Pilgrim 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

We looked for evidence that people were protected from abuse and avoidable harm, were in a safe environment, had a proactive and positive culture of safety, worked with people to understand and manage risks, maintained safe and effective staffing levels and managed medicines appropriately.

At our last inspection we rated this key question as good. At this inspection the rating remained good, however on this inspection we found some areas that required improvement. The service did not always maintain safe and effective staffing levels and there were some concerns in relation to Deprivation of Liberty Safeguards (DoLS) paperwork and restrictive practices. However, the service had a proactive and positive culture of safety, maintained a safe care environment, worked with people to understand and manage risks and made sure medicines and treatments were safe and met people’s needs.

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 3. 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. We scored the service

Staff raised concerns and reported incidents. Staff felt safe to speak up without fear of blame and felt there was an open culture. Concerns were raised proactively to prevent risks and were taken seriously by ward leaders. Staff felt confident to intervene to prevent harms occurring where they identify an immediate risk.

Mandatory training in key skills is provided to all staff and leaders make sure everyone completed it. Mandatory training was sufficiently comprehensive to meet the needs of patients and staff. Staff considered safeguarding concerns when an incident occurs, referrals would be made or advice would be sought.

There were no never events on the wards we inspected between January 2025 and January 2026.

As part of the inspection process we requested reviewed all datix information and looked at a selection of incidents of varying types and degrees of harm. Evidence showed investigations had taken place into all of the identified incidents and lessons learned were identified. Learning included additional training for staff and teams, reminders about processes and procedures and strengthening of the handover process. We also saw actions involving the freedom to speak up guardian and the patient experience team.

There was consideration of themes and trends and these were addressed as such rather than as isolated incidents. Falls, slips, and trips followed by pressure injuries and moisture associated skin damage were the most reported incidents. The service had working groups in place to provide oversight and support with improvement work such as the skin integrity group and the falls steering group. There had not been any specific thematic reviews undertaken in the wards or areas we inspected.

The provider had a current incident reporting and reviewing policy that reflected the national guidance. The policy was reflective of Patient Safety Incident Response Framework (PSIRF) and policies were accessible. The PSIRF set out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. The service had mechanisms to disseminate learning, however this was not standardised across all areas we inspected. Staff shared examples of involvement in incident investigations. Staff received feedback from investigations of patient safety events. Managers debriefed and supported staff after patient safety events.

Staff understood Duty of Candour and when it applied. They were open and transparent and gave patients and families a full explanation when things went wrong. Staff could get support when they needed it and could provide examples of when they had been supported. As part of the data request, we were provided with examples of written duty of candour, which had been completed appropriately and followed up verbal duty candour. The trust monitored compliance against both verbal and written duty of candour via datix.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The evidence showed some shortfalls. There were some concerns in relation to Deprivation of Liberty Safeguards (DoLS) paperwork and restrictive practices. However, the service worked with people to understand what being safe meant to them and how to achieve that. They concentrated on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

The service had a safeguarding policy, and staff were aware of it and followed it. The safeguarding policy followed national guidance. Staff were confident identifying and reporting abuse and neglect and concerns were documented. Staff could provide clear examples of safeguarding concerns they had reported.

The service ensured that all staff were trained to appropriate levels for their role, including the recommendations set out in the intercollegiate guidance. As part of the inspection process, we requested safeguarding mandatory training data from the trust. The average completion rate across the wards we inspected was 97.3% for adults and 97.4% for children, with no individual wards or modules falling below the 90% trust target.

Staff had access to the safeguarding team and lead if required. Staff told us the safeguarding team were accessible. Staff could access safeguarding expertise outside of usual hours. Staff had access to the hospital social work team.

Staff applied Mental Capacity Act (MCA) principles consistently and it was embedded in practice to minimise restrictions. Patients were supported to understand information and make decisions. When people lacked mental capacity, best interest decisions were made, taking into account the views of friends and family.

Staff were trained in MCA and Deprivation of Liberty Safeguard (DoLS). As part of the inspection process, we requested MCA and DoLS mandatory training data from the trust. The average completion rate across the wards we inspected was 88.9%, with 5 wards falling below the 90% trust target. However, all wards had at least 80% mandatory training completion.

When patients were subject to DoLS, the required assessments and documentation were not always completed when restrictions were put in place for their safety. On the day of inspection, we reviewed a patient who was identified as requiring mittens during the handover process however the mittens were not in use at that time. When asked, a staff member explained that the patient could become agitated during personal care, sometimes hitting or scratching staff so mittens were used. The patient’s notes did not have the appropriate DoLS authorisation. A DoLS pathway was in place, and the Mental Capacity Assessment (MCA) completed by staff indicated that the patient lacked capacity and required DoLS. However, it stated that the patient did not require restraint (including physical restraint or equipment such as mittens). The issue of restraint (mittens) being marked as “no” on the DoLS pathway was raised with the nurse in charge. They confirmed that the DoLS should be reviewed regularly when there are any changes and asked the nurse caring for the patient to review and update the pathway.

