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The Princess Royal Hospital Inadequate

Reports


Inspection carried out on 9 to 10 June 2020

During an inspection looking at part of the service

Our rating of services stayed the same. We rated them as inadequate because:

During this inspection we used our focused inspection methodology. We did not cover all key lines of enquiry. We have rated the service as inadequate and have taken enforcement action as a result of this inspection to promote patient safety. Our enforcement action included the use of our urgent enforcement powers where we placed conditions on the trust’s registration in relation to the assessment and management of risk, care planning, and incident management. We also served two warning notices to the trust requiring them to make improvements in the following areas; end of life care staffing, end of life staff competencies, end of life governance systems and the way the staff support patients in line with their personal preferences and individual needs.

  • Staff did not keep detailed records of patients’ preferences for care and treatment provided at the end of their life. This had not improved since the last inspection.
  • The service did not ensure that all staff were competent for their roles, placing patients at risk of receiving unsafe and inconsistent care. This had not improved since the last inspection.
  • Staff did not consistently support patients who lacked capacity to make their own decisions.
  • The end of life care service did not have enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. This had not improved since the last inspection and was identified at our inspection in 2018.
  • Specialist palliative care services were not available on site seven days a week to support timely patient care. This had not improved since the last inspection.
  • It was possible that palliative and end of life care patients could be missed due to the lack of systems to identify patients. This had not improved since the last inspection.
  • Leaders did not demonstrate that they had the skills and abilities to run the services. They did not demonstrate that they understood and managed the priorities and issues the service faced. They were not always visible and approachable in the service for patients and staff.
  • The culture of the services was not centred on the needs and experience of patients.
  • The services did not operate effective governance systems to improve the quality of services. Leaders had not effectively implemented new ways of working to drive improvement and they were not always available to provide day to day support to staff. This had not improved since the last inspection.
  • Staff did not always complete risk assessments for each patient in a prompt manner. Action was not always taken to remove or minimise risks to patient’s health and wellbeing. Safety incidents were not always managed well to protect patients from avoidable harm. This had not improved since the last inspection.  

Inspection carried out on 18 February 2020

During an inspection looking at part of the service

We carried out an unannounced focused inspection of the emergency department at Princess Royal Hospital on 18 February 2020, in response to concerning information we had received in relation to care of patients in this department.

We did not inspect any other core service or wards at this hospital, however we did visit the admissions areas to discuss patient flow from the emergency department. We also undertook an unannounced inspection of the emergency department at Royal Shrewsbury Hospital on 17 February 2020 which has been reported separately.

During this inspection we inspected using our focused inspection methodology. We did not cover all key lines of enquiry however we have rated this service in accordance with our enforcement policy.

This was a focused inspection to review concerns relating to the emergency department. It took place between 10am and 4pm on Tuesday 18 February 2020.

We found:

The design, maintenance and use of facilities, premises and equipment did not keep people safe.

Staff did not always promptly identify and quickly act upon patients at risk of deterioration. Staff did not always complete risk assessments for each patient in a prompt manner. They did not always act to remove or minimise risks or update the assessments when risks changed.

The service did not have enough permanent nursing staff with the right qualifications, skills, training and experience to consistently keep patients safe from avoidable harm and to provide the right care and treatment. However, staffing gaps were filled with temporary bank and agency staff.

The service did not have enough permanent medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.

People could not always access the service when they needed to, and they did not always receive the right care promptly. Waiting times from arrival to treatment and arrangements to admit, treat and discharge patients fell well below national standards.

Leaders did not have the skills and abilities to run the service in a safe and effective manner. Leaders did not understand and manage the priorities and issues the service faced. Senior leaders were not always visible and approachable in the service for patients and staff.

The service did not have a clear vision for what it wanted to achieve or an effective strategy to turn it into action. However, senior leaders engaged with stakeholders regarding the planning of future ED services.

Leaders in the ED did not operate effective governance processes throughout the service. The service did not always identify, escalate and mitigate relevant risks and issues.

Staff did not always feel respected, supported and valued by the senior executive team.

Importantly, the trust must:

Action the hospital MUST take to improve

Ensure patients are risk assessed in a timely way and that risks associated with the delivery of health care is mitigated as far as is reasonably practicable.

