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Royal Cornwall Hospitals NHS Trust

  • Royal Cornwall Hospital, Treliske, Truro, Cornwall, TR1 3LJ

Latest inspection summary

Last inspected 21-22 and 25 January 2014

These checks were made using our new inspection model. If we are taking enforcement action, we highlight it below.
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Royal Cornwall Hospitals Trust is a medium sized teaching district general hospital trust providing acute, specialist and community healthcare to the people of Cornwall and the Isles of Scilly, serving a population of around 450,000. This population is often doubled when the area is visited by holiday-makers and tourists in the summer months. The trust provides services at three hospitals. These are the Royal Cornwall Hospital in Truro (known locally as Treliske Hospital), St Michael’s Hospital in Hayle and West Cornwall Hospital in Penzance. There are approximately 750 beds across these three hospitals. The trust is registered to provide assessment or medical treatment for persons detained under the Mental Health Act 1983; diagnostic and screening procedures; family planning; management of supply of blood and blood-derived products; maternity and midwifery services; surgical procedures; termination of pregnancies; treatment of disease, disorder or injury.

Last year the trust provided services to about 130,000 inpatients, provided 480,000 outpatient appointments and 73,000 people visited the emergency department at Treliske Hospital and the urgent care centre at West Cornwall Hospital.

To carry out this review of acute services we spoke to patients and those who cared or spoke for them.  Patients and carers were able to talk with us or write to us before, during and after our visit.  We listened to all these people and read what they said.  We analysed information we held about the hospital, and information from stakeholders and commissioners of services.  People came to our two listening events in Truro and Penzance to share their experiences.  To complete the review, we visited all three hospitals with specialists and experts.  We spoke to more patients, carers, and staff from all areas of the trust on our visits.

The trust had undergone a number of changes and improvements over the last few years, most noticeably at Treliske Hospital.  This had included a new accident and emergency (A&E) department, which opened in December 2013.  There had also been a change in leadership of the hospital trust.  Many staff told us these changes had been positive, and they felt the trust had improved and they were proud to work there.  There was a high degree of respect for the executive team. 

Many of the services provided by the trust were delivered to a good standard, but overall the trust required improvement. Patients received safe care and were treated with dignity, respect and compassion.  Patient records were not being accurately completed on all wards.  Records were not always being held securely.  The trust was finding it challenging to plan and deliver care to patients needing surgical or critical care, both to meet their needs, and to ensure their welfare and safety. This was because of the pressures it faced in meeting the increasing demand for its services, combined with  delays in patients being able to leave hospital when they were ready  because of capacity issues in the wider community. The plans to improve in this area needed to include the trust’s partners who share the responsibility, either as commissioners or providers, for the effectiveness of health and social care services. The trust had made a significant investment to increase the number of staff. While that work continued, the trust was managing shortfalls by using bank and agency staff.

Patients’ records were at risk of being seen by people not authorised to do so.  The pressures upon beds meant that patients’ procedures were being cancelled, or they were not being cared for in the most appropriate environment or ward.  At times, shortages of staff meant staff were not able to provide the best care at all times, records were not being completed, and vulnerable patients may not have had the additional attention they needed.

Staffing

The impact of the investment in recruitment and training had made a significant difference to the trust and had been a factor in the improvements that we saw and that staff and patients described. This work was ongoing and in the meantime some staff felt under particular pressure. We observed that these pressures were felt most keenly in the medical and surgery wards at Treliske hospital. At Treslike, some nurses we met said they did not have enough time to spend with patients; nurse managers said they were often fulfilling clinical shifts and not their managerial duties; nursing staff said training often had to be postponed if their area was short-staffed. The nursing staff shortages were covered by agency and bank staff.  At West Cornwall and St Michael's Hospitals, we found that there were sufficient staff of an appropriate skill mix to enable the effective delivery of care and treatment. Staff at St Michael's, both nursing and allied health professional such as physiotherapists, told us that they were often moved to work at Treliske, and this was a concern to them. Patients told us that consistency of staff was important to them. They said it was good to have the same staff on duty during your stay, and felt that this meant they had better and more consistent care. There were many, very positive comments from patients regarding their care from across the trust.

Cleanliness and infection control

The hospitals were clean.  We observed good infection control practices among staff.  Staff were wearing appropriate personal protective equipment when delivering care to patients.  At West Cornwall and St Michael's Hospitals information about infection control, including the use of hand gel, was clearly displayed, alongside gel dispensers throughout all areas. Infection rates were low. At Treliske Hospital we were concerned about the distribution of hand-wash gels, and instructions for people, patients, visitors and staff to ensure their hands were clean and they used sanitising gels appropriately.  There was not enough provision of hand-gel at the entrances to wards and units in all places.

The number of patients with a catheter who got a urinary tract infection was higher than the average for England in the majority of the last 12 months. The number of MSRA bacteraemia infections and c. difficile infections attributable to the trust were with the acceptable range for a hospital of this size.

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application/pdf icon Quality report published 27 March 2014 340 KB

Background information for inspection on 21-22 and 25 January 2014

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Inspection areas

We found the services at the trust were safe however some improvements were required. Patients were protected from the risk of abuse. Incidents were mostly reported appropriately, and there was evidence of learning from them to improve care. Examples of improvements included the learning from never events in theatres and around pressure area care.  (Never events are largely preventable patient safety incidents that should not occur if preventative measures are taken.) There were reliable systems, processes and practices in place to keep people safe who worked within the hospitals and across the trust.

The board and senior team had a focus on safety as demonstrated in interviews and board minutes. Staff at all levels described the focus on safety and referred to it as a priority. Staff felt able to raise concerns when they felt operational pressures, such as shortages of staff, had an impact on safety. The trust monitored safety at ward, specialty, divisional and trust level. The trust responded to risks and there was evidence of how plans for individual patients were changed in response to changing needs. The trust had anticipated and planned for problems relating to safety; for example, using additional funding for winter pressures to open the Frailty Assessment Unit.

