Royal Cornwall Hospital

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

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 service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

The provider was in breach of legal regulations in relation to good governance systems and processes.

We rated well-led as requires improvement. We assessed 6 quality statements on leadership and governance. The service did not always understand the challenges and needs of people. Leaders did not always have the skills and knowledge, experience and credibility to lead the service. The department was prepared for emergencies and major incidents and worked with other partners and community organisations to plan care for their communities.

However, governance and risk management systems and freedom to speak up arrangements were not always robust to improve how the service could deliver safe and good quality care and treatment.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The trust had a strategy which included the vision and values for the hospital. The overarching vision for 2022-2032 was to achieve outstanding care for one and all by 2032, and the strategic objectives included supported and valued people, safe high quality care and a journey of improvement over the first 3 to 5 years of the plan. There were priorities and a delivery plan aligned with the vision and objectives.

Senior leaders in the trust were aware of areas that needed improving, and the trust was introducing a new Clinical Vision for Flow which had been developed with input from clinical teams during a workshop in March 2025. The model outlined ambitions for future patient flow and set clear goals for improving patient outcomes, including: reduced preventable mortality, "home first" (increasing the number of people discharged back to their home), reduction in higher level harm events increased number of patients seeing a consultant on same day as being admitted, reduced outliers, being an 'active hospital' and increased patient awareness (every patient to have a "what matters to you" conversation record). The Clinical Vision for Flow outlined specific actions for services to take.

Due to changes to the health and social care landscape, there were trust-wide plans to refresh the strategy in Summer 2025, to ensure it reflected the needs of the local population and aligned with national and local policy and longer-term legislative and national plans.

Staff were given opportunities to engage in the development of the service strategy across the trust, with over 50 departments and 580 staff involved in feeding back on proposals. However, we did not hear staff talk about being involved from medical wards.

Some staff told us there was a clear focus in the organisation on the value of structured processes, clear guidelines and established protocols for example in managing care pathways and prescribing antibiotics. However, we heard from other staff they did not feel listened to by leadership or asked about ideas for improvements, and there was a focus on improving flow in the emergency department, forgetting about patients on the wards.

Staff also did not feel they were able to directly contribute to organisational and service decision-making. For example, due to recent significant ward changes, several staff told us they felt let down by the lack of communication regarding this direct change from leadership. As a result of staff not feeling they could directly contribute to decision-making, there was a lack of staff sense of belonging to the organisation. In the 2024 staff survey, the percentage of staff who would recommend the organisation as a place to work was 51%, below the trust’s target of 55% and below the previous year. Additionally, in the March 2025 staff friends and family survey, only 58% of staff would recommend the trust as a place to receive care, below the trust’s standard of 65%.

The leadership team was made up of senior nurses, medical staff and general managers who lead services across the urgent and emergency and medical care wards and departments.

The leadership team were working hard under significant pressure to address the challenges faced by medical care services. The trust had mechanisms to support future and succession planning.

There was a strong, committed and capable leadership team who had the skills, experience and knowledge to lead the service effectively and with credibility. They were open, honest and willing to learn and improve. However, we were concerned that the wellbeing of the triumvirate leadership team was not prioritised, given the number of significant changes they were delivering, at pace.

There was a disconnect between other leadership teams in the trust, and leaders told us decisions were often operationally driven, rather than clinically led. Staff also felt changes had been operationally led and their clinical judgement was not always listened to. For example, one staff member had told managers they had been unable to accept any more patients onto their ward and did not feel it was safe, but this had not been listened to, and they had been sent an additional patient.

However, there were some gaps in governance leadership roles which impacted on the service's ability to identify learning and improvements. Some specialities in both AEM and SSS care groups had gaps in their governance structures and had not had governance leads for some time. Due to these gaps, and operational pressures some governance structures were not working well.

Staff told us they felt supported by managers and had opportunities for development. Service and care group level leaders and managers were visible and approachable. Leaders of the service were knowledgeable about the issues and priorities of the service and worked for change and improvement when needed. They recognised where the service needed to be improved and were working to make improvements. They focused on staff wellbeing and ensured a culture promoting good practice, good quality and aspired to provide safe care and treatment.

As part of the trust leadership and management training, managers completed modules in emotional resilience and wellbeing to support them to be compassionate leaders.

