Safe delivery of care – Acute hospitals national overview report forward and summary: September 2025
This report was carried out between 2021 and March 2025.
Foreword
Welcome to our first Safe Delivery of Care Overview report, which highlights the key findings from this programme of inspection.
The Safe Delivery of Care inspections of acute hospitals across NHS Scotland have highlighted the challenges in the delivery of frontline care, as well as the areas of good practice and the dedication of NHS Scotland staff.
Over the past four years, our inspections have stressed the current and sustained system pressures being experienced across NHS Scotland and have provided independent assurance of the quality and safety of care across NHS acute hospitals. The inspections have highlighted areas of required improvements in the care of patients within non-standard care areas, such as corridor care; patient dignity and respect; and the safety and delivery of essential care within emergency departments and other assessment units.
Our inspections have also emphasised the impact of staffing levels on care delivery and the need for improvements in communication between teams, particularly safety information shared at hospital and ward level safety huddles. Improvements in the management of medicines, fire safety, and the need to ensure a safe and clean environment to support patient safety and quality of care have been essential elements of numerous areas inspected. In recent inspections we have highlighted the need for improvement in paediatric immediate life support training and incident management.
The inspection programme has also recognised a wealth of good practice across the 31 inspections. This includes staff working hard to provide kind and compassionate care, including taking time to reassure patients, with patients describing they felt well cared for. Many ward areas have been well led, calm and organised despite increased hospital capacity and staff shortages.
The ultimate objective of this inspection programme is to improve patient care and wellbeing of staff across NHS Scotland. These improvements are evidenced through NHS board improvement action plans and where follow-up inspections have taken place. The inspections also seek to ensure wider national learning is identified and shared.
This report highlights areas for improvement that all NHS boards may wish to consider and serves to support wider learning and improvement in patient care across NHS Scotland.
Themes relating to safe care
Our inspections found the following common themes related to safe care:
- Care in non-standard care areas
- Appropriate staffing
- Medicine governance
- Dignity and respect
- Healthcare build environment
- Staff training
This resulted in the following requirements by theme:
- Communication
- Training
- Governance
- Fire safety
- Medication governance
- Management of incident reporting
- Leadership
- Fundamentals of care
- Documentation
- Infection prevention and control
- Safe management of care environment
- Staffing
- Privacy, dignity and respect
- Miscellaneous
- Non-standard care area/ overcrowding
Safe delivery of care in numbers
A total of 31 inspection reports published, covering:
- 24 hospital sites
- 12 territorial boards
- 1 special board
These inspections and reports resulted in
- 282 requirements
- 186 areas of good practice
- 27 recommendations