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.

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.

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.

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.