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.

The services had implemented a new clinical leadership structure, which meant leaders did not yet fully understand the context in which the service delivered care, treatment and support. The services did not have effective governance and quality monitoring processes.

A positive work culture and morale had not been embedded across all staff groups. Staff did not always feel they could speak up and that their voice would be heard.

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 surgical services had been restructured into clinical service groups in April 2026 as part of the trust’s clinical leadership model implementation. The services reported the clinical service group objectives for the upcoming year were in the process of being developed at the time of our inspection. The clinical services’ leadership teams took part in an away day in May 2026 to discuss the priorities for 2026/27. The services reported they planned to update the strategic objectives annually.

The previous division of surgery and the Manchester Centre of Clinical Neurosciences (MCCN) division had developed local strategies (priorities) for 2025/26 prior to the clinical leadership model being implemented in April 2026. The local priorities had incorporated the strategic objectives and ambitions outlined in the trust’s 10 year strategy (vis10n).

The 2025/26 local priorities had included objectives relating to improving clinical outcomes for patients, improving staff survey response rates and staff satisfaction, improving wating times performance and reducing readmissions and patient length of stay. Progress against the objectives and key priorities had been reviewed as part of routine divisional and hospital-level meetings. However, our findings from this inspection showed the surgical services did not achieve all local priorities and objectives for the previous year.

The 2025 NHS staff survey results (published in March 2026) for the division of surgery showed the surgery wards, surgery management, theatres and urology services scored worse than trust averages and worse than 2024 survey results across most indicators including for engagement and morale, indicating a worsening trend since our previous inspection. However, the response scores for the trauma and orthopaedics specialty were better than trust averages and had improved since the 2024 across most indicators.

The hospital did not provide 2025 staff survey data relating to the neurosurgery, spinal surgery and gynaecology services, however the 2024 staff survey results had shown these services performed worse than trust averages across most indicators.

A staff pulse survey undertaken in January 2026 was based on 1,217 responses (5.8% response rate). The pulse survey reported a decline in several survey indicators compared to pulse survey results from January 2025. This included staff survey indicators relating to staff engagement, staff coming back to work unwell, staff feeling informed about important changes and around supporting staff health and well-being. The survey also reported improvement in some indicators, such as positive sentiment indicators and around flexible working.

The surgical services had analysed the NHS staff survey results and pulse survey findings and developed action plans to improve compliance. Whilst these included actions relating to improving staff engagement and well-being, the action plans had not yet been fully implemented. The services reported 84% of actions following the 2024 NHS staff survey had been completed, 8% were in progress and 8% had not yet started. The services reported 59% of actions following the 2025 NHS staff survey had been completed, 37% were in progress and 4% had not yet started.

During our previous inspection, we received mostly negative feedback from staff about the culture, morale, leadership and direction of the surgical services. We found there had been some improvement during this inspection but significant challenges around staff culture and morale still remained.

We spoke with over 80 staff in the ward and theatre areas and during staff focus groups involving nursing, medical, gynaecology, theatres and anaesthetic staff during this inspection.

Most ward nursing and support staff told us the culture and morale had improved since the previous inspection. They told us they received better support from line managers, they were redeployed to other wards less and there had been some improvements to ward staffing and workloads. However, they still experienced workload challenges due to ongoing staff sickness and vacancies.

The anaesthetic and medical staff told us staff morale was still low and had not significantly improved since our previous inspection. Some medical staff groups (such as spinal and gynaecology consultants) and some theatre staff reported continuing concerns about bullying and harassment from managers and senior leaders.

Staff told they still had concerns about the strategic direction of the surgical services and they still felt disconnected from and did not have a shared identity with the wider trust. They told us processes to standardise systems and processes across all sites were still being implemented and had not led to significant improvements in local standards and performance since our previous inspection. They also told us the clinical leadership structures had not yet been in place long enough to enable meaningful culture change.

We scored the service as 2. The evidence showed some shortfalls. The services had implemented a new clinical leadership structure, which meant leaders did not yet fully understand the context in which the service delivered care, treatment and support. Whilst leaders understood the culture and values of their workforce and organisation, they had not yet been fully embedded into their new roles.

