Royal Shrewsbury Hospital

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At our last inspection we rated this key question requires improvement. This was because governance processes did not consistently ensure safe care was being delivered. At this assessment the rating has remained requires improvement. Governance at the service was not always used to ensure patients were safe from harm.

We have not awarded this service a score for Well-led.

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

The service did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The vision for the department was in the process of being updated. However, the physical transformation of the urgent and emergency care departments at both of the trust’s acute hospitals was underway. The transformation included urgent and emergency care for adults, children and young people being moved from the Princess Royal Hospital at Telford to a reconfigured and enlarged ED and PED at Royal Shrewsbury Hospital. The scope of the transformation was ambitious and was supported by a tiered transformation process. Posters about the different stages were displayed around the ED explaining what was going to happen and by what timeframe.

However, the reception and administrative staff in ED had not been given information about the transformation. They were unaware of the changes to the layout of the department that took place while we were on site. They told us they felt “unvalued”, and, “excluded”. They also said when relatives came into the department looking for a relative it was vital for them to be able to direct them to the correct part of the ED.

As a trust the vision was ‘to provide excellent care for the communities we serve’ and to ensure patients received the right care, in the right place, at the right time. The trust were working with their partners in the community to achieve this. There was a transformation programme to improve flow in the department. Staff did not mention this programme to us. Instead, they told us the trust’s executive team were very concerned about the ambulance patient handover data but did not appear concerned about the number of admitted patients in the department. Or in the overcrowding in fit to sit and ARA.

Staff demonstrated an understanding of the operational need to receive patients arriving by ambulance and recognised the importance of maintaining patient flow through the emergency department. However, many staff described feeling under significant pressure to accept ambulance arrivals despite existing crowding and staffing challenges within the department.

Staff consistently raised concerns that risks associated with crowding and low nursing staffing levels, particularly within ARA and fit to sit, were not always given sufficient consideration when decisions were made about patient flow. Several staff felt there was a disconnect between operational priorities and the day-to-day pressures experienced by frontline teams.

These concerns had affected staff morale, with some staff describing feeling unsupported and perceiving that organisational focus was placed primarily on performance measures, such as ambulance handover delays and breach targets, rather than on staff wellbeing and patient safety. This had contributed to a culture where some staff felt their concerns were not always heard or acted upon.

Staff told us that they did not have a safety huddle during their shift to look at capacity and patient safety. However, the nurse in charge (NIC) completed a shift log 4 times each day that was used monitor activity in the department.

Most staff described positive and collaborative working relationships between nursing and medical teams. However, this was not consistently reflected across the service. Some staff gave examples of interactions that did not demonstrate a culture of mutual respect and understanding of professional roles. For example, a student nurse told us that a doctor had asked them to take a patient’s blood. When the student explained they were not able to undertake this task, the doctor reportedly became frustrated and instructed them to “just do it”.

We also identified examples suggesting that staff were not always clear about the scope of practice and responsibilities of colleagues. The Matron’s weekly bulletin dated 27 February 2026 reminded nursing staff not to ask resident doctors to review and sign electrocardiograms (ECGs), as they were not qualified to do so. The bulletin also reminded staff to be kind and respectful when doctors declined these requests. This demonstrated that leaders had recognised issues relating to professional understanding and behaviours between staff groups and had taken steps to reinforce expectations around respectful, collaborative working.

These examples indicated that, while there was evidence of positive multidisciplinary working, a shared culture based on consistent understanding of roles, mutual respect and constructive challenge was not yet embedded across all teams.

Staff had made formal complaints about the lack of staff in the department, which had resulted in them not being able to deliver high and safe standards of nursing care. They were not satisfied with the responses they had received, which they felt either ignored the problem or deliberately misunderstood it. The reported situation aligns with warning signs of a ‘closed culture’, where low staffing leads to unmanageable risks such as missed care, patient distress, and lack of staff breaks.

