Royal Shrewsbury 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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last inspection we rated this key question as requires improvement. At this assessment the rating stayed the same. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. COSHH was not always stored safely to keep people safe from avoidable harm. Infection prevention and control guidance was not always followed. The service did not always have enough nursing and support staff to keep patients safe. Medicines and treatment were not always safe and did not always meet people’s needs.

The service was in breach of regulation for staffing, Malnutrition Universal Screening Tool and safe management of medicines.

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. We scored the service

Staff knew how to report incidents through the electronic reporting system and could give examples of incidents they had reported or would report. Over the 12 months prior to our inspection, a total of 5,602 clinical incidents and 1,017 non-clinical incidents were reported across both trust sites. There was 1 serious incident recorded during this period for the Acute Medical Unit.

We reviewed a selection of after-action reports relating to clinical incidents, including cases such as an unsafe discharge where a patient’s care package had not been reinstated, and a missed referral to haematology outpatient services following an inpatient stay. These reviews showed that leaders carried out thorough investigations, involving external parties when necessary. Action plans were developed and regularly updated. Incidents were discussed on a weekly basis during medicine safety huddle meetings, where overdue incidents were also highlighted to ensure follow-up.

Managers promoted regular communication through "message of the week" notices, safety reminders and clinical guidance updates. Information was readily available to support staff learning, adherence to standards and awareness of current priorities.

Staff understood the duty of candour. The Trust had clear processes for disclosing incidents to patients. We found the medicine division followed the duty of candour policy by providing feedback and investigation outcomes when necessary. Incidents were regularly audited where pressure ulcers, skin integrity, and falls were the most common issues identified. We reviewed three incident investigation reports and found all included clear action plans.

Debrief sessions were available following serious incidents, and staff described these as an opportunity to review what had happened.

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 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. Clinical records reviewed showed evidence of comprehensive assessments, escalation planning, care planning and consultant review. Documentation relating to falls, nutrition, observations and risk assessments was generally completed appropriately.

Staff maintained comprehensive documentation relating to falls prevention, capacity assessments and discharge planning. Staff told us falls prevention was a key priority. The wards used comprehensive assessment documentation, including mobility assessments, falls prevention plans, bed rail assessments, mouth care assessments and personalised care planning for people identified as being at risk of falls. Staff completed comfort assessments that considered accessibility of walking aids, environmental risks and patient well-being.

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. Staff described increasing pressures on same day emergency care (SDEC) and acute medicine pathways. Significant numbers of referrals were received from community and primary care services. Capacity pressures meant some patients could spend prolonged periods within SDEC while awaiting assessment, treatment or onward plans. Staff reported that cross-border commissioning and funding arrangements could contribute to delays. cross-border commissioning is the process of planning, funding, and arranging healthcare services for patients who live in one area or country but receive treatment in another.

The service had oversight of the patients who were medical outliers. From 8 January to 16 March 2026, the service had 10 medical outliers (medical patients cared for in surgical wards). All senior consultants were responsible for the daily review of medical outliers, as defined within the Trust's standard operating procedure (SOP). The manager of the day acted as the daily accountable officer and ensured that this SOP had been adhered to consistently, supporting the safe and timely care of medical outliers. Patient flow co-ordinators were responsible for identifying any non-compliance with this SOP and ensured that timely escalations had been made to the manager of the day when required.

Key blood tests results were available within 1 hour of arrival at the pathology laboratory. Systems were in place for tracking and reviewing any outstanding blood test results after patients had been discharged. There was a system in place for tracking reviewed and outstanding results post-discharge.

Records were clear, accurate and files were stored securely and not accessible by anyone other than staff working at the service. Digital systems supported secure, up-to-date sharing across care partners.

The service had a system in place to identify and respond to deteriorating patients. Staff we spoke with demonstrated awareness of deteriorating patients and escalation processes. The service used visual management systems, daily board rounds and multidisciplinary reviews to identify risks and ensure deteriorating patients were reviewed promptly. Records reviewed showed that patients with increased early warning scores had been appropriately escalated, reviewed and managed. In one example, a deteriorating patient had commenced oxygen therapy, and an escalation strategy had been documented within the clinical record, including actions to take if the patient deteriorated further.