Staff had mixed views about leaders. On 3 wards, staff spoke highly of nurse leaders, and told us they were approachable, visible and supported staff who escalated concerns. However, on one ward there were mixed opinions on the service leadership, and staff told us they knew the leadership team and felt some leaders were approachable, but some were not.

Medical and nursing leaders of the board did regular walkarounds. This allowed staff to raise concerns directly, improve their understanding of services and ensure they remained visible to staff. However, some staff were unclear about the leadership structures above the care group leaders and told us they did not know who the executive team were.

There were trust wide mechanisms to attract young talent to careers in the hospital. In January 25 the trust held a 'discovery day' event to provide information and advice to young people considering a career in health and social care. More than 300 young people considering a career in health and care attended to explore the work of various departments in the hospital.

Staff knew about the Freedom to Speak Up (FTSU) arrangements in the organisation and details were displayed in some wards we visited.

Staff surveys showed staff did not always feel secure raising concerns, this had declined from 2024 to 2025.

In the 2024 staff survey over 70% of staff in the care group that included medical care said they would feel secure raising concerns about unsafe clinical practice. However,the trust reported from the March 2025 staff pulse survey, only 59.6% of staff responded that they felt secure raising concerns or speaking up. This had declined from the staff survey position.

We heard that concerns raised by staff did not always result in improvement or action.

Staff told us they had escalated concerns regarding patient safety and needs but they did not always feel they were listened to or action was taken even when it resulted in harm to patients. Staff had escalated concerns about using temporary escalation spaces and the surge policy but did not feel listened to. Staff told us they felt under pressure to take patients even when it wasn't appropriate or safe. Additionally, staff pushed for patients with dementia to remain in the same ward for consistency of environment. However, staff told us they were frequently overridden by leadership, causing distress to the patient.

Ward leaders in some areas told us they escalated concerns to senior leaders and the executive team but had seen no changes.

However, some staff told us they were comfortable speaking up and there was a good culture of feeling heard. Staff in some areas of medical care spoke about doing reflection when things went wrong on the ward.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Risks were not always reviewed and updated in a timely way, and the risk register showed a number of risks where patient care may be compromised, often there were capacity and resource challenges across medical care. Of the 54 risks on the register, 22 were overdue for review, with the oldest date in October 2023, and 7 other risks were due for review in the 4 weeks before our assessment. Extreme risks related to major trauma staffing and higher than target mortality for stroke patients, and there were 34 risks rated as high, relating to stroke pathways, staffing challenges, environment and equipment and pathway delays in referral to treatment for various pathways, including cancer care. Half of the risks categorised as patient safety were past their review date, including oldest date in October 2023. They were all moderate or high risks, and workforce capacity, or failure to maintain safe staffing was a common description in the areas concerned. It was unclear from the risk register how often risk entries were updated, because dates were not always used to update the controls.

Service leaders were aware of the risks and performance issues, and monitored them closely to make improvements, for example within the stroke service and delayed discharges.

Changes to the trust medical model had improved performance in some areas of the stroke pathway, by increasing the hours that senior decision makers were available and in March and April 2025 performance was improving. However, in April 2025, the improvement plan had some areas off track for delivery, including the financial support required, and “significant cost pressures remain to address recognised staffing shortfalls”.

The Stroke Improvement Board met monthly, chaired by the Director of Nursing, Midwifery and Allied Health Professionals to review progress against a service improvement plan. The Integrated Care Board (ICB) were supporting the trust to improve and had a system-wide external peer review planned in April 2025.

Delayed discharges remained above the trust target; the trust reported 96 delayed discharges in March 2025, which was worse than the target of 42. Although there was a system wide priority to move to a discharge to assess model in 2025/26, we did not see plans or actions taken to make improvements in this area.

Actions were taken to address action plans, but we did not always see evidence that actions turned into outcomes. For example, for 3 wards the service was responding to FFT responses with action plans to address concerns. However, there was no evidence of the outcome and if the actions had been successful.

Ward leaders had the knowledge and skills to provide clinical leadership. However, senior ward leaders told us decision making around the use of surge spaces had been taken out of their control. We heard examples of ward leaders refusing patients because they were not appropriate for an escalation space being overruled or that patients were moved after these staff members left the shift.

