Source · CQC inspection
Fairfield General Hospital
Provider The Pennine Acute Hospitals NHS Trust
Type NHS Healthcare Organisation
Region North West
Last inspected 12 Sep 2019
Overall rating: Outstanding View full CQC report
Domain ratings
Safe
Good
Effective
Good
Caring
Outstanding
Responsive
Outstanding
Well-led
Good
Earlier inspection findings
Must-do actions (2)
Must-do action 1 of 2
Must do
Effective
The trust must ensure it improves staff understanding of the processes for assessing and recording of mental capacity, appropriately completing Deprivation of Liberty Safeguards and recording of Do Not Attempt Cardio Pulmonary Resuscitation.
Must-do action 2 of 2
Must do
Responsive
The trust must review its systems and processes to monitor and improve the waiting times for surgery.
Should-do actions (62)
Should-do action 1 of 62
Should do
Well-led
The trust should continue to ensure that improvements are made to its IT infrastructure and reduce the risk in cyber vulnerability, system failure and downtime and the associated disruption to clinical services and risk to patient safety.
Should-do action 2 of 62
Should do
Safe
The trust should ensure it improves staff compliance in mandatory training and safeguarding training.
Should-do action 3 of 62
Should do
Responsive
The trust should ensure it continues to improve waiting and treatment times and arrangements to triage patients in line with national expectations.
Should-do action 4 of 62
Should do
Effective
The trust should ensure it continues work to meet its clinical quality standards such as the Royal College of Emergency Medicine audits and continue to analyse and reduce the number of unplanned patient reattendances within seven days and the number of patients that left the department without being seen.
Should-do action 5 of 62
Should do
Responsive
The trust should consider taking action to improve complaint response times.
Should-do action 6 of 62
Should do
Safe
The trust should ensure that all equipment available for use in the clinical areas are within the serviceable dates for use.
Should-do action 7 of 62
Should do
Effective
The trust should ensure that all documentation is completed fully, especially mental capacity act assessment and DNACPR forms.
Should-do action 8 of 62
Should do
Safe
The trust should continue to monitor the venous thromboembolism forms to ensure patient safety until the online forms are used consistently and fully.
Should-do action 9 of 62
Should do
Safe
The trust should ensure that all medications for use in the clinical areas are within the agreed expiry date for safe use.
Should-do action 10 of 62
Should do
Safe
The trust should ensure that the safety information boards in each of the clinical areas are all fully completed.
Should-do action 11 of 62
Should do
Safe
The trust should ensure that medical staff receive their mandatory training and safeguarding training to at least the trust target.
Should-do action 12 of 62
Should do
Effective
The trust should ensure that patient outcomes for chronic obstructive airways disease are improved and the service should have an action plan to support this.
Should-do action 13 of 62
Should do
Safe
The trust should ensure it improves staff compliance of mandatory training targets including adult’s level three safeguarding training.
Should-do action 14 of 62
Should do
Safe
The trust should ensure medicine fridge and room temperatures in the surgical assessment unit are in line with guidelines.
Should-do action 15 of 62
Should do
Well-led
The trust should continue to improve appraisal rates.
Should-do action 16 of 62
Should do
Effective
The trust should consider the development of a policy to manage post-operative nausea.
Should-do action 17 of 62
Should do
Effective
The trust should ensure it continues to improve the risk of readmission for elective surgery.
Should-do action 18 of 62
Should do
Responsive
The trust should ensure it continues to improve their referral to treatment times for admitted pathways.
Should-do action 19 of 62
Should do
Responsive
The trust should continue to improve the time taken to respond to complaints.
Should-do action 20 of 62
Should do
Safe
The trust should ensure that all members of the team have undertaken the required level of safeguarding training.
Should-do action 21 of 62
Should do
Safe
The trust should ensure that medical consultant’s hours are in line with the 16 hours national expectation.
Should-do action 22 of 62
Should do
Safe
The trust should ensure that it continues to work towards increasing medical staffing numbers in line with recommendations for consultant to patient ratios.
Should-do action 23 of 62
Should do
Safe
The trust should ensure effective expiry date medicine management and that fridge temperatures are in line with legislative standards.
Should-do action 24 of 62
Should do
Effective
The trust should ensure it continues work to meet its clinical quality standards such as the Royal College of Emergency Medicine audits and continue to analyse and reduce the number of unplanned reattendances within seven days.
Should-do action 25 of 62
Should do
Effective
The trust should ensure that all records for DNACPR decisions and Mental Capacity Act decisions are completed.
Should-do action 26 of 62
Should do
Safe
The trust should ensure that venous thromboembolism risk assessments and re-assessments should be completed in the electronic record and audited for compliance.
Should-do action 27 of 62
Should do
Safe
The trust should ensure that ambient room temperatures for storage of medicines should be consistently measured and recorded.
Should-do action 28 of 62
Should do
Safe
The trust should ensure that all staff complete mandatory training.
