Royal 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

At our last inspection we rated this key question requires improvement. At this inspection the rating has remained requires improvement.

We assessed 8 quality statements and looked for evidence that patients were protected from abuse and avoidable harm.

The provider was in breach of legal regulations in relation to safe care and treatment. In considering safe care and treatment, the provider was in breach of regulations regarding assessing the risks to the health and safety of service users receiving the care or treatment, ensuring that persons providing care or treatment to service users have the qualifications competence, skills and experience to do so safely, the proper and safe use of medicines, and premises and equipment being properly maintained.

The service did not always have a proactive and positive culture of safety based on openness and honesty. Safety concerns were not always investigated and learning identified and shared in a timely way. The service did not always work well with patients and health system partners to establish and maintain safe systems and continuity of care. People were not always involved to manage their risks and some aspects of care provided was not always safe or specific to patients’ needs. The service did not always detect and control potential risks to the environment. There was not always enough qualified and skilled experienced staff and they did not always receive effective support and development. The service did not always make sure that medicines and treatments were safe and met patients’ needs.

However, staff understood what safe meant for patients and they concentrated on trying to improve patients’ lives while protecting their rights and infection risks were managed and responded to well.

This service scored 56 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

There were delays in carrying out safety reviews following patient safety events, including patient deaths. For example, at the March Mortality Review and Oversight Group it was noted that there were 5 structured judgement reviews (SJRs) for patients with a learning disability outstanding. This meant there may have been missed opportunities for service improvement and to identify lessons learnt.

Due to operational pressures and gaps in governance leads at speciality level, some specialities across both care groups had not carried out regular Morbidity and Mortality meetings and there were sometimes delays in undertaking learning responses following incidents. For example, in the AEM care group, cardiology monthly morbidity and mortality meetings had been stood down due to operational winter pressures. Respiratory morbidity and mortality meetings had also not been held at speciality level due to gaps in the speciality governance team.

We reviewed a learning response that had been investigated to identify learning. The Patient Safety Review was detailed and considered an in-depth history of the patient, and external and internal factors that contributed to the incident. There were clear recommendations and accompanying safety actions. Within the last 12 months, the service had completed 7 system-based learning responses within inpatient medical areas.

Patient deaths were reviewed at trust level and tracked at executive level as well as monthly at the Mortality Review and Oversight Group (MROG). The MROG used data including the HSMR (Hospital Standardised Mortality Ratios) and `heat maps' to identify themes and trends in relation to in hospital deaths in specific services across the trust. Leaders told us if it was identified that there were excess deaths within a particular speciality this would prompt a detailed clinical review. To improve governance of mortality reviews, from April 2025 the trust would be introducing new monitoring of them using their AMAT (Audit Management and Tracking tool) system.

Complaints were not always investigated and responded to in agreed time scales. The key performance indicator (KPI) for formal complaints being responded to within the agreed timeframe was 95%. During the 6 months prior to our visit, an average of 82.5% of complaints across the Specialist Services and Surgery (SSS) and Acute and Emergency Medicine (AEM) care groups were completed within these agreed timescales. Compliance with this KPI varied monthly across both care groups. For example, in March 2025 only 57% of complaints (8 out of 14) received in the AEM care group were responded to and completed in line with trusts set timeframes. There were 6 outstanding complaints. The care group prioritised these for review to identify if a Structured Judgement Review (SJR) was required. SJR is a methodology for reviewing the quality of care provided to a patient who died.

The service provided us with information following our inspection, acknowledging that due to the complexity of managing individual cases, complaints had not always been investigated and responded to within agreed timescales. A defined process for cases that could not be resolved within the standard 30 working day timeframe provided appropriate oversight and accountability for delays beyond the standard process.

The top 3 themes for complaints in both AEM and SSS were communication, clinical treatment, and patient care. Trends within these themes included: patients not feeling listened to, conflicting information, care needs not adequately met and delay or failure in diagnosis, treatment and procedure. We reviewed responses to 3 complaints and found the trust had investigated families' and patients' concerns in full, provided responses to the concerns and made improvements.

