You are here

Royal Cornwall Hospital Requires improvement

We are carrying out a review of quality at Royal Cornwall Hospital. We will publish a report when our review is complete. Find out more about our inspection reports.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 14 December 2018

Our rating of services improved. We rated it them as requires improvement because:

  • Urgent and emergency care remained the same and was rated as requires improvement. Safe and responsive remained the same and were rated requires improvement. Effective and caring stayed the same and were rated good. Well-led improved and was rated good.
  • Medicine improved since our last inspection and was rated requires improvement. Safe and well-led improved and were rated requires improvement. Effective improved and was rated good. Caring remained the same and was rated good. Responsive stayed the same and was rated inadequate.
  • Surgery had improved since our last inspection and was rated as requires improvement. Safe and responsive had improved since our last inspection and were rated requires improvement. Effective and well-led remained the same and were rated as requires improvement. Caring also stayed the same and was rated good.
  • Critical care services remained as good overall. Safe went down one rating since our last inspection and was rated as requires improvement. Effective, caring and well-led remained the same as our last inspection and were rated good. Responsive went up one rating and was rated good.
  • Maternity services had improved since our last inspection and were rated as requires improvement. Safe and well-led had improved and were rated requires improvement. Effective and responsive had improved and were rated good. Caring stayed the same and we rated it good.
  • End of life services had gone up one rating since our last inspection and were rated requires improvement. Safe had stayed the same and was rated requires improvement. Effective, responsive and well-led had improved and were rated requires improvement. Caring remained the same and was rated good.
  • Outpatient services were rated as requires improvement. Safe, responsive and well-led were rated requires improvement. Caring was rated good. Effective was not rated.
  • Diagnostic imaging was rated outstanding. Responsive and well-led were rated outstanding. Safe and caring were rated good. Effective was not rated.
  • Children and young people’s services remained the same and were rated good. Safe remained the same and was rated as requires improvement. Effective, caring, responsive and well-led also remained the same and were rated good.
Inspection areas

Safe

Requires improvement

Updated 14 December 2018

Effective

Good

Updated 14 December 2018

Caring

Good

Updated 14 December 2018

Responsive

Good

Updated 14 December 2018

Well-led

Requires improvement

Updated 14 December 2018

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 14 December 2018

Our rating of this service stayed the same. We rated it as inadequate because:

  • The systems in place to promote flow were not all effective and the increasing demand outweighed the capacity available within the trust. The hospital had problems maintaining flow from admission to timely discharge because of both the increased demand for admission but also because patients were delayed in being discharged.
  • Bed management for the winter was of concern. The trust had a provisional winter plan for 2018 currently under review. The plan was not fully agreed and confirmed but the winter pressures were already evident.
  • When the hospital was under pressure with surges in demand for inpatient beds, the trust used a system where patients were placed in the centre of ward bays pending an admission bed. They did not have access to equipment or privacy and dignity. This practice was called Safer Placement for Patients; however, this did not ensure a safe and dignified admission for patients.
  • Staff used a modified early warning score as part of an electronic observation system to identify patients who had deteriorated. The system had connectivity problems in some areas of the hospital and had to be supported by paper systems. This was problematic for some staff and risked patients’ observations not being recorded in a timely manner, or the correct people not being alerted if a patient was deteriorating.
  • There was a chronic staffing shortage which resulted in reduced welfare for patients and poor staff morale. There were high vacancy rates on the wards which were covered by agency and bank staff. The staffing establishment had not been increased despite the wards sometimes having to take extra patients.
  • There were consultant vacancies in different specialities throughout the medical care group. This meant the consultants were challenged to be present in all areas of their role and some had to prioritise the work they undertook.
  • Bed moves and discharges were taking place both during the day and night, despite the trust trying to avoid this. These moves and discharges included patients with dementia or who lived alone.
  • Statutory and mandatory staff training compliance did not meet the trust’s 95% completion target.
  • Staff did not feel the mandatory training in mental health needs, learning disabilities, autism and dementia was sufficient to provide them with the knowledge and skills required to care for these patients.
  • Some ward and unit areas were not fully equipped with oxygen and suction for each bed space.
  • Delays were seen in the response time to answering patient call bells.
  • Complaints were not consistently managed in a timely manner.
  • Leadership from the board was not evident to all staff. Several staff expressed the wish for a consistent and visible board leadership, but after numerous changes the ward and unit level staff had become concerned about the instability.
  • Staff felt their pride in the role and work they undertook was undermined by the higher-level management instability. None of the staff we spoke with knew who the Chief Executive told us they never saw members of the board on the wards.
  • Feedback from patients and relatives was not consistently used for learning or celebration opportunities.