Staff also told us what the impact of stopping the clinical educators’ role was having on the department. As well as the impact on patient safety from not completing role specific competencies, staff told us new staff felt anxious and unsupported in the department, especially because the high volume of patients meant their other colleagues did not have time to support them.

Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. However, leaders within the ED had the skills, knowledge, and experience to lead effectively. They did so with integrity, openness and honesty.

ED leaders were visible in the service and approachable for patients and staff. Staff told us the matrons worked across the trust’s two acute hospitals, but they were responsive when their support was required. Staff also told us their line managers were responsive and supportive, but several nurses said they felt their managers were, “let down” by the senior leadership team who did not support them to improve patient safety and staffing issues. Staff mostly made negative comments when asked about senior hospital leaders.

Staff told us that, as part of trust-wide cost improvement measures, bank shifts were paid at a maximum of Band 5 rates. This meant that Band 6 and Band 7 nurses undertaking bank shifts were remunerated at Band 5 rates and understood they would be expected to perform duties commensurate with a Band 5 role. However, staff consistently reported that, despite being paid at Band 5 rates, they were expected to undertake responsibilities aligned to their substantive banding. This included leading clinical areas, such as the Fit to Sit service, and providing oversight and supervision of other staff members during shifts.

These accounts were not aligned with assurances regarding workforce deployment and raised concerns about the effectiveness and transparency of leadership arrangements. In particular, it was unclear how leadership ensured staff were undertaking duties appropriate to their paid role and level of responsibility. The information shared by staff challenged the credibility of leaders' descriptions of workforce management and raised concerns about whether staffing arrangements were being deployed in a fair, open and inclusive manner.

People did not always feel they could speak up and that their voice would be heard.

Staff were aware of the Freedom to Speak Up Champion for urgent and emergency care and told us they would feel comfortable raising concerns through this route. We saw information displayed within the department promoting the trust’s Freedom to Speak Up service and the mechanisms available for staff to escalate concerns.

However, despite awareness of the service, staff consistently told us they did not feel their concerns about patient safety risks associated with low staffing levels and crowding in the emergency department were adequately heard or acted upon. Staff reported that issues they had raised repeatedly did not result in meaningful change and felt there was a disconnect between the concerns raised by frontline staff and the trust’s organisational priorities. This affected staff confidence that speaking up would lead to improvement.

Patients and their relatives had opportunities to give feedback on the service they received in a manner that reflected their individual needs. For example, people could leave feedback using quick response (QR) codes on posters in patient areas. People who did not want to use phones to provide feedback could be supported by staff to give written feedback. Managers and staff had access to the feedback from patients, their relatives and members of the public and used it to make improvements.

We saw evidence that complaints were investigated and improvements were made to improve patient safety. For example, a complaint had been made about a doctor who failed to diagnose a spinal fracture. This incident was investigated and the doctor was provided with additional training on reviewing spinal x-rays.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The service did not always act on the best information about risk, performance and outcomes. However, the service had clear responsibilities, roles, systems of accountability and a governance structure.

There were structures, processes and systems of accountability to support the delivery of care in the ED. However, at our last 2 inspections we raised concerns about the care and treatment of patients. We were pleased to see many of these issues had been resolved but some had not. The provider had failed to take effective action on several of our concerns. They had not ensured risks associated with the delivery of health care was mitigated as far as was reasonably practicable. There was inconsistent oversight of patients in the ED waiting room, patients were not consistently triaged within 15 minutes of arrival, and not all patients were issued with an ID wristband.

Standard operating procedures (SOPs) did not always contain evidence to show they had been reviewed in line with set review dates. For example, the SOPs for ‘protecting beds for emergency admission of stroke patients to the stroke unit v1’ and, the ‘acute stroke patient conveyancing and escalation standard operating procedure v5’ did not contain evidence to show they had been reviewed by their review dates.

