Royal Cornwall Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

At our last inspection we rated this key question good. At this inspection the rating has changed to requires improvement.

We looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

We rated effective as requires improvement. We assessed 4 quality statements. Staff were not always able to provide care and treatment in line with evidence-based practice or to achieve good outcomes. Not all staff had a good understanding of consent and capacity. Staff did not always work together in the hospital to share information when assessing people’s needs to maintain continuity of care. However, staff worked well with external partners to support discharge and community care.

This service scored 58 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

The service planned care in line with national guidelines and legislation. Clinical guidelines were readily available, and staff told us they were widely used, especially during the night when consultants and senior decision makers were on call. This ensured resident doctors could provide safe care. Pathways we reviewed were based on good practice and national guidance.

However, care delivery was not always in line with evidence-based practice. The stroke service did not deliver good quality care to patients in line with national standards and best practice. In March 2025, the Sentinel Stroke National Audit Programme (SSNAP) had notified the trust that again it had been classified as an outlier for 30-day stroke mortality rate.

The stroke service was a part of the Acute and Emergency Medicine Care Group and was managed directly by the Service Manager for Eldercare and Stroke and the Consultant Specialty Lead for Stroke. Performance was monitored monthly through the Stroke Improvement Board, Chaired by the Director of Nursing, Midwifery and Allied Health Professionals. The Trust Board received a monthly update from the Stroke Improvement Board within the Integrated Performance Report. A Royal College of Physicians peer review was scheduled and pre-review documentation had been submitted.

There was a trust wide approach to improving dementia and delirium care, with an action plan developed in line with national recommendations, guidance and the National Audit of Dementia outcomes, insights gained from patient safety incidents and incident themes. This was overseen by a clinical lead and progress was monitored through the annual dementia and delirium report and quarterly Dementia and Delirium Action Group meetings.

In most patient records we reviewed, care was recorded in line with guidance, however in 4 records, care provided was not documented in line with guidance, for example not recording fluid balance when intravenous (IV) fluids were administered, and no record of family or next of kin involvement in discussions about future care planning and do not attempt cardiopulmonary resuscitation (DNACPR).

Most patients reported their pain was managed well.

Staff and patients shared mixed experiences about how staff spoke with and about each other. Some teams worked together well to deliver the best care they could to patients, but we heard some examples of challenged relationships and poor handovers including between doctors and nurses and between services.

Within teams, staff worked well together to make sure patients received regular review, continuity of care and ongoing oversight. There were daily medical and nursing handovers. Staff supported each other across grades and roles and had effective systems to prioritise patient reviews and urgent assessments, with clear escalation routes that staff felt comfortable following.

However, communication and handover processes between wards did not always work well.

Poor handovers between wards and departments resulted in harm to patients, including patients in temporary escalation spaces. For example, a patient was admitted to Kerensa ward following a fall at home. The patient had a falls risk, but this information was not communicated in the handover and so staff were unaware. Patient was sat in a temporary escalation space. The patient had a witnessed fall by staff and passed away due to a bleed on the brain.

Lack of adequate communication and clear processes in the handover process between wards resulted in direct harm to a patient.

Pharmacy support was available on the wards by request, and some services had a direct telephone line to them. Staff reported they did not always utilise this because they did not have time to call.

We heard examples from staff on medical wards who worked well with other services in the community to support discharge, for example the homelessness team, acute carer at home team and using virtual wards to provide support in the community when a patient no longer needed inpatient care.

Virtual wards were consultant led and were multidisciplinary. They could make direct referrals to primary, community and social care services to enhance care and support out of hospital.

Multidisciplinary team (MDT) huddles and meetings took place to discuss and agree management plans for patients with complex needs, and different specialities and clinicians were included where appropriate. We reviewed 5 patients' records and spoke with the patients and their clinical teams to understand their journey throughout the care system. 5 out of 5 records showed clear and comprehensive handover between teams and clear communication throughout MDT working. For example, for a patient with a broken leg, there was a joint approach from the medical and orthopaedic surgeons in caring for the elderly patient. Early occupational therapy and physiotherapy input was sought and received to aid recovery and discharge.

