We ask five key questions of services we inspect. Are they safe, are they effective, are they caring, are they responsive and are they well-led? Because this was a follow up inspection we focused on two of those five questions; are they safe, are they effective.

At our inspection on 27 and 28 November 2013 we found the service did not always protect people against the risks from unsafe management of medications. People were at risk from unsafe or inappropriate care and treatment because accurate and appropriate records were not always maintained.

Is the service safe?

At this inspection we found that the service was safe as medications management had been improved. Records of medication showed that medical, pharmacy and nursing staff communicated effectively about as required medication. Pharmacy and ward managers audited the management of medications and fedback to staff to monitor and improve safety.

Is the service effective?

We found that care was effective as records of care and key documents were completed appropriately. Patient care records included comprehensive assessment of risks and of the care provided. There were appropriate records showing that patients and relatives had been included in discussions about care.

During the inspection we spoke with 23 people who used the service, eight visitors and 23 staff members. We spent time in nine wards or clinics and looked at 15 sets of records relating to people's care and treatment.

People we spoke with told us they were well looked after. One person said "It’s the best hospital ever. I have been in quite a few, this is certainly the best one." Another told us that, "Staff are kind and caring and very respectful." We were told by another person that, "All the staff are very professional, from the doctors through to the cleaners."

Care records we looked at showed that people's needs had been assessed either before they were admitted or on admission and people we spoke with told us they received nutritious food. Supplements were available where people had an identified risk of malnutrition.

We looked at infection control and prevention measures in place. We found that staff were committed to carrying out care in a safe manner and that risk assessments and procedures were in place to prevent or manage the risk of infection or contamination.

We spoke with 23 staff who told us about the training they received. We were also given copies of planned training for the coming year. Although we were told that there were staff shortages on some of the wards we visited during the inspection, we were assured by the provider that a full review of staffing was underway to ensure that adequate staffing was in place.

We spoke with people using the services but their feedback did not relate directly to this to this standard. However, we looked at people’s records and crosschecked these with what people told us about their care and treatment and with what we observed.

One visitor told us that the “standards of care vary”. They said that hygiene standards on the wards was not always as good as it could be. They also said that staff did not always understand how to meet some people’s needs. Another visitor told us that the care had been very good and that their relative had everything they needed. One patient told us that they “could not complain” everything was alright and they had been looked after.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that no treatment for the termination of pregnancy was commenced unless two certificated opinions from doctors had been obtained.

People we spoke with who had been admitted to the hospital were generally complimentary about their treatment, how their medicines were managed and had no complaints. People said that they were provided information about medicines in a way that was useful to them. People told us they were provided pain relief when they needed it without delay.

One person told us that the staff were very good. They said they had been informed about their care and what arrangements were being made for them to move from the hospital. We were told the person had received a form about the possible arrangements for their discharge and how this was to be managed. They confirmed that they had received support from the therapy team to help improve their mobility and had been given a different walking frame from the one they used at home. They said this was more stable and they felt more confident with it.

Another four people told us that they were happy with their care and treatment. They thought there were enough staff on duty and had not had to wait unacceptable lengths of time for support. They had been kept informed about their treatment.

We were told by another person that they had been asked about their pain and given tablets to control this when they needed them. We heard staff asking people whether they were comfortable and explaining what they were doing to try and ensure people were involved and clear about what was happening.

We observed that, when people were receiving care, their dignity and privacy was sometimes compromised. For example, one person was receiving attention from two staff present at their bedside. Their clothes were elevated over the thigh and the curtains around their bed had not been closed.

Another person with a catheter in situ was being assisted with mobility from their bedside chair to the centre of the bay where their bed was. The person’s ‘flies’ were not covered in any way to prevent any accidental exposure.

People with whom we spoke told us that they were happy with the service they received. One person said that the meals look, smell and taste good. Another person said that they were “excellent”. Several people said that staff asked them frequently if they were alright or if they needed anything more. One person said they had observed staff assisting people with their meals without rushing them.

People told us that they received the meals they had asked for and that they were suitable. They also said that staff supported them with hand wiping and to use the facilities when needed.

One person told us that staff assisted them into a comfortable position prior to their meal and “are always coming round with drinks”

A relative told us that they had been asked for information about their relatives needs because they were unable to clearly state these for themselves.

