The unannounced inspection was carried out by a team of five inspectors in addition to a specialist advisor and an Expert by Experience. We visited six wards where concerns had been raised through a variety of sources. Concerns were mainly around people’s care, treatment and involvement and the lack of respect for privacy and dignity. People had also raised concerns in relation to how the trust had managed their complaints.

We spoke with patients and staff on all of the wards we visited and spent time observing how care and support was delivered. Our findings were very mixed with some marked differences between wards. There were differences in leadership and therefore effectiveness of systems and processes. We identified a range of concerns about consultation and involvement of patients, documentation of care planning and evaluation and key issues such as ‘do not attempt resuscitation’ (DNAR) orders.

Prior to our inspection the trust had acknowledged that capacity pressures across the hospital were impacting on people’s experiences. They were actively addressing the challenges with health and social care partners. There was also recognition of the issues we identified during our inspection and action was being taken. A member of staff told us that increased admissions had resulted in “huge pressures placed on the workforce”.

Overall patients described very positive experiences of their care and treatment. Comments included, “I couldn’t be treated any better if I was the King” and, “The care from the doctors is very good and the nurses are excellent”. Most patients we spoke with told us that staff respected their privacy and dignity. Other patients commented that improvements were needed in how staff involved them in discussions and decisions about their care and treatment, for example their diagnosis, progress and discharge arrangements.

Patients we spoke with were not aware of how to make a formal complaint, although they told us they had not had cause to complain. We found information about complaints was not readily accessible for patients and their representatives. We saw the trust had responded to complaints but letters did not contain information for people on what to do if they were unsatisfied with the response provided by the trust. We found the trust had started to redress the identified backlog of complaints and the shortfalls in processes and acknowledged it was very much “work in progress”.

People told us what it was like to be a patient in Royal Shrewsbury Hospital. They described how they were treated by staff and their involvement in making choices about their care. 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 joined by a second CQC inspector, practising professional and an expert by experience, who has personal experience of using or caring for someone who uses this type of service.

We visited two wards providing adult inpatient care across the hospital. We spoke with nine patients who were receiving a service, two relatives and 10 staff from different disciplines. Patients we spoke with shared positive experiences about the care they received and how they were treated. They told us staff were respectful, promoted their privacy and dignity and kept them well informed about their care and treatment.

Patients were complimentary about the meals and food choices available. They told us their meals were served hot, were appetising and well presented. Where patients required assistance with eating, we saw staff provide support discreetly and respectfully. Patients who required specific meals to meet their dietary needs told us they were provided with the “right” food.

Patients told us they were well cared for and said they felt safe. They described staff as competent and caring. One patient said, “Everyone is wonderful here. They treat you properly and are very respectful.” Patients told us they were confident in raising any concerns with the staff.

Patients considered there was generally enough staff on duty to meet their needs. All but one person told us that staff attended to their call bells in a timely manner. One patient commented, “The staff are rushed off their feet here but I’m not kept waiting”. Another patient said, “The staff know what they are doing”. Staff were confident that numbers and skill mix could be changed in order to meet any changing circumstances of patient care.

Patients told us staff regularly spoke with them prior to completing their records. We saw evidence of good incident reporting processes in place. However, the current system for recording patient information was not integrated or unified. The trust had already identified this as an area requiring improvement.

The inspection was unannounced and consisted of a team of three inspectors in the morning and four inspectors in the afternoon. We visited four wards providing adult inpatient care across the hospital. We spoke with 38 people who were receiving a service, three representatives and 10 staff from different disciplines. Most people we spoke with shared positive experiences about the care, treatment and support they had received. They said they were treated with dignity and respect; that staff asked before helping them with personal care tasks and explained what they were doing when carrying out tests or procedures. They told us staff responded to their needs in a timely manner most of the time.

Most people told us they were consulted about their care and treatment. Although one person told us that they had waited all day for an operation only to be told by a Housekeeper that their operation had been cancelled and served a meal they disliked. We saw a person being discharged and observed positive interaction by a member of staff wishing them a safe onward journey.

Overall we found that staff had a good knowledge of people's needs. However we found that assessments, care plans and risk assessments were not individualised or comprehensive. Most people we spoke with said that their needs were being met. Although we did not find that outcomes for people were poor, we did find that care plans and risk assessments were not being reviewed and monitored sufficiently to ensure appropriate treatment was consistent.

People told us the food was generally good with sufficient choice and support when needed. However, we observed one older person, who was a vegetarian, being assisted to eat a meat dish. A notice was displayed above their bed indicating their specific dietary preference, however there was nothing documented in their care plan in relation to their dietary requirements. We saw the staff member take swift action to rectify the situation.

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. People who had raised concerns told us these had been dealt with in a timely manner.

Most people told us there were sufficient staff and skill mix to meet their individual needs although at times staff were “stretched” and that this can impact on their care and treatment. People said staff were competent, attentive and caring.

Overall people told us that staff involve them in their care, treatment and support and that their privacy and dignity is respected. Most people told us that staff call them by their preferred form of address and respond to their needs quickly. They said that staff are kind and explain what they are doing. One person said, “The staff are very careful how they handle me” another person said, “One time I was being washed and they left me in the middle of my wash to attend to someone else. I was left about half an hour”.

People said they are offered a good choice of food but this is not always the option they actually receive. Most people told us they felt their nutritional needs and dietary preferences were well met. All but one person we spoke with was happy with the food portions and how their food was presented. One person said, “I’m quite impressed with the food and the care is fantastic. The staff are very good at offering lots of drinks. They really are doing it very well”.

Our rating of services went down. We rated them as inadequate because:

• Our rating of safe was inadequate overall. 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 and patients’ privacy and dignity was maintained.
• 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.