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Royal Cornwall Hospital Requires improvement

All reports

Inspection report

Date of Inspection: 25 January and 25 May 2011
Date of Publication: 29 June 2011
Inspection Report published 29 June 2011 PDF

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Not met this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

Our judgement

A culture of reacting to problems rather than monitoring and preventing them, mean that some patients receiving surgery are still at an increased risk of receiving unsafe care and treatment.

User experience

Staff told us that they use a sticker, in the patient’s notes, to sign to show that the WHO safety checks had been done. All patients’ notes we saw had stickers signed to say the WHO checklist had been done.

A computer system is used to record that the checks have been done and that swab checks have been done and are correct. The system does not record the quality of this check or details of what it included. This means that audits may not pick up poor practice.

One consultant said that he believes in the computerised system but did not think it was sufficient to cover the WHO checklist. Another said he used to do a more rigorous checklist until, the computerised system took over. Another added that there are far too many similar checks done too early before the patient reaches the theatre, meaning that the important checks are not done when they really need to be by the people who need to do them such as the anaesthetist, surgeon and nurse.

All of the staff knew about the WHO checklist. The NPSA ‘five steps to safer surgery’, to be used in conjunction with the WHO surgical safety checklist was displayed on the wall in each theatre we visited. The staff had adapted it in their own way and in so doing had left out important parts of it.

Other evidence

Reports received before our visit informed us that an internal investigation had taken place with every ‘never event’ reported but these had not been linked together to ascertain whether there may be systemic issues within the operating theatre departments.