Salisbury District 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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

At our last assessment we rated this key question as good. At this assessment the rating has remained the same. This meant people were safe and protected from avoidable harm.

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.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Leaders investigated incidents and shared lessons learned with the whole team and the wider service through various forums some of which included learning from incidents forum, medicine safety bulletins and governance meetings. We reviewed the learning from incident forum meeting minutes for the month of April which showed evidence of incidents being reviewed and learning from incidents being shared.

In addition to this, incidents were discussed at the weekly patient safety summit (PSS). The trust undertook patient safety reviews (PSR) for all cases where moderate or above harm had occurred to patients and shared learning from these through the learning from incidents forum.

There were clear open and transparent processes for reporting and learning from incidents. We spoke with members of staff who told us they received learning from incidents via newsletters and daily huddles.

The trust followed the NHS England Patient Safety Incident Response Framework (PSIRF) which set out the service’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents and issues for the purpose of learning and improving patient safety.

Staff recorded all patient safety incidents (PSI) or near misses on the trust’s local management risk system. Incidents were discussed daily at the patient safety huddle with matrons and patient safety to ensure that any immediate support, learning and or actions were addressed and implemented.

Incidents were also discussed bimonthly at the Patient Safety Oversight Group (PSOG) to ensure the correct oversight was undertaken in line with the PSIRF standards.

Staff had access to the incident reporting policies and procedures through the trust’s intranet. Leaders kept a log of National Patient Safety Alerts and shared this with staff and actioned as appropriate. We saw evidence that information had been shared with staff.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service’s referral and admission processes ensured that all essential information about the patient was received to determine if the patient’s needs could safely be met. Continuity of care was maintained by effective handover of patients and their individual needs. Staff of all grades attended regular safety huddles during their shift. This was an opportunity to share safety information.

The trust held bed meetings three times a day to review flow within the service and escalate patients who faced delays. Leaders told us this was effective as it helped coordinate patient flow within the hospital through multidisciplinary collaboration.

Leaders were aware of how many escalation beds they could safely accommodate through bed meetings. An escalation bed is a temporary hospital bed opened to manage sudden, overwhelming increases in patient demand, such as during winter pressures or other operational surges.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge.

All inpatient discharge summaries were produced on the electronic patient record, and then electronically sent to the patient’s GP on discharge. The department shared discharge information to relevant healthcare providers via transfer of care forms. We reviewed three transfer of care forms which consisted of a body map, summary of care provided and pressure ulcer risk. All three forms had been fully dated and signed by a member of staff.

Additionally, staff had access to a leaving hospital integrated care system policy which identified the roles of those involved in the discharge of patients and set out how acute and community hospitals and local authorities could plan and deliver hospital discharge.

Staff were aware of how to escalate concerns about patients whose condition deteriorated.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff 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.

Staff knew how to recognise, report and escalate their safeguarding concerns. The trust had a designated safeguarding lead who staff had access to for advice and support.

Staff received training relevant to their role on how to recognise and report abuse. At present, the accuracy of compliance data for mandatory and statutory training, including adult safeguarding levels 2 and 3, the mental capacity act (MCA), and children’s safeguarding, was compromised due to ongoing issues with the trust eLearning reporting systems. As a result, the reported completion rates for these modules were currently below the organisational target of 85% compliance. While system issues were being resolved, departmental managers told us they had oversight of training compliance at individual staffing levels, to ensure frontline staff were not operating without appropriate safeguarding knowledge.

The trust’s integrated safeguarding team reviewed all onboarding staff to ensure the correct level safeguarding training was added to individual online learning trees.

Staff received targeted communication reminding them of the mandatory nature of safeguarding training and encouraging timely completion.

The trust had a safeguarding adults at risk and safeguarding children and young people policy. This provided staff with guidance on how to identify possible abuse and the processes to follow if they needed to raise a safeguarding concern. Both policies were in date and reflected current legislation and guidance.

