Salisbury District Hospital

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

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

The service had safety systems in place, including incident reporting and outcome monitoring, and staff were willing to raise concerns, indicating a developing learning culture. However, assurance that care was consistently safe was limited by inconsistent completion and documentation of venous thromboembolism risk assessments, reducing confidence that risks were proactively identified and managed.

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 evidence showed a good standard. 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.

The service had established processes for incident reporting, organisational learning, and continuous improvement. Staff described what events were considered as incidents and how to report them. Monthly ward and theatre department meetings served as platforms where incidents were routinely discussed, ensuring staff could review recent events and learn from them. Meeting minutes showed discussions regarding both theatre and ward based incidents. For example, needlestick injuries to staff, environmental concerns relating to broken equipment in theatres and pressure ulcers for ward based patients.

Minutes from these meetings were made available to all staff, promoting transparency and enabling engagement. Additionally, the service employed visible methods to share learning outcomes; an information board within the ward displayed recent incidents and the lessons learned, ensuring staff, regardless of their shift patterns, were kept informed of safety updates and procedural improvements.

A culture of daily learning and communication was ingrained in the service. Staff routinely discussed issues in real-time and took immediate actions. Leaders described how this approach contributed to a culture of continuous improvement.

The surgical service adhered to the principles of the Duty of Candour (DoC) and staff could describe when they would use it. This ensured incidents were not only reported but were also communicated openly to the affected individuals and their families, reinforcing a sense of trust and accountability. We saw feedback from an investigation after an incident within surgical services where timely completion of DoC was noted within the positive findings of the review.

The department’s approach to managing complaints was similarly effective. Staff reported formal complaints were rare, as most concerns were resolved promptly and informally at the local level.

Feedback from staff was consistently positive about the supportive environment in which they worked, where students benefitted from structured learning, mentorship, and practical experience. We observed student nurses on surgical wards managed patient care, prioritising needs under mentor supervision. Ward Managers told us they encouraged professional growth. Theatre staff told us healthcare assistants were regularly supported to train as assistant theatre practitioners and operating department practitioners through funded apprenticeships.

The evidence showed a good standard. 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 surgical service worked collaboratively with internal colleagues and external partners to maintain patients’ safety. 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. Staff used these forums as an opportunity to share safety information.

Alerts on the electronic patient record enabled staff to be aware of and follow specific care plans if a patient had needs required additional support or there were signs of deterioration.

All planned surgical patients were pre-assessed prior to admission and surgery. There was effective sharing of pre-assessment information using embedded and agreed processes and systems.

Surgeons and theatre teams used the World Health Organisation (WHO) Surgical Safety Checklist. We observed staff using the WHO checklist before, during and after surgery. We noted good engagement from all members of the surgical team during the different stages of the checklist. This checklist served as a vital safety mechanism, ensuring all necessary precautions were taken before, during, and after surgery. Such practices reduced the likelihood of errors, contributing to a safer surgical environment for patients.

There were good working relationships within the hospital to manage flow through the hospital. Regular hospital level meetings and board rounds on wards throughout the day to ensured patients waiting admission or discharge were facilitated in a timely manner.

Staff carried out most risk assessments for patients in line with national guidance. Staff used the National Early Warning Score 2 system (NEWS2) to recognise patients who were becoming unwell. Patient observations were recorded on handheld devices, which calculated the NEWS2 score. The data was recorded on the patient’s electronic record and could be accessed centrally if required. Care plans for patients with elevated NEWS2 reflected up-to-date medical reviews and clear plans known to the nursing team.

Effective systems supported daily reviews of patients by medical and nursing teams. Staff were aware of how to escalate concerns about patients whose condition deteriorated.

The trust provided evidence that they were working to improve the discharge process for patients. This work was on-going at the time of the inspection and included targeted project work, for example a review of discharge documentation. We saw that the trust had invited patients who has been discharged in the previous 12 months to join a focus group. The goal was to understand the process from the patient point of view, with the aim to improve the experience.

The evidence showed some shortfalls, specifically regarding safeguarding training compliance. Despite the low levels of training compliance, 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.

The service had established processes for identifying and reporting safeguarding concerns, supported by accessible policies available to all staff via the intranet.

Safeguarding training was provided by the trust but not all staff had completed the training. The reported completion rates for staff within the surgical service were below the organisational target of 85%. Data provided by the trust showed compliance for adults safeguarding levels 2 and 3 stood at 79% and 41% respectively. Despite this, all staff we spoke with had a clear understanding of safeguarding procedures and told us they knew how to make a safeguarding referral. They could explain what constituted a safeguarding concern and described the correct process for raising issues, including who to contact within the safeguarding team.

