West Cornwall Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

There was a positive culture of incident reporting, with staff demonstrating a good understanding of the reporting process and duty of candour. Managers were responsible for reviewing incidents, which were investigated in line with trust policy. Where required, individual feedback was provided to staff. Learning from serious incidents, including Never Events, was shared through written communication. Never Events are serious, largely preventable patient safety incidents that should not occur when appropriate preventative measures are established. In the last 12 months, 2 incidents resulting in minor injury or illness had been reported. There was also 1 Never Event, and we saw evidence of a thorough investigation into this incident.

Opportunities for shared learning included group discussions held during daily theatre huddles. There were no daily huddles on the surgical ward due to previous challenges with effective implementation; however, managers told us there were plans to reinstate a more structured approach to daily communication. Incident themes were also discussed at monthly meetings, with minutes circulated to all staff.

The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There was a local process to ensure patients received the required level of monitoring and support before the surgical team left the site. Clinical observations were recorded in line with trust policy, and clear escalation processes were established for any clinical concerns. Sepsis guidelines were displayed throughout the ward for staff reference. Compliance with sepsis pathway completion and documentation was monitored through paper-based audits, supporting oversight and quality improvement. The introduction of a new electronic patient record system was expected to further enhance this process.

There was a policy outlining the safe transfer of patients to the main acute hospital when required due to clinical concerns.

The discharge process ensured patients were clinically safe prior to discharge, were provided with relevant information, and had transport arrangements to return home safely. Patients said discharge planning was discussed with them and they felt safe at the time of discharge.

The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The service shared concerns quickly and appropriately.

Staff understood safeguarding processes and knew how to raise concerns. They had access to the trust’s safeguarding policy, which was aligned with national guidance.

Staff received safeguarding training required for their roles. Surgical staff were compliant with Level 1 and Level 2 adult safeguarding training; however, not all had completed Level 3 training. This was due to a temporary pause while a new national training module was being introduced. At the time of the assessment, the new module had been introduced and training restarted. The trust aimed to achieve full compliance by 2027. Staff also had access to support and extra supervision if required, as laid out in the trust’s safeguarding supervision policy.

The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff ensured patients understood their care and treatment and provided clear information on how to prepare for surgery, including guidance on medicines and fasting requirements. Pre‑operative risk assessments were completed to confirm patients were fit for surgery, covering areas such as mobility, mental capacity, communication needs, skin integrity, and swallowing.

Staff used the National Early Warning Score (NEWS2), a nationally recognised tool for identifying patients at risk of deterioration, to record and escalate vital observations before, during, and after surgery. The trust had a policy setting out safe standards for surgery, aligned with the NHS England mandate for the National Safety Standards for Invasive Procedures (NatSSIPs 2). Staff followed a checklist based on the World Health Organisation (WHO) Five Steps to Safer Surgery, designed to reduce errors and adverse events and improve patient safety and outcomes. The WHO checklist was well embedded in practice, and performance data demonstrated consistent compliance with checklist completion.

The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Surgical wards and theatres were clean and well organised; however, some areas required redecoration and refurbishment. For example, flooring was starting to lift away from the wall in one area of theatres.

Personal protective equipment (PPE) was readily available, and we observed effective waste management arrangements. Ward doors were dementia friendly, supporting accessibility and patient orientation.

In theatres, there were adequate supplies of PPE for staff, alongside accessible hand‑wash basins and sharps bins. The difficult airways trolley had been checked, and all equipment was confirmed to be within date.

The trust had a Medical Equipment Management Policy that described how medical devices were managed and maintained. Electrical equipment had been safety tested, and the service actively monitored the environment, making improvements where required. We reviewed an environmental assessment that considered factors such as furniture, lighting and ward layout. Regular fire walkarounds and risk assessments were conducted, and evacuation plans were implemented for both theatre and ward areas.

Theatre ventilation systems were subject to annual checks. They were still working, but due to their age, remedial actions were identified. These were logged in a formal tracker with actions and risks managed and monitored through the trust’s governance arrangements, including the trust’s risk register.

The evidence showed a good standard. The service made sure there were enough qualified, skilled, and experienced staff, who received effective support, supervision, and development. They worked together well to provide safe care that met people’s individual needs.

Staffing levels within theatres were aligned with the Association for Perioperative Practice (AfPP, 2022) safe staffing recommendations. The team reported there were sufficient staff members on duty to work safely, although at times this felt close to the minimum safe level.

There were instances of dual-role working for minor surgical procedures. In these cases, a single practitioner acted as both the scrub practitioner (responsible for sterile equipment) and the surgical first assistant (supporting the surgeon directly). While the AfPP supports scrub practitioners undertaking this dual role, it is important this is reflected in local trust policy. Following discussion, the trust agreed to update its policy to clarify the role of scrub practitioners.

Staff described having protected audit time each month, during which they could complete some mandatory training. However, they noted finding additional time for training could be challenging.

Mandatory training compliance across surgical and theatre teams was 86% (the trust target was 90%). While compliance was lower in some specific courses, the majority of these were refresher courses, and staff were observed to be competent in their roles. The leadership team was actively working to improve compliance, supported by the education team. Staff reported developmental training was encouraged, although time constraints could make this difficult. Managers stated staff had opportunities to attend the main acute site for further training.

Staff had recently participated in surgical simulation (SIM) training and emergency scenario training. Additionally, staff trained in Advanced Life Support (ALS) were available on site.

Most staff had received an appraisal and described the process as meaningful.

The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

In theatres, there were adequate supplies of personal protective equipment (PPE), and staff were observed using PPE correctly. There were sufficient handwashing facilities and sharps bins. Good waste management practices were evident, and sterile procedures were followed.

The surgical wards were clean, tidy, and well maintained, with ‘I am clean’ stickers in use. We observed safe handling of sharps boxes and waste on the wards. Cleaning audit results demonstrated compliance rates above 95%. Patients said the wards were clean and well kept.

Hand hygiene audits monitored staff adherence to trust policy. Recent findings showed 100% compliance in both theatres and surgical wards. During our observations, staff were seen washing their hands between patient interactions, and hand sanitiser was readily available and routinely used.

Infection prevention and control (IPC) performance at peripheral sites was reported to the trust board through ‘Ward to Board’ reports and monitored regularly through IPC committee meetings.

The evidence showed a good standard. The service made sure medicines and treatments were safe and met people’s needs, capacities, and preferences. They involved people in planning, including when changes happen.

Staff demonstrated good practice in medicines management. Medicines were stored safely and securely, with access to emergency medicines within the theatre environment. Emergency resuscitation equipment and medicines were also stored securely, and log sheets confirmed these were checked daily. Blood supplies were available on site.

A pharmacy service was available on site, and patients told us medicines were clearly explained to them.

Medicines were subject to weekly checks by the pharmacy team. The service conducted regular medicines audits, including controlled drug audits, to ensure compliance with legal requirements and safe management of high-risk medications. The most recent medicines audit for the surgical wards showed 100% compliance.