Pilgrim Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that people’s care needs were assessed and reviewed.

At our last inspection we rated this key question as good. On this inspection we found some areas that required improvement, however, we only looked at a small number of quality statements. Therefore, the rating has remained good. This meant that people’s care needs were not always assessed and reviewed.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

Patients were assessed on arrival to identify urgent needs. When reviewing care records, we could see appropriate risk assessments were completed on entry to the ward. We could see that specific pathways were identified and followed, such as the delirium pathway and frailty assessment. Specific risks such as falls and tissue viability are identified early. However, assessments were not always regularly reviewed and updated to ensure care remained appropriate. When reviewing care records there was some inconsistency with regularly reviewing of risk assessments.

When reviewing care records, we saw that some patients were requested to be on daily weights by the doctor and the paper form had not been completed for the week. Staff completed the falls‑risk checklist for patients, but they did not consistently ensure that high‑risk patients wore yellow wristbands as required by the assessment. Staff did not consistently give non slip socks to patients who required these.

Patients’ communication needs were not always clearly assessed and supported using appropriate tools or strategies. During our visit, we observed that there was no signage displayed on the bedside to identify patients with communication needs. Staff also reported issues with accessing the interpretation service for patients who did not speak English when patients could not mobilise to the phone on the ward. Accessing in person translation services was not always timely.

Staff completed a handover process which highlighted patient risks and needs for the staff member coming on to begin their shift. Staff demonstrated an understanding of clinical risk indicators, such as the National Early Warning Score (NEWS2). Staff discussed appropriate escalation pathways and used these to manage clinical risk. Patients for discharge were highlighted. Staff identified patients in isolation, patients at high risk of pressure injuries, diabetic patients, patients requiring enhanced care, new admissions to the ward and outstanding risk assessments.

Matrons undertook monthly documentation and risk assessment audits. As part of the inspection process, we reviewed data from July to December 2025 from the trust for the areas we inspected. The skin‑integrity audit showed mixed results. Wards 6A and 7B performed well, although daily documentation on 7B was not always complete. Ward 8A also performed well, but staff did not always share the booklet with patients. Several areas on wards 6B and 7A needed improvement. Falls‑documentation audit results were consistently good across all wards, except for one issue on ward 7A: the daily falls‑risk monitoring checklist was not always completed correctly.

Staff identified patients who were at the end of their life as early as possible to make sure support was in place. Staff knew how to contact the specialist palliative care team and would do so if they required additional support. Staff told us they involved family and friends in the process.

Staff screened patients for malnutrition and dehydration risks. Staff knew how to contact the team for specialist dietary support. Staff used the national tools to assess patients, and followed correct procedures for high risk patients. However, when reviewing care records, we saw that fluid balance charts were not always completed consistently.

The service had systems in place to support patients nutrition and hydration needs. We observed staff appropriately using red meal trays for patients needing assistance during mealtimes. The red tray indicated that the patient needed additional support. We observed that all patients had a jug of water placed on their bedside table. We saw staff providing additional support to patients who required further assistance. There were differences in practices on the wards, with some going through a pilot scheme using different coloured lids.

Matrons undertook monthly nutrition documentation audits. From July to December 2025, nutrition audits showed good practice across all wards, except for consistently poor evidence of oral care being completed. Hydration audits were good on wards 6A, 6B and 7B, apart from issues with completing daily balances and carried‑forward columns. Several areas on wards 7A and 8A required improvement.

Patients were screened for mental health needs and referred appropriately. Staff told us they were aware of the process for referring. We saw evidence of a referral being made when reviewing care records. Staff told us that the mental health team were very supportive and would prioritise review for patients who are ready for discharge.

Staff could access additional support from other teams when needed. Staff told us that they received regular support from physiotherapists and occupational therapists. Allied health professionals were visible on the wards we visited, and we saw evidence of their involvement in care plans we reviewed. The service had a dementia lead who was visible across all the wards we visited. Staff spoke positively of the support received.

We did not look at Delivering evidence-based care and treatment during this assessment. There is no previous rating for the Effective key question so we cannot yet publish a score for this area.

We did not look at How staff, teams and services work together during this assessment. There is no previous rating for the Effective key question so we cannot yet publish a score for this area.

We did not look at Supporting people to live healthier lives during this assessment. There is no previous rating for the Effective key question so we cannot yet publish a score for this area.

We did not look at Monitoring and improving outcomes during this assessment. There is no previous rating for the Effective key question so we cannot yet publish a score for this area.

We did not look at Consent to care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.