Discharge coordinators were in inpatient areas and supported planning discharges, family liaison and working with community, social and charity sector services. Planning started early in a patient’s journey and included relevant referrals to occupational therapy and safeguarding services. When young adults were admitted with mental health needs, staff reported working well with safeguarding and child and adolescent mental health services (CAMHS). Patients who regularly attended were discussed at the longest stay and discharge meetings, and staff worked collaboratively with specialties and other teams to make appropriate referrals before discharge.

There was positive working with the chaplaincy service. Once a patient was referred to the chaplaincy service, staff completed an assessment and if required they were seen each day of their stay in hospital.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

Care and treatment were not always provided in line with current evidence-based guidance, standards and best practice; patients on the stroke pathway did not consistently experience positive outcomes.

The stroke service did not deliver good quality care to patients in line with national standards and best practice and had faced challenges since 2021. Due to demand for beds across the hospital, there were issues ringfencing beds for stroke patients on the stroke ward. In March 2025, the Sentinel Stroke National Audit Programme (SSNAP) notified the trust that it had been again classified as an outlier for 30-day stroke mortality rate. The trust had historically been notified that it was an outlier for this rate in 2018, and in 2024 for the 2021-2023 period.

Stroke patients were not always assessed by Allied Health Professionals in good time. Data in March 2025 showed for stroke patients 50% of patients received a dysphasia assessment, 48% of patients received an occupational therapy assessment and 45% received a physio-therapy assessment within 72 hours, which was not in line with recommendations.

Leaders had made changes to the medical model to increase the hours senior decision makers and stroke specialists were available. As a result, the rate of patients reviewed by a stroke specialist within 14 hours of arrival had increased from 57.8% in February 2025 to 69% in March 2025 and early results of 89.5% in April, aiming for the trust target of 85%.

During 2024-2025, the trust participated in national clinical audits. These included Society for Acute Medicine Benchmarking Audit (SAMBA) and National Heart Failure Audit. The trust also carried out 82 local audits within Acute and Emergency Medicine and Specialist Services and Surgery. The majority of the audit findings confirmed good practice however a number also identified areas for improvement. For example, a local audit about 'Improving driving advice provided to cardiology patients' resulted in refreshing staff knowledge around patients need to contact the relevant government agency following cardiovascular events and the SAMBA made recommendations to improve access and capacity to same day services.

The annual dementia and delirium care improvement plan was informed by national recommendations, audits and local incident thematic reviews. It was monitored quarterly, and an annual report was produced which showed better outcomes for patients with dementia were being achieved. Examples included reduction in prescribed medications which enhance delirium, reduction in out of hours transfers and updated training and awareness for staff in assessment, treatment and management of delirium.

Local nursing and care audits were completed monthly and most areas achieved above the 75% target in the AEM care group. The data was at care group level, so we could not determine that medical wards were meeting the required standards of care.

Staff had a mixed understanding of consent and capacity assessments.

Not all records we reviewed were completed appropriately and there were examples across multiple wards where consent, capacity and best interest decisions were not recorded in line with the relevant legislation. For example, on AMU we reviewed a patient record where covert medication was administered and records did not show appropriate legislation had been considered. 2 out of 5 do not attempt cardiopulmonary resuscitation forms (DNACPR) reflected appropriate decision making had not been documented, and families were not involved in the decision making.

Recording next of kin details for patients varied, and there were examples where patient records had conflicting information. For example, where next of kin details were recorded on a patient record, but DNACPR decisions were not discussed with family, or DNACPR forms stated there was no next of kin, when their details were elsewhere in the patient record.

However, in other examples records showed appropriate conversations with patients and their families had happened, including about DNAPCR and consent to care and treatment.

Staff we spoke with gave mixed examples of their understanding of capacity and consent. For example, we spoke with staff about the records of a patient with a cognitive impairment about their incomplete Deprivation of Liberty Safeguards (DoLS) care plan. Some staff we spoke with were not aware of DoLS and could not explain them, but other staff could explain the principals of consent and actions they would take if a patient did not consent to treatment.

Audits on MCA and DoLS had not taken place for the 6 months prior to our visit due to staff absence. The trust confirmed the audits would be restarted by 6 June 2025, however there was no system to check staff applied their training around capacity and consent and that patients received appropriate information when decisions were made.

Staff received mandatory training in the MCA 2005 and compliance was 77.6% across all staff groups which met the trust target of 75% but below the standard of 90%. The Safeguarding Adults Level 2 syllabus also covered MCA and (DoLS) which 88.7% of staff had completed, which also met the trust target.