Salford Royal 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.

Our rating of well-led stayed the same. We rated well-led as 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.

Staffing capacity and workload challenges had negatively impacted staff morale. Staff survey results were worse when compared with previous surveys and trust averages across most indicators, including for engagement and morale.

Leaders did not always promote a work culture based on equality, diversity and inclusion. Staff did not always feel respected, supported and valued by senior leaders. Staff were not always supported to speak up or raise concerns. Staff were not fully involved or aligned with the strategic direction of the service.

The surgical services did not have effective governance and quality monitoring processes. We found significant shortfalls around the safety, effectiveness and responsiveness of the services. Actions taken to address key issues or reduce their impact had not resulted in effective and timely improvements in the management of risks, issues and performance across the service. The services had also failed to make any significant improvements to address most regulatory breaches identified during our previous inspection in December 2022.

However, leaders engaged with partners and the wider community to plan and manage services. Staff demonstrated a willingness to learn, innovate and make improvements to the service.

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 2. The evidence showed some shortfalls. The service did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

The trust vision was ‘to be the safest and most effective organisation in the NHS and the place where people want to work. We are passionate about tackling inequalities and improving health outcomes and experiences in all our places’.

The division of surgery and the Manchester Centre of Clinical Neurosciences (MCCN) division had developed their own local strategies (priorities) for 2025/26. These were based on 6 key ambitions: Improving quality, focusing on people, embedding an inclusive and just culture, improving planned and unplanned care and being financially sustainable. The divisional priorities had incorporated the strategic objectives outlined in the trust’s 10 year strategy (vis10n) and the Salford Care Organisation strategy for 2024-2027.

Managers told us progress against the objectives and key priorities was reviewed as part of routine divisional and hospital-level meetings. The staff we spoke with were aware of the vision and strategy.

The NHS staff survey 2024 results had been analysed by the surgical services at divisional, directorate and departmental level. The survey results showed the overall staff response rates across the MCCN division (50.4%), and the division of surgery (42.9%) were below the overall trust response rate of 55%.

The staff survey showed most surgical specialty teams and wards in the MCCN and division of surgery scored worse than overall trust scores and when compared with the 2023 survey results in most survey indicators, including for engagement and morale. Survey responses from ward T4 (major trauma) and ward B7 (neurosurgery) and the surgery scrub and clinical support team were more positive when compared with the other surgical teams and departments. Departmental and divisional action plans had been put in place following the survey to improve areas such as staff engagement, team working and staff well-being.

A further staff pulse survey was undertaken in July 2025, which received 113 responses for the division of surgery and 70 responses for the MCCN division. The pulse survey included questions relating to feedback, support, well-being, engagement, and processes for raising concerns. The results showed most responses for the surgical division were negative and over 3% worse than the trust comparator scores across most of the survey indicators. The MCCN division responses were also negative in relation to support and well-being but showed positive responses better than trust scores relating to engagement.

We spoke with over 100 staff in the ward and theatre areas and during staff focus groups involving nursing, medical and anaesthetic staff. We found staff across the surgical services were passionate and committed to providing safe care and treatment. However, we received mostly negative feedback from staff about the culture, morale, leadership and direction of the surgical services.

Nursing staff told us staffing challenges in the wards impacted staff morale and well-being which led to increased sickness. The anaesthetic and medical staff also told us staff morale was low.

Staff expressed their concerns about the strategic direction of the surgical services. Most staff we spoke with were proud of working for the hospital but felt disconnected from and did not have a shared identity with the wider trust. They told us the trust had implemented processes to standardise systems and processes across all sites, but they felt this had not led to improvements in local standards and performance. They told us approvals for local policies and procedures took much longer because additional checks and approval steps were required to ensure these were aligned and standardised across the trust.

Staff also told us they felt financial restrictions and increased capacity constraints had impacted their ability to deliver safe care and improve services. They told us they had experienced issues with faulty equipment not being replaced and business cases for equipment and staffing resources were not always fulfilled.

We scored the service as 2. The evidence showed some shortfalls. Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation.

The surgical services were incorporated into 2 divisions across the hospital. The division of surgery included the general surgery, gynaecology, urology, plastics and trauma and orthopaedics specialties. The major trauma, spinal, neurosurgery, head and neck and ear, nose and throat (ENT) specialties formed part of the MCCN division.