Access to the wards was secure and was provided by staff at the reception after a brief assessment of the patient. This was via a door buzzer system and staff carried electronic passes to gain entry.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Trust data showed there had been 2 incidents from October 2024 until January 2025 where Venous Thromboembolism (VTE) assessments had not been completed and there was a delay in prescribing the prophylaxis (treatment to reduce the risk of a patient acquiring a VTE). We reviewed 7 patient records and none of these had VTE assessments completed. Additional data provided by the trust following the inspection confirmed compliance in VTE risk assessment completion to be consistently low across the medical wards. The trust had taken a number of steps to mitigate the risks of this to ensure the right people were receiving treatment to reduce the risk of VTE when this was required. However there was an ongoing documentation issue of the VTE assessments.

The service used the National Early Warning Score 2 system (NEWS2) to recognise patients who were becoming unwell. Scores were recorded on an electronic system.

The department used electronic patient record system and paper records for patient notes. Staff commented how it was sometimes difficult to find information due to this. We also found that staff did not always scan the admission paper notes onto the system which meant staff were not always aware of specific risks for patients.

Following admission and transfer of the patient, staff completed the checklist and safety plan for admissions of adults at risk of self-harm from ligature and high risk items. Wards also completed environment risk assessment checklist for high risk mental health admissions. We saw evidence of completed risk assessments and found these to be completed well and of good quality.

Staff told us they used Braden scale on admission and completed this daily to assess for changing needs. The Braden Scale is a nationally recognised risk assessment tool in healthcare for predicting the likelihood of a patient developing pressure ulcers (also known as bedsores or pressure sores).

Leaders told us they were using improving together to improve compliance and had seen some improvement since the initiative was launched in 2023. Improving Together is about Quality Improvement, giving the people closest to the issues the time, permission, skills and resources they need to problem solve. It involves a systematic and coordinated approach to solving problems using specific methods and tools with the aim of bringing about a measurable improvement.

Staff changes and handovers included all key information to keep patients safe. During the inspection we attended safety huddles and found all the key information needed to keep patients safe was shared. Each staff member had an up-to-date handover sheet with key information recorded.

The department had access to the mental health liaison 365 days a year. Face to face assessments took place from 8am until 9pm Monday to Thursdays and 9am until 00:00 from Friday to Sunday. Outside of these hours the South Wiltshire Intensive Delivery Service were contactable by phone to discuss referrals and attended face-to-face assessment as required.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

We found fire doors open and fire escape routes blocked by equipment in a medical ward during the inspection and fed this back to the trust. Following this, the trust took immediate actions and reported the issues observed to be resolved. The trust also conducted a fire safety visit to these areas within the division.

There were systems which ensured clinical waste, including sharps, was appropriately segregated, and disposed of.

The design of the environment followed national guidance. Staff told us they had enough suitable equipment to help safely care for patients. Call bells were in place in patients bedrooms to support their safety.

Resuscitation equipment was readily available and easily accessible. The hospital had systems to ensure it was checked regularly, fully stocked, and ready for use.

Clinical staff knew where to find the equipment they needed to respond to an emergency and had received appropriate training to enable effective use.

Staff had access to the equipment they required to keep patients safe and reported faulty equipment through the medical devices team. We spoke with a range of staff who confirmed that when equipment broke, they had access to replacement equipment.

The trust carried out environmental risk assessments for medical wards and departments. Level of risk was identified by a colour code system of yellow (high) and blue (moderate) and whether additional controls were required.

The service reported staffing gaps within the medicine division. Staff did not always receive appraisals and the service was not meeting the trust target.

Whilst the staff we spoke with told us they had received appraisals, data provided by the trust showed the lowest appraisal compliance for Breamore and Spire ward. This was 45.45% and 66.67%. Employee appraisals are an important element of performance management to improve organisational efficiency by ensuring that individuals perform to the best of their ability, develop their potential and identify any potential areas for improvement.

Staffing and failure of workforce planning leading to significant gaps in service provision for diabetes patients was one of the highest rated risks within the division. Since the inspection, the trust had appointed two consultants in diabetes and a lead nurse.

The trust relied on the temporary workforce for both medical and nursing staff to meet the capacity and demand. Data provided by the trust showed that 380 shifts were covered by the locum doctor workforce from January 2025 to May 2025. This equated to 2.53 shifts a day for the entire medical workforce across the hospital in the medicine division and included cover for maternity leave and paternity leave.