Leaders in the service described the accuracy of compliance data for mandatory and statutory training was compromised due to ongoing issues with the trust eLearning reporting systems. Whilst the trust were able to provide data for the surgical division, they were unable to provide data split by staff grade or profession.

While system issues were being resolved, departmental and ward managers confirmed they had oversight of training compliance at individual staffing levels, to ensure frontline staff were not operating without safeguarding knowledge. We spoke with managers and ward leaders about this issue. They confirmed they liaised directly with staff regarding their training compliance, rather than rely on trust-level data.

Posters displaying the safeguarding team’s contact information were visible across the unit. However, although staff knew who and how to contact the safeguarding team, not all staff were aware of the safeguarding lead for the organisation, highlighting the need for improved visibility and communication regarding safeguarding leads. Staff were observed discussing safeguarding concerns during handovers, including cases under the Deprivation of Liberty Safeguards (DoLS). A patient’s notes reviewed included a completed DoLS form, demonstrating that procedures were being followed appropriately.

The evidence showed some shortfalls. The service worked well with people to understand and manage risks. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. However, challenges with the trust electronic patient record system meant it was not easy for staff to complete and record risk venous thromboembolism (VTE) assessments effectively.

The surgical service demonstrated a proactive approach to managing risks, underpinned by embedded risk assessment protocols and patient safety practices. However, risks associated with venous thromboembolism were not always documented. Staff put patients at the centre of their own care and spent time with patients to understand their individual needs. For example, ward based staff used board rounds to discuss individual patient needs and circumstances, both physical and social.

Staff used the National Early Warning Score (NEWS) to identify early signs of patient deterioration. We reviewed 5 sets of patient records, all of which had NEWS scores with documented escalation. Ward staff told us doctors responded quickly when concerns were escalated about a deteriorating patient.

There was variable completion of venous thromboembolism (VTE) assessments to identify and minimise the potential risk of blood clots through prophylaxis. There was inconsistency in completing VTE risk assessment documentation on the patient record because of challenges with the electronic patient record system used to document VTE risk assessments.

As part of the assessment we reviewed 31 patient records, specifically looking at VTE. Staff told us there were system limitations which did not support timely or user-friendly completion of the VTE risk assessment. However, there was one surgical ward who were able to achieve good compliance with documenting the VTE risk assessments. This was as a result of positive engagement between ward leaders, nurses and doctors.

We found all of the 31 patients we reviewed had been prescribed VTE prophylaxis relevant to their clinical presentation. However, as a result of the system limitations a documented VTE risk assessment was not always completed or available to view. Therefore it could not be determined whether a VTE risk assessment had been completed or not. As such, there was no clarity about whether all patients who were prescribed VTE prophylaxis actually required it and patients may have received prophylaxis medication unnecessarily.

The trust acknowledged and recognised the VTE risk assessment issue and had commissioned a new patient record system to address the problem. Leaders said the timeframe for implementation of the new system had not been finalised. It was expected to be delivered within the next 12 months, however this would not resolve immediate risks to patients. To mitigate the challenges, the service had introduced additional measures to monitor compliance with completing VTE risk assessments, such as monthly audits. Despite the increased frequency of monitoring we were not assured staff were adhering to trust policy regarding effective documentation of VTE risk assessments.

All patients attending for planned surgery were pre-assessed. Staff trained in pre-assessment completed pre-assessments with patients either remotely, over the telephone or in a face-to-face clinic. Staff demonstrated how information was entered into a computer system which guided them through the required parameters.

Staff shared information when handing care over to other teams using a structured communication tool. This ensured handovers contained all relevant information regarding a patient. Each episode of care was recorded by health professionals on the electronic patient notes system and any paper records being used.

Staff described procedures to support patients with mental health conditions. Although we did not observe any patients requiring additional support during our inspection, staff described how they used a range of strategies, including verbal de-escalation, to reduce the need for restrictive interventions. Staff told us they had access to trust guidance to support them when caring for patients in crisis. For example, these included the use of rapid tranquilisation and restraint, although these were a last resort option. Staff understood the legal framework for their use. Trust policy was only security staff and police who had completed required training could carry out physical restraint. In accordance with trust policy, nursing staff had no training in restraint but did receive training in conflict management.

