Salford Royal Hospital

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.

Our rating of safe stayed the same. We rated safe as requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The surgical services did not have effective systems and processes to ensure surgical wards had sufficient and suitably qualified staff to meet the needs of all service users.

The services did not have effective systems and processes to identify and address risks affecting quality and safety in the surgical wards. Staff did not always complete risk assessments or appropriately manage deteriorating health or consistently complete the surgical safety checklist.

People who used the service were not always safeguarded in the surgical wards. Formal duty of candour was not always undertaken in a timely way in accordance with trust policies.

The general environment in some surgical wards was aged and worn. Equipment servicing and maintenance compliance in the surgical wards was below trust targets. However, the service had plans to improve this.

Staff were not always trained to provide safe care. The surgical services reported that only 18.3% of eligible staff had completed dementia awareness training during the past 3 years. The proportion of staff that had completed life support training was below trust targets.

The services did not always manage infection prevention and control risks well. Staff compliance with hand hygiene standards and admission screening processes was consistently below trust standards. The services did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

However, most staff had had regular appraisals. The service had enough medical. Staff understood how to identify and manage sepsis.

We have not awarded this service a score for Safe.

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

We scored the service as 2. The evidence showed some shortfalls. Whilst the service investigated and reported safety events, formal duty of candour was not always undertaken in a timely way in accordance with trust policies.

Staff knew what incidents to report and how to report them. They raised concerns and reported incidents and near misses on an electronic incident reporting system, in line with the trust’s patient safety incident response policy. Staff used the patient safety incident response framework (PSIRF) to aid learning and improvement. Incidents were reviewed and investigated by staff with the appropriate level of seniority, such as clinical leads, ward managers and matrons.

Staff received feedback following the investigation of incidents. Staff met to discuss the feedback and look at improvements to people’s care during daily safety huddles, handover meetings and during routine departmental, directorate and divisional staff meetings so shared learning could take place.

Staff understood duty of candour. They were open and transparent and gave people who used the service and families a full explanation if and when things went wrong. However, formal duty of candour was not always undertaken in the timelines specified in the trust’s duty of candour policy. This was a breach of regulation.

The duty of candour policy stated the stage 1 target was to notify the relevant person within 72 hours but no later than 10 days after the incident and document this in the person’s care records as soon as practically possible. Records showed staff notified the relevant person within 10 days on 68% of occasions in the division of surgery and on 81% of occasions in the Manchester Centre of Clinical Neurosciences (MCCN) division.

The duty of candour policy stated the stage 2 target was to contact the relevant person within 3 working days of the investigation report or learning response document being approved. Records showed both divisions achieved 0% compliance within 3 days. Stage 2 duty of candour was undertaken 4 days or later on 7% of occasions within the division of surgery and on 15% of occasions in the MCCN division. The trust also reported a high number of incidents had been listed as requiring duty of candour but had not been tracked as a safety incident or serious incident. This meant the data for this key performance indicator could not be accurately calculated as some incident records did not have the investigation completed date recorded.

There had been 2,532 incidents reported by the surgical services across the hospital between October 2024 and September 2025. Most reported incidents resulted in no or low harm. The most frequent reasons for incidents were falls, slips and trips, skin injuries other than pressure ulcers and medicine related incidents. There had been 3 severe harm incidents reported during this period. We looked at the investigation reports for 2 serious harm incidents. These showed the incidents had been appropriately investigated and improvement actions were identified to aid learning and reduce reoccurrence.

There had been 3 never events reported by the surgical services during the 12 months prior to our inspection. Never events are serious safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious harm or death but neither need have happened for an incident to be a never event.

We looked at the investigation report for one never event, relating to a misplaced nasogastric tube. This showed learning had been shared with staff and remedial actions had been undertaken to minimise reoccurrence. The 2 remaining never events related to wrong site surgery incidents and the investigations were still in progress at the time of our inspection.

There had been 7 death incidents reported by the surgical services during the 12 months prior to our inspection. This included 4 deaths relating to the division of surgery and 3 deaths in the MCCN division. We looked at investigation reports relating to 4 death incidents, which showed these had been appropriately investigated and action plans were put in place to aid learning and improvement.