Should-do action 29 of 62
Should do
Safe
The trust should ensure it continues to improve compliance with paediatric life support training.
Should-do action 30 of 62
Should do
Safe
The trust should ensure there is a formal on call system if a second emergency theatre team is required and plans to recruit a second team are followed through.
Should-do action 31 of 62
Should do
Safe
The service should ensure it continues to address shortages of staff in theatre to minimise the number of cancelled operations.
Should-do action 32 of 62
Should do
Responsive
The service should ensure it improves theatre utilisation rates and reduces the number of cancelled operations for non-clinical reasons.
Should-do action 33 of 62
Should do
Effective
The trust should ensure it acts to address poor performance in national audits, specifically the National Hip Fracture and National Oesophago-gastric Cancer audits.
Should-do action 34 of 62
Should do
Well-led
The trust should ensure all medical staff receive an annual appraisal.
Should-do action 35 of 62
Should do
Effective
The trust should ensure all staff follow Deprivation of Liberty Safeguards legislation so that no patients are deprived of their liberty without lawful authority.
Should-do action 36 of 62
Should do
Responsive
The trust should ensure it continues to improve referral to treatment waiting times in general surgery.
Should-do action 37 of 62
Should do
Well-led
The trust should ensure the system to track and monitor compliance with Deprivation of Liberty Safeguards and the Mental Health Act is understood by staff.
Should-do action 38 of 62
Should do
Safe
The trust should ensure that all medicines are stored safely and are within the expiry date.
Should-do action 39 of 62
Should do
Responsive
The trust should ensure it continues to work towards offering follow-up support and patient diaries to patients.
Should-do action 40 of 62
Should do
Safe
The trust should ensure it continues to build on the improved allied health professional staffing figures to become fully compliant with Guidelines for the Provision of Intensive Care Services (GPICS) Core Standards.
Should-do action 41 of 62
Should do
Responsive
The trust should ensure that discharge processes are person-centred.
Should-do action 42 of 62
Should do
Safe
The trust should ensure it continues with the business plan to recruit more pharmacy and allied health professional staff to meet best practice guidance.
Should-do action 43 of 62
Should do
Safe
The trust should ensure review of consultant weekend cover arrangements, implementation of twice daily ward rounds and block shifts to meet best practice guidance.
Should-do action 44 of 62
Should do
Safe
The service should continue to ensure that all nurses are trained in immediate life support.
Should-do action 45 of 62
Should do
Well-led
The trust should consider developing a vision and strategy for critical care services.
Should-do action 46 of 62
Should do
Responsive
The trust should consider a follow-up service for patients.
Should-do action 47 of 62
Should do
Safe
The trust should consider the introduction of a critical care outreach service to patients at Fairfield General Hospital.
Should-do action 48 of 62
Should do
Safe
The trust should ensure all fridge temperatures are checked and recorded to ensure medicines are stored correctly.
Should-do action 49 of 62
Should do
Safe
The trust should ensure all staff working with children are trained to level three safeguarding.
Should-do action 50 of 62
Should do
Effective
The trust should ensure staff have access to flow charts and sepsis trollies for the management of sepsis patients.
Should-do action 51 of 62
Should do
Safe
The trust should ensure records containing patient sensitive information are not left on open shelves in view of people passing through the corridor, including other patients.
Should-do action 52 of 62
Should do
Effective
The trust should ensure they review the trauma pathway so that all information relating to the patient is conveyed to staff on the day surgery ward, so that they can assess the patient’s suitability for admission.
Should-do action 53 of 62
Should do
Safe
The trust should ensure all staff recognise and report incidents.
Should-do action 54 of 62
Should do
Safe
The trust should ensure all staff who provide cross cover at another site complete a local induction, so that they are familiar with the equipment and area.
Should-do action 55 of 62
Should do
Effective
The trust should ensure staff caring for children are familiar with Gillick competence and understand the importance of it.
Should-do action 56 of 62
Should do
Responsive
The trust should ensure staff complete patient passports to support patients with additional needs if they were to return to hospital.
Should-do action 57 of 62
Should do
Caring
The trust should ensure they have provisions in place to support those unable to communicate using suitable assessment tools.
Should-do action 58 of 62
Should do
Well-led
The trust should ensure staff have information about equality and diversity networks and groups.
Should-do action 59 of 62
Should do
Caring
The trust should consider provisions for children for example access to a child friendly area and play specialist to provide distraction and coping skills for children waiting for surgery.
Should-do action 60 of 62
Should do
Effective
The trust should ensure there is a plan for the dates scheduled for staff to be trained in their new competencies in the endoscopy unit.
Should-do action 61 of 62
Should do
Well-led
The trust should ensure staff appraisal rates meet trust target and ensure that rates are monitored through performance reports.
Should-do action 62 of 62
Should do
Safe
The trust should consider a re-audit of resuscitation trolleys so that audits reach full compliance.