On the day of inspection on ward 6A, most of the patients had their bedrails up. A bedrail risk assessment with RAG rating was in place in the patients’ notes. However, when we asked a staff member how they decide whether a patient requires bedrails, the staff member stated that if patients are sleeping and they feel the patient may be unsafe without bedrails (e.g., may roll out of bed), they put the bedrails up. There was signage in patient bedspaces indicating whether the patient wanted the bedrails up or not. However, none of these signs had been completed. Bedrails may constitute a restrictive intervention, particularly for patients who are not cognitively impaired or who have capacity, leading to potential breaches of patient autonomy and human rights.

On a monthly basis matrons undertake audits, these include looking at use and documentation of MCA and DoLS. As part of the inspection process, we requested this data between July and December 2025 from the trust for the areas we inspected. The results for ward 6A were 100% for everything, for wards 6B, 7B, 8A and the discharge lounge results mostly positive and for ward 7A consistent issues in relation to ‘patients shown to lack capacity have the appropriate best interest care plans’ and ‘use of the DoLS scoping tool’ were identified.

The safeguarding team also completed MCA audits of wards, which included looking at DoLS practice. We were provided with the most recent examples as part of the data request. On wards 6B, 7A and 8A no issues were identified. On ward 6A, issues were identified with ‘DoLS checklists in place but still not followed the guidance about chasing up with the local authority’, with the action of ‘ward staff be reminded to familiarise themselves with the DOLS process’ being identified.

The evidence showed a good standard. 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.

Risk assessments were aligned with national guidance and covered key risks `with clear timeframes for action. Risk assessments were used to tailor care with support from the wider hospital multi-disciplinary teams. These risk assessments included falls, frailty, dementia, tissue viability, malnutrition, hydration, Venous thromboembolism (VTE) and sepsis. However, risk 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. Risks and mitigation strategies were shared with patients and families. Patients were regularly assessed for the presence of pain and pain was managed.

Staff were supported to identify and manage deterioration of patients’ condition. The service had policies and processes in place which followed national guidance, and staff were aware of these. Leaders were assured that deterioration was recognised and managed. Temporary staff had access to electronic systems.

The hospital used the national early warning Score 2 (NEWS2) to allow rapid detection of the signs of early clinical deterioration in adult patients. NEWS2 was calculated on admission and used for ongoing monitoring of patients, with scores clearly displayed on screens for staff. Staff demonstrated a strong understanding of NEWS2, and prompt action was taken when a patient deteriorated. Staff triggered appropriate escalation pathways used to manage clinical risk. As part of the inspection process, we requested mandatory training data from the trust, which included resuscitation. The average completion rate across the wards we inspected was 94.3%, with only ward 7B (81.4%) being below the trust target.

There was a hospital-wide approach to deterioration and appropriate clinical staff would respond when called. Staff told us there was a good out of hours response to clinical deterioration. Staff could also access senior reviews out of hours and consultants would attend.

Patients and families could raise concerns. We saw families raise concerns with staff whilst on inspection. At the time of inspection, the service was in the process of implementing Martha’s rule. Martha’s Rule was an NHS England patient safety initiative allowing patients, families, and carers to request an urgent, independent review if they are worried that a patient's condition is worsening and they are not being heard. Patients and families were kept informed about treatment decisions.

Staff avoided restraint where possible. Restraint use was safe and proportionate but not always monitored and recorded. It was discussed at handover to ensure staff were aware. We observed a patient who was subject to restraint (mittens) marked not requiring restraint on the DoLS pathway.

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 environment on the wards was safe. Staff ensured that corridors were not overly cluttered despite having equipment on them. Equipment was stored in storerooms where possible. Exits were not blocked and there was no evidence of storage of equipment or consumables on any stairwells. Both patient and staff lavatories were clean and were designated single sex. Doors were locked appropriately and staff had swipe card access. Patients could not access stairwells, high balconies or roof spaces. Window restrictors were in good repair. Staff had a private and confidential staff area on the ward. Water temperature for handbasins, baths and showers safe was safe. Control of Substances Hazardous to Health Regulations (COSHH) substances and cleaning products were locked away from vulnerable people. Waste was managed appropriately, including clinical waste.

The service had access to equipment to accommodate diverse needs, such as bariatric patients. All bed spaces had curtains and oxygen. There were minimal trip hazards in any areas where there are patients at increased risk of falls, however some clutter was seen at patients’ bedsides, including personal belongings such as clothes and toiletries stored in bags on chairs rather than in bedside cupboards. There were sufficient call bells on the wards and in the toilets which patients could access. Lights were dimmed at night.

