\n Inspectors highlight significant problems with the physical environment and storage in theatres, where sterile packs of surgical instruments and equipment were being stored in corridors and on open racking in both the main theatre suite and the day surgery unit.\n<\/p>\n
\n Best\u2011practice guidance says sterile packs should be kept in well\u2011ventilated areas to protect their integrity, but the CQC found heavy packs stacked on top of each other, damaging the wrapping so staff could not be sure the contents were still sterile and forcing extra checks before packs went into surgery.\n<\/p>\n
\n The report notes that these storage and environmental issues \u2014 including limited space, extension leads used to power equipment and restricted access to gas safety valves \u2014 were first raised in 2018 but remain unresolved in 2025.\n<\/p>\n
\n Plans for a new theatre suite with additional storage have stalled because of funding, and although the trust has increased fire\u2011safety walk\u2011rounds and training, the CQC says the risks persist.\n<\/p>\n
\n Bed pressures and poor patient flow are another concern. Inspectors found some patients were kept in recovery for up to four hours awaiting a ward bed, with the main theatre reception area being used to admit and discharge patients before and after surgery.\n<\/p>\n
\n Curtains around bed spaces did not provide enough privacy for clinical conversations, and delayed transfers from the emergency department meant patients often spent more than four hours in A&E after a decision to admit.\n<\/p>\n
\n Salisbury District Hospital (Image: Newsquest)\n<\/p>\n
\n Record\u2011keeping around venous thromboembolism (VTE) risk is also criticised. Reviewing 31 patient records, the CQC found inconsistent documentation of VTE assessments due to problems with the electronic patient record system used by the trust.\n<\/p>\n
\n All patients had been prescribed blood\u2011clot prophylaxis appropriate to their clinical presentation, but inspectors say decisions were \u201cnot based on the patient\u2019s individual assessed needs\u201d and warn patients may have received medication unnecessarily because formal risk assessments were missing.\n<\/p>\n
\n The trust has commissioned a new electronic patient record to replace the current system, due for implementation in April 2026, and introduced monthly audits to track VTE assessment compliance, but the CQC says these measures do not fully resolve the immediate risk.\n<\/p>\n
\n On governance, the report says surgery has established committees, risk registers and regular divisional meetings, but questions the effectiveness of leadership in getting persistent problems fixed.\n<\/p>\n
\n Risks such as damaged sterile packs and fire hazards from extension leads have been on the register since December 2023 with documented actions, yet remain open with \u201cno long-term plan\u201d, and divisional leaders are described as \u201cnot always effective\u201d in influencing trust\u2011level decisions.\n<\/p>\n
\n Safeguarding training compliance is below the trust\u2019s 85 per cent target, with adult levels 2 and 3 at 79 and 41 per cent respectively, and the e\u2011learning system makes it difficult to track completion by staff group.\n<\/p>\n
\n Managers told inspectors they maintain their own oversight of individual training and were confident frontline staff understood safeguarding and knew how to raise concerns, but the CQC calls for better system\u2011level data and visibility.\n<\/p>\n
\n Medicines optimisation is rated as showing \u201csome shortfalls\u201d, with the clinical pharmacy team reconciling medicines within 24 hours of admission in around 30 per cent of cases against a 100 per cent national target, though this performance is broadly similar to peer trusts.\n<\/p>\n
\n Pharmacy is embedded in surgical pre\u2011assessment, and inspectors heard examples of pharmacists proactively working with GPs and patients to adjust medicines ahead of surgery, including for people with substance\u2011misuse treatment needs.\n<\/p>\n
\n Despite the downgrade, the report contains extensive praise for frontline staff and the quality of care. Patients and relatives told the CQC they were treated with kindness, dignity and respect, and that communication was good and they felt included in decisions.\n<\/p>\n
\n Friends and Family Test data shows 98 per cent of responses for the day surgery unit and 96 per cent for surgical inpatient wards were positive between October 2024 and October 2025, and caring remains rated \u201cgood\u201d.\n<\/p>\n
\n Clinical outcomes are also strong in some areas. Data submitted to the National Hip Fracture Database shows Salisbury exceeding national averages on key metrics, with 98 per cent of patients receiving prompt orthogeriatric review compared with 89 per cent nationally, and 77 per cent having timely surgery against a national figure of 57 per cent.\n<\/p>\n
\n The hospital participates in national audits and uses mortality and morbidity meetings to review cases and drive learning, with inspectors describing a \u201cproactive and positive culture of safety\u201d at ward level.\n<\/p>\n
\n Nursing staffing in surgery is generally stable, with vacancy rates reported as zero in the day surgery unit over the 12 months before inspection and overall turnover around seven per cent, although theatre staff raised concerns about cramped working conditions and the impact on morale.\n<\/p>\n
\n Salisbury NHS Foundation Trust has been ordered to submit an action plan setting out how it will address the CQC\u2019s concerns and deliver immediate improvements in safety and governance.\n<\/p>\n
\n The CQC says it will continue to monitor progress and may return to check whether promised changes to storage, VTE documentation and bed flow have been put in place.\n<\/p>\n