Salford Royal Hospital

On this page

• 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.

We issued a warning notice under section 29A of the Health and Social Care Act 2008 during October 2025 because we identified significant concerns relating to staffing and the systems and processes to identify and address risks across the surgical wards during our previous inspection. We found the services had made sufficient improvements to reduce the risks and comply with the warning notice during this inspection. However, we identified an ongoing need for the surgical services to ensure that improvements made to improve staffing levels and reduce risks to patient safety were sustained and fully embedded.

Whilst improvements in ward staffing had been made to enable safe care and treatment, actions to improve staff vacancies and sickness rates had not yet been fully implemented. Whilst improvements had been made to identify and address risks affecting quality and safety, improvements in some areas such as fluid monitoring and bed rails management had not yet been fully implemented or embedded.

Incident investigations and lessons learned were not always undertaken in a timely way in accordance with trust policies. Training compliance in autism awareness and dementia awareness was below expected trust standards. Not all staff had completed life support training relevant to their roles. The surgical services did not have sufficient numbers of trained staff in the theatres department.

Whilst routine audits showed improvement in infection control standards, compliance around hand hygiene and use of personal protective equipment was still below trust standards. The service did not always make sure that medicines and treatments were safe and met people’s needs.

However, staff understood how to protect patients from abuse. Premises and equipment were clean and well-maintained. Most staff had regular appraisals.

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. The service did not always have a proactive and positive culture of safety based on openness and honesty. Whilst the service investigated and reported safety events, incident investigations and lessons learned were not always undertaken in a timely way in accordance with trust policies.

Staff understood what incidents to report and how to report them. Incidents and near misses were reported using 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. However, staff told us the quality of incident investigations varied depending on the lead investigator and not all staff undertaking incident investigations had received formal training. The trust reported all incident investigators were supported by a member of the governance team who had undertaken formal patient safety investigation training.

The trust reported formal training in PSIRF investigations was being rolled out and 62 staff across the hospital had completed this training at the time of our inspection. The trust did not provide an overall compliance rate or the number of staff who still required PSIRF investigation training.

Leaders told us there was a high administrative burden with the PSIRF process, impacting clinician time. They told us there was an inconsistent approach across specialties around who was responsible for undertaking investigations. They also told us the quality of investigation reports varied and there was an ongoing need for governance managers to support departments in order to meet PSIRF investigation requirements. Some staff also reported concerns about the management of incidents, including inconsistencies in how incidents were graded for level of harm.

The patient safety incident response policy stated local and national priority patient harm incidents should be investigated within 3 months. We looked at the patient safety incident investigation reports for 6 incidents between December 2024 and February 2026. The investigation completion timelines ranged between 4 months and 12 months, which meant investigation reports were not always completed within the 3 month timeline specified in the trust’s policy. The investigation action plans also showed remedial actions were not always completed within specified timelines.

Staff received feedback following the investigation of incidents. Staff met to discuss the feedback and look at improvements to patient’s care during daily safety huddles, handover meetings and during routine departmental and clinical service unit and group level meetings so shared learning could take place. Staff were able to give examples of learning following incidents such as improvements in patient falls and incidents involving violence and aggression towards staff.

We identified a regulatory breach during our previous inspection in September 2025, where we found formal duty of candour was not always undertaken in the timelines specified in the trust’s duty of candour policy.

We found improvements had been made during this inspection. Staff understood duty of candour. They were open and transparent and understood how to give patients and families a full explanation when things went wrong. The incident reports we looked at showed formal duty of candour had been undertaken as part of the incident review process.

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 patient’s care records as soon as practically possible. Records showed staff had notified the relevant person within 10 days on 87% of occasions between September 2025 and May 2026 across the surgical services. Records showed there had only been 1 instance during this period where stage 2 formal duty of candour had not been documented to confirm the relevant person had been notified following completion of the investigation report or learning response.

There had been 1,845 incidents reported by the surgical services across the hospital between September 2025 and May 2026. Most reported incidents were graded as resulting 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 17 incidents graded as severe harm during this period. We looked at the investigation reports for 2 severe harm incidents. These showed the incidents had been appropriately investigated and improvement actions were identified to aid learning and reduce reoccurrence.

There had been 162 incidents relating to gynaecology services at this hospital between September 2025 and May 2026. Most reported incidents were graded as no or low harm and 2 incidents relating to the gynaecology services were graded as moderate harm. There had not been any incidents graded as severe harm or patient death relating to the gynaecology services at this hospital during this period. Prior to our inspection, we received anonymous information which alleged some gynaecology incidents had not been graded or investigated properly. Whilst we did not see evidence of this in the small proportion of incidents we reviewed, limited investigator training and poor governance processes increased the risk that not all incidents were graded or investigated effectively.