Staff changes and handovers included all key information to keep patients safe. During the inspection we attended handovers and 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 evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

The hospital’s theatre provision consisted of a main theatre suite, with 10 theatres, and a Day Surgical Unit (DSU) with 6 additional theatres. The main theatre suite and the surgical day unit were located in different areas of the hospital.

There was inadequate storage in both the theatre areas, with equipment and sterile packs of surgical instruments stored in corridors in both main theatres and the surgical day unit. This included surgical instruments that had been sterilised and packaged ready for use being stored on open racking.

The service recognised the challenges with storage was a contributory factor with sealed packs of sterilised instruments being damaged. For example, heavy packs being stored on top of each other resulting in damaged wrapping. Additionally, staff told us the limited space in the corridors meant that occasionally sealed packs were damaged inadvertently by equipment being moved around. This meant the service could not always be assured they remained sterile and safe to be used in theatre. To mitigate this, tray labelling has been relocated on the trays to reduce the need for handling when identifying contents. The service had introduced additional checks of the sealed packs in storage areas, prior to use in theatre, to confirm their integrity. This was an additional process for staff and it had meant no damaged packs had gone to theatre. This also reduced theatre delays for example when previously damaged packs had been identified and a replacement sourced before a procedure could proceed.

Best practice guidelines (HBN0301-PartA, section 8.50 and 8.51) state sterile packs and equipment should be stored in well-ventilated areas to limit potential contamination or damage to integrity of the packs. The challenges with space and storage meant the service was not adhering to these guidelines. Data provided by the trust showed regular servicing and air-handling checks had been carried out. However, the data referenced specific theatres, and not the corridor areas, so we could not be assured the corridor area met the required checks. Mitigations taken by the service ensured there had been not reported evidence of harm to patients as a result of damaged sterile packs.

A CQC inspection in 2018 identified issues regarding storage of some equipment used in theatres, specifically at that time in the day surgical unit.

Although not directly related to the previous 2018 issues the continuing lack of space and storage hindered the safe movement of staff, equipment and access to medical gases safety valves, posing potential safety risks.

Hospital leaders were aware of the lack of storage and these concerns had been documented in the service risk register. Minutes of surgical division governance meetings and Health and Safety committee’s indicated evidence of on-going discussions relating to identified issues. Leaders confirmed plans for a new theatre suite, which had included additional storage capacity, had not materialised due to funding restrictions. Consequently, the existing space constraints remained a significant challenge.

The service put in interim measures to mitigate and manage current storage capacity issues until more permanent solutions were implemented. For example, the service had increased the frequency of fire safety walk-arounds and these were carried out weekly by fire wardens from the theatre team. Theatre fire wardens documented their findings using a checklist and submitted these to trust fire team and Health and Safety committee for oversight. Additional fire safety training for staff had also been rolled out. Despite these additional safety measures the potential risks remained.

Staff reported the physical space within the surgical footprint of the hospital lacked the capacity to support the current patient volume. This resulted in delays and the admission or discharge of patients to areas not designed for this purpose. Despite mitigation to manage the challenges of this. for example, restricting access, limiting footfall and the use of curtains up around bed spaces, we saw examples whilst onsite where the reception area for main theatres still lacked privacy for patients. For example, we observed theatre staff collect a patient for surgery from this reception areas. They undertook a verbal handover of the patient in the area directly outside of the main theatre doors. The handover included confirmation of the patient’s identification and included the nature and details of their procedure. Other members of staff not involved in the patient care were observed walking past at this time.

The newest part of hospital building was built in the early 1990’s and, although compliant at the time of construction, did not fully comply with best practice standards as set out in current Health Building Notes (although these are not retrospective). For example, the day surgical unit did not have piped oxygen and suction for all beds, which was not in line with best practice standards. The service mitigated the risk to patients should they deteriorate or become unwell, by use of portable oxygen cylinders at bedside locations. There had not been any reported incidents or harm to patients as a result. However, we were not informed of any plans to improve the position regarding the old premises although longer‑term estate improvements were being considered.

Staff told us there were insufficient plug sockets within the main theatre suite. This was partly attributed to the age of the theatre suite and increased amount of electrical equipment used in modern day surgery. This meant the service was using extension leads to enable equipment to be powered. This had been documented on the trust risk register and minutes of governance meetings evidenced on-going awareness of the concerns.

Actions included the trust estates team had increased the frequency of monitoring of the extension leads to daily, and had implemented additional safety checks of equipment. For example, ensuring leads did not create a trip hazard for both staff and patients, and checking one extension lead was not connected to another, as this practice is a known fire safety risk.