Deaths were also reviewed and shared with staff as part of routine mortality and morbidity reviews to aid learning and improvement.

We scored the service as 2. The evidence showed some shortfalls. The service did not always maintain safe systems of care. Not all staff had completed life support training relevant to their roles.

The surgical services had operational policies and pathways that provided guidance for staff around admission, transfer and discharge processes. There were clear processes around managing admissions for major trauma, spinal and neurosurgery, day surgery and inpatient surgical specialties. People who used the service told us they were kept informed about their care and treatment throughout their hospital stay.

The hospital was the regional centre for major trauma and neurosurgery and the tertiary referral centre for complex spinal surgery. Staff in the spinal and neurosurgery specialties used a web-based tertiary referral platform to facilitate referrals from other hospital-based services. This allowed for real-time two-way communication between the referrer and the tertiary service. We noted the trust reported 2 serious incidents in 2023 and 2024 whereby the investigations highlighted a need for improvements to the referral platform and guidance to ensure that communication between Salford clinicians and referring organisations improved. The service worked with a neighbouring NHS trust to develop the guidance in January 2025 and shared it with regional NHS trusts. Feedback from stakeholders and partners about the patient pass referral system was mostly positive.

People requiring critical or high dependency care following surgery could be transferred promptly. There was a 10-bedded surgical enhanced care unit (ward B2M) used for general surgery, urology and gynaecology speciality service users that required closer monitoring and care but did not require critical care support. Ward H5 (neurosurgery ward) also had 6 enhanced care beds that were used for elective neurosurgical service users who required arterial lines, ketamine infusion therapy or cardiac monitoring. Service users with a tracheostomy in place were admitted to specific wards (such as ward B7, B8 and H7) with a limit of up to 5 people admitted per ward.

We identified a regulatory breach in life support training compliance during our previous inspection in December 2022 and found improvements had not been made during this inspection.

Whilst some staff had completed adult and paediatric resuscitation and life support training, overall compliance varied and the trust’s 90% training target had not been achieved across all staff groups. Records showed 64% of medical staff, 84% of theatres staff and 88% of surgical ward staff had completed adult basic life support training. Records also showed 82% of theatres staff and 63% of surgical ward staff had completed adult immediate life support (ILS) training. The training data showed no medical staff had completed ILS training. The trust reported that ILS training was not required mandatory training for medical staff. In addition, 89% of theatres staff had completed paediatric theory level 2 resuscitation training. The training data showed no medical staff had completed paediatric resuscitation training. The training records also showed only 7 staff (anaesthesia associates in theatres) had completed advanced life support training across the surgical services.

The trust reported the anaesthetic staff at the hospital completed continuing scenario based anaesthetic resuscitation training (COSBART) on an annual basis. The scenario-based training simulated adult and paediatric emergencies and included an assessment of basic life support training and defibrillator use by a member of the hospital’s resuscitation team. Records showed 40 staff across the theatres, raptor theatre and paediatric theatre teams had completed COSBART training during 2025.

There were pathways in place for the transfer of service users to other NHS hospitals for surgical treatments not provided at this hospital. This included burns, isolated liver trauma, oral or facial soft tissue injury and some vascular surgery.

There had been 331 transfers from the surgical services to other NHS hospitals between October 2024 and December 2025. This also included repatriations from the specialist spinal, neurosurgery and major trauma services back to local hospitals for non-specialist care.

Nursing and medical staff handovers took place during daily shift changes and these included discussions about people’s needs and any staffing or capacity issues. Shift changes and handovers included the necessary information about people’s risks and needs. Staff also took part in daily safety huddles where discussions took place around safety, capacity and risks.

Staff used both electronic and paper-based care records and these were securely stored in each area we inspected. Paper-based records included surgical pathways, daily observation charts, nutrition and fluid balance charts and intentional rounding records. The electronic care record system was used for recording risk assessments, care plans, vital observations and for recording daily nursing and medical notes. The theatre teams also used an electronic operating theatre management system for scheduling and documenting information during people’s surgical procedures.

Service partners and stakeholders told us the systems pathways for people who used the surgical services worked well. They told us there was effective communication during referral processes and a good awareness of the importance of maintaining safe transitions between services.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well with people and healthcare partners to understand what being safe meant to them and how to achieve that.