Service wide safety briefings were circulated to inform staff of learning identified following incidents or where areas for improvement had been identified. Learning was also shared with staff at daily ward briefings and weekly senior management team meetings. A monthly learning from incidents newsletter was also circulated with staff via email.

We found the SSS care group invited all colleagues to attend virtual shared learning events to discuss learning and improvements with staff. Past topics included: end of life care, falls, debriefs, patients experience and pressure ulcers. This was part of the care groups work on promoting an open learning culture.

Staff gave mixed responses regarding the learning culture of the organisation and how leaders respond to incidents. Some staff told us they were passionate about reporting incidents that affected patient safety, gave multiple examples of when they had reported incidents, and received feedback, including from the patient safety team leader. However, not all staff felt listened to or that they received feedback when they reported incidents. For example, on Tintagel Ward, staff raised a concern about an incident when a patient without a bed space suffered seizures. Although a matron attended the ward to support staff and the patient at the time of the incident, staff did not feel their underlying concerns about the lack of bed spaces to ensure the safe care and treatment of patients had been addressed with lessons learned.

The hospital faced significant operational pressure and demand across its Medical Care and Urgent and Emergency Care services. Average bed occupancy across all medical care wards from October 2024 to March 2025 was consistently above the trust target of 92%; in March 2025 it stood at 97.21%. This impacted the number of delayed discharges which also remained significantly above target in March 2025 (96 against the target of 46).

The service introduced a Clinical Vision for Flow programme from March 2025, which intended to positively impact overall system risk, reduce harm, and improve patients' experiences while improving flow through the hospital.

A revised medical model of care which aimed to facilitate patient moves to the correct ward, saw the Acute Frailty Unit (AFU) and Acute Medical Unit (AMU) merge in mid-March 2025 to create a combined Acute Medical Frailty Unit (AMFU) for short stay patients and increased the availability of senior clinical decision makers on wards at the times of greatest demand. The standard operating procedure (SOP) was being revised to reflect the new medical model being implemented.

Flow varied between services which impacted how patients moved through the hospital. The same day medical assessment unit (SDMA) was working as a same day emergency care (SDEC) and temporary escalation area. Referrals were received from the acute GP service, specialist services and the emergency department for patients to receive diagnostics, treatment and criteria-led discharge. SDMA had a faster, more predictable flow, whereas flow on the wards varied by speciality. Discharges from all areas were impacted by community support, availability of family or carers, and whether the patient's usual residence was a care home.

Staff in the discharge lounge felt the service was underused, and they had seen a reduction in the number of patients they cared for.

To support the move of patients onto medical wards, `Your Next Patient' assessments and new handover processes had been introduced. In February 2025 the service had implemented a timely handover protocol (THP) and a revised medical model to improve performance and patient flow. The THP facilitated moving additional patients onto medical wards. Where bedspaces were not available, patients were moved into temporary escalation spaces (TES).

Risks and individual needs of patients being transferred under the THP were not always communicated to staff effectively, which put them at increased risk of avoidable harm. The exclusion criteria within the procedure were not always adhered to.

The THP protocol was not always carried out safely which put patients at risk of avoidable harm. We found examples where patients who met the exclusion criteria were moved into TES spaces. Staff told us about a patient who was moved to the fit to sit area on Tintagel Ward who needed support for personal care, which meant they would have been excluded from the area if guidance had been followed.

Staff raised concerns that handovers continued to not be carried out safely which impacted the quality and safety of patient care. Most staff raised concerns about patients who were transferred to wards either with no written handover, or a poor handover. For example, a renal patient had been transferred to Eden ward as a medical outlier without prior knowledge of the ward. The patient had not been seen by a specialist in ED and there had been no handover by staff. Staff on Karensa ward told us a lack of clear communication on patient transfer led to a patient experiencing a fall

Some patients were transferred and treated in TES spaces on wards when staff felt it was not always safe to do so. Feedback from staff on wards was not always listened to and transfers onto wards took place when they felt it was not safe to do so.

Some staff expressed concerns about the surge protocol and the suitability of ward areas to meet patient needs. For example, on Eden ward, 2 patients living with dementia were accommodated in chairs outside the line of sight of staff. On Tintagel ward, the escalation space was a chair space in the day room. We heard about two incidents where patients had seizures in this area.