The surgical services had been restructured into 3 clinical groups (CG’s) following the implementation of the clinical leadership model in April 2026. Each CG consisted of a number of clinical service units (CSU’s). Each CSU incorporated specific clinical specialties operating across the trust’s hospital sites under a single triumvirate leadership structure.

The neuro and spinal surgery CSU and major trauma CSU (including hands and plastic surgery) formed part of the neurosciences and major trauma clinical group and most clinical specialties were based at this hospital due to the specialist nature of the services provided.

The surgery clinical group included 7 CSU’s covering clinical specialties across the trust’s hospitals, including ear, nose and throat (ENT) and oral surgery, urology, ophthalmology, trauma and orthopaedics, intestinal failure and upper gastrointestinal surgery. The theatres and gynaecology services formed part of the families, anaesthetics, critical care and theatres clinical group.

Each clinical group was led by a medical director, along with a nursing director and head of operations. Each CSU was led by a clinical director, along with an operations manager and head of nursing. Most of the leadership roles had been fully recruited to and deputy roles (such as deputy operations and nursing leads) were also in place. The leadership teams consisted of senior leaders appointed from a mixture of hospital sites and clinical specialties.

We spoke with the clinical group leads for all 3 CG’s and the CSU leads for upper GI surgery, gynaecology and for neuro and spinal surgery as part of the inspection. They all demonstrated a good understanding of the key risks and challenges across the surgical services. They told us they regularly engaged with staff to discuss their concerns and were in the process of prioritising actions to address key risks within their respective areas responsibility. They told us the delivery of safe patient care and treatment was their main priority, followed by improving staff workload and culture and improving performance.

The clinical group and service unit leads were able to give examples of improvements they had already made since April 2026, such as expediating business case approvals to support staff recruitment and improvements in the delivery of patient care and ward staff morale. They told us the new leadership structure would facilitate improved standardisation of services and processes and enable better integration and cross-working across hospital sites. However, they told us they had only been in post for 2 months at the time of the inspection and required sufficient time to identify, implement and embed planned improvements.

The clinical group and service unit leads told us the clinical leadership model was a positive step, but the changes had not been implemented in an organised and effective way. This included issues resulting from the launch of a new governance and meeting structure at the same time as the structure change. Medical directors and clinical directors told us they were still required to undertake clinical activities alongside their leadership responsibilities, impacting their workloads.

The clinical group and service leads felt there had been limited communication and engagement from the senior trust leadership prior to and during the implementation of the new structure. They told us there had not yet been any formal evaluation around how well the changes had been implemented. However, they told us the new structure allowed them to engage with the trust leadership team more frequently. They felt the senior executives were now more receptive and had started listening to concerns. They gave an example where the trust leadership had reduced the number of meetings the clinical group and service leads were required to attend following their feedback.

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

Most staff we spoke with were positive about the support they received from their line managers, including from clinical leads, ward and theatre managers and matrons. However, staff feedback about the senior trust leadership was still negative.

Most staff felt clinical group and clinical unit leaders were approachable and communication had improved compared with the previous divisional leadership structure. Staff told us some financial restrictions had eased and the process for submitting business cases for additional resources was less bureaucratic since the implementation of the clinical leadership model.

Most of the staff we spoke with in the clinical areas and during focus groups felt it was too early to determine how effective the new clinical leadership structure was as it had only recently been implemented.

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. There was a trust-wide FTSU lead and a dedicated FTSU lead for the surgical services across the trust, who had 6 hours of protected time per week for undertaking FTSU activities. There were also 13 additional FTSU champions across the hospital.

The trust-wide FTSU lead told us they routinely engaged with staff to raise awareness of the team and to promote FTSU processes. This included providing information for staff on the trust’s intranet and through staff engagement, such as participating in foundation leadership training programmes for new managers.

There had been 4 FTSU cases reported by the surgical services between September 2025 and May 2026. The services reported 3 of these had been resolved and 1 case remained in progress at the time of our inspection.

We received negative feedback from staff about the culture and freedom to speak up processes during our previous inspection in September 2025. We reported that staff understood how to contact the FTSU guardians and raise concerns. However, staff did not always feel confident in raising concerns.