The MCCN division was led by a triumvirate team including an interim divisional chair (clinical lead), the divisional managing director and the divisional director of nursing. The triumvirate team was well established. The divisional managing director and divisional director of nursing had been in post for over 5 years, while the chair had been in post for 12 months.

The division of surgery (and perioperative care) leadership team included a divisional managing director, a divisional director of nursing, and a combined clinical lead role covered by a divisional clinical director and an interim divisional chair. The combined role had been in place for 4 weeks at the time of our inspection.

The surgery divisional leadership team oversaw surgery and perioperative care at this hospital and also across another of the trust’s hospitals. The interim chair had been in post for 12 months. The divisional director of nursing had been in post for 17 months and the managing director had been in post for over 5 years but had only been involved at this hospital for the past 6 months. The clinical director had been in post for 3 years but was primarily based at the other hospital site.

The division of surgery and MCCN division chair roles were interim until the new clinical leadership model structure was established.

The directorates across both divisions also had a triumvirate leadership structure based on a clinical, operations and nursing lead. The division of surgery had 2 vacant directorate leadership posts, for the clinical director of general and oral surgery and the senior manager for peri-operative care. The MCCN division did not have any vacant posts in the directorate leadership.

The ward and theatre managers were responsible for the day to day management of the ward and theatre areas. The lead consultants and anaesthetists had clinical responsibility for the people they treated within their surgical specialty areas.

The division of surgery and MCCN divisional leaders understood the key risks and challenges across the surgical services and were able to articulate the improvement actions they had undertaken or planned to address key risks. However, the actions taken to address key issues or reduce their impact had not resulted in effective and timely improvements in the management of risks, issues and performance across the surgical services.

Managers told us they engaged with staff daily and through routine department, directorate, divisional and hospital-level meetings. Senior divisional and hospital leaders also engaged with staff through away days and routine staff forums. Staff forums involved clinical, anaesthetic and nursing staff and included discussions around addressing workforce challenges and to identify and implement service improvements.

Most staff we spoke with were positive about the support they received from their line managers at department and directorate level, including from clinical leads and the ward and theatre managers. However, staff feedback about senior leadership was mostly negative. Staff told us they felt disconnected with the senior leadership. They told us senior divisional, hospital and trust leaders were not always visible, did not engage with them effectively and did not always involve them or take their views into account when making decisions about the surgical services.

Divisional leads told us they continued to engage with staff about the implementation of trust-wide initiatives to standardise systems, processes and services. They told us they had experienced some resistance to change from some staff groups, and this had impacted on the delivery of some service improvements, such as proposed changes to theatre list planning and scheduling to improve efficiency.

We scored the service as 2. The evidence showed some shortfalls. People did not always feel they could speak up and that 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.

There had been 12 FTSU cases reported by the surgical services between April 2024 and September 2025, of which 7 related to the division of surgery and 4 related to the MCCN division. Records showed 11 of these had been addressed and one remained on-going. Four of the closed cases included positive feedback about the way the concerns had been managed by the FTSU guardians.

We received negative feedback from staff about the culture and freedom to speak up processes during our focus groups. Staff told us they understood how to contact the FTSU guardians, and that they were supportive. However, some staff told us they did not feel confident in raising concerns because they felt their concerns would not be addressed by senior leaders. Staff told us the surgical services did not have an open culture. They gave examples where they had raised concerns in the past and felt they had received a dismissive or punitive response from senior leaders.

We scored the service as 2. The evidence showed some shortfalls. The service did not always value diversity in their workforce. They did not always 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 an equality policy in place to provide support and guidance. Managers told us they routinely engaged with staff to maintain an inclusive, diverse, and supportive work environment. Staff could access support from network groups, such as neurodivergent staff networks, disabled staff networks and race equality networks.

The Workforce Race Equality Standard (WRES) and Workforce Disability Equality Standard (WDES) 2024 survey results across the surgical services at this hospital showed Black, Asian and minority ethnic (BAME) staff and those with a disability were more likely to experience harassment, bullying or abuse from other colleagues and service users when compared with white ethnic background and non-disabled colleagues. They were also more likely to report experiencing discrimination from managers and were less likely to feel the organisation acted fairly regarding career progression/promotion.

The WRES and WDES action plans (2025/26) included actions around developing systems to better capture and monitor workforce demographics, improving engagement and support for ethnic minority and disabled staff, education for staff around cultural sensitivity, implementing just culture and developing behaviour charters for staff and service users.