Staff highlighted high-risk concerns during handover. We observed a structured and well-organised handover process on ward 28. Staff used a safety huddle pro forma and documented risks, escalation requirements and overnight events clearly. Following the ward handover, nursing staff undertook more detailed patient-specific handovers and introduced themselves to patients in a respectful and friendly manner.

Staff used the Sick, Home, Other, Plan (SHOP) model to support structured ward reviews and discharge planning. The SHOP model is an operational structure used by NHS Trusts across the UK to manage daily ward rounds and improve patient flow. Patients were supported through established referral pathways to physiotherapy, occupational therapy, speech and language therapy, dietetics and respiratory services. Information and eligibility criteria were clearly available to staff.

The service operated virtual ward pathways which enabled monitoring and treatment for selected patients in their own homes. These services included frailty and heart failure pathways, remote monitoring, blood testing, medication reviews and clinical assessment.

The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The service shared concerns quickly and appropriately. Staff were trained to the national guidance recommended levels of safeguarding.

The trust had a target of 90% for the completion of safeguarding training for the various levels that different groups of staff were expected achieve. During our last inspection in 2024, we told the service they must ensure all staff complete mandatory and legally required training and medical staff complete safeguarding children’s level 3 training in line with trust targets. This had improved during this inspection. Compliance varied across safeguarding levels with 97.4% of staff compliant in adult safeguarding level 1 training, 97% compliant in adult level 2 training, and 93% compliant in adult safeguarding level 3 respectively. Similarly, 96% of staff were compliant in safeguarding children level 1 training and 95.5% compliance in safeguarding children level 2 training. However, only 77.8% of staff were complaint in level 3 safeguarding children training. Children and young people aged 16 to 18 years were cared for on dedicated wards within the medical care and surgical care services.

Staff we spoke with were confident in identifying and reporting abuse and neglect. Staff across various areas demonstrated a clear awareness of safeguarding and were alert to safeguarding concerns.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. Staff were aware of safeguarding responsibilities and escalation processes. They were able to recognise safeguarding concerns and make appropriate referrals.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

All staff we spoke with demonstrated an understanding of the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). MCA and DoLS documentation we reviewed had been completed appropriately.

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.

Staff had access to clear pathways to identify and respond to deterioration. NEWS monitoring, sepsis screening tools, escalation pathways and treatment escalation planning were used across the service. We reviewed an example of where a deteriorating patient had been recognised promptly and escalated appropriately, including the implementation of individualised escalation plan.

Risk assessments aligned with national guidance. Falls prevention was a significant focus across ward areas. Staff used falls risk assessments, bed rail assessments, neurological observation pathways, intentional rounding and post-falls review processes. Dedicated falls prevention equipment and visual prompts were available to support staff. We reviewed an example of an inpatient fall where the patient was reviewed promptly, neurological observations commenced and escalation processes followed.

Staff consistently recorded National Early Warning Scores (NEWS) across all records reviewed. However, the most recent deteriorating patient audit identified observation compliance for inpatients as significantly below the 90% target, achieving only 50%. An action plan had been developed to address and improve this performance. The nursing staff interviewed demonstrated confidence in recognising and escalating concerns relating to patients showing signs of deterioration.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. Patients and relatives, we spoke with said staff kept them updated with plans for their treatment.

At the time of our inspection, Martha’s Rule had not yet been implemented. However, plans were in place for its forthcoming introduction. Martha’s Rule is a patient safety initiative in NHS hospitals in England that gives patients, families, and carers the right to request an urgent clinical review if they are worried that a patient’s condition was deteriorating, and staff were not responding adequately.

Staff enabled patients to give feedback on the service they received. We saw posters publicising the Friends and Family Test on wards. Staff enabled patients to make advance decisions when appropriate.

Staff followed established sepsis pathways and had access to outreach and resuscitation teams, enabling timely clinical assessment and intervention when required.