Leaders had not ensured effective governance arrangements were in place to support collaborative working across internal and external teams. Staff did not consistently demonstrate a clear understanding of the processes for working with other services to meet patients’ needs. Internal and external staff described variations in practice relating to the assessment and monitoring of patients cared for on the rear of ambulances, with processes dependent on which staff were on duty at the time. Staff told us this was because there was no formal policy or standard operating procedure outlining the roles, responsibilities, and expected processes for joint working. As a result, governance systems had not ensured a consistent approach to patient care and oversight.

There was a framework of what must be discussed at a ward, team or directorate level in team meetings to ensure essential information, such as learning from incidents and complaints, was shared and discussed. However, not all staff felt patient safety incidents caused by crowding and low staffing levels were shared, learnt from or acted upon.

Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance about infection prevention and control. However, some other audits, for example, sepsis audits and the audit of clinical observations, demonstrated the department had long standing patient safety problems that they were not able to consistently improve on.

Staff maintained and had access to the risk register at directorate level. The Board of directors was sighted on the department’s performance and associated risks. For example, from reports such as ‘UEC - action to improve 12-hour waits and ambulance handover performance’ which was presented to the Board in September 2025. The report contained the following information, “There is clear evidence that delays in emergency care are harmful. Prolonged waits for admission from the Emergency Department are associated with increased mortality. Furthermore, crowding contributes to longer inpatient stays, diminished quality of care, and a poorer patient experience. It also places considerable strain on our workforce, leading to higher levels of burnout, reduced job satisfaction, and moral injury”. As well as acknowledging long waits to be reviewed by a doctor as increasing risk of harm to patients, the report acknowledged the primary cause of crowding as, “delayed admission for inpatient care, with 66.52% of patients spending in excess of 12 hours in ED being admitted patients. A further 23.52% of patients are referred for admission but receive investigation and treatment in ED due to no available inpatient bed and are then discharged from ED”.

Staff did not consistently have access to the equipment and information technology needed to do their work. Staff in majors told us as typically all the patients there were patients waiting to be transferred to a medical ward. Which led to high levels of staff from the medical speciality there, who were competing with them for desk space and use of computers.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The trust worked in partnership with a local community trust to try and reduce hospital admissions through the ED. In August 2025 they formed an integrated front door designed to reduce pressure in the ED. The integrated front door team worked with GP's, care homes, community nursing teams, and others to find alternative care to hospital for patients. For example, people who could receive care from a virtual ward, a community hospital, a frailty clinic, or a community nursing team. The team assessed patients while they were on an ambulance or inside the ED and made suggestions to doctors about potential appropriate alternative treatment placements. ED doctors and advanced clinical practitioners could contact the team directly if they suspected an alternative placement might be appropriate and required support accessing this for the patient. The integrated front door team could relocate patients on multiple treatment pathways, for example, patients with a urinary tract infection (UTI), increased falls, a new and significant change in blood pressure, and chronic obstructive pulmonary disease (COPD). The team also provided enhanced support to care homes when their patient was repeatedly attending the ED, by helping them provide care in the care home with additional support from community teams.

The trust worked with other trusts to identify how they could improve the service. For example, to reduce (improve) the waits for triage the trust visited another hospital to understand how they delivered triage and how they could incorporate aspects of this delivery to improve their service.

There was a focus on continuous learning, innovation and improvement across the organisation and local system. Staff were encouraged to find creative ways of delivering equality of experience and outcome for patients.

Staff were given the time and support to develop opportunities for improvements and innovation, and this had led to changes in care delivery. For example, waits for triage in the PED had frequently been above 15 minutes. Staff identified the main reason for this was because they had to check 2 separate systems to see if there were existing safeguarding concerns for the child they were about to triage. This process took over 2 minutes. Staff developed a new process so all safeguarding information could be reviewed using 1 system in 1 minute.

Staff used quality improvement methods and knew how to apply them. Quality improvements projects were undertaken to improve patient outcomes. However, the projects did not always result in changes being made or sustained. For example, the project to reduce waits for triage in the ED identified how improvements could be made but the lack of staff in the department meant that the delivery phase of the project could not be completed.