There was a governance meeting structure for each care group. Meetings were held weekly, attended by the ward leaders and a governance lead to discuss and escalate issues. They fed into a monthly care group business and governance board, attended by senior leaders and supported by human resources (HR) and finance.

However, due to gaps in governance leadership and operational pressures some governance structures were not working well. There were no governance leads in cardiology or respiratory, and meeting minutes reflected that actions in those areas were not always progressed in a timely way. For example, in February 2025 there was an action to benchmark the AEM care group against other hospitals, but no progress had been made.

Additionally, some morbidity and mortality reviews and oversight group meetings had not taken place in the appropriate time frames, which meant case reviews, action plans and shared learning were not agreed and disseminated, and speciality specific and structured reviews were not taking place in a timely way. Meetings minutes showed 5 specialties had not held meetings in the last quarter. Mitigating the overarching risk, mortality was reviewed trust-wide and any specific condition with excess deaths prompted a detailed clinical review..

Audits were carried out to provide assurance about the quality and safety of care provided. Most care audits met the trust target of 75%, however they were carried out across care groups, so we did not receive assurance that medical wards were meeting this target. We also found there were delays to mental capacity act (MCA) and Deprivation of Liberty Safeguard (DoLS) audits due to capacity challenges.

Leaders were aware of key areas of risk to be addressed. They had introduced a new Clinical Vision for Flow in 2025 which was developed with input from clinical teams to improve flow in the service and patient outcomes. It was early in the implementation phase to see improvements, but this evidenced action was being taken to address long term issues with flow in the hospital.

The trust had plans to ensure business continuity to enact in unexpected circumstances including fuel disruption, severe weather, heatwaves and other emergencies.

Staff worked with partners to enable services to work well for patients. For example, staff in the AMU explored all resources to support discharge, including the homelessness teams and acute carer at home.

There were virtual wards so patients could receive acute care in the community, to support recovery and discharge as an alternative to hospital admission. Clear escalation processes were embedded and once care and treatment had been completed with the virtual ward, staff could make referrals to primary, community or social care to ensure relevant support for patients when discharged.

The trust took part in a `perfect week' over Easter 2025 where providers in the system were testing and learning new ways of dealing with the increased demand seen at peak holiday times from tourists. Learning points were identified and allocated to each relevant provider to action, and the hospital took part in the process. Areas included in the work were community issues, risks, and care pathways. There was a log of key learning points to be actioned.

There was also an integrated pressure ulcer prevention improvement plan and through joint working, a reduction had been seen across both organisations in pressure ulcers resulting in harm. As part of these plans the trusts were considering moving towards delivering integrated tissue viability team as well as falls, given the lack of skilled staff within these specialties. There was an integrated falls prevention improvement plan with another local trust as part of a system wide priority to reduce falls and make improvements. The trust was engaged in delivering the plan.

The service encouraged improvement and innovation, and there were examples of quality improvement (QI) initiatives that were mapped to the clinical vision of the care group and areas for improvement that had been identified and improving patient outcomes.

For example, the trust was introducing a new "Clinical Vision for Flow" in 2025 which outlined their ambitions for future patient flow and set clear goals for improving patient outcomes and specific actions to take to make service improvements.

In SSS care group, to help address overdue patient care and treatment assessments, teams had created “live overdue dashboards” on their electronic monitoring system to flag any overdue assessments at handover times to improve handovers. We were told this had reduced overdue assessments and improvements had been made in care planning as a result.

The service shared learning and best practice with partners. We reviewed a report which outlined the last 12 months, and it highlighted internal and external engagement to share learning. They held an annual QI conference where acute, community and third sector partners came together to learn and demonstrate commitment to supporting improvement and national initiatives.

The SSS care group were promoting an open learning culture and held virtual shared learning events to discuss learning and improvements with staff. Past topics included: end-of-life care, falls, debriefs of patients and staff experience and pressure ulcers. A nutritional steering group also identified and made improvements to how key areas of care in nutrition and hydration were recorded, and changes were communicated to staff, including learning from the audit, which prompted improvements.

Staff told us there was clear support for staff to learn, and innovate in their professional development, with departmental teaching weekly and educational support available. They were encouraged to do QI projects. The trust ran a preceptorship programme for newly qualified professionals as a multi-disciplinary team programme. Staff completing this programme gave positive feedback of learning with colleagues. Staff were encouraged to participate in a quality improvement project in their preceptorship.