During the assessment we identified a theme in the quality of handovers which had affected patient safety. The trust took action to address these issues. Actions included implementing new measures to protect critical nursing time and ensure robust communication. The practice of completing the paper handover form and transferring the patient will stop and instead timely escalation and direct communication between clinical teams will occur. [AH1] [CS2]

All reasonable steps to mitigate risks to patients had not always been taken, because not all risk assessments and care plans had been completed. There were gaps in patients' documentation that left them at risk of harm following transfer. Of the 46 patient records we reviewed, 13 patient records had gaps in notes, documentation of conversation, or completion of risk assessments. On AMU, one patient had suffered a fall, and this had not been documented in their notes. We were assured by staff that this would take place. However, the following day when this patient was being transferred this had still not happened. On Pheonix ward, 1 patient's care plan had not been transferred to the electronic patient observation system and there were assessments that had not been completed.

The April 2025 Integrated Performance report demonstrated that while efforts were actively being pursued to address falls and their number had reduced, there was an increase in patients experiencing moderate to severe harm. Leaders told us that a thematic analysis of incidents, along with data obtained from the National Audit of Inpatient Falls (NAIF) would inform the service-wide initiatives being outlined in the Integrated Falls Prevention Improvement Plan for 2025-2026, which was currently under development.

We raised concerns with leaders, and they took immediate action to make initial improvements and provided further assurance after our assessment. Leaders described a proactive model to help them shift from a `push' to a more efficient `pull' system, particularly supporting AMU in moving patients to the base ward. Early indications were that some improvements had been made.

There were two stroke pathways for patients who were more and less acute, however the service was experiencing challenges maintaining the pathways, due to resources and capacity.

Patients who did not require level 3 stroke care were sometimes admitted to the hyper-acute stroke unit (HASU) as outliers, and there were stroke patients outlying on other medical care wards where staff did not have specialist knowledge and experience. The trust had worked hard to decrease the proportion of non-stroke patients on the ward in the last 12 months, however 26% of patients admitted to the stroke ward remained non-stroke patients, which impacted on the stroke pathways.

Staff on Wellington Ward told us there was an established discharge process working with community liaisons. Discharge Coordinators had been implemented in the inpatient areas to support nursing staff with discharge planning, liaising with families, community services, social care and charities to support safe, effective and timely discharges. For patients with complex needs, there was a Community Hospital Allocation Team (CHAT) who triaged these patients and responded to requests within 18 hours. We found 2 patient notes that we reviewed in the discharge lounge contained all the required information and a good handover using the Situation, Background, Assessment, and Recommendation (SBAR) form.

However, staff in the discharge lounge expressed concerns regarding recent changes that had been made regarding medical cover and the take home medicine arrangements as the previous processes had worked well and supported prompt discharges. They also told us that transport was an issue and sometimes patients were still waiting at 6:30 pm for transport to arrive.

The Virtual Wards Standard Operating Procedure 20/10/23 guided the delivery of the multidisciplinary virtual ward across the integrated care system (ICS), to prevent avoidable admissions and support early discharge from the hospital. It provided chronic disease management from the hours of 9am-5pm, 7 days a week. The service could access community diagnostic services. There were appropriate escalation processes and an out of hours service was provided by the community assessment team unit.

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There were mechanisms to ensure effective systems, processes and practices to protect people from abuse and neglect. The safeguarding policy reflected national guidance and best practice and outlined the processes that staff should follow. The policy emphasised the importance of safeguarding responsibilities and encouraged nurses to take on link nurse roles to address safeguarding issues.

The service's policy highlighted the importance of (at least quarterly) mandatory safeguarding supervision for designated and safeguarding leads and mandatory training for all staff in all roles. This was to ensure mechanisms were embedded to foster a strong understanding of safeguarding and commitment to taking immediate action to keep people safe, including collaboratively with partners. Information provided to us by the service demonstrated overall compliance rates with training across each level ranged between 88.7% and 90.9%

Three members of staff discussed the safeguarding training and told us they completed level 1 and 2 each year and that level 3 was optional. They also told us that children safeguarding concerns would be discussed on a case-by-case basis.

