Our rating of services went down. We rated it them as requires improvement because:

• Safe, effective, and responsive were requires improvement, caring was good and well-led was inadequate because end of life services and urgent and emergency care were rated as inadequate, however leadership at the trust level overall was rated as requires improvement.
• Urgent and emergency overall was rated as requires improvement. Safety remained requires improvement, caring remained good. Effective was rated as requires improvement. Responsive went down from good to requires improvement. Well-led went down from requires improvement to inadequate. Staff did not have the appropriate level of children’s safeguarding training, staffs did not follow the trust policy on safeguarding and mandatory training for all staff were below (worse than) the trusts targets in a majority of topics. The senior leaders were not visible within the department, leaders were not aware of the risks to patients in the department. There was a significant disconnect between the CAU, the emergency department and the UCC.
• Surgery overall was rated as requires improvement. Safe remained requires improvement, effective, caring and responsive remained good and well led remained requires improvement. Patients did not always receive their medicines as prescribed, mandatory training was low and did not meet the trusts target of 85%. Leaders did not ensure effective action was taken to improve aspects of compliance, risk and performance. Staff did not always document risk assessments regarding patients’ risk of falls or malnutrition. The leaders had not ensured that changes to services had been planned to use inpatient beds effectively. However, patients and their relatives were happy with care and treatment they received. Staff were competent for their roles. Managers appraised staff’s work performance. Patients could access care and treatment in a timely way with referral to treatment times in line with the England average.
• End of life overall was rated as inadequate. Safe went down to requires improvement, effectiveness went down from good to inadequate, caring remained good. Responsive went down from good to requires improvement and well led went down from outstanding to inadequate. The trust did not always ensure there were sufficient quantities of equipment to maintain the safety of patients. The service did not ensure there were sufficient numbers of suitably qualified, competent, skilled and experienced persons in end of life care services. Staff did not always have the appropriate skills and experience for their roles. The delivery of end of life care training was not sufficient throughout the hospital and ward staff were had not been kept up to date with new processes and procedures. The trust did not have managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. The end of life care strategy and vision for the trust remained under development. There was no governance framework for reviewing patient harm incidents within end of life care services. There was a lack of any systematic audit programme relating to end of life care, few measures to review risk and quality, and no governance framework to support the delivery of care. The trust had not always engaged well with patients, staff, the public and local organisations to plan and manage appropriate services. However, we observed good infection control practices. Staff kept appropriate records of patients’ care and treatment. Staff ensured that relatives were supported, involved and treated with compassion as best they could. Staff involved patients and those close to them in decisions about their care and treatment.
• Previously in May 2014, we rated outpatients and diagnostic imaging together. On this inspection, we rated each service separately therefore, we are unable to compare with the previous ratings.
• Outpatient services were rated as required improvement overall. Safe and responsive and well led was rated as requires improvement. Care was rated as good. Effective is not currently rated. Mandatory training for all staff was below (worse than) the trusts target in a majority of topics. Staff did not have the appropriate level of children’s safeguarding training. The trust did not complete regular audits of infection prevention and control practices. Patients were unable to access services for assessment, diagnosis and treatment in a timely way due to waiting times, delays and cancellations.
• Previously in May 2014, we rated outpatients and diagnostic imaging together. On this inspection, we rated each service separately therefore, we are unable to compare with the previous ratings. Diagnostics imaging overall was rated as good overall. Caring, responsive and well led were rated as good. Safe was rated as requires improvement. Effective is not currently rated. The service managed patient safety incidents well. Staff across different disciplines worked well together to deliver effective care and treatment. The service provided care and treatment based on national guidance and evidence of its effectiveness. The service had managers at all levels with the right skills and abilities to run a service, Managers were visible. There was a positive culture of support, teamwork and focus on patient care. However mandatory training for all staff was below (worse than) the trusts target in a majority of topics. Staff did not have the appropriate level of children’s safeguarding training. The department was not consistently using the computerised reporting system to check that paediatric scans had been reported on appropriately.
• On this inspection we did not inspect medicine (including older people’s care), critical care, maternity, and services for children and young people. The ratings we gave to these services on the previous inspection in May 2014 are part of the overall rating awarded to the trust this time.
• Our decisions on overall ratings take into account, for example, the relative size of services and we use our professional judgement to reach a fair and balanced rating.

Our focus during this inspection was to look at whether the hospital met the care and welfare needs of patients, met patient nutritional needs and look at the staffing arrangements on the wards and units we visited.