We found significant improvements had not been made during this inspection. Feedback from staff during our ward and theatre visits and during focus groups was similar to our previous inspection. Some staff groups told us there had not been any significant change in culture and they did not have confidence in senior leaders addressing their concerns. They told us they were still reluctant to raise concerns because they feared their concerns would be dismissed or lead to punitive actions from senior leaders.

The January 2026 staff pulse survey showed 43.4% of staff responded positively in relation to a survey question about staff being supported to raise concerns around unwanted behaviours. The survey showed 32.2% of responses were neutral and 24.4% answered this question negatively.

We scored the service as 2. The evidence showed some shortfalls. The service did not always value diversity in their workforce. Whilst the service worked towards an inclusive and fair culture by improving equality and equity for people who work for them, these improvements had not yet been fully embedded.

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.

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 patients.

Improvement actions were still being implemented at the time of our inspection. A trust-wide equality, equity and inclusion objective tracker 2025/26 listed improvement actions relating to improving women’s safety, racism, disability staff experiences and around embedding equality across the trust. The tracker showed 19 actions had been completed, 2 were ongoing and 14 actions were still in development.

The surgical services reported a number of initiatives had been undertaken or planned in to improve equality, diversity and inclusion. An analysis of flexible working requests during 2023/24 and identified higher rejection rates in certain staff groups. The services reported improvement actions had been undertaken including engagement with line managers and the introduction of additional assurance steps within the approval process.

The services had plans in place to monitor uptake of conflict avoidance training in order to address workforce experience of inequalities. They also planned to roll out additional health checks and wellbeing support sessions to provide targeted support to staff groups showing poorer health outcomes or negative indicators. There was also an ongoing initiative to increase the number of staff trained as cultural ambassadors across the trust.

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. The trust reported they had undertaken a number of remedial actions to improve staff engagement and the culture across the surgical services.

Most of the staff we spoke with in the ward and theatre areas told us they had not experienced any discrimination. However, feedback from some theatres staff and medical staff groups (such as spinal surgery and gynaecology) during individual interviews and staff focus groups highlighted significant improvements had not been made since our previous inspection. They told us they felt a culture of racism, bullying and harassment still existed within the service. This highlighted that the remedial actions taken by the trust following the Breen review had not yet been embedded effectively.

There had been 10 reported incidents relating to bullying, violence and aggression in the surgical services between September 2025 and May 2026. However, 9 of these related to violence and aggression by patients and 1 incident related to violence by another staff member. Incident records showed these had been investigated and appropriate actions had taken following the incidents. No incidents related to bullying by a manager.

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 trust had launched a new governance meeting structure alongside the implementation of the clinical leadership model in April 2026. This included a restructure of meetings and performance reports to align with the new clinical service unit and clinical group structures.

There were routine departmental, clinical service unit and clinical service group 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.

Clinical service leads told us they had initially experienced some challenges in implementing the new governance structure due to an increase in the number of meetings staff were required to attend. They told us this had since been evaluated and the volume of meetings had been reduced and was more manageable. Staff told us the new governance and meeting structures had only been in place for a short period of time and were still being embedded.

Performance dashboards were accessible to staff and provided data and information in areas such as performance and activity monitoring, theatre activity, referral to treatment and waiting lists performance. The services reported most performance reports and data dashboards had been aligned to the new clinical service unit and group structures. There was an ongoing project to align data dashboards for services that had been transferred to new clinical service groups structures, such as the ear, nose and throat (ENT) and plastic surgery specialities. Staff also utilised external dashboards such as the NHS Oversight Framework (NOF), Model Health System and the Healthcare Evaluation Dataset (HED).

The surgical services had made some improvements to audit and monitoring processes since our previous inspection in September 2025. The hospital’s quality assurance audit (QAA) process had been transferred to an electronic audit management and tracking system since January 2026 to enable improved data recording and reporting mechanisms. The trust planned to replace the inpatient assessment and accreditation system (IPAAS) ward accreditation process with the new electronic audit management system.

We reviewed the hospital’s QAA audit results between February 2026 and May 2026 across the 14 surgical inpatient wards at the hospital. The audit results showed there had been significant improvements in overall compliance compared with our findings from the previous inspection. However, compliance was still below the 80% compliance target for a number of audit indicators. Managers told us there had been an increased focus on patient safety processes since our previous inspection. The services had implemented daily and weekly nurse coordinator and ward manager checklists to monitor staff activities, patient safety and completion of patient records. Ward staff told us the additional monitoring and oversight had led to improved compliance.