Senior staff had oversight of enhanced care requirements, one-to-one observations, patients subject to Mental Capacity Act assessments, Deprivation of Liberty Safeguards and patients displaying behaviours that could place themselves or others at risk. Enhanced Care Teams reviewed patients requiring one-to-one support and reassessed need regularly.

The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure facilities supported the delivery of safe care.

The service did not always have suitable facilities to meet the needs of patients’ and their families. The sluice rooms across several areas had unrestricted access, as they were not fitted with locks or controlled swipe card entry systems. Control of substances hazardous to Health Control of Substances (COSHH) cupboards located within these rooms were left unlocked, with chlorine tablets accessible to unauthorised individuals. This created a risk that patients, including those who may be confused or vulnerable, could gain access and ingest hazardous substances, potentially resulting in harm. We raised these concerns with senior staff at the time of our inspection. They informed us that immediate action would be taken to ensure access to sluice rooms and COSHH cupboards was appropriately restricted across various areas.

Systems were in place for routine servicing, calibration, and auditing of equipment. Staff conducted daily safety checks on specialist equipment, and cleaning records showed no gaps. Cleanliness audits from December 2025 to February 2026 showed consistently high standards across Medicine wards at Royal Shrewsbury Hospital (RSH), with all areas meeting or exceeding required targets of over 95%.

Staff checked equipment regularly and responsibility was clearly assigned. Resuscitation equipment, sepsis trolleys, suction equipment and defibrillators were checked regularly and were in date. Drug and notes trolleys were secured appropriately. Electronic systems supported monitoring of emergency equipment checks and observation requirements.

Resuscitation trolleys were checked daily. We reviewed these checklists, and each had been completed appropriately. The resuscitation trolleys were correctly stocked, oxygen cylinders were full, suction machines and defibrillators were in working order.

Sharps boxes were correctly assembled, labelled and not overfilled. Staff segregated clinical and domestic waste.

Patients could reach call bells from their beds. Patients could access call bells in the toilets and wash areas if they needed assistance. During our inspection we observed staff attending to patients promptly when a call bell had sounded.

The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff.

The service did not always have enough nursing, support and pharmacy staff to keep patients safe. The number of nurses and healthcare assistants did not always match the planned numbers. We identified gaps in nurse staffing, with consistent shortages of both registered nurses and healthcare assistants across several areas we visited. These included AMU, SDEC, Short Stay Unit, AAU and ward 38. Staffing pressures continued to affect service delivery with staff reporting that band 7 leaders and ward managers were rostered to work 40% of their working hours clinically and frequently worked within clinical numbers due to workforce shortages.

Staff reported ongoing pressures relating to staffing and recruitment. They told us there were vacancies within the pharmacy team, which had contributed to delays in dispensing medicines and obtaining medications for patients. Staff described pharmacy staffing and retention as an ongoing challenge.

Ward managers could adjust staffing levels daily to take account of case mix. Staffing meetings took place twice daily and senior staff reviewed staffing requirements over the following 72 hours, including enhanced care needs, one-to-one observations, sickness absence and workforce gaps. Escalation processes were in place to redeploy staff between wards where required.

Training and workforce development were supported by practice development educators and professional education facilitators. Staff described receiving structured support, competency assessments and one-to-one development opportunities. However, this was limited as practice education facilitators had been required to spend 100% of their time working clinically to maintain safe staffing, which impacted on training and onboarding of newly appointed staff. Practice education staff were also undertaking significant clinical duties to maintain safe staffing levels. These concerns had been escalated through governance routes.

Some staff raised concerns regarding workforce pressures, recruitment and retention challenges and reliance on temporary staffing. Staffing levels and skill mix were regularly reviewed through operational meetings. The service attempted to minimise agency use and relied heavily on internal escalation processes and bank staffing.

During safety huddles, staff reviewed patient risks, bed capacity and operational pressures. We heard there were occasions when patients remained in the emergency department awaiting admission and when capacity pressures affected patient flow across the division.

There was adequate 24-hour medical cover. Consultant cover was available overnight, and staff were able to request support from the on‑call consultant when required. Consultants reviewed their patients once a day, usually during the morning ward round. Doctors told us they were able to contact their consultants at any time if they had concerns about a patient. There was 7-day advanced healthcare professional cover in place to support discharge and maintain patient flow.