Staff did not always act to ensure people using the service were safeguarded from abuse or improper treatment. Our observations and discussions with people who used the service during the inspection identified poor care and potential neglect relating to 3 vulnerable service users in the surgical wards. We escalated our concerns to ward staff at the time, and the staff had not been previously aware of these concerns. The trust provided further assurance of their safety following our inspection and stated each case would be investigated to identify learning and improvement.

Staff could access policies for the protection of adults at risk of abuse and neglect and for safeguarding children. These provided guidance for staff on how to identify and report any safeguarding concerns, including making referrals internally and to external agencies, such as the local authority safeguarding team.

Staff told us they had received safeguarding training and understood how to identify abuse and report safeguarding concerns. They told us learning from any reported safeguarding incidents was shared as part of daily huddles, handovers and during routine staff meetings.

Staff completed training specific for their role on how to recognise and report abuse, in line with current intercollegiate guidance for adults and children.

Most staff across the surgical services had completed adult and children’s safeguarding training (level 1,2 and 3) and overall training compliance for nursing and support staff was better than the hospital’s target of 90%. Training compliance for medical staff was in line with hospital targets for level 1 and 2 adult and children’s safeguarding training. However, 84% of medical staff had completed adult and children’s safeguarding level 3 training.

Training in the Mental Capacity Act, deprivation of liberty safeguards (DoLS) and female genital mutilation was incorporated into the adult and children’s safeguarding training. 97% of staff had completed preventing radicalisation basic awareness training and 96% of staff had also completed prevent WRAP e-learning training.

There had been 47 safeguarding incidents reported by the surgical services between October 2024 and September 2025. The most frequent reasons related to discharge incidents and for 16 to 17 year olds admitted to an adult bed or ward. Records showed appropriate actions had been taken to safeguard vulnerable people, including undertaking risk assessments and maintaining privacy and dignity where young people were placed on adult wards.

Staff understood how to seek advice and support from the hospital-wide safeguarding team. Safeguarding incidents were reviewed during routine directorate and divisional governance meetings and also by the hospital’s safeguarding steering group, which held meetings every two months to review safeguarding incidents and look for trends and to identify any opportunities for improvement.

The adult patient restrictive interventions policy provided guidance for staff on the use of restraint. The policy stated restrictive intervention should be used as a last resort and the method used should be the least restrictive, proportionate, effective, and safe. We looked at the care records for 2 people where use of restraint was considered and found this had been managed effectively, with regular input and reviews undertaken by the nursing and medical staff as well as mental health liaison specialists.

We scored the service as 1. The evidence showed significant shortfalls. The service did not work well with people to understand and manage risks. Staff did not provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

We were not assured the surgical services had effective systems and processes to identify and address risks affecting quality and safety in the surgical wards.

Staff carried out risk assessments to identify people at risk of harm on admission to the surgical wards and before surgery. Risk assessments included venous thromboembolism (blood clots), falls, pressure ulcers, nutrition and hydration, moving and handling, bed rails, dementia and mouthcare assessments.

The care records we looked at identified shortfalls in relation to managing risks around nutrition and hydration, pain management and the use of bed rails in the surgical wards.

Staff did not always use pain assessment tools to monitor pain symptoms at regular intervals. Acute pain symptoms were managed by the surgical consultants and staff could access support from the hospital’s specialist pain team when needed. However, the hospital’s quality assurance (QAA) audit standard 28 related to evidence of accurate pain management and assessment being available, baseline pain assessments undertaken on admission and pain scores recorded for people receiving analgesia. The surgical wards achieved overall compliance of 23% between June 2024 and September 2025. Ward B1 achieved 18% compliance and ward B2 (general surgery ward) achieved 9% compliance during this period. This was below the compliance target of 80% and demonstrated significantly poor compliance against this audit standard.

Additionally, during our inspection, 4 people on ward B1 (general surgery ward) told us they had experienced extended pain symptoms and had experienced delays in receiving pain relief medicines, including patient-controlled analgesia (PCA). Staff also told us multiple service users had experienced delays in receiving post-operative pain relief, including PCA medicines.

