During this inspection we observed how surgical staff completed the World Health Organisation Surgical Safety Checklist (WHO checklist) in three theatres. The WHO checklist was implemented by the World Health Organisation to improve the safety of surgery. We found that the trust had made improvements in this area since our last inspection in July 2012.

We also visited four wards and the Endoscopy Suite and spoke with patients and visitors. We found that patients were generally happy with their care and that it met their needs. One person we spoke with told us, "They do their best, really." We asked another person if there was anything they were not happy with and they told us, "Not off the top of my head." Some of the patients were not able to give us their views directly either because of their dementia or because they were too poorly. For this reason we spent time on all the wards we visited observing people’s interactions with staff. We did this for 20 people and found that staff gave them care and support that met their needs.

We found that that pressure relieving equipment was available, maintained appropriately and that staff had been trained in its use.

We found that the trust had effective measures in place to protect people from the risk of infection.

We saw that staff were supported to be trained to an appropriate standard and we looked at records which showed that the trust was regularly monitoring the quality of its service.

This inspection was carried out because there had been a number of never events at this hospital trust since May 2011. Never events are serious, largely preventable, patient safety incidents that should not occur if the available preventative measures have been implemented. A number of these related to events in theatres which is where we focused our inspection visit.

The inspection took place on 25 July 2012 and was unannounced. We were accompanied by a professional clinical advisor from the Care Quality Commission to carry out this inspection. Our visit consisted of speaking with staff, looking at policies and procedures, records and observing theatre practice. During this inspection we visited all main theatre areas, and other non-theatre areas where surgical procedures took place.

We spoke with staff who covered a range of different roles within theatres. This included medical and nursing staff who had specific responsibilities in ensuring that any surgery was completed safely. We also met with the medical director, a clinical director, a divisional medical director and the chief nurse as part of this inspection.

We did not speak with many people during this inspection because we were reviewing practice in the operating theatres. We observed staff treating people with dignity and respect. We also saw that people were put at ease and staff were observed to be kind and caring, offering reassurance at all times.

We found improvements were needed in how the trust was monitoring surgical practice in theatres. The completion of surgical safety checks has been accepted in the NHS as good practice in support of the prevention of avoidable errors and omissions in surgical care. We observed procedures where the required safety checks were fully completed by theatre staff as a team. In other procedures, some important checks were either missed or not completed with the full involvement of all members of the theatre team.

We undertook this review to check whether improvements had been made following our earlier inspections in March and May 2011. Whilst at the hospital, we visited two wards (D20 and D8) and the patient information centre.

Overall patients told us that they were receiving the care they needed. We were told that staff were kind, pleasant and caring. We sat on the wards and observed some of the practice. We saw that staff were busy but the atmosphere on both wards was relaxed with staff working efficiently to meet the different needs of people who had been admitted. We saw staff communicate with patients and their relatives in a sensitive way. One patient said “All are very polite and always explain what they are going to do”. When asked if anything could be improved the patient replied, “can't think of anything - all is fine - I am very satisfied with the care I am getting”.

We saw and heard about the systems in place to make sure that people were getting appropriate support with eating and drinking. We observed mealtimes on both wards which were protected which meant that patients had time to eat their meals without being interrupted. Patients told us that the food was good quality and there was always plenty of choice. We saw patients were assisted to eat and drink and that referrals were made when assessments identified a need for more specialised input.

Patients and relatives told us that they had been involved in planning their discharge home. We heard examples from both wards about the new 'e discharge' forms which gave more information to the doctor or district nurse on discharge. We were told that information supplied to nursing homes who provide a step down facility was variable and "dependent on who completed the forms". Staff told us that when referrals were made, these tend to happen quickly. One patient told us how they had been referred to a specialist whilst in hospital and had already been seen.

The trust had systems in place to assure themselves of quality. Since our March 2011 review the trust has conducted thorough and extensive investigations into five mortality outliers. An outlier is generated from routine patient data and is generally a measure that lies outside an expected range of performance. We analysed this information with other data we had. These investigations found no evidence of poor care and no avoidable deaths, but identified a small proportion of cases where there were process or system errors. Examples of good practice were also identified. Similarly we knew that any actions and learning triggered by serious incidents or complaints were monitored and reported on regularly.

There continue to be changes in how complaints were being managed. We spoke with a random sample of people who had made a complaint recently. Whilst not everyone was satisfied with the handling of their complaint, they had been satisfied with the outcome and actions taken by the trust to learn from the incidents.

Most people we spoke with told us they were satisfied with the care, support and treatment they had received on the wards we visited as part of this review and during a visit to the trust on 23 March 2011. Comments from people using the service included, “I think I have received excellent care on this ward. The staff are very polite, courteous, and respectful” and “Brilliant, nothing is too much trouble”. People also described less positive experiences in other parts of the hospital, which suggests care and support may vary between wards.

People told us of their experiences when they transferred between wards and departments and gave us varying views of whether they thought enough staff were around to meet their needs and those of other people. We found that most people were not aware of the process or where to get information about raising complaints, but said they would speak with staff if they had any concerns.

People told us they have been pleased with the care and support they have had on the wards we looked at as part of this review. People said they felt they had a say in their treatment and what happened to them while they were in hospital. People told us their privacy and dignity is respected and their independence promoted and that staff help them if they are less able to do some things.

One person commented that they “couldn’t wish for better care”, another person described staff as “golden” but described them as being “rushed off their feet”.

Most people gave positive feedback about the quality, range and availability of food. They told us that staff had asked them what they like to eat and whether they need support with eating and drinking. One person said, “staff asked me about options and asked about allergies and they check I’ve had enough to eat” another described how staff check on them regularly and encourage them to eat and drink, however they told us they had been unable to eat their main meal commenting that they, “couldn’t eat fish, couldn’t swallow it, it was hard”.

We saw improvement from the last inspection in 2015.

We rated effective, caring, responsive and well led as good, with safe being rated as requires improvement.