People with whom we spoke who were admitted to the hospital were generally complimentary about how their medicines were managed. However, we identified that some people experienced poor outcomes in relation to how their medicines are managed by the service.

People with whom we spoke were complimentary about the food they had received. They told us that there was sufficient choice and that the meals were appetising, served at the correct temperature and tasty. One person told us that their relative did not always receive the amount of fluid that they should have and the food was not always suitable for the persons needs.

We were told by one person that they received “first class treatment”. Another person said that they felt well cared for. A relative told us that they did not always feel that their relative’s needs were being met.

In addition to checking if the trust had met the requirements of the warning notice issued in respect of meeting people's nutritional needs, we checked how well the trust were meeting the requirements under outcome areas: 04, Care and Welfare of people who use services; 016, Assessing and Monitoring the quality of service provision and 021, Records. During this visit, we did not check if the service was complying with the compliance action made following the last inspection in respect of 09, Management of Medicines. We will check this at the next inspection.

People with whom we spoke told us that they felt well informed about any treatment and care that was provided. People said that they had been involved in decisions about them and knew what would happen when they were discharged from the hospital. When we asked one person about how staff promote their dignity, they said staff made efforts to make sure they were covered up during personal care, they appreciated the same sex wards and though staff had not asked them how they preferred to be addressed, they called them by their first name and that made them feel more relaxed. People told us that their care had been very good. They said things like “Everything has been spot on”, “Absolutely fantastic” and “We have a laugh with the staff.” One person said “They couldn’t have been nicer.”

People in the maternity unit said they were provided with lots of information that helped them to make informed decisions about how they wished to give birth and about the way they wished to feed their new born baby. The people with whom we spoke were all satisfied with the advice and support given in this respect. One person said "All the staff have been very good, they have always told me everything and answered questions." Another person said that “staff don’t use jargon”.

Some people were critical about their experience, saying that the visiting times were too long. “You sometimes need a rest” and “It is a long day without radio or television”. One person told us that they had become partially sighted as a result of a recent stroke and were unable to read or see the clock. When asked they told us that staff did not seem to be aware of their difficulties. One visitor told us that when they had telephoned the ward on the morning of our visit they were given some information about their relative that led them to be very concerned. When they had called again an hour later they had discovered that the information they had been given was about a different person. However, they confirmed that apart from this one incident they had been kept well informed at a difficult time.

One person using the service told us that their medicine record had recently been mislaid on two separate occasions and in each case this had contributed to significant delays in them receiving the pain relief they required. They told us that on the first occasion they had been in considerable pain for three hours during the night and had been told by staff that they could not have any medication because they had an epidural in place. Staff subsequently found that the epidural was not working but the person had been in pain without medication in the interim. On the second occasion they had been in pain for two hours before medication was given and they told us that they had missed a dose of painkiller.

Some people expressed the view that there were not enough staff on the wards, saying “They are worked off their feet” and “They do their best”. One person told us that the day before our visit, the ward had been chaotic and that, as a result they felt under pressure to fit in with the ward routine, rather than express their wishes regarding their care. A visitor of another person who had been an inpatient for six weeks said that some of the “general” wards were very short staffed.

People gave us mixed feedback about their mealtime experience. One person said "The food is OK, a bit bland but OK and enough of it". Another person told us that the food was very good and they were looking forward to tea.

We were told on the maternity ward that the meals are good with one person saying they thought they were ‘better than expected’. We were told that choices are given on a list the day before and that ‘there is always a lighter diet or soup if we are not too hungry’. We noted the drinks trolley being offered mid morning with choices available.

We spoke with a person who visits every day and who is present to support their relative at both lunch and teatime. They told us that their relative requires a pureed diet but on the previous day were provided with a full un-pureed lunch time meal. The member of staff took this away and brought back an omelette which was still unsuitable. This relative also said the teatime meal was also inappropriate, as a jacket potato was offered. This person only had soup on the day. The relative was concerned that, if they had not been present all day, the incorrect food would have been offered and could place the person at risk of choking. A visitor told us that there were no offers of support with hand washing before lunch. Hand wipes are supplied on the meal trays but “staff don't always have time to help people to use them”. Another visitor also told us that they had bought special cutlery to help their relative to eat independently. Staff then told her that they had some on the ward but this had not been offered.

In addition to checking if the trust had made improvements in respect of outcomes areas 01 and 05 we checked how well the trust was meeting the standards in outcome areas 04, 07, 13 and 16. During our visit to the hospital we also identified concerns in outcome area 09, management of medicines and our findings have been included in this report.