Three members of staff we spoke with were able to provide examples of where they had implemented the safeguarding policies and procedures including when the Mental Capacity Act was applicable. These staff demonstrated a good understanding of their roles and responsibilities as well as those of partner agencies.

To support patients who exhibited behaviour that challenged, staff, including security staff, received an in-house initial training course on restraint and de-escalation skills during their induction. This training was then refreshed on an annual basis. While 92.9% of NHS staff had undertaken this training, at the time of our visit, only 67% of security staff had completed this training. The service was taking action to address the remaining 33% non-compliance.

Although the `Mental Capacity Act (MCA) and Deprivation of Liberty (DoLs)' combined training was not mandated in Royal Cornwell Hospital, Mental Capacity Act 2005 training was mandated and Safeguarding Adults Level 2 syllabus covered MCA and DoLs. Compliance of Mental Capacity Act 2005 training was 77.62% across all staff groups at the time of our assessment, above the trust's target of 75% but below the target for statutory compliance of 90%. The Safeguarding Adults Level 2 training compliance was 88.7% across all staff groups.

Staff we spoke with about MCA and DoLs demonstrated a good understanding of this in their day-to-day work.

The service did not always holistically assess and manage risks to patients. This meant some aspects of care provided was not always safe or specific to people's individual needs.

Nursing Fundamental of Care Audits were carried out monthly to review the quality and completeness of patient care records. The audits included reviewing skin care bundles, falls risk assessments and mitigations. Indicators used across care groups showed some areas where compliance was consistently low and the quality of patients care record keeping was at a varying standard. For example, indicators for acute and emergency medicine (AEM) care group compliance had varied for the 6 months prior to our assessment from 63% to 83%. Compliance for the completion of patient's Treatment Escalation Plans and holistic safe handling care plans was low at 50% in April 2025.

Venous thromboembolism (VTE) assessments were not always completed within 14 hours of admission, as recommended in national guidance. The service was aware of this, and compliance had been improving since January 2025. However, in March 2025, VTE assessments completed within 14 hours was 71% across SSS services and 76% AEM services. This increased the risk of patients developing a VTE because these assessments help identify individuals at risk and reduce the chance of VTE by ensuring treatment was given as soon as possible.

To help address overdue assessments of patient care and treatment, teams created `Live Overdue Dashboards', which would flag any overdue assessments to staff at handover times and make it easier for teams to allocate these for completion. The service told us by making this change, the SSS Care Group had reduced overdue assessments significantly and there had been an improvement with patients care planning standards.

The service did not always assess and mitigate potential risks to patients' health. The themes from the top three incidents for AEM were pressure ulcers, falls and the discharge processes. For example, we found that staff conducted safety checks for 1 out of the 5 patients we reviewed when the patient was in the hospital over two admissions. When planning the discharge for both visits, staff did not conduct risk assessments to understand the level of care need the patient would need at home. However, 2 out of the 5 patients and next of kin (NOK) were involved in risk mitigation discussions prior to discharge.

There was a new sepsis audit that was rolled out up to April 2025. Records available at the time of our assessment showed compliance with this had varied across the different wards. Across the 9 records viewed, only 55.5% of the full Sepsis Six was delivered within 1 hour. The lead sepsis nurse was continuing to promote the new Sepsis 6 tool at the time of our inspection and a Trust-wide Safety briefing, `Trust Standard for the Recognition of High-Risk Sepsis and the documentation of the delivery of the Sepsis 6 for adults over 16 years,' had been circulated. The brief updated all staff on the current clinical guidelines, the requirement to use the Sepsis Screening tool and the need to record Sepsis Six care in the electronic observation recording system as standard.

The service had also held a Sepsis World Day joint conference with a neighbouring trust for staff to attend and raise awareness of current best practice.