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. However, improvements were still ongoing in some areas such as staff recruitment and, fluid monitoring and bed rails management compliance.

We also identified a further 11 regulatory breaches in addition to the concerns identified within the warning notice during our previous inspection. We found improvements had been made in 4 of the 11 regulatory breaches during this inspection.

The services had made improvements in areas such as surgical safety checklist compliance, person-centred care, duty of candour compliance and Deprivation of Liberty Safeguards (DoLS) processes. However, we found significant improvements had not been made in relation to access and flow, dementia and life support training compliance, staff culture and morale and around improving governance processes. We also identified new concerns around theatre staffing, medicines management and around the timely completion of complaint and incident investigations.

The get it right first time (GIRFT) review report from August 2025 of the spinal services included several recommendations. These included submitting data to the British Spinal Registry (BSR), 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. A follow up visit by the GIRFT team in April 2026 highlighted progress made in implementing recommendations and progress against agreed actions was ongoing.

The GIRFT review of gynaecology services across the trust (December 2024) identified 22 recommendations for improvement, relating to process workforce, and theatres improvements. The GIRFT review of urology services (January 2026) included 1 recommendation around implementing a focused urology elective inpatient service with a clear timeline for the consolidation of the service to ward H4.

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 most actions identified in the Breen and spinal look back action plans had been completed, but further work was planned to ensure improvements were sustained and embedded. We also received negative feedback from some staff groups about the effectiveness of the remedial actions taken to date.

An independent patient safety diagnostic review of spinal surgery concerns (reported in April 2026) found that both the Breen and spinal surgeon look back review action plans had delivered some improvements in governance, MDT working, consent and leadership arrangements. However, both plans were predominantly task-focused, lacked clear outcome measures and contained recommendations that were difficult to translate into sustainable improvement. The review concluded that the impact of actions taken had not been sufficiently evidenced and that further work was required to demonstrate lasting change and address gaps in previous recommendations.

The services reported new concerns about clinical practice and patient harm relating to the spinal surgery service during 2026 and had commenced an investigation.

The surgical services had also reported 13 of the 15 actions identified in the improvement plan relating to historical concerns about governance and administrative practices in gynaecology had been completed. Some staff in the gynaecology service also told us they had previously raised concerns about patient safety in 2024 and had requested an external review but felt this had been ignored by senior leaders.

Following the inspection, the trust reported in July 2026 that they had commissioned an external independent review of the spinal and gynaecology services to identify any safety and quality concerns which remained unaddressed.

We scored the service as 2. The evidence showed some shortfalls. The service did not always understand their duty to collaborate and work in partnership, so services worked 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, skull base and neurosurgery and major trauma networks to review pathways and practices.

We received mixed feedback from service partners and stakeholders. Service partners gave positive feedback about staff engagement, communication, coordinated care and collaborative working. However, some service partners and stakeholders also gave examples of poor communication and team working between the surgical services and other services within the trust and externally across the region.

The services routinely engaged with patients and local communities to gain feedback and improve people’s experiences of using the service. We saw examples of patient and public engagement events relating to surgical specialties, including gastrointestinal surgery, spinal and neurosurgery and the intestinal failure unit. The engagement events were focused on raising awareness about medical conditions, such as cancer and to support patient education and health promotion. Staff in the intestinal failure unit also carried out an annual intestinal awareness engagement event in February 2026, 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.

The surgical services had made improvements to address some of the regulatory breaches and warning notice requirements identified during our previous inspection in September 2025. However, further improvements were ongoing as compliance was still below trust compliance targets in some areas. We found significant progress had not been made in key areas identified during previous inspection, including around access and flow and dementia and life support training. We also identified new concerns in areas such as medicines management. This showed a culture of learning and improvement was not fully embedded across the surgical services.

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.

Staff participated in a number of quality improvement (QI) projects aimed at improving the delivery of care and patient experience and outcomes. This included QI projects aimed at reducing violence and aggression towards staff, improving cerebral abscesses pathways, reducing external ventricular drain (EVD) infections and to develop a psychoeducation programme to improve life after subarachnoid haemorrhage.