We found poor staff practice around the management of fluid (urine) output monitoring during our inspection of wards B1 and B2 (general surgery wards).

Staff told us service users would leave their individually labelled bed pans or bottles in the bathroom for staff to collect when they had time. There was a risk this could lead to inaccurate recording of fluids as the bed pans and bottles absorbed some of the liquid.

Bathroom checks were on the staff safety huddle as an incident theme. Staff told us that this was to remind staff to check the bathrooms more regularly as there had been instances where used bed pans or bottles had been left in the bathrooms for long periods.

Staff on ward B1 and B2 told us fluid output measurements for all service users on each ward was the responsibility of a single healthcare assistant. This differed to other wards, such as ward H5 and H7 (neurosurgery wards), where staff told us the nurse and support workers managed this activity only for the service users they were allocated and responsible for.

The hospital’s QAA audit standard 37 related to fluid balance charts being completed accurately including accumulative balance. The surgical wards achieved overall compliance of 24% between June 2024 and September 2025. During this period, ward B1 achieved 18% compliance and ward B2 achieved 9% compliance. This was below the compliance target of 80% and demonstrated significantly poor compliance against this audit standard.

During this period, the surgical wards also achieved overall compliance of 66% for QAA standard 38 (hydration risk assessments being evidenced as completed within 6 hours of admission, and daily before midnight thereafter, with the appropriate hydration monitoring in place). This demonstrated poor staff compliance against this audit standard.

The safe and appropriate use of bed rails policy provided guidance for staff around use of bed rails, including undertaking risk assessments for their use. We looked at the care records for 3 people who had bed rails in use during our inspection. We found bed rails risk assessments had not been completed in 2 of these records.

During June 2024 to September 2025, the surgical wards achieved overall compliance of 46% for QAA audit standard 33 (falls, moving and handling and bed rail risk assessments completed within 4 hours of admission, reassessed a minimum of weekly or following a change in the person’s condition). This was below the compliance target of 80% and demonstrated poor compliance around the timely completion of falls, moving and handling and bed rail risk assessments.

Staff used the national early warning score 2 system (NEWS2) to carry out routine monitoring and to identify any changes to people’s medical condition.

The hospital’s quality assurance audit standard 61 related to evidence of escalation when a person had scored NEWS of 3 in a single parameter or NEWS of 5 or above. The surgical wards achieved overall compliance of 52% between June 2024 and September 2025. This was below the compliance target of 80% and demonstrated poor compliance against this audit standard.

The service reported ward staff had taken part in education and training programmes to improve the accuracy of respiratory rate recording and timely escalation. Staff had also been given pocket guides to support accurate respiratory rate completion.

We observed 4 theatre teams undertaking surgical procedures, including the use of the World Health Organization (WHO) checklist. The theatre staff completed safety checks before, during and after surgery and demonstrated a good understanding of the WHO five steps to safer surgery standards.

A swab and instruments count audit was undertaken to assess staff practice following a previous retained swab never event in February 2024. The audit report (March 2025) showed overall compliance of 83% had been achieved and concluded that swab and instrument count processes were not followed consistently in line with trust policies and national guidelines. Improvement recommendations following the audit included undertaking staff competency assessments and to develop a non-interruption time during the surgical count process.

We identified a regulatory breach around staff compliance with aspects of the surgical safety checklist during our previous inspection in December 2022. We found significant improvements had not been made during this inspection.

A weekly WHO snapshot audit had been in place since June 2025 to observe theatre staff compliance against the WHO five steps to safer surgery standards. The audit showed poor staff compliance against WHO standards and average compliance had consistently deteriorated each month between June 2025 and September 2025. The theatre teams achieved average monthly compliance of 85% in June 2025, 81% in July 2025, 66% in August 2025 and 56% in September 2025.

The WHO snapshot audit highlighted poor practice themes relating to staff being distracted or not focused during the time out and sign out stages and clinicians not always being present during de-briefs.

A trust-wide peer audit to check staff compliance against the 8 sequential steps of the revised national safety standards for invasive procedures (NatSSIPs2) was also carried out every 3 months. The June 2025 peer audit at this hospital identified good compliance overall with some negative findings relating to theatre staff not observing silent focus and around staff practice when carrying out instrument tray checks at the sign out stage.