Ensure there are enough numbers of staff across all professions and grades with the right skills, competency and experience, are always employed and deployed . This includes but is not limited to ensuring there are enough numbers of competent staff to care for infants and children.

Ensure staff comply with local early warning systems to ensure patients at risk of deterioration are recognised and treated within defined time scales.

Ensure care records are always readily available.

Ensure patients can access care and treatment in a timely way.

Ensure there are robust governance processes in place which assist in evaluating and improving the quality of care provided to patients accessing the emergency care pathway.

Ensure patients are treated with dignity and their privacy is always protected .

Ensure patients are managed in an environment which is fit for purpose.

Professor Edward Baker

Chief Inspector of Hospitals

Inspection carried out on 12 November 2019 to 10 January 2020

During a routine inspection

Our rating of services stayed the same. We rated it them as inadequate because:

  • The safe key question remained as inadequate.
  • Effective key question went down to inadequate.
  • Caring key question went down to requires improvement.
  • Responsive went down to inadequate.
  • Well led key question remained as inadequate.

Inspection carried out on 16 April 2019

During an inspection looking at part of the service

Shrewsbury and Telford Hospital NHS Trust (SaTH) is the main provider of acute hospital services for Shropshire, Telford & Wrekin and mid Wales.The trust provides care from multiple locations, but there are two main hospital sites, which are The Princess Royal Hospital in Telford and The Royal Shrewsbury Hospital in Shrewsbury.

We carried out an unannounced focused inspection of the maternity service, including the Wrekin midwife led unit (MLU) at Princess Royal Hospital on 15 April 2019, to review the assurances we had received relating to conditions imposed on the trusts’ registration following the inspection in August 2018. The conditions imposed on the registration included:

  • The registered provider must ensure that there is an effective system in place to ensure effective and continued clinical management for low and high-risk patients who present to the midwifery services in line with national clinical guidelines. This includes cardiotocography (CTG), Modified Early Obstetric Warning System (MEOWS), reduced fetal movement and triage guidelines. The provider must ensure that trust guidelines include a clear escalation plan to secure timely review from medical staff.

  • From 14 September 2018 and on the Friday of each week thereafter, the registered provider shall report to the Care Quality Commission describing the system in place for effective clinical management of patients presenting at the midwifery services at The Princes Royal and Royal Shrewsbury Hospitals. The report must include the following:

  • The actions taken to ensure that the system is implemented and effective.

  • The actions taken to ensure the system is being audited and monitored and continues to be followed.

  • The report should include results of any monitoring data and audits undertaken that provide assurance that an effective clinical management system is in place, and patients are escalated appropriately for medical support and review in line with national clinical guidelines.

We did not inspect any other core service or wards at this hospital. During this inspection we inspected using our focused inspection methodology and inspected specific key lines of enquiry within the safe and well led domains.

We met the deputy head of midwifery and other members of the maternity team whilst on site. The assurances were reviewed and seen to be in place relating to effective and continued clinical management for low and high-risk women who present to the midwifery services in line with national clinical guidelines. A clear escalation plan had been embedded to secure timely review from medical staff when necessary.

During our inspection we found improvements in practice. Examples include but are not limited to Cardiotocography (CTG), Modified Early Obstetric Warning System (MEOWS) and the implementation of reduced fetal movement and triage guidelines. The MEOWS observation chart facilitates a standardised approach to recording women’s vital signs to alert the clinical team to any clinical deterioration. The MEOWS score determines the urgency and scale of the clinical response. This guideline provides guidance for staff within the maternity services on recognising and monitoring the obstetric patient using MEOWS. This enables early recognition of deterioration, advice on the level of monitoring required, promote better communication with the multi-disciplinary team and ensure prompt management of any woman who is deteriorating.

There were areas of poor practice where the trust needs to make improvements.

Action the trust SHOULD take to improve:

  • The trust should ensure a review of the staffing at the midwife led unit is undertaken as part of the Better Births programme.

  • The trust should ensure the environment in the MLU is safe by keeping harmful chemicals secure.

  • The trust should ensure all medical staff are appropriately trained in cardiotocography analysis.