There had been 2 never events reported by the surgical services between September 2025 and May 2026. These related to the administration of medicines by the wrong route and a retained foreign object post procedure. 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.

Both never events had been investigated and remedial actions had been identified to minimise reoccurrence, such as sharing investigation learning with ward and theatre staff, updates to policies and processes and implementing additional monitoring and checks.

There had been 5 incidents relating to patient deaths reported by the surgical services between September 2025 and May 2026. We looked at investigation report relating to 1 death incident, which showed the incident had been appropriately investigated and action plans were put in place to aid learning and improvement.

Patient deaths were also reviewed and shared with staff as part of routine mortality and morbidity reviews to aid learning and improvement. We looked at a selection of mortality and morbidity meeting minutes between September 2025 and May 2026. These showed patient deaths were reviewed appropriately and discussions identified key learning and improvement. However, we found the frequency of meetings and the meeting minutes varied in format and details across the different surgical specialties.

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.

We identified a regulatory breach in life support training compliance during our previous inspection in September 2025. We found there had been some improvement in life support training compliance during this inspection and most staff had completed relevant training. However, the trust’s 90% training target had not been fully achieved across all life support training modules, and medical staff compliance was worse than other staff groups.

Records showed that compliance among surgical ward, theatre and support staff met the trust's 90% target for adult basic life support training at 93%, paediatric basic life support training at 92% and immediate paediatric life support training at 95%. However, only 69% of ward, theatre and support staff and 70% of medical staff had completed adult immediate life support training. In addition, 74% of medical staff had completed adult basic life support training. Although this had improved from 64% at the previous inspection, it remained below the 90% target.

Records also showed 76 staff (83% of all eligible staff) had completed advanced life support training across the surgical services. This had improved from 7 staff during our previous inspection.

The training data showed no medical staff had completed paediatric basic life support training or paediatric immediate life support training. The trust reported their existing training needs analysis had identified that medical staff across the surgical wards and theatres did not require paediatric basic life support and paediatric immediate life support training because they did not provide care and treatment for children. The trust also reported the training needs analysis was under review following the transition to the clinical group model, which may introduce changes to training requirements across the service.

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. Patients spoke positively about the way their care was delivered throughout their hospital stay.

The hospital was the regional centre for upper gastrointestinal surgery, 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. There had been no incidents reported relating to the patient pass referral system between September 2025 and May 2026. There had been two serious incidents relating to patient pass in 2023 and 2024 which we noted at our last inspection of the service.

Patients 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 patients that required closer monitoring and care but did not require critical care support. Ward H7 (neurosurgery ward) also had up to 8 enhanced care beds that were used for elective neurosurgical patients that required close observation post operatively for associated surgical complications.

Staff followed policies for admitting and transferring patients to the enhanced care beds. There was a clear inclusion criteria detailing which patients could be admitted to enhanced care beds. Patients requiring high dependency or critical care support or patients requiring invasive respiratory support were excluded from the monitoring beds and received care and treatment in the hospital’s high dependency or critical care units.

Patients remained in enhanced care beds for up to 48 hours and were transferred back to surgical wards when enhanced monitoring was no longer required. There had been no incidents reported relating to inappropriate transfer of patients to the enhanced care beds or any incidents where patients required transfer to critical care following enhanced monitoring between September 2025 and May 2026.

There were pathways in place for the transfer of patients 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 271 transfers from the surgical services to other NHS hospitals between September 2025 and May 2026. 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 patient’s needs and any staffing or capacity issues. Shift changes and handovers included the necessary information about patient’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 told us they worked closely with staff across the surgical services to maintain continuity of care when patients transitioned between services.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

During our previous inspection in September 2025, we found staff did not always act to ensure people using the service were safeguarded from abuse or improper treatment. We found poor care and potential neglect relating to 3 patients in the surgical wards.

During this inspection, we found improvements had been made. Patients and relatives we spoke with told us they felt safe and did not have any safeguarding concerns. Patients told us staff provided assistance and support when requested and they had not experienced or witnessed any poor care or neglect. Our observations of care and review of patient records showed staff providing appropriate care and treatment for vulnerable patients.

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. Whilst most medical staff had completed safeguarding adults level 3 training (89%) and children’s safeguarding level 3 training (83%), compliance was below the hospital’s 90% compliance target.

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. The overall training compliance for all staff across the surgical services was 97% for preventing radicalisation basic awareness training and 96% for prevent WRAP e-learning training.

There had been 80 safeguarding incidents reported by the surgical services between September 2025 and May 2026. 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 patients, including undertaking risk assessments, children’s safeguarding team involvement, open visiting for parents 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 departmental and clinical service unit and group level meetings. The hospital reported a new safeguarding learning, audit and review sub group had recently been established to review safeguarding incidents rated as moderate or above for harm. The sub group reported directly to the trust safeguarding group.

