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 assessment we rated this key question good. At this assessment the rating has changed to requires improvement. We assessed 8 quality statements.

We looked for evidence that people were protected from abuse and avoidable harm.

The service was in breach of legal regulation Safe care and treatment and staffing. Care and treatment was not always provided in a timely way in line with clinical guidance. Patients were not always admitted from the emergency department to a ward bed in a timely manner. Consultant cover was not in line with national guidance. Mandatory and specialist training compliance was below the trust target. Risk assessments including National Early Warning scores 2 were not always completed in line with trust policy. Medicines were not always managed safely and staff did not always follow trust policy in relation to the disposal of controlled drugs.

There was a positive learning safety culture where events were investigated, and learning was shared and embedded to promote good practice. Staff we spoke with were open and honest when things went wrong, and they had the opportunity to learn and gain experience. Patients and staff were encouraged and supported to raise concerns they felt confident that they would be treated with compassion and understanding. The environment was safe and well maintained. Staff maintained high standards of infection prevention and control.

This service scored 59 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Patients told us they were happy to raise concerns with staff and that they were confident they would be listened to.

Staff told us they felt there was a strong and positive safety culture where staff were open and honest. In the 2024 NHS Staff Survey, 63% staff working in the Emergency Department (ED) said they felt safe to speak up about anything that concerned them in the organisation. This was slightly above the England average.

The trust was an early adopter of the NHS England's Patient Safety Incident Response Framework (PSIRF). The trust focused on effective learning and compassionate, meaningful engagement with those affected when incidents occurred.

Staff at all levels had a good understanding of how to use incident reporting systems and what to report. Data showed between 1 October 2024 and 31 March 2025, a total of 2789 incidents were reported. The vast majority of the incidents reported (81%) resulted in no apparent injury or minor injury requiring first aid. The top three themes for incidents reported were in relation to: Pressure ulcer (65% of the total reported were reporting concerns on admission), slips, trips and falls and relating to discharge.

The service had an up-to-date Patient Safety Incident Response Framework (PSIRF) policy and a Patient Safety Incident Response Plan, which set out how the service sought to learn from patient safety incidents reported by staff, patients, their families and carers. Leaders analysed incident reports and took urgent actions to manage or remove risks.

There was a culture of safety and learning. Safety events were analysed, investigated, thoroughly, and lessons were learned to continually identify and embed good practices. For example, fall huddles had been implemented in response to a theme of patient falls.

Learning had been taken and shared with staff following incidents within the department. Learning responses resulting from patient safety events demonstrated a good level of family and patient involvement in the investigation of patient safety events. Families and patients were given the opportunity to ask questions as part of the investigation. Patients and their families received copies of the final report.

The trust had processes and policies to foster a learning culture. Senior staff met regularly, and evidence showed staff feedback was documented and taken forward with teams for learning.

Leaders could articulate the themes and trends of incidents, the action they had taken to address these, and the methods used for feeding back to staff.

There were several ways that learning was shared across both the service and trust wide. These included safety alerts encrypted electronic messages, safety huddles, handovers and newsletters. There was a central log of National Patient Safety Alerts, which were shared with staff and actioned as appropriate.

The service used the learning from complaints and concerns as an opportunity for improvement. Senior members of staff and leaders were involved in reviewing complaints and incidents. For example, a leader within the ED told us that there had been a complaint relating to a patient not receiving adequate pain relief. In response this was communicated to staff at handover and safety huddles that all observations should also include a pain score. Patient records confirmed this was happening.

Data showed between October 2024 and March 2025 there were 28 complaints received. The top three themes relating to complaints were communication, clinical treatment and admission and discharge.

The service had a duty of candour policy, which set out staff roles and responsibilities regarding openness, honesty and transparency if something went wrong with a patient's care or treatment. We saw learning responses which confirmed that duty of candour was completed appropriately.

Staff worked hard to establish and maintain safe systems of care in challenging circumstances. However, staff told us they were concerned systems and processes meant they were not always able to provide safe patient care. Crowding and the use of temporary escalation areas were identified as ongoing issues.

Most patients reported a joined-up approach to providing care and treatment that involved them and their relatives. Patients told us the initial assessment of their symptoms had been timely, and treatment initiated where needed. Patients using the temporary escalation area told us they were fully informed, understood their treatment plan.

Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not in line with national standards. Data showed that between January 2025 and March 2025 the average time a patient spent in the department was nearly 6 hours against the target of 4 hours.

Patients often spent longer than necessary in the department prior to being moved to a specialty ward. During our assessment on the 8 April at 9:15 am there were 58 patients in the department. The longest wait for a patient requiring a ward bed was 18 hours, there were 16 patients who had waited longer than 12 hours for a bed and a total of 29 patients waiting for a bed.

Data showed that between January 2025 and March 2025 the average time a patient spent waiting for admission to a ward was 5 hours 36 minutes.Data indicated in the last 12 months the hospital performed consistently worse than the England average for all patients waiting more than 12 hours from arrival to admission. The latest data available (March 2025) indicated 15% of all patients waited more than 12 hours from arrival to admission, compared to the England average of 10%.

Despite some specialities such as medical care being based in the department, patients requiring review by a specialty service still experienced delays due to the workload elsewhere in the hospital.

