for the trust were consistently better than the England average we have subsequently learned that data collection in the department is not reliable and are not assured that targets are truly at that level. Work is being undertaken with the trust to clarify the current position.

Cleanliness and Infection control

• The trust had infection prevention and control policies in place, which were accessible to staff and staff were knowledgeable on preventing infection.
• Clinical areas were visibly clean, and there were were processes in place to maintain standards of cleanliness.
• There was enough personal protective equipment available, which was accessible for staff and staff used this appropriately.
• Staff generally followed good practice guidance in relation to the control and prevention of infection in line with trust policies and procedures.
• Between April 2015 to December 2015, there were no case of MRSA bacteraemia reported across the hospital.

Nurse Staffing

• The trust undertook biannual nurse staffing establishment reviews as part of mandatory requirements. As part of this, key objectives were set though this work to support safer staffing.
• We found that there were not always sufficient numbers of trained nursing staff in the emergency department to meet patients’ needs, as the existing establishment did not always have the flexibility to cope with the number of patients attending the department.
• Nurse staffing levels on medical wards overall met the needs of patients; however, there had been a reliance on temporary staff on the some of the wards.
• There had been a decrease within the specialist palliative care team which meant patients did not have appropriate access to specialist care and treatment from this team on Mondays or at weekends.
• Staffing information was available for patients and the public on a boards at the entrance to wards..
• Pressures in nurse staffing meant that the critical care unit did not always meet the standard set by the Intensive Care Society for supernumerary shift co-ordinators at band 6/7.

Mortality Rates

• Mortality and morbidity meetings were held on a monthly basis. Meeting minutes showed that actions and learning were identified but it wasn’t always clear who was responsible for their implementation or the timeframe that it would be expected in.
• The Summary Hospital-level Mortality Indicator (SHMI) is a set of data indicators which is used to measure mortality outcomes at trust level across the NHS in England using a standard and transparent methodology. The SHMI is the ratio between the actual number of patients who die following hospitalisation at the trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated at the hospital. The risk score is the ratio between the actual and expected number of adverse outcomes. A score of 100 would mean that the number of adverse outcomes is as expected compared to England. A score of over 100 means more adverse (worse) outcomes than expected and a score of less than 100 means less adverse (better) outcomes than expected. In September 2014 the hospital score was 106.8. Actions had been put in place to improve the outcome for patients. These included review of the care pathway and further end of life training for staff.
• Within critical care, mortality and length of stay for ventilated admissions and patients with severe sepis was higher than in similar units.

Nutrition and Hydration

• Patients had access to food and drink whilst in emergency and outpatient departments.
• We found that there were policies and procedures in place to support patients nutritional and hydration needs. Patients nutritional needs were risk assessed and results were acted upon appropriately.
• Patient received assessments of their nutritional requirements using the malnutrition universal screening tool (MUST), which highlighted if they were at risk of dehydration or malnutrition. However, audits undertaken across medical wards showed that this assessment was not always completed.
• A variety of food choices was available to patients. Special diets, for example diabetic, gluten free, renal, soft textured and allergy diets were available.

There were also areas of poor practice where the trust needs to make improvements.

Importantly, the hospital must:

Emergency and Urgent Care

• Take appropriate actions to improve nursing and medical staffing levels.
• Take appropriate actions so that patients attending the department are assessed and treated in a timely manner.

Medical Services

• Ensure that records are kept secure at all times so that they are only accessed by authorised people.
• Ensure that all staff are aware of the procedures for capacity assessments and these are completed where necessary
• Ensure that assessments of patient’s nutrition and hydration needs are fully completed and patient’s receive appropriate support where necessary
• Ensure that the discharge lounge and ambulatory care unit is fit for purpose and patients supported to have conversations about their care where they cannot be overheard.

End of life care

• Ensure that the DNACPR procedure is always completed in accordance with the accepted legal requirement to either gain the patient’s consent, or where a patient lacks capacity, following a discussion with the patient’s family.

• Ensure that where a patient lacks capacity to make a decision about DNACPR, a mental capacity assessment has been carried out.

• Ensure that it takes action to ensure the DNACPR documentation is always completed in line with its own policy.

In addition the hospital should:

Emergency and Urgent Care

• Consider improving mandatory training compliance.
• Consider improving the processes for reviewing and managing key risks to the services.
• Consider taking appropriate actions to improve the processes for monitoring and improving the management of sepsis.

Medical Services

• Consider that rooms used to care for patients who have an infection are managed appropriately
• Consider that patients are discharged as soon as they are fit to do so.
• Consider that patients are not moved ward more than is necessary during their admission and are cared for on a ward suited to meet their needs.
• Consider implementing formal procedures for the supervision of staff to enable them to carry out the duties they are employed to perform.
• Consider that patient pain is consistently recorded
• Consider that all staff seek consent for the use of bedrails and if they lack capacity apply the Mental Capacity Act (2005) principals and this is reflected in procedures.

Surgical Services

• Consider embedding a recognised early warning system which gives clear and unambiguous guidance on escalation procedures and care for the deteriorating patient.

• Consider the recording and disposal of controlled drugs where the whole of one vial is not prescribed, is in line with trust and Royal Pharmaceutical Society of Great Britain guidance.

• Consider implementing a pracise where no arrest trolleys are padlocked, but that they are sealed with unique reference number tags as per trust policy.

• Consider ensuring doctors’ handwriting is legible, particularly on important documents such as consent forms and the detailing of side effects of surgery.

• Consider that in the anaesthesia and surgery divisionthey are compliant with all elements of the NICE clinical guidance 83 concerning the rehabilitation of critically ill patients.

• Consider that they take steps to improve compliance with the recommendations of the British Orthopaedic Association standards for Trauma (BOAST) to prevent patients waiting longer than 72 hours before seeing an orthopaedic specialist.

• Consider that the division take steps to address their very high readmission rates.
• Consider ensuring they work towards compliance with all of the recommendations of the Faculty of Pain Medicine’s Core Standards for Pain Management (2015).

• Consider taking steps to improve theatre utilisation.

End of Life care

• Consider a full review of the staffing requirements to introduce seven day specialist palliative care services at the hospital.
• Consider how to respond to the complex symptom control needs of EOL patients out of hours.
• Consider how to provide training to middle grade doctors about the complex symptom control needs of EOL patients.
• Consider whether the current SPCT staffing levels are sufficient to meet the current demands on the service.
• Consider how to involve SPCT in the service developments required to implement the EOL strategy.
• Consider the level of support and education required from EOLC facilitation team for FGH to embed the use of the IPOC documentation across all its wards.
• Consider how to develop a sensitive tool to ascertain when incidents occur related to EOL issues.
• Consider how to provide SPCT staff with feedback from incidents submitted to enable action to be taken to prevent such incidents reoccurring.

Outpatients and Diagnostics

• Consider changing the way that patient records are being scanned onto the EVOLVE system so that historic records are prepped and scanned on demand in advance of patient attendance at an outpatient clinic. This system has been seen working well in other trusts and ensures that “active” patient notes are prioritised.

Professor Sir Mike Richards

Chief Inspector of Hospitals