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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 17 February 2021

We carried out a short notice announced focused inspection of the surgical care group of Royal Cornwall Hospitals NHS Trust (RCHT) on the 9 and 10 December 2020.

The aim of the inspection was to see if the trust had taken the necessary action and made the required changes following six never events between February 2020 and September 2020, within the surgical care group, and one never event in medical services. The trust had a further incident in September 2020 which did not meet the never event criteria but was declared as a never event by the hospital. Never events are serious incidents that are entirely preventable as guidance, or safety recommendations providing strong systemic protective barriers, these are available at a national level, and should have been implemented by all healthcare providers. Each never event type has the potential to cause serious patient harm or death. However, serious harm or death is not required to have happened as a result of a specific incident occurrence for that incident to be categorised as a never event.

The never events happened over three locations,

February 2020. Retained swab, Breast Surgery theatres at St Michaels Hospital.

May 2020. Wrong site surgery, Dermatology West Cornwall Hospital.

June 2020. Wrong site surgery, Dermatology Unit Royal Cornwall Hospital.

May 2020. Partial retained wire, Cardiac Catheter Laboratories Royal Cornwall Hospital.

September 2020. Incorrect lens fitted, Ophthalmology Theatre Royal Cornwall Hospital.

September 2020. Wrong medicine given, Emergency Department Royal Cornwall Hospital.

October 2020. Wrong site surgery, Dermatology Unit Royal Cornwall Hospital.

During this focused inspection we concentrated on specific key lines of enquiry within the ‘safe’ and ‘well led’ domains for surgery. This meant we could assess the trust’s learning and changes to practice in response to the never events. We did not inspect the effective, caring or responsive domains and therefore we did not change the rating for surgery which remains requires improvement overall. This is because the safe and responsive domains were rated as requires improvement when we inspected these in November 2019. As a result of that inspection the trust overall was rated as requires improvement. We will continue to monitor the performance of this service. With the risks relating to Covid-19 still present, we’ll draw from the best of our existing methodologies and adapt them to work in the current environment. We are clear that our focus will continue to be on services where we have concerns about quality and/or safety, and we’ll continue to take appropriate action to protect people if necessary.

Royal Cornwall Hospitals NHS Trust (RCHT) is the main provider of acute hospital and specialist services for most of the population of Cornwall and the Isles of Scilly, approximately 500,000 people. The population can more than double during busy holiday periods. The trust employs approximately 5,000 staff.

The trust delivers care from three main sites – Royal Cornwall Hospital in Truro, St Michael’s Hospital in Hayle, and West Cornwall Hospital in Penzance. The trust also provides outpatient, maternity and clinical imaging services at community hospitals at other locations across Cornwall & the Isles of Scilly.

The trust has seven care groups which include medicine, clinical support, general surgery and cancer services, women, children and sexual health, anaesthetics, critical care and theatres, specialist services and surgery, and urgent, emergency and trauma. The surgical care group at the Royal Cornwall Hospital provides emergency inpatient surgical treatment, elective (planned) inpatient surgical treatment and day case surgery across a range of specialities. These services include acute surgery, trauma and orthopaedics, general, thoracic, ENT (ear, nose and throat), plastic, breast and ophthalmic surgery.

The Royal Cornwall Hospital Trust has undertaken approximately 51,458 elective procedures and 24,496 emergency surgical procedures from January 2020 to November 2020.

The hospital has three main theatre suites Trelawney, Newlyn, and Tower theatres.

We inspected areas of the surgical care group at Royal Cornwall Hospital. These included Trelawney, Newlyn and Tower theatres, recovery areas and two surgical wards. We also visited the Cardiac Catheter Laboratory the Cardiac Investigations Unit, and the Dermatology Unit. A team of one manager, two inspectors, and two specialist advisors spoke with 35 nursing staff and seven medical staff, three health care assistants and three administrative staff. We took part in five virtual interviews with staff. We looked at 12 sets of patient notes and reviewed audit data and policies and processes. ​At this inspection because of the risks caused by Covid-19, we did not speak to patients and relatives.

Following the inspection, we took regulatory enforcement action as a result of our findings in surgical care services. We issued a Warning Notice under section 29A of the Health and Social Care Act 2008. This means that we asked the trust to make significant improvements in the quality of healthcare it provides. Further details can be found at the end of the report.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Inspection areas

Safe

Requires improvement

Updated 17 February 2021

Effective

Good

Updated 17 February 2021

Caring

Good

Updated 17 February 2021

Responsive

Requires improvement

Updated 17 February 2021

Well-led

Good

Updated 17 February 2021

Checks on specific services

Medical care (including older people’s care)

Requires improvement

Updated 26 February 2020

  • The service did not have enough medical staff in all areas and staff mandatory training was not fully completed.
  • Not all staff were fully aware of the rights of patients under the Mental Health Act 1983.
  • Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not all in line with national standards.