  • The trust should ensure clinical specimens are handled and managed in line with policy.

  • The trust should ensure all actions are taken to ensure governance arrangements are effective.

Professor Edward Baker

Chief Inspector of Hospitals

Inspection carried out on 15 April 2019

During an inspection looking at part of the service

This was a focused inspection to review concerns relating to the emergency department. It took place between 1pm and 9pm on Monday 15 April 2019.

We did not inspect the whole core service therefore there are no ratings associated with this inspection. We also inspected the Royal Shrewsbury Hospital as part of this inspection. Due to the nature of services and same leadership team, there are similarities across both location reports.

Our key findings were:

  • Provision for mental health patients was not consistent with national best practice standards. The environment in which patients presenting with mental health conditions had not been risk assessed, despite this being noted as an area for improvement following our previous inspection. The environment continued to present risks including ligature points.
  • The initial management of patients who self-presented was poor. Health professionals deviated from the trusts standard operating procedure for the streaming of patients. This meant patients experienced significant delays in having a full clinical assessment which should have occurred in a timely way as defined by national standards.
  • The management of children was poor. There was no clearly defined escalation or prioritisation protocol. Increased demand for services meant children were leaving the department without being seen and without having received appropriate clinical assessments.
  • The department implemented patient safety initiatives including early warning systems and patient safety checklists however staff did not consistently use these.
  • There were occasions when the privacy and dignity of patients was not always promoted or protected.
  • Compliance against constitutional standards remained challenging. Local escalation protocols failed to deliver the necessary action to decompress the emergency department.
  • There remained a focus on delivering performance and avoiding twelve-hour breaches as compared to providing holistic care to patients; this was compounded by continued challenges around bed capacity and the estate.
  • Whilst clinical governance processes existed, the information used to provide assurance was not sufficiently robust.
  • Morale remained low although it was reported to be improving.

As a result of this inspection, we opted to utilise our enforcement powers and imposed urgent conditions of the Provider’s registration. Namely,

  1. The registered provider must ensure that within three days of this notice, it reviews and implements an effective system with the aim of ensuring that all children who present to the emergency department are assessed within 15 minutes of arrival in accordance with the relevant national clinical guidelines.
  2. The registered provider must ensure that the staff required to implement the system as set out in the previous condition are suitably qualified and competent to carry out their roles in that system, and in particular to undertake triage, to understand the system being used, to identify and to escalate clinical risks appropriately.
  3. The registered provider must ensure that the system makes provision for effective monitoring of the patient’s pathway through the department from arrival.
  4. The registered provider must provide the Commission with a report setting out the steps it has taken to implement the system as required in conditions two to three, within five days.
  5. The registered provider must ensure there is a system in place which ensures that all children who leave the emergency department without being seen are followed up in a timely way by a competent healthcare professional.
  6. From 26 April 2019 and on the Friday of each week thereafter, the registered provider shall report to the Care Quality Commission describing the system in place for effective management of children through the emergency care pathway. The report must also include the following:

a. The actions taken to ensure that the system is implemented and is effective.

b. Action taken to ensure the system is being audited monitored and continues to be followed.

c. The report should include results of any monitoring data and audits undertaken that provide assurance that a process is in place for the management of children requiring emergency care and treatment.

d. The report should include redacted information of all children who left the department without being seen; details of any follow-up and details of any harm arising through the result of the child leaving the department without being seen.

  1. The registered provider must ensure that within three days of this notice, it implements an effective system with the aim of ensuring that all adults who present to the emergency department are assessed within 15 minutes of arrival in accordance with the relevant national clinical guidelines.
  2. The registered provider must ensure that the systems in place across the department can account for patient acuity and the location of patients at all times.

The trust must also ensure

They operate an effective clinical governance process which is supported by reliable and tested information and datasets.

Ensure staff receive feedback on incidents and outcomes from morbidity and mortality reviews.

Ensure staff comply with local hand hygiene and infection control protocols.