However:

  • Staff showed a kind and supportive attitude to patients and their relatives. We observed staff cared for patients with compassion. They took time to interact with patients and their relatives in a respectful and considerate manner.
  • We overheard staff explaining procedures and apologising when a short delay had occurred. Emotional support was considered by staff and was included as part of review and handover information. We observed staff providing emotional support to patients and relatives during their visit to the department.
  • There were safeguarding systems, processes and practices in place. They were well understood by staff and used to ensure patient safety.
  • There was a strong incident reporting culture at ward and unit level. Staff were encouraged to report incidents and other concerns. But, feedback following this reporting varied.
  • Risk assessments were carried out for patients. and risk management plans were developed to meet any identified area of need.
  • Medicines were managed and stored safely and the design, maintenance and use of facilities and premises kept people safe.
  • The trust had systems and processes to ensure standards of cleanliness and hygiene were maintained.
  • Policies and guidelines had been developed in line with national policy and staff assessed patients’ nutritional and hydration needs in line with national guidance. Patients’ pain was assessed and managed effectively.
  • The trust was undertaking a review of falls and how they were being managed. Information gained was being used to reduce the risk of falls.
  • Staff had the right skills and knowledge to provide safe care and treatment for patients and worked across healthcare disciplines and with other agencies when required.
  • The service regularly reviewed the effectiveness of care and treatment through local and national audit.
  • Leadership at a local ward and unit level was mostly strong and enabling. A minority of ward staff felt local leadership did not support them. Ward leaders had the skills, knowledge and experience to lead teams effectively.
  • Staff believed they understood the vision and strategy, which included working with each other, compassion, promoting integrity and trust and respect.
  • The trust had systems in place that helped manage and monitor quality and assurance. Processes were in place to look at risks at divisional and board level. Real time data around performance, quality and safety was used to review the service provided and to identify areas where further work was required.
  • Learning from complaints was shared on wards through staff safety briefs and an overview of complaints was reviewed through the medical services governance board.

Services for children & young people

Good

Updated 14 December 2018

Our rating of this service stayed the same. We rated it as good because:

  • Staff adhered to infection prevention and control policies and protocols.
  • The units were clean, organised and suitable for children and young people.
  • Incidents were reported and acted upon with feedback and learning provided to staff.
  • Treatment and care were effective and delivered in accordance with best practice and recognised national guidelines.
  • There was good multidisciplinary team working within the service and with other agencies.
  • Children and young people were at the centre of the service and the priority for staff.
  • Children, young people and their families were respected and valued as individuals.
  • Care was delivered in a compassionate manner. Parents spoke highly of the approach and commitment of the staff who provided a service to their children.
  • Children received excellent care from dedicated, caring and well-trained staff who were skilled in working and communicating with children, young people and their families.
  • Staff understood the individual needs of children, young people and their families and designed and delivered services to meet them.
  • There were clear lines of local management in place and structures for managing governance and measuring quality. The leadership and culture of the service drove improvement and the delivery of high-quality individual care.
  • All staff were committed to children, young people and their families and to their colleagues. There were high levels of staff satisfaction with staff saying they were proud of the units as a place to work. They spoke highly of the culture and levels of engagement from managers.
  • Innovation, high performance and the high quality of care were encouraged and acknowledged.

However:

  • There was poor compliance with mandatory training levels.
  • Safeguarding training compliance remained a challenge and required continued improvement. We were not assured there was a consistency of understanding of processes and policies at the named lead doctor level.
  • The location of the high dependency unit and the nursing observation arrangements remained a risk to children who were not visible to the main nursing station.
  • Some staff had little training in mental health beyond their mandatory training. There was no further formal training to manage children and young people with complex mental health conditions who were in a crisis. Some staff said they did not feel adequately equipped to deal with these patients.
  • Risk assessment and decision-making processes for children and young people with mental health needs were not always documented and some staff did not understand the requirements.
  • There was a lack of coordination between patient record systems and this hampered delivery of effective care and treatment.