The trust had and was continuing to work with the fire service to determine their risks and to increase fire safety awareness amongst staff. The fire service had assisted with staff training. They had assessed the theatre suite in relation to evacuation in the event of an emergency.

Specialised emergency equipment, such as the difficult intubation trolley and the cardiac arrest trolley, were checked and secured following national guidance and local policies, guaranteeing its readiness for immediate use in emergencies.

The day surgery unit relied on some specialised emergency equipment that was, at the time of the inspection, located within the main theatre suite. Not all staff could effectively describe the process for obtaining the equipment in the event of an emergency. This, together with the distance between the 2 departments, raised a concern about the ability of staff to respond effectively should there be a time-critical emergency. Following feedback, the trust immediately reviewed their provision of emergency equipment within day surgery unit and located additional emergency equipment within the day surgery unit.

The ward-based environment for the surgical service was generally well-maintained, designed and managed in accordance with national safety guidelines to meet patient and staff needs effectively. The surgical wards were observed to be in good condition, promoting a safe and efficient care.

Staff reported some challenges with capacity during times of increased patient activity. These periods of increased activity were managed in accordance with trust policies and procedures. For example, placing extra beds in ward based bays and then removing them when not required.

Staff managed clinical waste safely and in accordance with trust policy.

The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Staffing was planned and managed according to national guidance. Leaders used recognised staffing tools to ensure there were enough staff to deliver care and treatment.

Nursing staffing levels were generally stable, with the service having enough nursing and support staff with the right qualifications, skills, and experience to provide safe care. During our inspection for example, the nursing establishment was met on the Day Surgical Unit (DSU). Nursing staff vacancy and turnover rates were consistently low across the surgical service, for example in the 12 months prior to the inspection day surgical unit this was recorded at 0% (zero). The highest turnover rate for the service was in theatres, at 11%. The average across the surgical service was 7%.

Managers reviewed and adjusted staffing levels and skill mix daily to ensure adequate coverage. Staffing was discussed during regular site management meetings at trust level so staff could be deployed if needed. We attended one of these meetings and observed staffing discussions between leaders and teams. Staffing was monitored through governance meetings and by the Director of Nursing to ensure there were sufficient staff to provide care. Where necessary, temporary staff were utilised, primarily bank staff who were employed by the hospital. The trust had a staffing policy that outlined procedures for managing and governing safer staffing levels, particularly during periods of high pressure.

The service utilised an internal staff bank, ensuring shifts were covered by staff who were already familiar with people’s individual risk assessments and communication needs. The service had a low dependency on agency staff; when they were required, the provider ensured they were regular workers who were familiar with procedures in the hospital and the needs of patients served by the service.

The service had recruitment practices to ensure that all staff, including agency and volunteers, were suitably experienced, competent, and able to fulfil their roles. All staff we spoke with, including medical personnel, nurses, and volunteers, confirmed they had received an induction and training to support them in their roles. The service also ensured competency documentation for medical and anaesthetic staff, supporting safer recruitment and staff development.

Managers made sure staff received training and regular appraisals to maintain high-quality care. Data provided by the trust showed high percentage rate of appraisal completion. For example, the trust reported that 86% of nursing staff in the surgical division had received an appraisal in the previous 12 months.

Nursing staff on wards had training in managing a deteriorating patient, specifically ILS (Immediate Life Support). In other areas, such as pre-assessment, nursing staff had training in specific key competencies to allow them to carry out their role safely and effectively.

Staff followed a programme of mandatory training. Staff told us the training provided was effective and they felt supported to access more training if they needed it. Mandatory training subjects included, but were not limited to, safeguarding, infection control, health and safety, moving and handling, information governance and equality and diversity. Training was a mix of e-learning and face to face sessions. Nurses were trained in medicine management, and their competencies were checked annually. The trust reported challenges with reporting their training. However, nurse leaders had access to dashboards displaying compliance rates for staff they managed. We reviewed a sample of dashboards during the inspection and data from the trust after the inspection. We found, with the exception of safeguarding training (as noted earlier in the report), good compliance rates. For example, compliance for Equality and Diversity training was 89%, Fire Safety was 86%, Infection Control was 88% and Moving and Handling was 88%.

The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff followed infection prevention and control (IPC) guidance, washed hands between patient contact and wore personal protective equipment (PPE). The trust had an infection control policy, and staff had access to it electronically. There were infection control lead and infection control link nurses available to support the ward staff with any infection concerns.

