People that we spoke to were pleased with the treatment they had received. We received comments such as, "I have had excellent care", "I am being well looked after" and "I am being cared for very well". One person told us "I can get hold of a daily paper. A nurse will go or a bloke came round yesterday", and another said "a gentleman comes round to offer to get things from the shop. He got me some tissues and some bottled water yesterday".

People that we spoke to were positive about the food at the hospital. People made comments such as "The food is very good, I wouldn't fault it", "The food is ok, I have really enjoyed some meals" and "I have put on weight, I would like smaller meals".

People that we spoke to were pleased with the cleanliness of the hospital and told us "I cannot fault them for cleanliness", and "It is very clean. They clean every day". One person told us "I was pleasantly surprised by how clean it was".

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

• In urgent and emergency care staff complied with systems and processes designed to keep people safe from avoidable harm including the management of safeguarding risks. Records, incidents, infection control, and changing risks of patients, including those of a deteriorating patient, were managed well. We found that patients needs were met in relation to pain management, and services were planned and delivered in line with best practice. Staff understood their responsibilities to mental capacity, and spoke to patients with compassion, dignity and respect. Although the department was busy, there had been innovative changes to patient pathways and streaming since our last inspection. There were concerns over local operational leadership at the hospital.
• In medical care staff understood how to protect patients from abuse, completed relevant risk assessments and kept clear and legible records of patient care. The service used audit processes to monitor patient outcomes and used this information to improve services. The care provided by staff continued to be good. People were supported, treated with dignity and respect, and were involved as partners in their care. The service met the needs of people it supported. The management of the service had improved since the last inspection.
• Staff in surgical services understood how to protect patients from abuse and the service worked with other agencies to do so. Staff completed and updated risk assessments for each patient. The surgical division participated in both national and local audits to monitor people’s care and treatment outcomes and compare with other similar services. All staff were committed to providing excellent care to their patients. Quality improvement projects had helped to improve the service being delivered to patients, however some projects were in their infancy.
• Staff in outpatients understood how to protect patients from abuse and there were clear processes for reporting safeguarding concerns. There were systems in place to manage maintenance of equipment and repair faults when identified. Staff kept appropriate records of patients care and treatment. The service made sure staff were competent for their roles. Patients were treated with compassion, kindness, dignity and respect throughout their visits to outpatient services. Staff within outpatients worked hard to ensure people with learning disabilities were able to access services. The trust identified where a system-wide approach was needed to meet the needs of the local population. Staff supported patients with additional needs such as patients living with dementia. The trust had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care. There was a positive culture within outpatient services. The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff and patients.

However:

• In the emergency department there was a continuing shortage of middle grade medical staff and heavy reliance on temporary staff. Also, the management of medicines could have been improved. We found the department was frequently crowded which meant that individual needs could not always be met. During busy times, we found that some patients felt their care was rushed. We found there was poor day-to-day operational oversight of the department. There was little engagement with patient groups.
• Although the timeliness of some elements of care provision had improved, patients did not always receive care and treatment within an acceptable timeframe and in the right place. Patient’s dignity and privacy were not always maintained and patients who became agitated did not always receive compassionate care from nursing staff.
• In medical care, systems and processes to keep people safe were not always followed in relation to infection control and medicines management and performance in national audits was variable and outcomes for stroke patients needed improvement. National targets for referral to treatment times were not met for most medical specialities. Risk management processes needed to be improved as risks were not always graded, mitigated and reviewed appropriately
• Although we found the surgical service had improved, the division still needed time to embed processes and practice, and improve certain areas, under new leadership. Medical gas oxygen cylinders were not being stored securely across surgical wards and theatres. Staff required some additional support to manage patients living with mental health needs safely. Staffing on wards was regularly at minimum staffing levels rather than at funded establishment, particularly at night times. A shortage of radiologists made it difficult to provide 24-hour cover. Staff demonstrated a limited understanding of the Mental Capacity Act. Systems used by the trust did not help promote flow and efficiency in theatres and risked the safety of patients.
• Outpatient services were primarily a five-day service. The introduction of a new patient appointment booking system, had presented a number of difficulties in the delivery of services. The trust has been unable to report referral to treatment data to NHS England since November 2016 because of data quality issues following the introduction of a new electronic patient record system in December 2016. Patients could not always access services when they needed them.