Professor Edward Baker

Chief Inspector of Hospitals

Inspection carried out on 21 August to 21 September 2018

During a routine inspection

Our rating of services went down. We rated them as inadequate because:

  • Our rating of safe was inadequate overall. At times of high operational pressures patients were not always assessed and treated in a safe and suitable environment. Services did not always manage patient safety incidents well. The deteriorating patient was not always recognised within urgent and emergency care services to ensure appropriate and timely care was provided. Not all services had sufficient numbers of permanent staff with the right qualifications, training and experience to keep people safe from avoidable harm and abuse. Staff completion data for mandatory training did not meet the trust targets, including Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards. There was no data available for adult safeguarding training for medical staff.
  • Our rating of effective remained requires improvement overall. Services monitored the effectiveness of care and treatment and used the findings to improve them. However, effective action was not always taken in response to poor audit results to drive improvement.
  • Our rating of caring remained as good overall. Staff delivered compassionate care, however we did see examples where compassionate care was not delivered in a consistent manner. Privacy and dignity was maintained and promoted by most services, however we found the trust’s approach to boarding meant patients’ dignity was not always promoted.
  • Our rating of responsive remained as requires improvement overall. The trust did not always plan and provide services in a way that met the needs of local people. Not all services always took into account the individual needs of patients.
  • Our rating of well-led went down to inadequate overall. Staff reported a disconnect between them and the senior management team and board. There were systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. However, timely and effective action was not always taken to mitigate risk. The trust did not always use a systematic approach to continually improve the quality of its services or safeguard high standards of care by creating an environment in which excellence in clinical care would flourish.

Inspection carried out on 12 – 15 December 2016

During an inspection looking at part of the service

Shrewsbury and Telford Hospital NHS Trust is the main provider of district general hospital services for nearly half a million people in Shropshire, Telford & Wrekin and mid Wales; 90% of the area covered by the trust is rural. There are two main locations, Royal Shrewsbury Hospital in Shrewsbury and Princess Royal Hospital in Telford. The trust also provides a number of services at Ludlow, Bridgnorth and Oswestry Community Hospitals.

The Princess Royal Hospital in Telford was built in the late 1980s. It merged with the Royal Shrewsbury Hospital in 2003, when the Shrewsbury and Telford Hospital NHS Trust was formed. The Princess Royal Hospital provides a wide range of acute hospital services, including accident and emergency, outpatients, diagnostics, inpatient medical care and critical care. The hospital is also the main centre for hyper-acute/acute stroke services, inpatient head and neck surgery, and inpatient women's and children’s services.

This was a focused inspection, following up our inspection that took place in October 2014. At that time the hospital was rated as requires improvement overall, with caring as good.

We rated Princess Royal Hospital as requires improvement overall.

  • The trust was not achieving the Department of Health’s target to admit, transfer or discharge 95% of patients within four hours of their arrival in ED.

  • The trust’s referral to treatment time (RTT) for admitted pathways for surgery have been lower than the England overall performance since September 2015.

  • Insufficient numbers of consultants and middle grade doctors were available.

  • Nursing staff vacancies were impacting on continuity of care and an acuity tool was not used to assess staffing requirements.

  • Compliance with the trust target for completion of staff appraisals was below the trust target.

  • Current safety thermometer information was not displayed on the wards.

  • The maternity specific safety thermometer was not being used to measure compliance with safe quality care.

  • Mortuary staff decontaminated surgical instruments manually; this exposed staff to unnecessary risk and did not provide a high level of disinfection.

  • Mental capacity documentation had not been completed for defined ceiling of treatment decisions when a person had been deemed as lacking capacity.

  • Service-wide sharing of learning from serious incidents was not evident, not all staff could give examples or learning from incidents and there was limited learning across the maternity service. Communication of incident learning was not consistently service wide or fed down to all staff.

  • The maternity service was in a transition period of change and although new senior leaders had begun to make positive changes, we had concerns as to whether this service had an embedded safety and learning culture. Governance processes were under review at the time of our inspection.

However, we also saw that:

  • Openness and transparency about safety was encouraged. Incident reporting was embedded among all staff, and feedback was given. Staff were aware of their role in Duty of Candour.

  • In every interaction we saw between nurses, doctors and patients, the patients were treated with dignity and respect. Staff were highly motivated and passionate about the care they delivered.