We scored the service as 2. The evidence showed some shortfalls. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Whilst improvements had been made to identify and address risks affecting quality and safety, improvements in some areas such as fluid monitoring and bed rails management had not yet been fully implemented or embedded.

We identified a regulatory breach during our previous inspection in September 2025, where we found the surgical services did not have effective systems and processes to identify and address risks affecting quality and safety in the surgical wards. We issued a warning notice under section 29A of the Health and Social Care Act 2008 during October 2025.

We found the services had made sufficient improvements to reduce the risks. Our observations of care, audits, review of records and discussions with staff and patients showed significant improvements had been made. However, improvements in some areas such as fluid monitoring and bed rails management had not yet been fully implemented or embedded.

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.

During our previous inspection we identified shortfalls in patient records relating to managing risks around nutrition and hydration, pain management and the use of bed rails in the surgical wards.

We looked at 29 patient records during this inspection. Most of the records we looked at included complete and up to date risk assessments and showed that nursing and medical assessments had been carried out in a timely manner and documented correctly. Observations were well recorded and the observation times were dependent on the level of care needed by the patient.

Staff used 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.

The surgical services reported the hospital-wide acute pain team supported staff training and 51 staff had attended a pain and pump study day since November 2025. A further 164 nurses across the surgical services had attended pain study training sessions in the 6 months prior to our inspection. The services also reported 76 replacement patient-controlled analgesia pumps had been purchased to replace the existing pumps in circulation.

Most patients we spoke with told us staff gave them pain relief medicines when needed and their pain symptoms had been managed appropriately.

A patient satisfaction survey had been carried out by the pain team during January 2026 and repeated in May 2026. This was based on 128 responses from patients across the surgical wards at this hospital. The survey results for May 2026 showed 67% of patients received pain relief promptly and a further 19% had to wait longer than 30 minutes during the day. 57% of patients received pain relief promptly and a further 30% had to wait longer than 30 minutes during the night. Only 5% of respondents reported they had waited longer than 1 hour for pain relief during the day or at night.

The survey also showed average ratings of 4.37 out of 5 relating to how well patient’s pain was managed during the day and 4.29 out of 5 during the night, demonstrating most respondents were positive about the way their pain symptoms had been managed.

Most patients we spoke with told us patient-controlled analgesia (PCA) was prescribed and administered in a timely manner. An audit of PCA observations reviewed 52 patients between October and December 2025. The audit showed good levels of compliance against local policies and improvement since the previous audit undertaken during 2024.

The audit showed PCA handover checks took place within 24 hours on 77% of occasions. This had improved from 21% compliance during the previous audit in 2024. The audit showed 15 minute observations took place within the first hour of commencing patient-controlled analgesia on 85% of occasions, compared with 55% compliance during the 2024 audit. Hourly observations took place in the next 4 hours on 58% of occasions (compared with 16% compliance during 2024) and 4-hourly checks took place thereafter on 71% of occasions (compared with 43% compliance in the 2024 audit).

The surgical wards achieved overall compliance of 23% in the hospital’s QAA audit standard 28 (relating to pain management) between June 2024 and September 2025. The surgical wards achieved overall compliance of 63% for completing initial pain assessment and 68% compliance for ongoing pain monitoring of patients receiving analgesia between February 2026 and April 2026. This showed compliance had improved but was still below the trust’s 80% compliance target.

We found poor staff practice around the management of bed pans and fluid (urine) output monitoring in wards B1 and B2 (general surgery wards) during our previous inspection. We found significant improvements had been made. Bed pans or bottles were handled and stored appropriately. Fluid output measurements were undertaken by nurses and support workers for the patients they were allocated and responsible for.

Patients with specific nutrition and hydration needs were assessed and fluid balance and food charts were in place for patients identified as at risk. Most of the patient records we looked at showed risk assessments and fluid balance charts were completed correctly and kept up to date by staff.

The surgical wards achieved overall compliance of 78% between February 2026 and May 2026 for the hospital’s quality assurance (QAA) audit standard 38 (relating to hydration risk assessments being completed within 6 hours of admission and daily before midnight thereafter). Audit compliance had improved from 66% between June 2024 and September 2025 and was close to achieving the trust’s 80% compliance target.

The surgical wards also achieved overall compliance of 35% for the hospital’s quality assurance (QAA) audit standard 37 (relating to completion of fluid balance charts) between February 2026 and May 2026. Whilst this had slightly improved from 24% compliance reported between June 2024 and September 2025, compliance was still below the trust’s 80% compliance target.