Key themes from the WHO audits were discussed during routine directorate and divisional meetings and as part of monthly trust-wide best practice theatre meetings. The services reported that the theatre department had renewed its focus on the NatSSIPs 8 process and was in the process of developing an e-learning training package to enhance staff understanding and engagement.

The service had policies, guidelines, pathways and screening tools that were based on national guidance for the management of people with sepsis, including neutropenic sepsis.

Staff understood how to identify and manage sepsis in line with policies and national guidelines. We identified shortfalls in sepsis training as a regulatory breach during our previous inspection in December 2022 and found improvements had been made during this inspection. Most staff (89.9%) had completed mandatory adult sepsis training across the surgical wards and theatres.

A hospital-wide sepsis audit undertaken during January to February 2025 identified good practice around the use of standardised protocols, and in relation to the early identification of suspected sepsis (above 97%) and commencing antimicrobial treatment within an hour for service users with an early warning score of 7 or above(91%). The audit also identified areas for improvement relating to the timeliness of clinical reviews. Audit findings had been shared across the service to aid learning and improvement.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure equipment, facilities and technology supported the delivery of safe care.

The theatres and surgical wards located in the Hope block (H wards) and Greater Manchester Major Trauma Hospital (T block) areas were refurbished to a good standard and well-maintained. The T block wards were newly built and had only been in place since 2024. Whilst the facilities and premises were suitably designed and maintained, we found the general environment in the surgical wards in the B block (wards B1, B2, B2M, B6 and B8) was aged and worn. We found some non-clinical areas with peeled paint and scuff marks on walls and cupboards. The trust reported there were no planned ward upgrades or refurbishment activities (apart from routine maintenance) across the surgical wards due to insufficient funding and lack of decant facilities to allow planned and scheduled lifecycle works.

All the areas we inspected had sufficient space for storage of equipment and consumables. All areas were easily accessible, including for wheelchair access. Access to the ward and theatre areas was secure with coded entry. However, we saw clinical waste bins had been used to prop open bay doors on ward B1.

Most people we spoke with told us they had not experienced any issues relating to equipment and premises. However, a service user on ward H4 (general surgical ward) told us the ward only had 2 commodes and people were often told they could not use a commode because it was not available. We raised this with staff and the trust reported following the inspection that additional commodes had been supplied to ward H4 and they planned to review commode and equipment inventories for each ward.

Staff told us equipment was readily available and any faulty equipment could be replaced promptly. Single use items and consumables were stored safely and were kept within expiry dates. Medical gas cylinders (such as oxygen) were stored securely. There was a planned maintenance schedule that listed when equipment was due for servicing. Equipment servicing was managed by the hospital’s medical physics service.

Whilst the majority of equipment we saw was clean and well-maintained, records showed overall equipment servicing and maintenance compliance across the surgical wards was only 74% in November 2025. The service reported the medical physics service was undertaking an asset review in targeted areas to confirm that equipment such as wall-mounted blood pressure monitors (sphygmomanometers) were in still in clinical use and to update the database where assets had not been found.

Emergency resuscitation equipment was available in all the areas we inspected, and this was checked daily and weekly by staff. Emergency resuscitation trollies were tagged to minimise the risk that items could be tampered with.

There were suitable arrangements in place for fire safety, including clear instructions for staff to follow in the event of a fire. Guidance for staff in the event of a major incident was available in the surgical services and staff were aware of how to access this information when needed.

We scored the service as 1. The evidence showed significant shortfalls. The service did not make sure there were enough qualified, skilled and experienced staff.

Nurse staffing levels were reviewed against minimum compliance standards every 6 months, based on a national safer nursing care acuity tool. The expected and actual staffing levels were displayed on notice boards in each area we inspected, and these were updated daily.

We found the surgical wards did not have sufficient and suitably qualified staff to meet the needs of all service users.

During the inspection, we found staffing shortfalls in 9 of the 11 surgical wards we visited, with each of these wards experiencing at least one shift with either a registered nurse and / or a healthcare support worker less than the establishment. All 9 wards had full bed capacity and included service users from mixed surgical specialties with mixed acuity needs. The staffing shortfalls impacted both staff ability to safely care for people and the quality of the care and treatment they provided.