  • There were clearly defined and embedded systems, processes and standard operating procedures to keep people safe and safeguarded from abuse.

  • Treatment was planned and delivered in line with national guidelines and best practice recommendations.

  • Local and national audits of clinical outcomes were undertaken and quality improvements projects were implemented in order

  • It was easy for people to complain or raise a concern and they were treated compassionately when they did so.

  • There was a clear statement of vision and values, driven by quality and safety. Leaders at every level prioritised safe, high quality, compassionate care.

  • The trust had made end of life care one of its priorities in 2015/2016.

We saw several areas of outstanding practice including:

  • The palliative care team had developed a fast track checklist to provide guidance to ward staff on what to consider when discharging an end of life care patient.

  • Staff told us that if the bereavement office arranged a viewing in the mortuary they would walk the relatives to the mortuary. If the mortuary department arranged the viewing, they would meet relatives at the main entrance and walk them to the mortuary department.

Importantly, the trust must:

  • The trust must ensure ED meets the Department of Health’s target of discharging, admitting or transferring 95% of its patients with four hours of their arrival in the department.

  • The emergency department did not have a compliant mental health seclusion room as described in the Mental Health Act 2007 (MHA).

  • The trust must ensure that it meets the referral to treatment time (RTT) for admitted pathways for surgery.

  • The trust must ensure there are sufficient nursing staff on duty to provide safe care for patients. A patient acuity tool should be used to assess the staffing numbers required for the dependency of the patients.

  • Stroke patients did not always receive timely CT scans due to availability and reliability of diagnostic imaging equipment.

  • The trust must review its medical staffing to ensure sufficient cover is provided to keep patients safe at all times.

  • The trust must ensure that all staff have an understanding of how to assess mental capacity under the Mental Capacity Act 2005 and that assessments are completed, when required.

In addition the trust should:

  • The trust should ensure that up to date safety thermometer information is displayed on all wards

  • The trust should ensure they are preventing, detecting and controlling the spread of infections, associated in the mortuary department by ensuring surgical instruments are decontaminated to a high level and there are arrangements in place for regular deep cleaning.

  • The trust should ensure all staff received an annual appraisal.

  • The trust should consider using the maternity specific safety thermometer to measure compliance with safe quality care.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 14-16th October 2014

During a routine inspection

The Princess Royal Hospital is part of Shrewsbury and Telford Hospital NHS Trust. They provide district general hospital services for nearly half a million people in Shropshire, Telford & Wrekin, and mid Wales. Of the area covered by the trust, 90% is rural. A recently-built Shropshire Women and Children’s Centre has opened at the hospital, and services for children across the county are provided at this one location.

We carried out this comprehensive inspection because the trust had been flagged as a potential risk on CQC’s Intelligent Monitoring system. The inspection took place between 14 and 16 October 2014, and an unannounced inspection visit took place on 27 October.

Overall, this trust requires improvement. We found that services for children and young people, maternity and gynaecology, outpatients, and A&E services, were good. Critical care, surgery, medicine, and end of life care services, required some improvements to ensure a good service was provided to patients. We rated it good for caring for patients, but it requires improvement in providing safe care, effective care, being responsive to patients’ needs, and being well-led in some areas.

Our key findings were as follows:

  • Staff were caring and compassionate, and treated patients with dignity and respect.
  • The hospital was visibly clean and well maintained. Infection control rates in the hospital were lower when compared to those of other trusts.
  • Patient’s experiences of care were good, and results from the NHS Friends and Family Test were in line with the national average for most inpatient wards, but were above the national average for A&E.
  • The trust had recently opened the new Shropshire Women and Children’s Centre at the Princess Royal site. This had seen all consultant-led maternity services and inpatient paediatrics move across from the Royal Shrewsbury site. We found that this had had a positive impact on these services.
  • The trust had consistently not met the national target for treating 95% of patients attending A&E within four hours. However, we saw at the Princess Royal Hospital that services were safe and effective, with adequate staffing, and the team were well-led.
  • There was some good care delivered in the medical wards, but high staff vacancies and heavy reliance on bank staff were putting considerable pressure on the staff.
  • The trust was not meeting the Core Standards for Intensive Care Units at the Princess Royal Hospital. We were concerned about nurse staffing levels, and asked the trust to look at the situation immediately. During our unannounced inspection we were assured to see that the trust had responded.
  • The trust had recognised that end of life care was an area for development for them, and had recently started to make progress; however, our inspection found that there was still much more to be done. Whilst the care on the wards was good, the mortuary area was poor, and required improvement. We were concerned about the safety and effectiveness of the mortuary arrangements at Princess Royal Hospital in that the maintenance of this area was poor and it could not cope with the current demands placed on the service.