Critical care

Good

Updated 14 December 2018

Our rating of this service stayed the same. We rated it as good because:

  • Staff followed best practice with regards to the prevention and control of infection. In general, there were good systems for staff to keep people safe and safeguarded from abuse. Most risks to patients were assessed and their safety was monitored. Staff had all the information they needed to deliver safe care and treatment. Staffing levels for nurses and doctors were provided at safe levels. Staff managed medicines safely. The service had a good track record on safety. When things went wrong, the team shared learning from investigations and made improvements.
  • In general, the team provided care based on the best available evidence. The service monitored care and treatment using data from internal and external audits. Patient outcomes were mostly good compared to other services. Staff had the skills, knowledge and experience to deliver effective care. They were competent and had good opportunities for development. Staff worked well together and involved other services and organisations to deliver effective care and treatment.
  • Staff were consistently caring and treated patients with kindness, dignity, respect and compassion. Patients were given the emotional support they needed. Patients and relatives felt involved in treatment decisions.
  • In general, patients received personalised care responsive to their needs. Patients could usually access treatment in a timely way. Staff ensured the individual needs of complex patients were met. Consent to care and treatment was always sought in line with legislation and guidance. Patients complaints and concerns were listened to and used to improve quality of care.
  • The local leadership team had the capacity and capability to deliver high quality sustainable care. Leaders understood the challenges to care and there was a strategy for improvement. There were clear roles, responsibilities and systems of accountability to support good governance and management. The culture of the unit was focussed on patient safety. Staff worked together to deliver good quality care.

However:

  • Some safety systems were not well monitored, such as mandatory training compliance. Not all risks to patient safety were assessed and well managed, such as the routine maintenance of medical equipment and the use of bed rails for patients.
  • Not all necessary staff were involved in assessing, planning and delivering care and treatment. There were gaps in the multidisciplinary team which reduced patients’ access to rehabilitation and specialist nutritional advice.
  • Not all care was responsive to patients’ needs. Patients sometimes were not admitted to the unit or discharged at the right time due to the demand for beds on the unit and the wider hospital. Complaints were not always handled in a timely way.

End of life care

Requires improvement

Updated 14 December 2018

Our rating of this service improved. We rated it as requires improvement because:

  • We were not assured the service was always meeting the requirements to provide safe care in all areas. The post mortem environment posed a cross infection risk and equipment did not meet standards. Consultant cover was stretched and compliance with treatment escalation plan was poor.
  • The service required improvement in effective care as the trust was not identifying all patients in the last year of their life. There had been a lack of improvement in the completion of treatment escalation plans, this had been highlighted as an area of concern on previous inspections. The service was in its first year of participating in the national audit of care for end of life patients and had not participated in any previous national audits.
  • Services were not always responsive to the needs of the local population. Consultant staffing levels and the facilities available could not meet the needs of patients, relatives and staff. Patients didn’t always attain their preferred place of care.
  • Well-led was rated as requires improvement. There was a lack of oversight and action taken to address issues, for example those seen in the mortuary. Not all actions had not been taken to address issues raised in previous inspections. Where audits had identified areas of poor performance, we did not see any action plans that addressed how this would be managed. The end of life risk register did not capture the risks to the service comprehensively, nor how they would be mitigated. There had been little momentum to improve this situation, and therefore the board could not be assured risks were identified or managed effectively.

However:

  • Safety was good in some key areas. There was good compliance with mandatory training and safeguarding training levels, although this was within a very small team. There was positive management of medicines.
  • To be effective, services were based around current evidence-based guidance. Staff were trained and competent to care for patients at the end of their life.
  • There was good care provided to patients and relatives. Patients spoke positively about the care they received. Staff recognised and provided emotional support. Patients were involved and informed about the treatment and care they were given.
  • Responsiveness was good in some areas. The SEPOL team were responsive to the needs of staff and patient needs regarding treatment and the withdrawal of treatment were respected.
  • Leaders had the skills and experience to carry out their roles. Staff spoke positively about leaders and felt they were approachable and listened.

Surgery

Requires improvement

Updated 14 December 2018

Our rating of this service improved. We rated it as requires improvement because:

  • There was no formalised process or system used to accurately calculate and risk stratify patients receiving surgery, and their requirement for the intensive care unit after surgery.
  • Mandatory training levels did not meet trust target. Compliance was poor for manual handling and safeguarding adults and children level two.
  • There were staff vacancies and a high use of agency staff was required to ensure wards and theatres were safely staffed.
  • Formalised competency frameworks were not always used to ensure staff had the correct skills and had been signed off as competent.
  • There were inconsistencies with obtaining the consent of patients as part of their treatment escalation plan. The approach in place was reactive rather than being proactive.
  • The completion of consent forms was variable. Some elective treatment patients were asked about their consent on the day and were not given sufficient time to make an informed decision. There was an incident at the time of our inspection where a patient had consented for the wrong treatment.
  • Patients did not always have access to care and treatment in a timely way. There were 11 specialities out of 14 that were failing to meet the referral to treatment time target.
  • There were a high number of patients who had been waiting for 52 weeks or longer for their surgery in trauma and orthopaedics and urology.
  • Although we had seen improvements in the governance of the surgical division, this was in the early stages and was still in the process of embedding.
  • The management and oversight of the risk register was not clear.