Patients NEWS2 scores were calculated via an e-observations module and there was a live screen on the wards that reported and highlighted high and overdue NEWS2 observations. While there was no adult NEWS2 audit undertaken within the adult inpatient wards, every 6 weeks a report which included analysis of various incidents, risks and near misses was presented at the Deteriorating Patient Operational Group. Themes and trends were identified, and action would be taken in response to these. Data presented at the May 2025 Deteriorating Patient Operational Group meeting, demonstrated that there had been an improvement in the KPIs of NEWS2 scores being recorded.

The Stroke dashboard showed while there had been improvements in the number of patients who had immediate and appropriate care following a stroke, there was still significant room for improvement. For example, in March 2025, the rate of patients that had a dysphagia (dysphagia is where you have problems swallowing), occupational therapist and dietician assessment following a stroke was higher than the previous month, however it was still worse than the average of the last 24 months. This meant there was a risk that patient's recovery from a stroke may not be impacted upon.

Mechanisms to monitor the safety and upkeep of the premises were not fully effective. While the facilities and equipment used with patients were mostly well maintained and in good working order, there was a lack of oversight regarding fire safety procedures and some inconsistencies and gaps in record keeping.

Information provided by the service demonstrated that the Patient Led Assessment of the Care Environment (PLACE) scores across ward areas for condition appearance and maintenance were generally good and above 80%. In addition to this, the service completed ligature point risk assessments to identify potential risks to patients.

Most areas were well maintained and clutter free, with accessible toilet and shower facilities. However, the environmental design did not always meet people's needs and keep them safe and there were unsafe environments in some areas. Some areas were cluttered, and staff had difficulty moving patient beds around the unit.

On Pheonix ward, each bed space was not supplied with the required equipment; 2 beds in the hyper-acute stroke unit (HASU) did not have monitors available. Additionally, a chair in the temporary escalation space (TES) blocked an exit.

Some staff also told us that a considerable amount of equipment was condemned with a shortage of equipment for all patients.

The service did not always assess and mitigate risks to the safety of patients. Fire safety prevention processes were not consistently applied throughout the department and floor plans did not always accurately reflect evacuation plans in the event of a fire. For example, on Wellington ward, there was no evacuation plan completed, and a bed had been stationed in front of doors which allowed access to AMU. In AMU, fire safety folders were partially out of date, and the date on the fire risk assessment had not been updated. These issues were escalated to a leader so they could be addressed.

The safe storage and use of equipment was inconsistent. For example, the resuscitation trolley in AMU 2 was secured and all equipment was in date. However, in AMU1 and Roskear ward, there were gaps in record keeping for the resuscitation trolley, oxygen and suction supplies due to duplication of dates. We also found an incomplete resuscitation trolley audit on MDU which showed 4 months in 2024 and 1 week in January where no checks were recorded.

The ward environment was not always secure. As a result, patients and visitors were not always kept safe from contact with substances hazardous to health. The storeroom on AMU was unlocked and used as a thoroughfare between AMU 1 and 2. COSHH (Control of Substances Hazardous to Health) products and venepuncture devices were stored here. We also found in the treatment room on Roskear ward that antibiotic medicines had been drawn up for use but had been left in a tray unattended. We escalated this to the nurse in charge.

Leaders were committed to keeping staffing numbers at a safe level with a suitable skill mix and checked these twice daily. Agency and bank staff were used when necessary, ensuring they were familiar with systems and processes. However, there were not always enough skilled and experienced staff available to effectively provide safe care that met people’s needs.

The service benchmarked Care Hours per Patient Day (CHpPD). This data gives ward leaders, nurse leaders and senior leaders a picture of how staff are deployed and how productively) against the national and regional performance for registered and non-registered CHpPD through the national Model Hospital platform. Model hospital data shows the organisation was performing in-line or slightly better than regional and national peers for CHpPD. In addition, the service also monitored safer staffing levels across the service daily and produced annual reports highlighting issues and improvements/ recommendations as part of their governance arrangements. (Data collection was undertaken using the National Safer Nursing Care Tool (SNCT)).