Where necessary, the division used bank and agency nursing staff to cover staff sickness and absences. Temporary staff usage (including bank and agency) from March until April 2025 was 10% (2.72% of this was agency staffing) for nursing staff and 20.46% (0% agency staffing) for healthcare assistants (HCA). The division reported challenges relating to turnover within HCAs and had a recovery plan in plan to address this. Additionally there were also ongoing work to improve staff recruitment and retention within nursing staff.

Locum data, use and spend, as part of overall staffing for medical and nursing, was monitored via speciality and divisional performance meetings. We reviewed the meeting minutes for the medicine divisional performance review meetings for the period of March 2025 to May 2025 which showed discussions on staffing countermeasures and experiments taking place. The trust reported the medicine division as the top contributor for locum spend.

We spoke with staff who told us there were staffing challenges at registrar level and Senior House Officer (SHOs). Leaders also commented on the high number of healthcare assistant vacancies across all areas of the division.

Staff told us they struggled with decisions for stroke patients during out of hours and weekends as dedicated stroke doctors were only available from 9am until 5pm, Mondays to Fridays. Data provided by the trust showed that the trust was not meeting the local target of 65% for the stroke 4 hour performance for the months of February, March and April 2025 and had failed to achieve compliance for 9 months in a row.

The trust employed a small acute Speech and Language Therapy (SALT) team who covered 18 wards and units. Due to this, there were areas of unmet needs within the division.

Significant reduced SALT for acute wards due to maternity leave was one of the risks in the SALT risk register. Although the trust had current controls to mitigate these risks, these weren’t effective as some patients were discharged before SALT input due to delay.

We spoke with a range of staff who described additional training and qualifications they had undertaken which supported their role and development. The department reported an overall mandatory training compliance of 78.8% for medical staff which was below the trust target.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Some of the wards we visited did not have any hand gel available on the entrance and we did not observe any handwashing in any of the wards we visited during the two days of inspection. The department carried out a range of IPC audits. We reviewed hand hygiene audits from December 2024 to June 2025 for the medical wards and found poor compliance for these. For example out of the seven months, Farley ward and Laverstock ward had only achieved compliance for the month of February 2025.

We observed staff did not always clean equipment in between patient use. To ensure safe patient care, medical equipment must be properly cleaned and disinfected between uses.

Cleaning products were in cupboards which were either left open or with keys left in the door making it accessible to patients and public. We found this to be the case in Redlynch and Farley ward. Under Control of Substances Hazardous to Health (COSHH) regulations, hazardous cleaning products must be stored securely, often in a locked cupboard or cabinet as this ensures safety and prevents unauthorized access to potentially harmful substances. This posed a risk that patients could access harmful chemicals.

We raised infection control concerns with the trust at the time of inspection. As a result the trust told us they had increased audits in hand hygiene, in situ hand gel and equipment management across all medical inpatient departments and wards.

Staff had access to the infection prevention and control policy which provided staff with guidance and good infection prevention control (IPC) practices to minimise the healthcare associated infections (HCAIs).

Wards were visibly clean and we saw use of ‘I am clean’ stickers for equipment which were all in date.

The trust also completed the annual patient-led assessment of the care environment assessment in November 2024. The assessment looked at 10 wards, four of these were medical wards. Results for this showed a 100% compliance in cleanliness for three of the wards whilst Pembroke ward had a compliance of 97.06%.

The service had safe systems for appropriate and safe handling of medicines. However, the limited pharmacy staffing was a risk to the ongoing delivery of an effective medicines optimisation service. This issue was recognised on the risk register. This risk was being mitigated in various ways and staff were still able to access advice from pharmacy when needed.

Medicines including controlled drugs were stored securely and safely. Staff followed established systems to manage medicines safely. Medicine administration records were complete. There were robust processes in place to ensure patients received their medicines on discharge both during pharmacy opening hours and out of hours.

Staff completed medicines management training and annual assessments were completed to ensure they remained competent. Medicines audits were completed regularly, actions identified were communicated with the ward and followed up by senior staff.

The service had systems to ensure staff knew about safety alerts and incidents. We saw that reported incidents were monitored, reviewed and where required changes to practice were implemented.