People told us what it was like to be a patient at the Royal Berkshire NHS Hospital and described how they were treated by staff and their involvement in making choices about their care and treatment. They also told us about the quality and choice of food and drink available. This was because this inspection was part of a themed inspection programme to assess whether older people in hospitals were treated with dignity and respect and whether their nutritional needs were met.

The inspection team was led by a Care Quality Commission (CQC) inspector, with a supporting inspector, a practicing professional and an Expert by Experience (people who have experience of using services and who can provide that perspective).

We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of patients who could not talk with us.

This inspection focused on two wards providing care to elderly patients. On the day of our visit there were 28 patients on one of the wards, which provided care to female patients. The other ward was providing care to 22 male patients. We spoke with 16 patients and 11 relatives or other visitors during our visit. We also spoke with eight staff members and looked at six patients' records.

All the patients we spoke with said they were treated kindly and with respect. Most said the doctors had discussed their treatment with them. A couple of patients said they would like to be addressed by their preferred name, not the name on their records.

One visitor told us their relative came back from having tests done and was found in wet clothing. Staff had not informed them their relative's catheter was leaking. The visitor said sometimes when they arrived their relative needed to be washed. They said staff attended to the person immediately when requested.

Another visitor said they thought the care was ''OK'' for their relative. A further visitor told us their relative ''was being looked after well.'' A patient told us the care she received was excellent. She said ''I couldn’t be treated any better if I was the Queen.''

Patients said the meals were ''good'' or ''very good.'' They said they had different options to choose from and were served their preferences. They said portion sizes were sufficient.

All patients said there was a good variety of food and it was hot when delivered to them. One patient said only cold food options were offered if a meal was missed (staff told us meals could not be re-heated, for food safety reasons).

Most patients thought there were enough staff but said they were always busy. One said there were not enough staff on duty later in the day and they had to wait for the call bells to be answered. Patients told us the weekends were much quieter, which gave staff more time to spend with them.

Patients we spoke with were generally happy with the quality of care provided by the hospital. They told us that staff maintained their dignity and privacy at all times by ensuring that the screens were always pulled around the bed when care and treatment were provided. They told us that staff were patient, kind and helpful and were quick to respond to calls for assistance. They told us that staff provided them with sufficient information about their care and offered them appropriate choices in relation to their treatment.

Patients and relatives that we spoke with on Burghfield Ward felt that staff were "doing their best" and that "the quality of care was good". Patients told us they were offered pain relief when they needed it and felt "well cared for". When asked if they were receiving the care that they needed one patient said " excellent, can't fault it". They said that the ward was always busy however; they were "able to get good nights sleep".

The patients we spoke with on Castle Ward said that they had been well cared for. They said the ward was “lovely and quiet at night”. They were generally happy with the care they received and felt that staff responded to calls for assistance in a timely manner.

Patients on the Clinical Decision Unit were in the main happy with their care. However, relatives of one patient felt that the start of treatment had been delayed due to waiting for a bed on the ward. As a result they felt that their relative had become "more poorly". Most patients felt that their care and treatment had been appropriate and timely. They told us that they had been referred to appropriate specialists and received the treatment they needed in timely way. One patient was waiting to be discharged. They told us that their experience on the unit had been "very good". Staff had been quick to diagnose their illness and provide treatment "so they could get back home".

Our rating of services improved. We rated them as outstanding because:

Safe, effective, and well led domains were good, and caring and responsive domains were outstanding.

• Urgent and emergency care remained rated as good overall. The question of safety stayed the same, effective was not rated the last time. Caring improved from good to outstanding, responsive improved from requires improvement to good, and the well led rating of good was unchanged. The integrated front door model was being used to improve both the efficiency of the service and respond better to patients immediate needs. The positive impact of the new service design was felt throughout the hospital.
• Medicine (including older people’s care) improved from requires improvement to outstanding. Safety improved from requires improvement to good, caring improved from good to outstanding, responsive and well led moved from requires improvement to outstanding. Delivery of the service and outcomes for patients had improved. Patients’ needs were met and treatment was delivered by competent, knowledgeable and caring staff. Services were flexible and highly personalised to meet patients’ individual needs.
• Surgery services improved from requires improvement to good overall. Safety improved from requires improvement to good. Effective and caring ratings stayed the same at good. Responsive and well led both improved from requires improvement to good.
• Critical care improved from requires improvement to good overall. Safety and responsive improved from requires improvement to good. Effective stayed the same at good, and caring remained outstanding. Well led improved from requires improvement to good.
• Outpatients improved from requires improvement to outstanding overall. (We did not inspect diagnostics as part of this inspection as it is now a different core service under the new methodology). Safe improved from requires improvement to good. Effective is not rated. Caring stayed the same at good, and responsive improved from requires improvement to outstanding.
• On this inspection, we did not inspect maternity, services for children and young people, and end of life care. The ratings we gave to these services on the previous inspections in March 2014 and November 2015 are part of the overall rating awarded to the location 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