However, staff vacancies had the potential to impact safe and effective staffing levels. The trust had a vacancy rate target of less than or equal to 10%. The medical care vacancy rate in March 2025 for substantive medical and dental staff was 9.6%, with the highest vacancies for resident doctors at 13.1% and middle-grade doctors were over recruited by 16.6%. The overall medical care vacancy rates for substantive adult registered nursing, midwifery and health visiting staff was 10.7% and vacancy rates of substantive clinical support staff was 16.6%. This demonstrated that although the service was hitting the trust vacancy rate target for medical staff, patient care may be impacted by the above target vacancy rates of the nursing and support staff.

The service relied on some bank and agency medical staffing to meet the needs of patients. The ward to board report for AEM showed that the use of agency staff had been reducing, though there were 5.9% unfilled medical shifts in AEM over the last 3 months. In November 2024 to April 2025, the staffing ratio for medical shifts was substantive doctors filled 79.7% of medical shifts (18819 shifts), 17% shifts filled by bank/overtime staff (4005 shifts), and 3.3% shifts filled by agency staff (784 shifts).

The April 2025 Integrated Performance report demonstrated that vacancy and turnover rates in medical care for registered nurses in May 2025 (including, adults, community midwives) had reduced. However, the shift fill rate for support staff within the care group of AEM had slightly reduced.

Staff were noticeably busy, worked under pressure and 24-hour safer staffing models were being used. Staff were positive about the standards of care and treatment they delivered and spoke of a supportive team who pulled together to maintain these standards.

Most staff we spoke with across 10 wards described staffing levels as a challenge and stated there were times when they were short staffed, worked under pressure, or were pulled across different wards to provide cover. However, they felt supported and that they could escalate staffing concerns to the matron who addressed issues. Though some staff told us they were frequently asked to manage without adjustments to the staffing levels or resolution of the staffing concerns.

Staff working on 3 wards spoke of heavy reliance on temporary agency and bank staff as there was not enough substantive staff to fill all shifts.

Staff confirmed where required, out-of-hours and specialist cover was provided. For example, some medical patients were being cared for in St Mawes ward and general surgery. Staff on these wards informed us there were processes to ensure that the patients’ care and treatment needs were met to support their recovery and health and wellbeing. Although most staff felt confident about addressing patients’ needs promptly using resources available, less senior staff in the surgical wards, told us they felt out of their depth providing care to medical patients.

According to the trust wide Integrated Performance report, while appraisal compliance was at 77.61%, below the trust target of 90%, this had improved. The service provided evidence to confirm that they were focussing on work with care groups and the corporate teams to identify those staff whose training was out of date to ensure this was completed. Recommendations had been shared at Strategic Workforce Group in May 2025 and leaders were actively involved in making improvements.

Although leaders were committed to providing support to staff to keep up to date with mandatory training and any role specific training they needed to deliver safe care and treatment, compliance rates were below the trust target. Expected statutory training compliance was 90% for the 19 mandatory/statutory training modules but compliance rates for 12 out of the 19 core competencies were below 90%. Compliance rates for 5 out of the 19 core competencies were below 75%. For example, only 61% of staff had completed adult basic life support (BLS) training and only 31.7% of staff had completed Paediatric basic life support training. Although only 21.3% of staff had completed the required Oliver McGowan Mandatory Training on Learning Disability and Autism (Tier 2), the service was working to ensure staff had the skills necessary to support patients with learning disabilities and autism.

Staff on Roskear ward, Pheonix ward, Wellington ward, AMU, and SDMA confirmed they had received extensive training during induction with further opportunities for additional training, which they felt was adequate. However, they spoke of training being cancelled due to staff shortages, and not receiving protected time for training, which impacted on their ability to complete the training.

In the 2024 staff survey in AEM (excluding ED) and SSS, the percentage of staff who agreed they were able to access clinical supervision opportunities when needed was lower across both care groups. In AEM, only 47.3% agreed and in SSS only 47.8%, the trust’s comparator was 54.3%. However, these percentages were still in line or above comparison organisations and other areas within the service.

The service had mechanisms, in line with current national guidance, to effectively assess the risk of infection, including clear roles and responsibilities around infection prevention and control. The service's Infection prevention and Control (IPC) policy outlined how it was the top priority for the service and there was an Infection Prevention and Control team who provided education, support and advice. Governance and reporting structures were outlined in the policy, as well as expected standards and practices, relevant legislation and guidance and training requirements for staff. Staff received information about clinical guidelines and patients received information leaflets to keep them informed and to embed the infection control principles.