However:

  • Staff we spoke with understood the processes for identifying safeguarding concerns and their responsibilities to report.
  • Patient risk was considered and there were processes to assess and respond to potential or presenting risks. Staff were clear how they would respond to patient observations and how to follow sepsis care bundles.
  • The effectiveness of care and treatment was reviewed through local and national audit. Outcomes were collected and monitored, and they were generally within expected range when benchmarked nationally.
  • The multidisciplinary team were involved and worked together to deliver the most effective care and treatment to patients.
  • People were treated with kindness, dignity, respect and compassion. Patients spoke positively about the care they received, and we observed good quality care being provided to patients.
  • The service was being reviewed and changes were being made to the delivery of the orthopaedic service to benefit the surgical division and the local population.
  • The leadership team were clear about the priorities for the division and were keen to make changes which were sustainable to ensure improvements.
  • Staff felt engaged and involved with the surgical governance at an appropriate level relevant to their role.

Urgent and emergency services

Requires improvement

Updated 14 December 2018

Our rating of this service stayed the same. We rated it as requires improvement because:

  • Systems to assess risks to patients did not always keep patient safe as they were not utilised well. This included the patient safety checklist.
  • Demand for services frequently outstripped capacity. Patients were consistently waiting over 15 minutes for triage and were waiting over four hours for ether discharge or admission to an inpatient ward.
  • The design and layout of the department did not always keep people safe due to patients frequently waiting in the corridor.
  • Patients’ privacy and dignity were not always respected, particularly when the department was busy. Call bells were also not answered in a timely way.
  • Not all medical and nursing staff had received the most up to date training in safeguarding or mandatory training.
  • Royal College of Emergency Medicine audit results were not consistently positive.
  • Staff did not always understand relevant consent and decision-making requirements.
  • Some staff were not engaged or enthusiastic about the safety checklist.

However:

  • The department was clean, medicines were managed well, and equipment was checked and maintained.
  • The service provided care and treatment in accordance with evidence-based guidance.
  • There were enough staff with the right qualifications, skills, training and experience. They had appropriate competence and support to develop.
  • All patients we spoke with told us they received care and treatment from attentive and caring staff. Friends and family and CQC emergency department survey results were positive.
  • Leaders understood the challenges to quality and sustainability.
  • There was a structure of governance, which evidenced accountability and quality assurance.

Diagnostic imaging

Outstanding

Updated 14 December 2018

We previously inspected diagnostic imaging jointly with outpatients, so we cannot compare our new ratings directly with previous ratings.

We rated this service as outstanding because:

  • People’s needs were met through the way services were organised and delivered. Patients could access the service when it suited them, and staff ensured the individual needs of complex patients were met. Consent to care and treatment was always sought in line with legislation and guidance. Patients’ complaints and concerns were listened to and used to improve quality of care.
  • The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care. Risk was understood and managed and there was a proactive and collaborative approach to reviewing and improving quality and safety.
  • People were protected by a strong comprehensive safety system, and a focus on openness, transparency and learning when things go wrong. There were safe levels of staff who were trained to provide safe care. Patient records, infection control practices, systems, and staff recognition and management of risks to patients assured us of a safe service.
  • The team provided care based on the best available evidence. The service monitored care using data from internal audits. Staff had the skills, knowledge and experience to deliver an effective service. They were competent and had good opportunities for development. Staff worked well together and involved other services to support them in providing effective care.
  • Staff were consistently caring and treated patients with kindness, dignity, respect and compassion. Staff made every effort to minimise any distress for patients.

However:

  • Some parts of the estate were not suitable for patient care and needed updating.

Maternity

Requires improvement

Updated 14 December 2018

The Care Quality Commission last inspected the maternity service as part of a maternity and gynaecology inspection, the report being published in October 2017. The rating for maternity and gynaecology service was inadequate overall. We previously inspected maternity jointly with gynaecology so we cannot compare our new ratings directly with previous ratings.