We saw several areas of outstanding practice, including:

  • The hospital had outstanding safeguarding procedures in place. The safeguarding team had links in every department where children were seen, with safeguarding information shared across the trust.
  • The hospital had an Independent Domestic Violence Advisor (IDVA). The post had been substantiated through funding from the Police Crime Commissioner, due to excellent outcomes recorded by the trust. We were told that referrals from the trust to the Multi-Agency Risk Assessment Conference (MARAC) had been endorsed as excellent practice by the Co-ordinated Action Against Domestic Abuse (CAADA). CAADA is a national charity supporting a multi-agency and risk-led response to domestic abuse.
  • The compassionate and caring dedication for end of life care within the renal service was outstanding, especially the development and introduction of the ‘my wishes’ document at the Princess Royal Hospital, for supporting people who had been diagnosed with an ‘end stage’ decision.

We raised some of the urgent issues at the time of our inspection and the trust has taken action to address the equipment staffing needs within critical care areas.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

  • The trust must review the levels of nursing staff across A&E critical care, labour ward and end of life services to ensure they are safe and meet the requirements of the service.
  • Ensure that all staff are consistently reporting incidents and that staff receive feedback on all incidents raised so that further service development and learning can take place.
  • Ensure that staff are able to access mandatory training in all areas.
  • Review pathways of care for patients in surgery to ensure they reflect current good practice guidelines and recommendations.
  • Ensure that mortuary services are safe through maintenance of this area.

There were also areas of practice where the trust should take action:

There were also areas of practice where the trust should take action. These included:

  • The trust should ensure that there is a designated safeguarding lead in the accident and emergency department.
  • The trust should review the arrangements for visitors entering and exiting the labour ward to ensure that it does not impact on midwives workload and that in the event of an emergency, staff and patients can easily leave the department.
  • The trust should ensure that the quality dashboard reports accurately reflect performance against targets at each site, and that thresholds are clear.
  • The trust should review sustainability plans and budgetary support for end of life care.
  • The trust should review arrangements for seven-day working in therapy and pharmacy services, to ensure wards and departments are supported over the weekends.
  • The trust should ensure that medicines are held securely in surgical ward areas.
  • The trust should ensure that the 'Butterfly Scheme' for dementia patients is rolled out and embedded across all wards in medicine.
  • The trust should develop a strategy for the improvement and delivery of end of life care.
  • The trust should review staffing and management structures for end of life care.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 25 April 2013

During an inspection in response to concerns

This responsive inspection was triggered by information that had been shared with us from patients, relatives, staff and a range of stakeholders. Concerns were raised about patient experience, care and safety. This was particularly around discharge arrangements, staff attitudes and an increase in the number of adult safeguarding referrals around poor care and patient experiences. Concerns about the lack of regard for patient privacy and the management of pressure ulcers were also raised.

We carried out observations on wards 9, 12, accident & emergency (A&E) and the medical assessment unit (MAU). We spoke with patients and staff in all the wards and departments we visited. Where patients were not able to talk with us for various reasons, we spent time observing how care and support was delivered. Most of the time interactions between staff and patients were positive and staff took time to explain what they were doing and why. We saw some positive examples of staff promoting patient privacy and dignity. However, we also observed situations where patients' privacy and dignity was not respected.

Patients described differing experiences but the majority of people we spoke with told us they were happy with the care they had received. Some patients experienced long delays in A&E waiting for a bed to become available on a ward. Not all of the patients we spoke with felt they had been involved and consulted in relation to their care and treatment.