The services reported a dedicated fluid balance task and finish group had been set up to drive further improvement. The group had analysed data to highlight specific areas for improvement and was in the process of reviewing and revising the fluid balance documentation.

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 patient records for 10 patients who had bed rails in use during this inspection. We found bed rails risk assessments had been completed appropriately in 7 of these records. The other 3 patients all had bed rails in use but appropriate bed rail assessments had not been completed.

During June 2024 to September 2025, the surgical wards achieved overall compliance of 46% for QAA audit standard 33, demonstrating poor compliance around the timely completion of falls, moving and handling and bed rail risk assessments.

QAA audit records between February 2026 and May 2026 showed improvements had been made. The surgical wards achieved 82% compliance around completion of bed rail risk assessments within 6 hours of admission and 63% compliance relating to reassessing bed rail risk assessments weekly or following a change in the patient's condition.

The surgical wards achieved 80% compliance around completion of falls risk assessments within 6 hours of admission and 62% compliance relating to reassessing falls risk assessments weekly or following a change in the patient's condition. The surgical wards also achieved 85% compliance around completion of moving and handling risk assessments within 6 hours of admission and 58% compliance relating to reassessing moving and handling risk assessments weekly or following a change in the patient's condition.

During our previous inspection, we identified poor staff compliance relating to processes for managing deteriorating patients.

During this inspection, we found staff used the national early warning score 2 system (NEWS2) appropriately and carried out routine monitoring based on patients’ individual needs to ensure any changes to their medical condition could be promptly identified. If a patient’s health deteriorated, staff were supported with medical input when required. The patient records we looked at showed most patients had received regular and timely observations and were escalated appropriately when required.

During June 2024 to September 2025, the surgical wards achieved overall compliance of 52% for QAA audit standard 61 (relating to the appropriate patient escalation for NEWS2 of 3 in a single parameter or NEWS2 of 5 or above combined). This was below the trust’s 80% compliance target.

QAA audit records for May 2026 showed the surgical specialty wards achieved 83% compliance for appropriate escalation and 100% compliance for reassessing patients following a raised NEWS score. The neuro and spinal specialty wards achieved 100% for appropriate escalation and reassessing raised NEWS scores during this period and compliance was in line with the trust’s 80% compliance target.

We identified a regulatory breach around poor staff compliance with aspects of the surgical safety checklist during our previous inspection in September 2025. We found improvements had been made during this inspection.

We observed 3 theatre teams undertaking surgical procedures, including the use of revised National Safety Standards for Invasive Procedures (NatSSIPs 2) and the World Health Organization (WHO) surgical safety checklists. The theatre staff completed safety checks before, during and after surgery and demonstrated a good understanding of the surgical safety standards.

A trust-wide peer audit to check staff compliance against the 8 sequential steps of the revised NatSSIPs standards was carried out every 3 months. The March 2026 peer audit at this hospital identified good compliance across all audit standards, with only one negative finding relating to a member of staff who did not introduce themselves during the time out phase.

Staff carried out a weekly snapshot audit of WHO checklist to observe theatre staff compliance against the WHO five steps to safer surgery standards. Audit results between January 2026 and May 2026 showed overall compliance ranged between 91% and 95% and was better than the trust target of 90%. The audit showed high levels of compliance for the team brief, sign in, time out and sign out phases (95%-100%). However, compliance for completing debriefs ranged between 70% and 75% during this period and was below the 90% compliance target.

A WHO action plan was in place. This included actions around improving data completion, improving debrief compliance and the implementation of additional observations of National Safety Standards for Invasive Procedures (NatSSIPs 2) processes by senior leads and the education team. A NatSSIPs e-learning package had also recently been developed and this was planned for rollout to staff during 2026.

The hospital reported that since March 2026 the number of snapshot audits performed had been increased from 1 audit per week to 5 audits per week with a total of 20 audits undertaken each month. The hospital reported audit results were shared with all staff during safety huddles and team meetings to aid learning and incident reports where a debrief did not occur were reviewed to identify themes, trends and improvements.

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. Most staff (93%) had completed mandatory adult sepsis training across the surgical wards and theatres.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made 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. We reported during our previous inspection that the general environment in the surgical wards in the B block (wards B1, B2, B2M, B6 and B8) was aged and worn. Ward B1 and the neuro short stay unit (NSSU) had undergone refurbishment since our previous inspection and ward B6 was undergoing refurbishment at the time of our inspection. The hospital had plans to carry out improvements across the other wards in the B block.

The ward and theatre areas were well maintained, free from clutter and provided a safe environment for treating patients. 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.

The equipment we saw was clean, well-maintained and readily available. Patients told us they felt premises and general environment was safe and well maintained. They also told us they had not experienced any issues relating to access to equipment (such as commodes) or toileting and shower facilities.