We rated this service as requires improvement because:

  • There was evidence that actions had been taken to make improvements service wide, but these needed more time to be able to reliably evidence any positive effects.
  • Improvements were required to evidence equipment checks had been completed as required. The service needed to evaluate damage to a shower and the birth pool at Helston community service and how cleaning procedures had been affected by this.
  • Emergency evacuation procedures from birthing pools used at the community services needed evaluating. There was a lack of community specific guidance and policies.
  • Whilst there was audit evidence regarding the completion of records, not all risk assessments had been documented in full and actioned in a timely manner. Nor were records available to show how serious incidents had been scrutinised, analysed and discussed for learning.
  • Learning from complaints was not clearly documented with actions taken, by whom and how this information had been disseminated
  • Improvements were required to review the equipment, processes, policy and guidance provided by staff for women regarding breast and bottle feeding on the postnatal ward.
  • A new senior management team were in place but some of these posts were not substantive. The maternity service would benefit from a period of leadership stability to see through change processes
  • Overall, the culture across the maternity service had been reported to be changing to be more positive but this was still relatively new and not embedded.
  • The trust board had supported a review of midwifery staffing levels and approved the appointment of an additional 11 substantive midwifery posts. The trust board had supported plans for a new maternity service build.
  • There was more emphasis on the establishing effective governance and risk processes but at the time of our inspection these were not fully established or embedded.
  • All pregnant women had their physical, mental health and social needs assessed and treatment and care was provided in line with evidence-based guidance. There was good understanding and compliance with safeguarding processes.
  • Women identified with additional health issues had these managed in line with national guidance and specialist ante and post-natal clinics were provided.
  • Feedback from women and those people close to them was mostly positive. Staff understood and respected the personal choices and the cultural needs of people and how these could relate to care needs.

Outpatients

Requires improvement

Updated 14 December 2018

We previously inspected outpatients jointly with diagnostic imaging so we cannot compare our new ratings directly with previous ratings.

We rated outpatients as requires improvement because:

  • We were not assured the service was always meeting the requirements to provide safe care in all areas. Patients were continuing to come to harm because the systems to mitigate the risks to patients on waiting lists were not working. There were issues around infection prevention and control standards. Staffing issues had resulted in a back log of GP letters in oncology meaning patients could be waiting too long before treatment commenced.
  • The trust was failing to meet referral to treatment times. Some patient outcomes needed to be better, having seen limited improvement over time.
  • RTT was still variable and not meeting national standards and complaints were not always responded to within target time frames. Despite this, responses were thorough.
  • Well-led was rated as requires improvement. There remained a statistically significant number of staff who felt communication with staff was not working and the culture of fear and intimidation remained. The governance processes were not adequate to ensure the issues with safety had been either discovered or addressed.

However:

  • Safety was good in some key areas. The fracture clinic had received significant investment to improve its environment. Staffing levels were acceptable to provide a safe service most of the time.
  • Services were provided in line with evidence-based practice. Staff were competent and had many development opportunities. Patients suffering pain were well managed within guidelines and protocols.
  • Staff were committed to giving the best care to patients, and frequently went above and beyond their responsibility for many patients to support those with social and other physical or mental health needs. Patients were involved, informed and supported in the care and treatment provided, and relatives were included and involved too.

HIV and sexual health services

Good

Updated 12 May 2016

               

We judged sexual health services as good overall because:

  • Patients were protected from avoidable harm. Openness and transparency about safety was encouraged. Staff understood their responsibilities and were encouraged to report incidents and near misses.

  • Safeguarding vulnerable adults, children and young people was managed proactively and effectively by staff trained to recognise early signs of abuse.

  • Staff were employed in sufficient numbers to run the service effectively. A daily briefing ensured all staff were aware of any potential risks or concerns regarding the operation of the clinics.

  • Patients’ care and treatment was planned and delivered in line with current national recommendations and legislation.

  • The service participated in local and national audits and used the outcomes to inform,develop and improve care pathways and patients’ care and treatment.

  • Staff worked well together as part of a multidisciplinary team to coordinate and deliver patients’ care and treatment effectively.

  • Patients were provided with sufficient information regarding their care and treatment needs to be able to give consent prior to procedures or treatments being carried out.

  • The sexual health service provided a caring service to patients.

  • The privacy, dignity and confidentiality of patients’ was protected and they were treated respectfully by the staff.

  • Patients we spoke with provided us with positive feedback regarding their experience of using the sexual health service.

  • The service was planned and delivered in various locations and at different times of day times, in order to meet the needs of the local population.

  • The facilities and premises we visited were fit for purpose.

  • The booking system for appointments was easy to use and supported patients to attend an appropriate clinic to meet their care and treatment needs.

  • Patients were advised on how to make a complaint, were listened and responded to and action was taken in response to complaints and suggestions received.

  • Staff were aware of a clear vision and strategy for the service in that the aim was to become a fully integrated sexual health service. However, this was dependent on future commissioning arrangements which lay with an external organisation.

  • There were effective governance systems within the service and the wider trust. The service was able to identify current and future risks and the actions required to address these issues.