Staff had access to sufficient equipment to meet the service demand to enable treatment and monitoring of patients. Electrical equipment was monitored for safe use. Resuscitation equipment checked regularly.

Staff report faulty equipment to estates. Staff told us estates issues can take a long time for things to be fixed, but if it was critical, it would be escalated. We saw that lots of estates issues had been reported by staff as signs were placed on the wards. On ward 6B there were 4 patient toilets on the ward with 1 not in use, staff told us this could cause issues with people waiting to use the toilet. This had been escalated to estates.

As part of the inspection process, we requested patient-led assessment of care environments (PLACE) data from the trust. Visits had taken place at Pilgrim Hospital within October and November 2025, these visits reviewed wards 6A, 6B and 8A. These visits had not yet been published so we did not have the data. The most recent published data was from March 2025, wards 6A, 7B and 8A had been reviewed. Categories reviewed were food, cleanliness, privacy, condition, dementia and disability friendliness. Ward 6A scored above 80% on all categories, ward 7B scored above 80% on all categories expect dementia friendliness (74.1%) and ward 8A scored above 80% on all categories except dementia friendliness (69.6%) and disability friendliness (78.6%).

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. However, they make sure staff received effective support, supervision and development. They work together well to provide safe care that met people’s individual needs.

Staffing met establishment levels, with qualified and competent staff across all shifts. Staff told us that when there were large numbers of enhanced care patients on wards with increased acuity, which could lead to an impact upon the overall staffing levels.

There was an appropriate skill mix on the wards and a supernumerary senior nurse on shift. Observation of the wards suggest that there were mostly adequate nurse staffing levels. However, when there were a large number of enhanced care patients or patients requiring 1-2-1 care it became stretched and patients could be left unobserved. This was an issue for combined staffing levels including healthcare support workers and nursing staff. Staff told us when it was busy or there were uncovered shifts it would be a struggle provide as much patient care as they would like to.

We observed on several occasions that the enhanced care bays were left without staff present. Staff were available to provide 1-2-1 care when needed. However, this had an impact on the safety of the staffing on the rest of the ward. Whilst on inspection we saw healthcare support staff were needed to provide 1-2-1 care for 2 different wandering patients on the same ward. This impacted their ability to maintain safe observation of enhanced care patients who were higher risk, as only 3 healthcare support staff were left with the remaining patients.

Staff told us that due to the nature of the patients on the ward this happened often, and could also happen in greater numbers, often no additional support is provided. Staff expressed concern that this is not safe for the patients or the staff, given the lack of staffing to meet enhanced care needs.

The service tested whether it had safe nursing staffing levels on all wards and other clinical areas on an annual basis. They did this by reviewing the care hours per patient day and making adjustments where needed. In the 2025 review all wards we inspected were reviewed. As part of this review, we saw evidence that establishment levels had been increased in some areas.

There were named consultants for patients on the wards. Senior clinicians were immediately available at all times for emergencies. Staff told us there was appropriate out of hours medical cover for the wards, and medical staff responded quickly.

There was no effective medical cover for patients in the discharge lounge, as patients were deemed medically stable and ready for discharge. There was an inclusion / exclusion criteria in place, however, at the time of inspection staff told us that there was no inclusion/exclusion criteria being used and patients were often arriving medically unstable and not fit for discharge. It was also a challenge to get patients medical reviews. We were provided with a standard operating procedure (SOP) which was going through governance processes at the time of inspection, this came into place on 20 February 2026, clarifying that patients remain under the care of the consultant team who have provided care for them on the wards or departments. This SOP also provided contact information for each speciality in and out of hours.

As part of the inspection process, we requested staffing data from the trust. As of December 2025, medical establishment for wards 6A and 6B was 81.3%, 7B was 107.7% and for 7A and 8A was 146.5%. Ward 7A did not technically have an establishment level as it was a temporary ward which explains why the over is much higher. There was no medical establishment level for discharge lounge, as patients remained assigned to the consultant which they were under on the ward.

When there were gaps in the medical rota or sickness, the service would use bank and agency staff to cover. Data provided by the trust showed that over the course of 2025 on average bank and agency staff usage had significantly reduced across the wards that we inspected.

As part of the inspection process, we requested staffing data from the trust. As of December 2025, nursing establishment for ward 6A was 109%, 6B was 114%, 7B was 120%, 8A was 86.7% and the discharge lounge was 83.7%. Ward 7A did not have an establishment level as it was temporary ward. Staff told us the biggest issue with recruitment was for healthcare support workers rather than nursing staff. The nursing establishment levels had been improved by a recruitment drive from overseas.

As part of the inspection process, we requested staff sickness data from the trust for the year 2025 and we looked at the average. Wards 6A (2.8%) and 8A (4.9%) had low staff sickness levels, the discharge lounge (6.5%) had average sickness levels and wards 6B (8.9%) and 7B (9.5%) had high staff sickness levels. Ward 7A was a temporary was so data has not been included.