We visited the accident and emergency department (A&E), the acute medical unit (AMU), clinical decisions unit (CDU), coronary care unit (CCU), Felix Holt, Bob Jakin and Nason Wards. We spoke with 22 patients and five relatives during the inspection. We reviewed the clinical care records of nine patients across the units and wards. We spoke with consultants, doctors, matrons, ward managers, ward sisters, nurses, healthcare assistants and health professionals. We also had discussions with the Director and Deputy Director of Nursing.

We observed many interventions from medical and nursing staff throughout the inspection. We saw that staff in each department and ward we visited were responsive, professional and appropriate in their interactions with patients.

Patient feedback on the care received was positive. Patients felt they had been kept informed by doctors, consultants and the nursing staff regarding their treatment. They felt that staff caring for them were skilled to do so appropriately.

Comments received included, "I can't find any fault,” "The staff are excellent," “They’re marvellous in here, always caring,” and “My dad couldn’t be in a better place.”

We found that records were very well completed and provided comprehensive evidence that patients had care delivered according to their preferences and needs. The individual care pathways seen had been completed appropriately and individual risk assessments were updated as necessary. This meant that the multidisciplinary team worked together to meet the needs of patients.

Patients chose what they wanted to eat and were generally satisfied with the food. One patient told us, “The meals are on time, there is a good choice and the food is hot”. Another patient said, “The food here is very good, much better than I expected.”

There were enough qualified, skilled and experienced staff to meet patient's needs. The trust had management structures, systems and procedures which were followed, monitored and reviewed to ensure appropriate staffing levels were maintained. Patients told us that there were enough staff to meet their care needs in a timely way. One person who had recently had treatment in AMU said, “I was very impressed. I was taken straight in there from A&E. The staff were very attentive, not just to me, but to all the patients on the unit.”

The inspection team included an ‘expert by experience’ – a person who has experience of using services (either first hand or as a carer) and who can provide the patient perspective. We visited a number of wards and departments including, two surgical wards, medical ward, children’s ward, accident and emergency department, emergency medical unit, clinical decisions unit and some outpatients departments.

During the course of the two day visit we spoke with patients using the service and received a lot of positive comments about the care and treatment provided by George Eliot Hospital. One patient said, “The treatment and care that I have received has definitely met my expectations, staff have been so helpful and obliging. I have not met a rude one yet.” Another patient told us that staff were ”very caring.” A relative commented, "We cannot fault the care and attention my (family member) has received here at this hospital.”

We were told that patients thought their privacy was protected and that they felt staff were respectful during their visit or stay at the hospital. Patients also told us that they had felt involved in planning their care or treatment. We were told that patients were very satisfied with the information given, either verbally or in leaflets, and the majority were confident that they knew exactly the nature of their treatment. One person told us, “They have informed me about everything, I understand about my treatment,” however another patient said, “I’d like to know more about my medical condition.”

Patients thought that the hospital was kept clean. We were told, “The cleaning is very good I have no concerns.” and “I can't fault the cleanliness of my ward.”

Patients said that they felt safe and there were usually enough staff on the wards. However, they thought that staff were often busy, which meant that patients might have to wait longer than they wanted to. One patient told us, “Sometimes you have to wait for them to come, but they are so busy I understand the wait.”

At this inspection, we inspected urgent and emergency services, medical care, surgery, maternity, children and young people and end of life services. We did not inspect critical care, end of life, outpatients or diagnostics services at this inspection, but we combine the last inspection ratings to give the overall rating for the hospital.

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

• Our rating for safe remained requires improvement because not all services ensured mandatory training was completed. Risk assessments were not always documented and medicines management was not always manged safely.
• Our rating for effective remained requires improvement because there was variable performance in some national audits and not all services had action plans to drive improvements. Not all staff had competencies to carry out their roles.
• Our rating for caring remained good because staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Staff provided emotional support to patients to minimise their distress. Staff involved patients and those close to them in decisions about their care and treatment.
• Our rating for responsive remained requires improvement because not all patients could access the services when they needed them, patient transfers occurred during the night and there were delays in patients discharges.
• Our rating for well-led improved from inadequate to requires improvement because there was insufficient resource in the leadership for the medical and urgent and emergency care services for them to consistently run a service providing high-quality sustainable care. Governance processes were not consistently embedded across the service, there was poor compliance with training and Mortality review meetings had not been held which meant the sharing of learning from death reviews was not consistent. Urgent and emergency care did not always collect, analyse, or use information to support all its activities, although it did use secure electronic systems with security safeguards. Although there had been a number of improvements since our last inspection, further actions were still required.