Operating theatres and surgical wards appeared visibly clean and free from dust including in hard-to-reach places. Cleaning staff were visible in most wards and departments. We observed nursing and theatre staff cleaning their clinical areas and equipment during periods of downtime or before clinics had started, for example in pre-assessment. However, the lack of space within the theatre environments meant it was difficult for effective cleaning.

Inadequate storage space for surgical equipment and sterilised surgical instrument packs had contributed to damaged sterile wrapping. The service implemented enhanced procedures and protocols to verify the integrity of the sterile packs. Where packs were found to be damaged they were removed and sent to be resterilised and packaged. Service reported that these additional checks had prevented damaged sterile packs from reaching surgery.

The trust monitored the number and type of infections seen in the hospital. Regular audits were mostly carried out by teams in clinical areas, supported by the infection prevention and control team. Hand hygiene and environmental audits including equipment audits were carried out. The results of these audits were discussed with the relevant departments and an action plan to identify areas of deficit agreed. For example, an audit on one surgical ward identified a lack of understanding of the importance for compliance with the hand hygiene policy. Ward leaders undertook a series of training sessions with their teams, including showing a hand hygiene video. Ward leaders report improved understanding amongst staff. Random sampling of hand hygiene audits in the surgical service carried out in February 2025 demonstrated the wards were consistently over 95% compliant.

Staff had access personal protective equipment (PPE) stations around the service. The stations included hand sanitiser, gloves in all sizes and aprons for staff. Staff used personal protective equipment correctly and in accordance with trust policies. Clinical waste was managed safely and segregated appropriately.

Staff were trained in the management of surgical wounds. Staff understood the risks and the impact of surgical site infections (SSI) for patients. The service collected data relating to SSI and reported these externally as required. For example, we saw external reports that compared trust SSIs for orthopaedic surgery against other hospitals carrying out the same procedures. Reported rates of SSIs at the trust were low and compared favourably against other hospitals.

Patients who required isolation care were provided with single rooms and staff managed barrier nursing effectively. These practices protected staff and patients from the spread of infection.

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. However, they involved people in planning, including when changes happened.

The service had safe systems for and the safe handling of medicines. Pharmacy staff formed part of the ward based team and contributed to ward level including activities such as medicines reconciliation and chart screening. Best practice guidance suggests medicines reconciliation should be completed as soon as possible after a person has been admitted or treatment has changed. Guidance stated changes must be fully documented, including the reason for the change, on the person's medicines care plan or electronic record. We saw this reflected in patient records. However, in the trusts annual medicines assurance report for 2024-2025 that the clinical pharmacy team were not achieving the national targets relating to medicines reconciliation within 24 hours of admission. It was reported the national target was 100% and the trust was achieving an average of 30% compliance. It was noted however, that despite the low rate of compliance, this was comparable to their peers. The trust and clinical pharmacy team were in the process of recruiting additional pharmacists and it was anticipated that this would improve the position.

Medicines including controlled drugs were stored securely and safely. Our observations and review of documents showed staff followed established systems to manage medicines safely. Medicine administration records we reviewed were complete. There were systems and processes 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. For example, we saw evidence of completed audits of controlled drugs (CDs) on surgical wards. The audits reviewed the accuracy of record keeping, ensuring it followed trust policy and noted any areas for improvement. One example identified was staff using initials, instead of full signatures, when signing out CDs. This was noted on the audit documentation and fed back to ward leaders.

Pharmacists played an integral role in supporting the surgical wards, providing timely assistance with medicine-related queries. An on-call pharmacist service was available outside regular working hours, ensuring continuous support. Medicine incidents were discussed in departmental meetings, with learning shared across the trust by the medication safety officers and technicians. The clinical pharmacy team noted in their annual report (2024-2025) that there was a good reporting culture for incidents involving medicinces. For example, for the period April 2024 to April 2025 (for the trust) 94% of incidents reported involving medicines were classed as No Harm.

The service had introduced a new, staff-led initiative within pre-assessment. Pharmacists were embedded within the surgical pre-assessment team and reviewed patient’s medications during the pre-assessment process. Staff described how this was a new development to the pre-assessment service and provided examples of how they worked with patients, the nursing teams and GPs to optimise patient’s medications prior to surgery. Staff described the positive impact this process could have for patients attending for surgery. For example, they described where they had been able to proactively liaise with a patient’s GP prior to admission. This had enabled them to arrange for medications that supported their management of substance misuse to be available on the ward post-surgery.