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.

We received information of concern prior to our inspection about equipment availability in the gynaecology services. However, the gynaecology medical and nursing staff we spoke with told us these issues had been resolved, and they had sufficient equipment available.

There was a planned maintenance schedule that listed when equipment was due for servicing. Equipment servicing was managed by the hospital’s medical device service. The overall equipment servicing and maintenance compliance across the surgical wards was 80% and below the trust target of 85%. However, this had improved from 74% compliance reported in November 2025. The hospital reported a significant proportion of overdue equipment related to wall-mounted blood pressure monitors (sphygmomanometers). There was an on-going programme to update and replace these with an expected completion date by the end of July 2026.

Emergency resuscitation equipment was available in all the areas we inspected, and checklists showed emergency equipment 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 2. The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. Whilst improvements in ward staffing had been made to enable safe care and treatment, actions to improve staff vacancies and sickness rates had not yet been fully implemented. Most staff had completed their mandatory training and appraisals. However, training compliance in autism awareness and dementia awareness was below expected trust standards.

We identified a regulatory breach relating to staffing across the surgical wards during our previous inspection in September 2025. We found the surgical services did not have effective systems and processes to ensure the surgical wards had sufficient and suitably qualified staff to meet patient needs. We issued a warning notice under section 29A of the Health and Social Care Act 2008 during October 2025.

We found the surgical services had made sufficient improvements to reduce the risks and comply with the warning notice. Our observations of care and discussions with staff and patients showed significant improvements had been made. However, the surgical wards still experienced staffing challenges due to staff sickness and vacancies. Staff recruitment activities were in progress but the services required more time to fully recruit and train the additional staffing required.

Nurse staffing levels were reviewed against minimum compliance standards every 6 months, based on a national safer nursing care acuity tool.

Staff used an electronic staffing and acuity tool to determine daily staffing needs. Ward managers completed updates and escalated shortfalls daily. Ward managers told us the process for escalating staffing shortfalls had been improved. They told us the acuity tool was utilised better and focussed on patient acuity. Concerns were escalated to and reviewed by matrons within their clinical specialty area each morning. A ward manager was also designated as a daily staffing bleep holder within each specialty area to support any ongoing staffing issues throughout the day.

Ward managers told us the localised process meant escalation was more responsive and actions taken to fulfil additional staffing requests had improved since our previous inspection. Records showed 95% of all requests for additional support for enhanced observations and care and additional / escalation beds had been fulfilled between September 2025 and April 2026. During this period, 94% of staff redeployment requests and 100% of requests for additional support due to high acuity had been fulfilled.

The overall nursing and support staff shift fill rates across the surgical wards showed sustained improvement between September 2025 and April 2026. Shift fill rates for nursing staff had improved from 89% to 94%, and shift fill rates for support staff had improved from 110% to 130% during this period. Most wards consistently achieved fill rates over 90% during this period. However, ward B8, ward H7 and the neuro short stay unit had nursing and support staff fill rates below 80% in some months during this period.

We spoke with over 40 nursing and support staff across the surgical wards we inspected and 21 additional ward staff during focus groups as part of the inspection. The majority of nursing and support staff told us there had been significant improvements around ward staffing since our previous inspection. They told us staffing challenges still remained due to ongoing vacancies and sickness. However, most staff told us their workload had improved and they felt better supported by the ward managers and matrons. Most staff told us they felt happier in their role and morale across the surgical wards had improved. They told us they felt the staffing levels were safe and they were able to provide appropriate patient care and treatment.

During our previous inspection we identified shortfalls in patient care and treatment resulting from staffing issues. During this inspection we found improvements had been made. We observed staff providing safe care and treatment across the surgical wards we visited. We saw staff responded to patient call bells promptly. We observed positive interactions between patients and staff. We did not identify any instances where vulnerable patients received inappropriate or unsafe care, including personal care. We saw patients requiring enhanced (1:1) care were appropriately monitored and received suitable care and support.

Most patients and relatives we spoke with were positive about the care and treatment they received. They told us they felt there were enough staff on the wards, including during the night. They told us staff responded promptly when called and supported them with their medical and personal care needs.

Nurse and healthcare support staffing levels were periodically reviewed against minimum compliance standards, based on a national safer nursing care acuity tool. The most recent ward staffing establishment review in January 2026 showed there had been increases in expected nurse and healthcare support staffing numbers across 8 wards. The review also showed a planned decrease in establishment of at least 1 nurse or healthcare support staff across some wards, including T4 and T5 (trauma wards) and B1 and B2 (general surgical wards). The planned decrease was linked to the implementation of the hospital’s bed reconfiguration plan, which planned to align more wards with dedicated clinical specialties, leading to a planned increase or decrease in overall bed numbers across some wards.