People with whom we spoke told us that they were satisfied with the service they had received. Those people who had been admitted for surgery told us that they had been made fully aware of what was involved with the surgery and that the procedure had been fully explained to them. When asked the question, are you happy with the way staff care for you, one person replied “Absolutely brilliant”. When asked the same question, another person replied “No complaints at all, everything absolutely wonderful”. People told us that on the whole staff treated them with respect and they were consulted about the way in which they received care and treatment. However, one person told us they had asked a member of staff who came to take some blood, what the blood test was for but the member of staff said they did not know. We asked people about how well they felt their needs were met. They told us that staff respond to their needs as quickly as they can. One person said “it is obvious that staff are very busy and might not respond at once”. This person said they had received excellent care from night staff when they needed prompt assistance.

People with whom we spoke were reasonably independent and able to express their needs and preferences to staff on the ward. They told us that they were offered a choice of meals that were of a good standard. Two people told us that they had been asked about what they like to eat and a menu was provided everyday. One person told us that they had an allergy to an ingredient used in various foods and that they had informed staff of this repeatedly. However, staff were not able to tell the person which foods contained the ingredient that the person was allergic to and this person said they managed their own diet by omitting foods that were most likely to contain it. Other people told us that staff had spoken with them about what they like to eat and what level of support they needed. Apart from the above, nobody expressed any concerns about the way in which they were supported to maintain a good nutritional intake. When we asked people if they were given the opportunity to wash their hands before and after their meal, they told us that hand washing had not been offered. One person told us that they had brought in their own hand wipes.

• The service did not meet the trust mandatory training compliance target (95%). One out of three medical staff (55%) had not attended five out of nine modules. Nurse staffing was 75% compliant. We raised this as a concern at the time of our last inspection.
• The service did not meet the trust mandatory training compliance target for safeguarding training; four out of 16 nursing staff (25%) and one out of three medical staff (33%) had not received safeguarding adults training. This was worse than at our last inspection.
• The trust employed one long term locum palliative care consultant. This meant the trust did not meet guidance from the Association for Palliative Medicine of Great Britain and Ireland, and the National Council for Palliative Care standard because the service had not been able to recruit a second substantive palliative care consultant. We raised this as a concern at the time of our last inspection.
• Staff had not completed plan of care for the last days of life booklets in eight out of ten patient care records for patients who had recently died.
• Patients could not access the specialist palliative care team (SPCT) directly without attending ED. Patients needed to be admitted via the emergency department (ED) for a referral to the SPCT to be triggered and the SPC service was not available 24/7, operating a telephone on call service out of hours and during the weekends.
• We were concerned that medical staff in the emergency department (ED) were not able to access community patient care records which were stored electronically when palliative care patients presented in ED.
• We were not assured that there was adequate identification and oversight of all risks within the organisation. We found that several risks that we identified on our inspection did not appear on the service’s risk register.
• The service had a strategy which reflected the whole spectrum of end of life care. There were effective systems in place to support and monitor the implementation of the strategy. However some improvements identified from our previous inspections had not been made.

However,

• The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. The service had reported no never events or serious incidents during the period May 2017 to April 2018.
• The service had suitable premises and equipment and controlled infection risk well. Staff kept themselves, equipment and the premises clean.
• The service prescribed, gave, recorded and stored medicines well. Patients received the right medication at the right dose at the right time and staff kept clear, up to date and appropriate records of patients’ care and treatment.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005 and knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
• The service provided care and treatment based on national guidance and planned for emergencies; staff understood their roles if one should happen
• The service monitored the effectiveness of care and treatment. They compared local results with those of other services to learn from them. In the 2016 end of life care audit: dying in hospital the trust performed better than the England average for all three metrics considered.

• Staff of different specialities worked together as a team to benefit patients. The trust planned and provided services in a way that met the needs of local people. The service made sure staff were competent for their roles. Managers appraised staff’s work performance.

• The service took account of patients’ individual needs including, dietary, religious and cultural needs. The trust was the primary provider in palliative care for the geographical area and the specialist palliative care team (SPCT) consisted of both hospital and community nurses.

• Nursing staff could access translation services for patients who did not speak English as a first language. The trust had facilities for family members to stay with their relative overnight and the mortuary had facilities for bariatric patients.