The trust commissioned the independent Breen review, which looked into the historic management of concerns relating to a consultant spinal surgeon who was employed at the hospital until 2015. The Breen report (2024) identified concerns around bullying, harassment and racism within the spinal surgery services at the hospital.

An action plan had been developed following the Breen report. This showed actions relating to recruitment processes and senior leadership appointments had been implemented. The surgical services reported any disciplinary hearings or senior staff recruitment (such as the appointment of the interim MCCN division chair) included cultural ambassador representation to enable unbiased employment practice and promote diversity and inclusion. A bullying and harassment policy had also been developed.

A review of racism and racist culture within the spinal service following the Breen report was completed in May 2025 and consisted of analysis of data between 2022 and 2024, and undertaking an anonymised cultural survey and staff focus groups. The spinal team cultural survey, based on 25 responses, (50% response rate) showed 72% of staff agreed or strongly agreed that they were aware of the ways they could raise concerns and 68% would feel comfortable about raising concerns. The report highlighted there was no significant disparity in recruitment processes and senior staff appointments based on ethnicity.

The review of racism report concluded that BAME staff in the spinal services had a poorer experience than other colleagues. The report highlighted the data and staff feedback from the spinal service was broadly in line with trust data and staff survey outcomes. However, the NHS staff survey 2024 feedback from the spinal medical staff team was worse when compared to the trust average and the 2023 survey results in relation to bullying, harassment and abuse from colleagues and managers.

The report recommended the trust’s chief medical officer and chief nurse arrange to meet with spinal service staff and to develop an improvement action plan. The trust reported the chief executive had sent written apologies and held individual meetings with some staff, and former staff, whose concerns had contributed to the trust’s commissioning of the spinal patient safety look back review and Breen report. The trust’s chief medical officer also held meetings with spinal service staff during July 2025.

During our medical staff focus groups, some staff told us senior leaders had not routinely engaged with or kept them informed about the progress of actions following the Breen report. They told us they felt a culture of racism, bullying and harassment still existed within the service.

We did not receive any significant concerns relating to equality and diversity from ward and theatre staff during our inspection.

There had been 23 incidents related to staff on staff bullying, violence and aggression across the surgical services in the 12 months prior to our inspection. Incident reports showed appropriate actions had been taken to address concerns raised, including reporting to HR and senior managers. Only one incident related to bullying by a manager.

The trust had commenced implementation of the North West NHS BAME anti-racist framework and had achieved bronze status in October 2024. Bronze status signified that the trust had taken initial steps towards becoming an intentionally anti-racist organisation, but systems and processes enabling an anti-racist culture had not yet been fully implemented or embedded.

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.

The surgical services had governance structures to provide oversight of key risks and performance measures. There were routine departmental, directorate and divisional governance meetings in place to discuss clinical safety, operational performance, governance and risks. 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 understood the key risks to the services and maintained departmental and divisional-level risk registers. The departmental and divisional 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.

Routine audit and monitoring of key processes took place to monitor performance against safety standards and organisational objectives. The inpatient assessment and accreditation system (IPAAS) ward accreditation process was in place to assess the quality of care delivered across the surgical wards. A hospital quality assurance audit (QAA) was also undertaken by the quality matrons every 2 months to review the quality of care records against a compliance target of 80%. The audit consisted of a representative sample of 5 care records per ward.

We reviewed the hospital’s quality assurance (QAA) audit results between June 2024 and September 2025 across the 14 surgical inpatient wards at the hospital. The audit results showed the surgical wards consistently achieved poor overall compliance against a number of the audit standards, highlighting poor staff practice around assessing and monitoring key risks to people who used the service.

Managers told us local action plans were put in place to address QAA audit findings, and these were monitored at routine departmental and divisional meetings. However, the monthly QAA audit data trends showed there had not been any significant improvements in audit compliance between June 2024 and September 2025.

During our previous inspection in December 2022, we identified 8 regulatory breaches across the surgical services at this hospital. We found improvements had only been made in 2 of the 8 regulatory breaches during this inspection. We found the services had improved appraisals and mandatory training compliance, including sepsis training. However, we found no significant improvements had been made in relation to the 6 regulatory breaches relating to compliance with surgical safety checklists, nurse staffing numbers and skill mix, governance systems relating to quality monitoring and performance and alignment of systems and policies and around access and flow measures (including admission, discharge, length of stay, readmissions and referral to treatment waiting times).