There were dedicated cleaning staff who were required to maintain high standards of cleanliness. The documentation provided by the service demonstrated that training compliance with IPC level 1 and 2 was at 92.2% and 75% retrospectively.

The environments we visited were generally clean and uncluttered with appropriate cleaning processes for equipment to keep people safe from infection. Staff followed proper IPC processes for hand hygiene, use of personal protective clothing and equipment.

While audits took place, the completion of these and the data acquired was sometimes inconsistent. The IPC audit for January 2025, showed mixed results in wards achieving the required standards. We were assured by leaders that where audits had not been completed matrons raised this with the wards and took action to improve compliance. When issues with IPC were identified these were discussed and actions were put into place. This had taken place on one ward and they had made improvements and achieved 100% compliance.

Patients we spoke with on AMU told us they had not been given their regular medicines. However, medicines including antibiotics were generally given as prescribed.

Staff were supported with the use of electronic tools to identify and support high risk patients. Staff spoke highly of the "Parkinsons Friends" tool which supported staff to administer people's Parkinson's medication in a timely manner. Data provided by the trust post assessment showed that less than 1% of medicines were missed due to inappropriate reasons. This had been achieved by allowing easier ordering of medicines for staff on wards and optimising pharmacy opening hours.

Medicines were generally stored safely and securely. Access was restricted to authorised staff. Wards were supported by a pharmacy top up service to ensure medicines were available. Staff showed us they could easily order medicine when required. However, some cupboards, drawers and fridges where medicines were stored were not always tidy or in the right place.

We could not be assured that staff were administering controlled medicines in line with the service policy. Controlled drugs that expired were not always disposed of line with guidance. We found expired controlled drugs on 2 of 4 wards visited. This included Zennor ward, where an expired liquid-controlled drug for pain relief had been administered to a patient on multiple occasions. We did not see "return to pharmacy" stickers used on the unwanted CD stock which was not in line with the services policy. Furthermore, there were multiple instances of a controlled drug where staff who had witnessed an administration had not signed the register. These were raised with the ward leader to investigate.

Wards were supported by a pharmacy service for clinical queries including discharge planning, prescribing and medicines reconciliation. There were examples of good collaboration with doctors, discharge coordinators and primary care colleagues. For example, additional pharmacist input on medicines discharge summaries highlighting the key changes and reviews required for patients on new medicines. This was well received by colleagues in the community. Furthermore, discharge information was regularly shared with people's community pharmacy through the "Discharge Medication Service" (DMS). The DMS is an NHS collaborative communication scheme which aims to improve medicine related outcomes and reduce readmission for patients on discharge from hospital.

However, pharmacist support was stretched due to vacancies. Whilst most patients on medical wards had their medicines reconciled as an inpatient, only 40% of them had their medicines reconciled within 24 hours of being admitted in line with national guidance to reduce the risk of medicine related errors. Leaders told us they were aware of the issue and had put forward a business case for increased resources for the admissions team and worked to fill vacancies. They also told us they expected vacancies to be reduced in the summer 2025 when new trainee pharmacists qualified.

Medicines "to-take-away" (TTAs) were supplied in a timely manner. Leaders tracked the performance of the service, and they generally supplied TTAs in line with the trust target of 2 hours.

Venous thromboembolism (VTE) assessments were generally completed in line with national guidance. The service used electronic systems to remind clinicians to complete and review VTE assessments and prescribing where appropriate.

Medicines for people on discharge were supplied in a timely way and the service worked well to identify areas that could be improved. The pharmacy regularly met the trust target for the timely supply of discharge medicines to medical wards.

There were examples of initiatives to improve medicine optimisation for people. For example, one initiative demonstrated improvements in de-labelling inappropriate allergy statuses of patients. This tested whether people were truly allergic to recorded allergies of antibiotics and allowed safer use of antibiotics.

Staff we spoke with told us they knew how to access relevant local medicines policies, procedures, and guidelines.