The January 2026 staffing review also showed at least 5 surgical wards were over established, which meant the expected staffing levels were higher than budgeted funded levels.

The expected and actual staffing levels were displayed on notice boards in each area we inspected, and these were updated daily. Whilst the actual staffing levels reflected expected levels on some wards, we found 7 wards had at least one shift with either a nurse or healthcare support worker less than the establishment. We found healthcare support worker numbers had been increased in some of these wards where nursing numbers were lower than expected to reduce impact. Staffing shortfalls were mainly managed through the use of bank and agency staff and through redeploying staff from other wards.

Staff told us there were still instances where nursing staff were redeployed from one surgical ward to another to support staffing shortfalls. However, most staff told us they were redeployed to other wards less frequently and were mostly transferred to wards within their clinical specialty area when they had been moved.

There had been 744 instances where staff had been redeployed to other wards between September 2025 and April 2026. Neurosurgery ward B8 (113), neurosurgery ward B7 (84) and the neuro short stay unit (74) had the highest numbers of staff redeployed to other wards during this period. Managers reported an increase in staff redeployments during January 2026 (133 instances) attributed to higher seasonal staff sickness rates. There had been an improving trend in redeployment rates since January 2026, with 90 redeployments reported during February and March 2026 and 77 redeployments during April 2026.

We found supernumerary ward managers and nursing associates were regularly included in the shift rotas because of nursing shortfalls during our previous inspection. Ward managers told us they still worked some clinical shifts to support nurse staffing shortfalls. However, they felt this had reduced since our previous inspection and they had more time to carry out their managerial duties.

Managers reported that reduced NHS Professionals pay rates for overtime and bank shifts made it harder to attract bank staff for day shifts. They did not have the same difficulty filling night shifts because the higher night rate provided a greater incentive. Some surgical staff groups had planned or undertaken industrial action about pay, including overtime pay.

Bank and agency staff received the same level of induction and training as substantive staff. Records showed bank staff accounted for 84% of all filled shifts between September 2025 and April 2026, where bank and agency support had been requested. Agency staff accounted for the remaining 16% of filled shifts during this period.

The average sickness rate for band 5 nurses (7.4%) and band 3 healthcare support workers (9.8%) and operating department practitioners (10.4%) was much higher than the trust target of 5.5% during April 2026.

Managers told us staff sickness was monitored and initiatives to improve sickness rates included improvements to staff workloads, improved engagement with individual staff members and initiatives to support staff returning to work following sickness. However, these initiatives had not yet led to significant improvements in staff sickness rates.

There were 36 whole time equivalent (wte) nurse vacancies and 27.5 wte healthcare support staff vacancies across all the surgical wards at the time of our inspection. Most wards had vacancy rates ranging between 1 to 3 wte staff. Ward H4 (general surgery) was fully established with no vacancies. However, ward B6 (trauma and orthopaedics) had 13.4 wte nursing vacancies and 10.5 wte support staff vacancies at the time of our inspection.

The higher vacancy rate for ward B6 was attributed to the hospital’s planned bed reconfiguration plan, which included implementing 2 dedicated wards for trauma and orthopaedics. The planned change would lead to 18 beds on ward B6 and the opening a new ward (T6) with 24 beds. Recruitment for additional nursing and support staff to support the reconfiguration plan was ongoing and vacant posts had been advertised. Interviews for newly qualified nurses had commenced and 4 new staff had been appointed.

Ward T6 was vacant and ward B6 was closed and undergoing refurbishment at the time our inspection. Patients from ward B6 had been temporarily relocated to the Bevan intermediate care unit. There were 8 patients in the unit at the time of our inspection and the unit was suitably staffed. Staff told us recruitment for vacant posts had commenced, staffing was monitored daily and staffing levels were maintained through the use of bank and agency staff. The ward manager told us they had received additional support from experienced orthopaedic specialty nurses that had been temporarily transferred from the trust’s other hospitals. The manager spoke positively about the cross-site support and how this enabled sharing of ideas and practices. The manager also told us there had been limited cross-site working in the past and felt this was an example of the new clinical leadership model having a positive effect. We did not identify any significant concerns around theatre staffing during our previous inspection in September 2025. However, during this inspection the theatres staff told us staffing challenges were a concern. Theatres staff told us there had been delays or procedure cancellations due to insufficient staffing and this had impacted on theatre utilisation (efficiency) and performance. Staffing shortfalls were managed through existing staff working additional shifts and through the use of bank and agency staff.

The theatres department had 13 whole time equivalent (wte) theatre staff vacancies and 1.14 wte vacancies for theatre support staff.