We identified significant shortfalls relating to nurse staffing and around managing people’s risks in the surgical wards during this inspection. Whilst we saw evidence action plans had been put in place to improve compliance, we found the actions taken to address key issues had not resulted in effective and timely improvements in the management of risks, issues and performance across the surgical services.

We found the surgical services had made some improvements in standardising systems and processes with the trust’s other hospitals, such as standardising Local Safety Standards for Invasive Procedures (LocSSIPs). However, the standardisation was still in progress at the time of our inspection. We found some policies (such as the NEWS observation policy) and systems and processes, such as for theatre equipment standardisation and electronic care records had not yet been fully standardised.

The get it right first time (GIRFT) review of theatres (November 2024) included recommendations to improve admission processes, theatre planning and efficiency, and strengthening workforce and clinical leadership. A GIRFT review report from August 2025 of the spinal services included recommendations around submitting data to the British Spinal Registry (BSR), around expanding the elective hub at one of the trust’s other hospitals for elective spinal surgery, improving pathways for 16 to 18 year olds and for emergency admissions for back pain to enable shorter length of stay. The surgical services had developed an action plan to implement improvements from the GIRFT review recommendations, and these actions were in progress at the time of our inspection.

The surgical services had implemented an action plan following the spinal patient safety look back review into historic concerns about the treatment provided by a single consultant spinal surgeon who had been employed at the hospital until 2015. There was also a related action plan following the Breen report (2024), which focused on how concerns about the spinal surgeon had been managed by the service.

The services reported 12 of the 25 identified actions in the action plan had been completed and 13 were still ongoing. We saw evidence actions relating to people’s safety had been undertaken, including identifying and reviewing affected individuals to reduce the risk of ongoing harm and undertaking duty of candour. However, a number of improvement actions relating to improving governance processes had not yet been actioned or implemented. This included actions relating to updating the incident reporting system to enable improved reporting of safety and cultural concerns and in relation to developing a standardised process for recording and storing mortality and morbidity meeting records using a central repository.

The surgical services had also reported historical concerns about some governance and administrative practices in gynaecology and in relation to temporary ureteric stent insertion (also known as JJ stents) in the urology specialty. Action plans showed affected service users had been assessed to reduce harm and updates to staff training, and policies had either been completed or were on track with expected completion dates.

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 surgical services worked closely with stakeholders, service partners and commissioners to plan and deliver services, including for spinal, neurosurgery and trauma pathways. Staff routinely engaged with regional spinal, neurosurgery and major trauma networks to review pathways and practices.

Stakeholders and partners told us staff in the surgical services understood the diverse needs of the local population. They told us staff in the surgical services were committed, and engagement was well coordinated, supporting continuity of care and the timely transfer of people between services. Service partners told us communication between the services worked well but there had been instances of communication problems and miscommunications of management plans and actions.

Staff told us they routinely engaged with local communities and people who used the service to gain feedback and improve people’s experiences of using the service. The skull base specialist nurse ran a regular support group for people with acoustic neuroma (a type of benign brain tumour) associated with the British Acoustic Neuroma Association (BANA). The intestinal failure unit carried out an intestinal awareness engagement event in February 2025, to raise public awareness as part of the Leading Intestinal Failure Equality (LIFE) initiative.

We scored the service as 2. The evidence showed some shortfalls. The service did not always focus on continuous learning, innovation and improvement across the organisation and local system.

Staff demonstrated a willingness to learn, innovate and make improvements to the surgical services. They told us learning from audits, quality monitoring and quality improvement programmes was shared to aid learning and improvement.

The surgical wards participated in the days kept away from home QI project, which focussed on discharge processes, deconditioning and improving strength-based conversations. The theatre teams had QI programmes in place relating to improving theatre efficiency and the standardisation of theatre equipment.

Staff across the surgical services participated in clinical audits and research trials to improve systems and processes. The intestinal failure unit (IFU) had implemented improvements that had led to reductions in catheter-related bloodstream infection in 2024/25 compared with the previous year.

Whilst we saw examples of staff involvement in learning and improvement initiatives across the surgical services, our review of audit and performance data showed the surgical services had not made sufficient improvements in key areas relating to safety and performance during the 12 months prior to our inspection. The services had also not made any significant improvements in some areas identified as shortfalls at our previous inspection in December 2022.