Some patient notes were not accurate or complete, which could mean that there was not appropriate information available to plan care or judge if a patient’s condition was improving or deteriorating. Staffing levels had increased and while recruitment continues, bank and agency staff are employed to deal with shortages. Despite this, the staff working in medical and surgical wards at Treslike hospital felt under pressure at times. This has been recognised and the trust was continuing to actively recruit staff.

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Patient care and treatment was effective in most areas of the trust. Outcomes for patients were good and the trust performed well when measured against similar organisations. National guidelines and best practice were applied and monitored, and outcomes for patients were good overall. Both national and local audits were undertaken to monitor care, and outcomes and action plans were implemented where required to improve care. Staff worked in multidisciplinary teams to co-ordinate care around a patient.  Staff were supported to be innovative and develop their clinical skills.  Most mandatory training and appraisals were on track to be completed annually.   

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application/pdf icon Quality report published 27 March 2014 340 KB

Patients were treated with dignity, respect and compassion. During our inspection we observed that almost all staff were caring, and patients confirmed this, saying also that staff were considerate, treated them with kindness and respect, and that they felt safe.  Patients and carers coming to the maternity and children’s services said staff were caring and kind.  A&E staff were praised for their kindness.  Staff in the critical care team provided outstanding emotional support. There was an exceptional service provided by staff in the surgical team, for people with learning disabilities who might be scared about coming to hospital.  We found people with learning disabilities were cared for well in other parts of the hospital.  Children and their parents were kept involved with decisions and care planning.  The care given to people at the end of their life was caring and sensitive.

People who came to our listening events had varied views about the care they received.  Most people who contacted us outside of the hospital visits, but not all, were concerned about poor care and their experiences.  Some described excellent care and compassionate staff.

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application/pdf icon Quality report published 27 March 2014 340 KB

The trust planned to provide services to meet the needs of the people they served. Treliske and West Cornwall Hospitals were very busy, with around 95% of available beds in use, while St Michael's Hospital had less than 50% of beds in use. At Treliske Hospital, the high occupancy level, particularly in medical and surgical beds, was having an impact on the quality of care, and on the trust’s ability to be responsive to people’s needs. The lack of beds in parts of the hospital caused delays in the A&E department. There was sometimes pressure on maternity services, leading to women giving birth to their babies on the antenatal ward.  The critical care unit was not meeting discharge targets, as there were sometimes no beds available into which to move patients who were recovering. Because of this, and other bed pressures, some surgical procedures were cancelled, and responsive care was complicated by medical patients being admitted to surgical wards due to shortages of beds on medical wards. 

Patients were sometimes also delayed in their discharge into community care, because this was not being arranged in good time with, and by, other providers. The hospital was cancelling too many operations, and in some circumstances, there were inadequate facilities to consult with patients, which was causing further delays. The improvements required to ease the pressure on the trust needed to involve partners in the wider community to help manage the impact of the increasing number of people seeking treatment and the delays in people leaving the hospital.

The trust supported vulnerable patients well to ensure care was delivered in their best interests.  Aspects of the care for people with learning disabilities were innovative and effective.

The trust had taken action to improve the way that complaints were handled. A complaints review panel identified and shared wider lessons from complaints. Changes had been made to processes and procedures following complaints and improvements in the timeliness of responses was seen.

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application/pdf icon Quality report published 27 March 2014 340 KB

The trust was well-led. The leadership and management of the trust had a clear vision and a credible strategy to deliver high quality care to patients. Some improvements were needed to deal with the challenges caused by the difficulties in moving patients through and out of hospital, and this would require working with partners and commissioners, so that needs were understood and planned for across the system. There were actions that the trust could take itself, in terms of planning service delivery and discharge. Many staff spoke about the executive team with respect and enthusiasm. Many staff from across the trust, working in a range of roles, talked about the difference that the Chief Executive had made over the past two years. There was a sense of energy and optimism, and improvements in engagement with staff. Staff talked about improvements in communication, and some staff said they felt they were encouraged to speak up and contribute their ideas. Staff were supported by their peers and managers to deliver good care and to support one another.  Staff said they felt proud to work at the trust, and were included and consulted about  plans and strategies.  The trust identified areas where improvements could be made, and organised work-groups and experienced staff to address them. 

Most wards were well-led, although the leadership on a few wards was not addressing the poor record-keeping, and some staff were unclear about their roles and responsibilities. 

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application/pdf icon Quality report published 27 March 2014 340 KB

CRM ID:REF

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All standards were being met when we inspected the service. If this service has not had a CQC inspection since it registered with us, our judgement may be based on our assessment of declarations and evidence supplied by the service.
At least one standard in this area was not being met when we inspected the service and we required improvements.
At least one standard in this area was not being met when we inspected the service and we have taken enforcement action.


What does a grey cross mean

At least one standard in this area was not being met when we inspected the service and we required improvements.

What happens next
The service will tell us how it is making improvements. Once we are happy that the improvements have been made, we will update our judgement to show a green tick. Other times, we may have to carry out a 'follow-up' inspection to check improvements.


How can I get more information
Our inspector's report will give you more information about why the service received a grey cross. You can also contact the service directly or visit its website for more details on any improvements it has made.



What does a red cross mean

At least one standard was not being met when we inspected the service and we took enforcement action.

What happens next
The type of enforcement action we take depends on the seriousness of our inspector's findings, and the service must make improvements before we update the judgement on our website.


How can I get more information
Our inspector's report will give you more information about why the service received a red cross. You can also contact the service directly or visit its website for more details on any improvements it has made.