Most staff had received and were up to date with appropriate mandatory training. Mandatory training topics were in line with national guidance and training was delivered through e-learning modules with some face-to-face training. Overall compliance for mandatory training for both nursing and medical staff was at 91% and slightly above the Trust target of 90% in February 2026. However, only 72% of staff were up to date with basic life support training. This presented a potential risk to people's safety, as staff may not have the necessary skills and knowledge to respond effectively in the event of a medical emergency, potentially impacting the timely delivery of life-saving interventions.

Leaders told us they had invested significantly in workforce development. Staff reported receiving bespoke training opportunities, protected learning time and support to develop advanced practice skills. Additional consultant support and training for advance clinical practitioners had been planned and implemented.

At the time of the inspection, practice education facilitators (PEFs) were undertaking clinical duties to support staffing shortfalls. However, leaders told us when PEFs were needed to deliver essential staff training or support the induction and onboarding of new employees, this was recorded on the rostering system to ensure they could be released from clinical responsibilities as required.

The online component of the learning disability and autism training was compulsory for all staff. At the time of the inspection, 84% of staff had successfully completed this training across medical care services. Due to funding and delivery challenges, the Trust was only able to provide training during 2024/25, with additional ICB-funded sessions between November 2025 and March 2026 offering 330 Tier 1 and 180 Tier 2 places, resulting in a modest improvement in compliance. For 2026/27, the Trust is finalising a programme to deliver 3,000 training places aiming to increase Tier 1 and Tier 2 compliance to 60% by March 2027 while developing a sustainable long-term training model.

Additional optional mental health training was available to all staff via the learning management system, covering a wide range of topics such as disorders, risk management, and legal frameworks, alongside specialised Mental Health Act and de-escalation training for relevant roles.

The evidence showed some shortfalls. 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.

Staff did not always adhere to infection control principles. Although isolation precautions were implemented for a confirmed community acquired Salmonella case on ward 27, there was limited involvement from the Infection Prevention and Control (IPC) team, and no evidence that the positive result had been reported to the local Health Protection Team or that appropriate contact tracing and IPC advice had been undertaken. This was not in line with the Health Protection (Notification) Regulations 2010 and increased the risk of additional cases going unidentified, potentially resulting in further transmission within the ward and wider community. The issue was raised during our inspection, and the microbiologist and IPC team took immediate action to ensure the case was appropriately notified and managed.

The trust had escalation processes for managing outbreaks and infection-related incidents. Ward teams worked closely with IPC specialists, microbiology services, divisional leaders and site managers to minimise risks and maintain patient flow. Cohorting arrangements, bay closures and enhanced cleaning schedules were implemented promptly when concerns arose. There had recently been an outbreak of diarrhoea and vomiting affecting patients on one of the wards we visited. Staff responded promptly once symptoms were identified, implementing appropriate outbreak management measures including cohorting patients, enhanced cleaning regimes, dedicated toilet and sink facilities, restrictions on movement between bays, and the use of appropriate personal protective equipment (PPE) by staff. The IPC team provided daily ward support and oversight. Staff undertook stool sampling, reviewed patient histories, monitored compliance with precautions and provided ongoing advice to ward teams. Patients were placed on stool charts and bays were closed to new admissions where required.

Although incidents were escalated through operational and divisional structures, communication with the Director of Infection Prevention and Control was not always timely. Leaders recognised this issue and planned further review and learning following the incidents.

Staff demonstrated awareness of infection prevention and control requirements. We reviewed an infection-related incident where an amber alert had been raised on the system and staff had worked with microbiology colleagues to manage the risk.

The IPC team and matrons conducted Quality Ward Walks (QWWs) across inpatient wards to assess compliance with hand hygiene, uniform standards, cleanliness and equipment management. From December 2025 to February 2026, the IPC QWW compliance score was 85.2%, which was below the expected standard and indicated poor compliance. Actions were implemented to address identified areas of non-compliance and improve overall infection prevention and control performance.