We requested further information from the trust following the inspection about the staffing levels on the surgical wards for the four days immediately after our inspection. The trust reported they had identified 33 vacant shifts for nursing and support staff during this period and had allocated 24 additional shifts through the deployment of existing and bank staff to address the shortfalls. However, this still left a shortfall of 9 vacant shifts across the surgical wards.

Records showed there had been 115 individual unfilled staff shifts between April and September 2025. This included 19 instances where shifts were left unfilled for enhanced observation requests and 17 instances where shifts were left unfilled for high acuity requests.

People who used the service told us the surgical wards did not have enough nursing and support staff. On ward B2 (general surgical ward), a service user told us there had been limited staff presence in their bay overnight and they had observed service users that had not received the support they needed during the night. On ward H4 (general surgical ward) another service user told us they felt the ward was short staffed. They told us they had witnessed other elderly service users not getting support with tasks such as eating.

We spoke with 9 staff across 6 surgical wards, who told us they were frequently understaffed. They told us this was mainly due to high levels of staff sickness. They told us supernumerary ward managers and nursing associates were regularly included in the shift rotas because of nursing shortfalls. Three of the staff we spoke with told us they felt staffing levels were unsafe, especially if enhanced (1:1) care or bay tagging was required. Two of the ward staff we spoke with told us nurses were regularly deployed to other wards, and this left their areas short-staffed.

We carried out a focus group for nursing and support staff (band 6 and below) across the surgical services during our inspection. This was attended by 30 staff, of which at least 25 staff told us ward staffing was a challenge, and shifts were frequently understaffed. Staff told us staffing shortfalls impacted their ability to complete service user observations and keep care records up to date, and that they could not always respond to call bells promptly to assist people. Staff also told us they were often redeployed to other surgical wards to address shortfalls.

There had been 231 instances where nursing staff were redeployed from one surgical ward to another between April 2025 and September 2025. There had been 117 instances where support worker staff had been redeployed from one ward to another during this period. The reason for staff moves included redeployment, vacancy cover, higher acuity and enhanced observation support.

The average sickness rate for nursing and support staff was worse than the trust-wide target of 5.5%. The rolling 12-month average sickness rate for nursing staff up to August 2025 was 6.9% in the division of surgery and 5.9% in the Manchester Centre for Clinical Neurosciences (MCCN) division. The rolling 12-month average sickness rate for support staff up to August 2025 was 13.9% in the division of surgery and 12% in the Manchester Centre for Clinical Neurosciences (MCCN) division.

Managers planned staff rotas in advance, using an e-rostering tool. Managers reviewed staffing levels daily and escalated any shortfalls to divisional and hospital-wide bleep holders. Staff told us they were encouraged to escalate staffing shortfalls, but requests for additional support were frequently unfulfilled.

There had been at least 62 reported incidents relating to staffing shortfalls across the surgical wards at the hospital between September 2024 and September 2025. This included 6 incidents where staff had been moved to another surgical ward leaving the existing ward understaffed.

This also included 56 incidents where staff shortfalls had been escalated across the surgical wards. In 32 of the 56 incidents (57.1%) where staffing shortfalls had been reported, the records showed no evidence of additional staffing resources being provided following escalation.

Whilst all the 62 incidents we identified had been graded as low or no harm, we found evidence of impact on the delivery of safe and effective care and treatment to people who used the service. Examples included incidents where people’s treatment had been delayed, where people had not received timely observation or pain relief and at least 4 incidents where no staff were available to provide 1:1 supervision and care for people with complex needs.

The surgical services reported low numbers of staff vacancies. The overall vacancy rate for nursing and support staff was reported as 8 whole time equivalent (wte) posts. The services reported 20 additional staff had been interviewed and were awaiting confirmation to commence employment.

The theatre teams were suitably staffed in line with national guidelines, such as the Association of Perioperative Practice (AfPP) and Association of Anaesthetists of Great Britain and Ireland (AAGBI) guidelines. The theatres department reported they had only 1 whole time equivalent vacant post. Theatre staff told us there had been instances where staffing shortfalls had been supplemented by supernumerary and newly inducted staff.