When there were gaps in the nursing rota or sickness, the service would use bank and agency staff to cover. Data provided by the trust showed that over the course of 2025 on average bank and agency staff usage had significantly reduced across the wards that we inspected. Staff told us that bank shifts were mostly covered.

There was a 7-day allied health professional service which covered wards to support discharge and prevent deconditioning. This included access to pharmacy support, dieticians, physiotherapists and occupational therapists. The service also had support from a frailty team, tissue viability team and dementia support. Patients received allied health professional support in line with their care plans. Wards had administrative and clerical staff.

The service had recruitment processes which met NHS Employment Check Standards, which included identification, DBS, health, qualifications, right to work and references.

All staff received inductions, appraisals, and revalidation support. Training, supervision, and continued professional development aligned with staff needs. The service had clinical educators who supported staff. Staff had regular appraisals. As part of the inspection process, we requested staff appraisal data from the trust. The average completion rate across the wards we inspected was 95.3%. The service had lots of internationally recruited nurses who were well supported and were part of the team.

All staff completed mandatory training, and this was monitored by leaders. Staff received mandatory training in conflict resolution, fire safety and local procedures, equality diversity and human rights, health safety and welfare, infection prevention and control, resuscitation, safeguarding adults and children, information governance and the Mental Capacity Act. As part of the inspection process, we requested mandatory training data from the trust. The average completion rate across the wards we inspected was 94.7%.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

Medicines were stored safely. There was sufficient storage for medicines, including refrigerated and controlled drugs. Storage rooms were secure and appropriately temperature controlled for all medicines. Temperature monitoring forms were completed daily by the night staff, as evidenced by the daily check forms. Emergency medicines were checked regularly for availability and date. Medical gases were managed safely and only piped gases appropriate for the area available. Oxygen ports were available at each bedside and staff had access to oxygen on the resuscitation trolley, no other medical gases were stored on the wards. Controlled drugs and patients’ own medicines were stored securely per policy. Patients’ own medicines were labelled and stored in individually assigned bedside cupboards. However, we observed two cupboards had been left unlocked after medication rounds. We informed the staff at the time and these were locked.

Critical medicines were identified, prescribed, supplied and administered appropriately. Staff on the wards have access to a pharmacy team. Pharmacy support was available out of hours. Staff on the ward reported that for medications required out of hours they will check the stock on other wards nearby to see if it is available. If it is not available, they will contact the on call pharmacist. Staff told us that pharmacy response was timely. We saw pharmacists on the ward providing medications support to staff.

Medication rounds were conducted by the nursing staff. The rounds were calm, timely, and uninterrupted. Staff wore red disposable tabards indicating that a drug round was in progress and they should not be distracted. Medicines were administered safely and in line with guidance, nurses checking patient identity, allergy status, and recorded administration promptly in the electronic medication system. We observed staff complete two nurse sign off where required.

Allergy status was recorded and visible consistently in records we reviewed. Venous thromboembolism (VTE) were carried out consistently. Weekly patient weights were recorded for long stay patients but daily weights were not always recorded when requested.

On one occasion during the inspection we observed time critical medication had not been administered. On the electronic system, the general medication overview screen does not immediately highlight time critical medicines. These alerts were available, but you had to go into the specific medicines within the system. This posed a risk, particularly for newly qualified staff or staff not familiar with the ward or system, as they may not yet be familiar with identifying critical medications.

Assessments were conducted in line with the Mental Capacity Act 2005 to determine if a person has capacity to decide about their care and treatment including refusal of prescribed medicines. If a patient who lacked capacity refused critical medication, the service had a process in place for administering covert medications. Staff would always encourage the patient to take the medication before using a covert approach.

The service audited its medicines management. Matrons undertook monthly audits, which included medications. As part of the inspection process, we requested this data between July and December 2025 from the trust for the areas we inspected. This audit included medications, missed doses and storage. We reviewed these results and they were mostly positive with a few exceptions. On wards 6B, 7B, and 8A there were consistent issues with ‘drugs trollies being triple locked’, on ward 7B and 8A there were consistent issues with ‘liquid medication in trolleys not having a date opened label’, and on ward 8A there were consistent issues with recording patients’ weights. The discharge lounge had more negative results in the audit. It performed inconsistently ensuring medication had been given, issues with drug trolley cleanliness and not being fixed to the wall between use, liquid medication in trolleys not having a date opened label and evidence of loose medication not in packages. Pharmacists also undertook controlled drugs audits.

Staff reported medications incidents and actions were taken as a result. Staff we spoke to did have any themes around specific medication incidents. As part of the inspection process, we requested incidents that had taken place between 1 February 2025 and 31 January 2026. We could see staff were reporting medicines incidents and actions were taken as a result.