However:

  • The service had enough staff to care for patients and keep them safe. Staff understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed most risks to patients, acted on them and kept good care records. The service continued to recruit staff with the right qualifications, skills, training and experience to keep patients safe.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Some services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service and received the care and treatment but sometimes experienced delays.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

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

Good

Updated 26 February 2020

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients and acted on them and managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service. Staff were working towards keeping good care records using a process of audit and improvement programmes.
  • We saw staff provided care and treatment which was suitable for patients at the end of their life. Staff gave patients enough to eat and drink and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it.
  • Staff had the skills, knowledge and experience to lead the service. Leaders ran services well, were developing information systems and supported staff to develop their skills. Specialist end of life staff understood the service’s vision and values, and how to apply them in their work. Most staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

  • Documentation did not always provide assurances that suitable, individualised care was provided for patients at the end of their life.

Surgery

Requires improvement

Updated 17 February 2021

Urgent and emergency services

Requires improvement

Updated 26 February 2020

  • Not all staff had completed or refreshed mandatory and safeguarding training at the required level for their role. Safety checklists were being used although recording of ongoing monitoring was not as frequent as it should have been.
  • The mental health assessment room did not meet required standards for patient safety.
  • The service did not meet the Department of Health’s standard for patients to be admitted, transferred or discharged within four hours of arrival, although it had been mostly better than the England average. Patients were not always assessed promptly and within 15 minutes of arrival in the emergency department. The percentage of patients waiting more than four hours from decision to admit to admission was also high.
  • The response time for complaints was not in line with trust policy and the average was more than twice the required time limit.

  • Some emergency equipment was not consistently checked.
  • The resuscitation room was too small to accommodate current demand and on occasion, some patients had to be transferred and treated elsewhere. However, there was a plan to upgrade this area.
  • Some staff did not have all the skills or tools to support them to communicate with people with sensory impairment, dementia or learning difficulty.

However:

  • The department was visibly clean, and most medicines were managed well.
  • There were enough staff with the right qualifications, skills and experience who were supported to develop.
  • Leaders understood the challenges to quality and sustainability.
  • Patient feedback was good while we were on site, though survey results showed some deterioration over the past nine months.
  • Nursing staff vacancy rates were reducing.
  • There was a structure of governance, which provided accountability and quality assurance.

Maternity

Good

Updated 26 February 2020

  • The service had enough staff to care for women and keep them safe. Maternity staff had training in key skills, understood how to protect women from abuse, and managed safety well. Staff assessed risks to women, acted on them and kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave women enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of women, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated women with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to women, families and carers.
  • The service planned care to meet the needs of local people, took account of women’s individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of women receiving care. Staff were clear about their roles and accountabilities. The service engaged well with women and the community to plan and manage services and all staff were committed to improving services continually.

However:

  • There were concerns surrounding infection control. We were not assured staff were following an agreed process when cleaning the birth pools. Staff were not always seen to be bare below the elbow.
  • Medical staff did not achieve the trust target for all mandatory training. It had not been recognised by the trust that medical staff required safeguarding children level three training.
  • There were documentation gaps in the completion of daily, weekly and monthly equipment checks on the birth centre. This was consistent with the last inspection in 2018 and had not improved.
  • Midwife patient group directions (PGD’s) training records did not always have an authorising signature recorded. Controlled drugs records were not kept in line with legislation.

Outpatients

Good

Updated 26 February 2020

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse and managed safety well. Staff assessed risks to patients and acted on them. Staff completed comprehensive records and managed medicines well. Staff kept themselves and patient equipment clean. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
  • Staff treated patients with compassion and kindness. Staff listened to patients and their carers and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. Some patients could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

  • Not all records in cardiology were stored securely. Staff were not always aware of learning from incidents in other clinics. There was a risk of cross infection because staff did not follow trust policy for cleaning the play equipment in outpatient clinics. Staff did not always complete safety checks on emergency equipment. Essential fire safety equipment was not available or was out of date.
  • Not all key services were available seven days a week.
  • Not all staff took care to maintain patient privacy and dignity in outpatient clinics.
  • There were delays for treatment in some specialties. Patients waited longer than expected for their complaints to be investigated and resolved.

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.

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.