Inspection carried out on 9 May 2012

During a routine inspection

The inspection was unannounced and consisted of a team of five inspectors. The inspection was a scheduled routine visit in addition to reviewing improvements that we had asked the trust to make following our last inspection undertaken in October 2011. We visited three wards on 9 May 2012 providing adult inpatient care across the hospital. We spoke with 36 people who were receiving a service, 12 visitors and 20 staff from different disciplines.

Everyone we spoke with told us that they were getting the care and support they needed. Comments included, �Everything is excellent.� �I am being well looked after.� and �Absolutely brilliant care.�

People told us that they had been involved and consulted in relation to their care and support. People said staff supported them sensitively and discreetly. Staff provided sound examples of how they promoted people�s privacy and dignity in their work.

Overall people shared positive experiences of the care and support they had received. Two people, on two separate wards, raised issues about the length of time it took for staff to answer call bells. People who were being discharged from hospital told us that they had received detailed information to take home with them. Staff told us about the improvements that had been implemented to improve people�s care and experiences including new documentation and tools in place to monitor the care delivered.

Everyone we spoke with told us that they liked the meals. People said there was always a choice and that food arrived hot when it was supposed to be. One person told us, �It�s like a five star hotel�. Staff told us protected mealtimes had ensured people were not disturbed when eating their meals and that staff were freed up to assist people who required support and supervision with eating and drinking.

People told us that they felt safe and well looked after. They said staff were kind and attentive. Before our inspection a number of people had experienced poor outcomes on one ward that had compromised their care and safety. The trust worked with us and outside partners over a number of months to improve the quality of care and people�s experiences. Staff spoken with across all three wards we inspected knew what to do in the event of observing abuse or poor practice. They told us they had received training in safeguarding people from abuse. One member of staff stated, �The staff are given permission to report and question practice.�

Most of the people who spoke with us said they thought there were enough staff on duty to meet people�s needs. One person told us, �They can�t help you enough�. Another person told us, �The staff are attentive, the care here is good.�

Everyone we spoke with told us that the nurses were are always asking them if they were ok and if they were happy with everything. They said that they were able to express their wishes and share their views about how they were feeling and what could be done to make them feel more comfortable. People said that if they had any concerns or worries that they would speak with a nurse. We were told the trust had robust systems in place to monitor and review people�s experiences and deliver improvement.

Inspection carried out on 11 October 2011

During a routine inspection

The inspection was unannounced and consisted of a team of five inspectors in the morning and four inspectors in the afternoon. We visited three wards providing adult inpatient care across the hospital. We spoke with 28 people who were receiving a service, 14 representatives and 18 staff from different disciplines. Overall people told us that they had received positive experiences during their stay in hospital and that they were, �satisfied� with the care provided. Some people however, including a number of people who shared information with us prior to our visit, had experienced poor outcomes that had left them feeling distressed and with their dignity compromised and their basic care needs not met. We observed some positive examples of good care during our visit but on one of the three wards we also saw people having to wait for support or not receiving the care required.

The hospital is working with outside agencies to improve the principles of good care and areas such as privacy and dignity and falls prevention had been identified for action.

We found that the introduction of protected meal time had had a positive impact on meal times for people creating a calmer and more relaxed environment. Most people felt satisfied with the quality of the food provided.

People told us that staffing was an issue giving numerous examples of having to wait for basic care and support. We saw that some people were left unsupervised when their plans and assessments identified that they needed to be supported. This could compromise patient safety as well as impacting on the quality of the experience that people in hospital received. We did see however some good examples of positive staff interactions and overall we found that staff had a good knowledge of people's needs

Although improvements had been identified to processes it was evident that not all wards had embraced the changes fully and that work is still required to ensure that all wards offer good quality and safe care and support. The hospital management team fully acknowledged this and were working to make improvements.

Records were not always completed leaving people at risk of not having the needs met safely.

People told us that they felt safe in the care of staff and that they had not observed any poor practice during their stay. Although not everyone had knowledge of the complaints procedure, they told us they would raise concerns with the staff on duty. Only one person told us that they had made a complaint during their stay and they were not satisfied with the outcome. Other information received prior to our visit reflected also that complaints were not always dealt with appropriately and that a small number of people continue to be in receipt of poor quality care when in the Princess Royal Hospital.