Some staff in the theatres department told us that a number of clerical staff had been made redundant or had moved to other posts as a trust-wide cost cutting exercise and this had led to issues with failed appointments and wrong dates being sent out.

There was sufficient medical staffing cover across all medical grades. Staff were also supported by a team of advanced clinical practitioners. There was sufficient on-site and on-call consultant cover over a 24-hour period including cover outside of normal working hours and at weekends. The service reported recruitment for vacant consultant posts had been planned or undertaken in the trauma and orthopaedics, general surgery, plastics and urology specialties.

Cover for sickness and leave was mostly provided by the existing staff and through the use of bank and agency staff. Where bank or agency staff were used, managers made sure they had a full induction and understood the service. Agency spend records showed the use of agency staff had continually decreased between April 2025 and September 2025.

We identified a regulatory breach relating to training, supervision and appraisal compliance during our previous in December 2022. We found improvements had been made. Most staff (94%) had completed mandatory training and the hospital’s training compliance target of 90% had been achieved.

We also identified a separate regulatory breach relating to the services developing staff training in autism awareness and dementia during our previous inspection.

During this inspection, we found most staff (98.6%) across the surgical services had completed relevant tier 1 learning disabilities and autism online training. However, the service reported they were working alongside system partners to develop tier 2 training to meet the standards within The Oliver McGowan Code of Practice. The code of practice standards includes a requirement for staff to participate in live and interactive training that is co-produced and co-delivered by people with a learning disability and autistic people.

The surgical services reported that only 18.3% of eligible staff had completed dementia awareness training during the past 3 years, indicating significant improvements had not been made since our previous inspection.

Staff received a full induction before they started work and had regular clinical competency checks. Most nursing and support staff (87%) and medical staff (97%) had completed annual appraisals within the past 12 months across the surgical services. The services reported there were no outstanding issues relating to staff recruitment checks or professional body revalidations.

Staff received competency-based training and development as part of their continual professional development. Competency-based training was provided by trained individuals (such as practice-based educators). Staff were positive about on-the-job learning and development opportunities and felt confident to do their role. Records showed most staff had completed competency-based training that was relevant to their role and surgical specialty area. However, some ward managers told us they were not always assured that all staff working on their ward at any given time had all the required competencies due to the mixed specialities and the redeployment of staff to address staffing shortfalls.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading promptly.

Most staff had completed mandatory training in infection prevention and control and aseptic non-touch technique and training compliance across all staff groups was better than the hospital’s 90% target. Records showed 95% of nursing staff and 89% of medical staff had completed aseptic non-touch technique training. There were infection prevention and control policies and procedures in place which provided further guidance for staff. People who used the service did not highlight any concerns around the cleanliness of the environment or equipment.

Cleaning schedules were in place and there were clearly defined roles and responsibilities for cleaning the environment and equipment. Surgical instruments were decontaminated in an accredited sterilisation unit.

The ward and theatre areas we inspected were clean and tidy. However, on wards B1 and B2 (general surgical wards), we observed used bedpans and bottles stacking up in the bathroom areas. This was an infection prevention and control risk as these could be accidentally spilt or knocked over.

Staff told us people who used the service underwent Methicillin-resistant Staphylococcus aureus (MRSA) and Carbapenemase-Producing Enterobacteriaceae (CPE) screening prior to admission for surgery. During June 2024 and September 2025, the surgical wards achieved poor overall compliance of 48% for hospital’s quality assurance (QAA) audit standard 59 (relating to the completion of CPE screening and risk assessments on admission) and 57% for QAA audit standard 60 (relating to MRSA pathways and screening completed appropriately. MRSA treatment prescribed and administered as per policy).

During November 2024 to October 2025, the surgical services reported 13 cases of Clostridium difficile (C.Diff) infections, 1 case of MRSA bacteraemia, 16 cases of Klebsiella bacteraemia, 13 cases of Methicillin-susceptible Staphylococcus aureus (MSSA) bacteraemia, 4 cases of Pseudomonas aeruginosa bacteraemia and 29 cases of Escherichia coli (E. coli) blood stream infections.