The services reported recruitment for an additional 17 theatre staff was ongoing with vacant posts at varying stages of recruitment. This included the recent appointment of 6 band 5 nurses and 2 band 7 recovery team nurses. The recruitment of 2 additional anaesthetic practitioners was at interview stage. There was approved funding to recruit 3 additional band 5 neuro scrub nurses and 3 additional band 6 theatre coordinator posts.

The service reported 79 incidents relating to staffing levels or shortfalls between September 2025 and May 2026. None of these had been reported as resulting in severe patient harm. There had been 9 incidents graded as moderate harm reported during this period. These were mainly due to cancellation of non-emergency surgical procedures due to insufficient theatre staffing.

There was sufficient medical staffing cover across all medical grades. Staff were also supported by a team of advanced clinical practitioners (ACP’s). 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. Staff rotas were maintained through the use of locum doctors. Recruitment for vacant posts was ongoing. The overall vacancy rate for medical staff was low (2.4%).

Consultant cover was available on site between 9am and 5pm on weekdays and 9am to 12pm on weekends with on-call cover during out of hours service. The medical team included 6 GP trainees and 3 clinical fellows. There were no middle grade resident doctors. The GP trainees and clinical fellows told us their workload was challenging during nights and weekends when they had limited on site consultant cover but they received good support and could contact consultants on site and on call when required.

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. Staff rotas were maintained through the use of locum doctors.

We received concerns about medical staffing levels prior to our inspection. However, the medical staff we spoke with during the inspection told us they felt they had sufficient staff in place. The gynaecology team at the hospital consisted of 10 substantive consultants and an additional locum consultant (due to a vacant post). The medical team included 6 GP trainees and 3 clinical fellows. There were no middle grade resident doctors. However, the GP trainees and clinical fellows told us they received good support and could contact consultants on site and on call when required.

Most staff (92%) had completed mandatory training and the hospital’s training compliance target of 90% had been achieved.

We identified a regulatory breach relating to staff training in autism awareness and dementia during our previous inspection. We found no significant improvements had been made.

During this inspection, we found most staff (89%) across the surgical services had completed tier 1 (e-learning element) of the learning disabilities and autism training. However, the trust had not yet commenced the tier 2 (face to face element) of the 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 12.8% of eligible staff had completed dementia awareness training, indicating significant improvement 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 staff (91%) and medical staff (96%) had completed annual appraisals within the past 12 months across the surgical services. The services reported there were no outstanding issues or concerns relating to staff recruitment checks or professional body registrations.

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 clinical specialty area. Compliance in specific competencies such as blood transfusions, intravenous (IV) therapy, nasogastric feeding and medicines administration was in line with the trust target of 90%.

Managers reported staff did not always have all the required competencies due to the mixed specialities and the redeployment of staff to address staffing shortfalls. However, managers told us they tried to redeploy staff within their clinical specialty area where possible to reduce the impact. The hospital’s ward reconfiguration plan aimed to move wards to defined clinical specialties which would reduce risks around staff competencies.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. Routine audits showed some improvement in infection control standards. However, compliance around hand hygiene and use of personal protective equipment was still below trust standards.

We identified a regulatory breach relating to staff compliance with hand hygiene standards and admission screening processes during our previous inspection in September 2025.

We found some improvements had been made in relation to staff compliance with hand hygiene standards during this inspection. However, hand hygiene audits showed compliance was still below the trust’s 90% target.

Surgical ward staff carried out weekly infection prevention and control (IPC) practice audits, encompassing 7 standards relating to hand hygiene, personal protective equipment, catheter care and lines and devices. Ward managers put action plans in place where shortfalls were identified and these were monitored by the matrons.

IPC practice audits between September 2025 and April 2026 showed the surgical wards achieved average compliance of 69% for hand hygiene observations and 79% for hand hygiene facilities. However, the monthly data showed an improving trend across most surgical wards. For example, the average compliance for hand hygiene observations during September-December 2025 was 64% and this had improved to 78% during January-April 2026.

The IPC practice audits between September 2025 and April 2026 also showed overall compliance for PPE (75%), cannula care (84%) and catheter care (84%) had improved since our previous inspection, but compliance was below the trust’s 90% compliance target.

We found improvements had been made in relation to infection screening procedures. Patients underwent Methicillin-resistant Staphylococcus aureus (MRSA) and Carbapenemase-Producing Enterobacteriaceae (CPE) screening prior to admission for surgery.

The surgical wards achieved overall compliance of 81% for the hospital’s quality assurance (QAA) audit standard 59 (relating to the completion of CPE screening and risk assessments on admission) and 84% for QAA audit standard 60 (relating to MRSA pathways and screening completed appropriately) between February 2026 and May 2026. This had improved from 48% compliance for CPE screening and 57% compliance for MRSA screening achieved between June 2024 and September 2025. The QAA audit compliance target was 80%.