There were side rooms available on various wards for patients with communicable diseases or who required isolation. The side rooms were of adequate size to safely accommodate patients and support isolation requirements.

Staff had access to appropriate PPE, hand hygiene facilities and isolation rooms. We observed appropriate isolation precautions for a patient with a communicable disease and saw that information and precautions were displayed clearly outside the room.

Staff maintained equipment well and kept them clean. Equipment carried cleaning labels and waste segregation systems were in place. Any ‘I am clean labels’ were visible and in date. A cleaning rota was in place and displayed on wards. The schedule was signed and dated, providing assurance that cleaning tasks were completed as planned.

Staff received IPC training during induction and through mandatory refresher programmes, with training compliance achieving 96%. This indicated a high level of staff compliance with IPC training requirements.

Medical devices and other equipment and items were cleaned between patients and were labelled as such. Staff adhered to uniform policy, and we did not need to raise any concerns during our inspection.

The evidence showed shortfalls. The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Staff did not always follow systems and processes when prescribing, administering, and recording medicines. A review of a sample of 15 medicines charts found that, although allergies had been documented, one patient had been prescribed a medicine to which they were allergic. Nursing staff identified the error and withheld the medication; however, there was a 2-day delay before an alternative antibiotic was prescribed, resulting in a delay in treating the infection.

Patients did not always receive their medicines as prescribed. In the Acute Medical Unit (AMU), several patients had missed doses of regular medicines because medication had either not been ordered from pharmacy or had not been administered after being supplied. Missed medicines included glaucoma eye drops and oral breast cancer treatment, increasing the risk of patient harm. Trust data showed that the AMU had the highest medicines omission rate at 27%, with 46.7% of all omitted doses across medical wards attributable to stock unavailability.

Medicines charts were often unclear with illegible handwriting. Documentation on medicines charts was often unclear when dose changes had been made, making it difficult to determine when adjustments had occurred. This lack of clear recording increased the risk of medication errors and compromised the safe management of medicines.

A clinical pharmacy service was available within AMU and supported medicines reconciliation, discharge planning and medication ordering. However, pharmacy staff did not have access to the care flow system to help prioritise patients, and concerns were raised that pharmacy staffing levels had not increased in line with recent AMU expansion. Trust data showed that only 34.5% of patients had their medicines reconciled within 24 hours, although staff on the respiratory ward reported positive and proactive pharmacy support, including involvement in inhaler recycling initiatives.

Antimicrobials were prescribed and reviewed in line with approved antimicrobial guidelines, and an inpatient survey found that 87% of patients reported having their medicines explained to them. Staff reported inefficiencies in discharge processes, and although discharge medicine turnaround time data were not submitted, a recent divisional quality report identified an increase in patient safety incidents related to discharge documentation and discharge medicines. In response, a discharge improvement group was established to review and improve discharge processes.

Antimicrobial stewardship practices were generally well maintained, with indications and review or stop dates documented for many antimicrobial prescriptions. Appropriate intravenous to oral antibiotic switches were also observed following microbiology input, supporting the safe and effective use of antimicrobials.

We observed medicines including controlled drugs in the areas we visited were stored safely and securely. However, there was limited assurance regarding oversight of the safe and secure handling of medicines, as no relevant audit data had been available since 2024. During the factual accuracy stage, the trust provided trust-wide annual pharmacy audit data covering the period from 1 August 2025 to 10 June 2026, along with the annual ward storage audits 2025/26. The audit findings showed mixed levels of compliance across the trust against the relevant standards.

Medicines incidents were reported, investigated and reviewed through clinical governance processes, with themes identified by the medication safety officer. Learning from incidents was shared with staff through one-minute briefings to support improvements in medication safety.

There was awareness of time-critical medicines, with medicines charts showing ‘Get It On Time’ stickers to highlight patients requiring timely administration of medication. This demonstrated staff understanding of the importance of administering time-critical medicines promptly to reduce the risk of harm.

Medication awaiting collection by pharmacy staff was found in the discharge lounge, and sodium chloride ampoules were observed on an unsecured dressing trolley. These issues were escalated at the time of inspection to ensure appropriate action was taken.