The services also reported 32 cases of CPE acquisitions during this period. The increased incidence of CPE was attributed to an outbreak across multiple surgical wards.

There had been 11 outbreaks reported across the surgical services between November 2024 and October 2025. This included 4 outbreaks relating to influenza A, 3 related to Covid-19 and 3 CPE-related outbreaks.

We saw evidence that infection incidents and outbreaks were investigated to minimise the risk of spread of infection, with involvement from nursing and clinical staff, as well as the hospital’s infection control team.

Staff told us people identified at risk of infection were isolated. They told us that people were barrier nursed in the bay areas if single isolation rooms were not available, such as during periods of high bed occupancy. We saw side rooms had appropriate signage to make staff, visitors and service users aware of any potential risks.

The hospital’s QAA audit standard 13 related to people with infection risks being isolated and an orange wristband and triangle (on bedside boards or side room doors) being in place. The surgical wards achieved overall compliance of 80% between June 2024 and September 2025, which was in line with the compliance target of 80%. A separate isolation audit to check if people with a known infection (such as MRSA or CPE) had been appropriately isolated across the surgical wards showed 63% compliance had been achieved (based on sample of 51 service users) which was below target.

Surgical ward and theatre staff carried out monthly audits to check cleanliness of the environment. Audit results between March and August 2025 showed high levels of compliance with most areas consistently achieving the 98% compliance target. Action plans were put in place where shortfalls were identified.

Staff also carried out monthly IPC practice audits across the surgical wards, encompassing 5 elements relating to hand hygiene facilities, hand hygiene observations, PPE, cannula care and catheter care. Audit results between March and August 2025 showed consistently poor compliance with most surgical wards failing to achieve the 90% compliance standard during this period.

The services reported staff were encouraged to challenge poor practice and hand hygiene issues were discussed with non-compliant staff members to improve individual compliance. A trust-wide hand hygiene improvement collaborative was also underway, which aimed to improve understanding and education of hand hygiene, identify barriers, and identify interventions.

Staff aimed to prevent, identify and treat surgical site infections. The hospital was identified as a national outlier for repair of neck of femur infections during April to June 2024 (infection rate of 3.2% against a national rate of 0.9%). This was investigated and no lapses in care or concerns about practice were identified. A repeat audit of 31 procedures performed between January and April 2025 showed no surgical site infections were identified.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Staff followed systems and processes when administering, recording and storing medicines. The service used an electronic prescribing system to prescribe and record the administration of medicines (EPMA). We found that 5 out of 13 people (across multiple surgical wards) missed prescribed medicines due to not being available on the ward at the right time.

There was a clinical pharmacy service provided to surgical wards; however, this could be limited due to staffing. Clinical pharmacists did not always attend ward rounds.

Pharmacy staff followed systems to check service users had the correct medicines (medicines reconciliation) on admission. Audits showed between October 2024, and September 2025 45% of people had their medicines reconciled within 24 hours. This was not in line with National Institute for Health and Care Excellence (NICE) guideline NG5 (medicines optimisation), which states medicines reconciliation should be carried out within 24 hours of admission.

Staff completed checks on controlled and emergency medicines, however on one ward we found that the controlled drug register had an incorrect balance for one item and there were multiple errors in the calculating of the balance which had not been picked up during the daily checks.

Staff completed audits related to medicines management including storage, controlled drugs and antibiotic stewardship audits. For example, between April 2024 and March 2025 the antimicrobial stewardship audit checked if prescriptions had indications recorded, that antibiotics prescribed were within guidance, prescriptions had review dates documented and were reviewed within 72 hours. The audit found wards had met the trust target of over 95% in the audit 11 out of 12 months.

Despite the trust being formed in 2021 and work being done to align all policies across the trust’s hospitals, we found the antibiotic prophylaxis in orthopaedic surgery antibiotic guidelines policy was past its review date and had not been aligned across the trust. The process for reviewing and aligning trust-wide policies was overseen at trust level.

Staff told us that not all surgical wards were set up to allow service users to manage or self-administer their own medicines if they wished to do so.

We saw that on one ward there had been work done to reduce incidents of violence, aggression and agitation amongst service users by working on providing distraction activities. We did not see any evidence that people had their behaviour controlled by medicines.