Most staff had completed mandatory training in IPC and aseptic non-touch technique. Staff followed IPC policies and procedures and understood how to contact the hospital’s IPC team for guidance and support.

Patients told us the general environment and environment was clean and tidy. They did not highlight any concerns around staff hand washing practices or around staff use of personal protective 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 visibly clean, tidy and well-maintained. We identified shortfalls around the use and storage of bedpans and bottles on some wards during our previous inspection in September 2025. During this inspection, we found bed pans, bottles and commodes were handled, stored and cleaned appropriately in between use.

Domestic staff monthly cleaning score audits to check cleanliness of the environment showed all the surgical wards and theatre areas consistently achieved the 95% compliance target between September 2025 and April 2026.

There were 6 infection outbreaks across the surgical services between September 2025 and April 2026, including 3 CPE outbreaks. Across 5 surgical wards, the outbreaks affected 9 staff and 23 patients.

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. Incidents had been investigated to identify learning and improvement. The MRSA bacteraemia infection was reported in May 2026 and had been reviewed by the IPC team. The review identified good practice around isolating the patient and some learning around the timeliness of blood culture requests and commencing MRSA decolonisation treatment.

Patients identified with an infection were isolated in single rooms or barrier nursed in the bay areas if single isolation rooms were not available. Where patients were isolated, we saw appropriate signage was in place to make staff, visitors and patients aware of any potential risks.

The hospital’s QAA audit standard 13 related to patients with infection risks being isolated appropriately. The surgical wards achieved overall compliance of 96% between February 2026 and May 2026, demonstrating good staff compliance with this standard.

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 the most recent reporting period (January-April 2026). The reporting period included 38 procedures, of which 1 surgical site infection was identified. This equated to an infection rate of 2.8% against a national rate of 0.8%. The incident investigation was ongoing at the time of our inspection.

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. They did not always involve people in planning, including when changes happen.

We saw that timely access to pain relief had improved since the previous inspection across the wards we visited. Staff consistently told us that there was good input from the specialist pain team when required. We reviewed patient records and observed that pain relief was routinely offered and administered appropriately. Patients told us they felt their pain was managed well and they were given information about how to manage their medicines following surgery.

Clinical pharmacy teams supported the wards. Pharmacists were visible, integrated members of the multidisciplinary team and were involved in reviewing medicines and supporting safe discharges. Pharmacy staff told us that there were generally enough staff to meet the demands of the service, and junior pharmacists had access to additional support where needed, particularly for complex discharge activity.

However, staff did not reconcile everyone's medicines on admission to ensure people continued to receive them appropriately during their stay. Areas with an embedded pharmacy presence, such as the surgical admission lounge, completed reconciliation promptly, but many other areas did not. Across all areas, staff reconciled 57% of patients' medicines within 24 hours, in line with national guidance. This increased to 91% within 72 hours, but delays increased the risk of medicines-related incidents.

Medicines were not always stored in a tidy or organised manner. This included medicines trolleys within bays, where disorganised storage increased the risk of mis-selection and errors. We saw excessive quantities of medicines stored in limited spaces. Ward leaders told us this was due to difficulties returning unused stock to pharmacy. The associate nursing lead told us they would escalate this issue with the pharmacy team. Furthermore, we saw on ward T4, the antibiotic cupboard was particularly disorganised.

Controlled drugs were kept secure and accessible by only authorised staff. However, they were not always managed in line with trust policy. We identified discrepancies in stock balances of liquid oxycodone on B1, which staff told us were regularly recalculated. Staff advised that discrepancies of up to 10% could be locally adjusted. However, this was not in line with the services policy which said that discrepancies of greater than 5% of volume should be investigated.

Fridge and room temperatures were recorded daily, including in areas that had been risk assessed as suitable for medicines storage. We reviewed temperature records and temperatures were maintained within recommended limits. However, on ward B5, staff routinely recorded standard minimum temperature ranges (2–8°C) rather than the actual minimum temperature. We raised this with ward leaders, who agreed to remind staff to record actual readings.

Staff told us there was improved workforce stability since the previous inspection, with fewer staff being moved between specialties. This supported continuity of care and safer medicines administration practices. In surgical theatres, staff reported no concerns regarding access to medicines and told us they were able to obtain medicines they needed promptly.

The service completed regular medicines management and controlled drugs audits. Whilst surgical wards tended to perform in line with trust targets, many wards had not completed the latest audit in line with the schedule, including wards we had visited. The service had not identified concerns around medicines management that we saw on inspection.

The service also completed regular clinical audits including antimicrobial stewardship audits. We saw surgical audits performed well in line with trust targets for antimicrobial choice and ensuring timely review.