St Michael's Hospital

The Royal Cornwall Hospitals NHS Trust is the principal provider of acute care services in the county of Cornwall. The Trust serves a population of around 532,273 people, a figure which can be doubled by holiday makers during the busiest times of the year.

This is an announced focussed inspection of Royal Cornwall Hospitals NHS Trust to assess if improvements have been made following the previous unannounced focussed inspection carried out in January 2017.

St Michael’s Hospital is located in Hayle and is one of the three acute hospital locations run by Royal Cornwall Hospital NHS Trust. St Michael’s Hospital provides surgery and outpatient services. We inspected both services as part of this inspection on 5 July 2017.

We rated St Michael’s Hospital as good overall.

Our key findings were as follows:

• Staff reported incidents and demonstrated knowledge of how to do this.
• Staff demonstrated how they learnt from never events which had occurred at the hospital and evidenced how changes to practice had been made.
• Patients were safely managed and staff identified and responded should a patient deteriorate. There was a good awareness of sepsis processes.
• The environments we visited were clean and tidy. Staff adhered to infection control policies and procedures.
• Equipment was in working order and had been serviced/calibrated as required. Resuscitation equipment was checked regularly.
• There were arrangements in place to safeguard adults and children from abuse that reflected the relevant legislation and local requirements.
• In theatres good practice was observed with the efficient and timely completion of the five steps to safer surgery World Health Organisation checklist.
• Resident medical officers were available 24 hours a day, seven days a week to provide medical support to nurses when caring and treating patients.
• There was exceptional multidisciplinary team working which was co-ordinated and delivered with the involvement of necessary staff.
• Physiotherapy provided services seven days a week. An Enhanced Recovery After Surgery programme was delivered to orthopaedic patients and early mobilisation was encouraged which had reduced the length of stay for patients.
• Care and treatment was delivered in line with best practice and evidence based guidance.
• All staff were competent to carry out their roles and learning needs were identified during their annual appraisal. Staff reported they were well supported and encouraged in training opportunities for professional development and skills.
• Patients were repeatedly positive about the care and treatment they had received.
• We observed staff providing care which was compassionate and supportive. Patient privacy and dignity was always respected. Staff took time to interact with patients in a respectful and considerate manner and ensured that patients understood the care and treatment they were receiving.
• Staff understood and respected patient’s personal, cultural, social and religious needs.
• Staff showed a supportive attitude to patients. When patients experienced physical pain, discomfort or emotional distress, staff responded in a compassionate, timely and appropriate way.
• There was good flow from theatres to wards. Theatres were well utilised and theatre lists were not restricted by bed capacity. Surgical cancellations were low at St Michael’s Hospital.
• Information about the needs of the local population was used to inform how services were planned and delivered.
• Patients’ individual needs were taken into account and adjustments made for example longer appointment times were available for people living with dementia and for those with mobility problems, hearing difficulties and visual impairment.
• The culture across the hospital and all staff roles was overwhelmingly positive.
• Staff spoke positively about the local leadership team. This team promoted good quality care and were aware of the key risks and mitigations.
• There was a clear vision and strategy for St Michael’s Hospital, this was discussed, along with other ways of improving the service, within the monthly St Michael’s Clinical Programme Board.

We saw several areas of outstanding practice including:

• The structured and co-ordinated multidisciplinary team working in a nurse and therapy led unit ensured patients care and treatment was seamless. This aimed to and had achieved improving patient experience and patient outcomes. Seven day working and twilight hours of physiotherapy enabled the enhanced recovery after surgery programme to be delivered. Data showed an increase in standing and mobilising patients on the day of their surgery and reductions in the average length of stay for orthopaedic patients.
• There was an exceptionally positive culture amongst the staff working at St Michael’s Hospital with a sense of good team spirit and flexibility within the staff groups.
• The happy and calm atmosphere enabled high standards of care to be provided to patients.
• Staff across all of the outpatient departments and we visited and reception staff were very patient centred and made great efforts to ensure patients were supported, given time to ask questions and understood the information they had been given.
• Patients were overwhelmingly positive about their care and treatment they had received.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

• Ensure staff investigating incidents are aware of the current guidance and the framework for reporting never events and comply with trust policy. The trust must review the never event incident of wrong side anaesthetic block at St Michaels Hospital in November 2016.
• Carry out a risk assessment and consider a long term solution to the ceiling tiles in the pre-operative assessment clinic waiting room to reduce the risk of them falling from the ceiling again.

In addition the trust should:

• Continue to review the security arrangements within the hospital, and seek feedback and confirmation from staff that they feel safe in their working environment.
• Ensure staff are checking and referring to the instrument list included with the set as part of the checking procedure in theatres during wound closure.
• Ensure medications are identified for return to pharmacy in a timely manner. Controlled drug expiry dates should be checked with the daily stock checks and patient own medication should be returned at the nearest point following discharge.
• Ensure chlorine tablets remain safely locked and are not accessible to patients and visitors.
• Review the use of fabric reusable curtains and their implications on infection prevention control within the hospital.
• Have in place a system to identify each individual prescription issued so that a prescription could be traceable if a problem arose in the future.
• Consider the security of the door to the pre-operative assessment clinic to prevent people being able to access the unit and the rest of the hospital without staff knowing and to maintain confidentiality of patient notes.
• Consider the need for call bells in the general outpatient consulting rooms.
• Ensure staff mandatory and local training gaps are addressed and compliance achieves trust targets.
• Consider a formal process for clinical supervision to ensure improvements in nurse practice and reflective learning.
• The trust should ensure there are processes in place for induction and orientation when St Michael’s Hospital staff are relocated to Royal Cornwall Hospital for their shift. Consideration should be given to the safe staffing provided when staff are required to work on wards or departments which they have never experienced or are not comfortable to work in.
• Continue to review the capacity at St Michael’s Hospital and the opportunities to increase theatre lists for the benefit of improving flow at Royal Cornwall Hospital and ensuring patients receive timely operation dates.

Professor Edward Baker

Chief Inspector of Hospitals