At previous assessments we found ambulance crews were held at the hospital looking after patients due to the lack of beds in the emergency department. This meant ambulances were unable to get to people in the community that required their services. However, the trust and local ambulance provider had implemented Timely Handover Process (THP90) which was in place between 08:00am and 6:00pm. The ambulance staff stayed with the patients for 90 minutes, then were released and clinical responsibility for these patients was taken over by the hospital. Data showed there had been a significant reduction in ambulance delays (over 60 minutes). However, staff told us whilst THP90 worked well between 08:00am and 6:00pm significant delays could build again overnight.

Staff told us that there was no clinical engagement with THP90 and that the pace of implementation alongside other operational changes had created additional stress for staff particularly in the morning.

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.

There was a doctor and trained triage nurses based within the triage area who assessed and directed patients, depending on their acuity, to an appropriate clinical pathway or department. Patients could be streamed to the medical and surgical same day emergency care (SDEC) departments or Minor Injuries Unit. Children and young people were directed to the Children's ED.

The service had 24-hour access to mental health liaison and specialist mental health support for adults. There was a good working relationship with the local mental health liaison teams. There was a 4 hour target for patients requiring psychological assessment by the mental health liaison team. Data showed between January 2025 and March 2025 this was achieved on average 78% of the time.

The ED had a clear pathway for supporting people with mental health needs. During triage, nurses complete the Mental Health risk assessment, patient records we reviewed confirmed this was completed.

The Child and Adolescent Mental Health Services (CAMHS) was available 24-hours a day. Staff said they were generally responsive although there could be delays out of hours. CAMHS could refer children and young people to Multi Action RapidResponse Service (MARRS) which is a joint health and social care crisis response service for children and young people with acute mental health difficulties in Cornwall. MARRS aims to foster a health and social care culture which focusses away from each service providing care in silos and towards meeting the needs of the child.

The trust did not have an observation and engagement policy. However, staff were guided by enhanced care planning guidance. The mental health liaison service did have an observation policy and staff supported staff within the emergency department with risk assessments and care plans.

There was a twice daily nursing safety huddle where staff allocation was facilitated by the nurse in charge. Key messages were also discussed and included safety alerts, learning from patient safety events, staffing, waiting times compliance, safety checks and safeguarding.

Patients were protected from abuse. The majority of staff had training on how to recognise and report abuse, and they knew how to apply it. Data showed that compliance with safeguarding training modules was more of less in line with the trust target (90%) for all staff groups with the exception of level 3 children safeguarding training.

Staff we spoke with knew how to identify adults and children at risk of, or suffering, significant harm. Staff understood how to protect children, young people and their families from abuse and the service worked well with other agencies such as police and local authority safeguarding teams, to protect them.

Staff we spoke with were aware of how to raise a safeguarding referral and knew who the safeguarding lead in the department was. The service had a safeguarding team that staff could readily access. Staff were able to tell us when they recently completed referrals.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Patients we spoke with told us they felt safe and that if they had any concerns or issues, they would feel comfortable to tell someone.

Staff had access to safeguarding policies, which referenced appropriate legislation and best practice guidance. Flags (identifiers) were applied to the electronic record systems to identify patients who were at risk. Safeguarding information was displayed throughout the department.

Staff had good knowledge of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS) and best interests decisions. The mental health trust delivered a training session on the MCA and DoLS staff told us that they found the training really helpful.

Some people attending the department experienced long waits and were therefore at risk of deteriorating. In March 2025, 15% of patients were waiting over 12 hours.

The department had effective processes and tools for assessing patients when they first presented. Staff used a national triage tool to triage patients. Patients with were triaged to the appropriate services. Generally most patients were quickly and accurately assessed to determine the urgency of their condition and staff prioritised care based on their need. Patients we spoke with told us their wait for triage had been timely. Data showed just over 90% compliance with triage training.

The trust used the National Early Warning Score (NEWS 2) to assess patients at risk of deterioration in the department and enable staff to take appropriate action. In the paediatric department the Paediatric Early Warning Score (PEWS) was being rolled out at the end of April 2025. Staff were clear how to escalate patients that needed clinical review. Records we reviewed showed that staff completed the observations and scores as required by the protocol and properly escalated for review where they needed to. Audits were completed which showed variable compliance with NEWS 2. For example, there was 100% compliance in March 2025, for NEWS 2 being calculated on admission to the department but only 87.5% of patients had subsequent physical observations taken in line with their NEWS 2 score.

Most patients told us that they were informed of why they were being moved between areas in the department and waiting times had been communicated.

Leaders and staff could articulate what risk assessments they used to keep patients safe. However, only 67% of in house security staff had completed the annual refresher training in least restrictive restraint. Actions were being taken to address compliance for the 6 non-compliant staff members (33%). Restrictive restraint was only used as a last resort and was monitored by leaders.

Patients told us they felt safe and supported whilst they were in the ED. They could approach staff if they felt their health was deteriorating and they were confident staff would respond to their concerns.

The trust recognised friends, and family could often see a patient's deterioration before anyone else does. Therefore, trust had a programme which enabled friends, relatives and patients themselves to make a direct referral to the critical care outreach team if they felt the clinical condition of an adult or child in-patient was actively deteriorating. There were posters and written information informing all patients and visitors of the programme.

Staff used an ED patient safety checklist outlining the clinical tasks and risk assessments needed for each patient. Data showed that in March 2025 only 79% of patients had all their risk assessments and nursing documentation completed. In addition, in March 2025 only 76% of patients had SSKIN bundle assessment completed. The SSKIN bundle is a bedside tool to help staff monitor skin concerns and reduce the risks of developing a pressure ulcer. This meant there was a risk that patients may not always have their immediate needs met to minimise any discomfort or manage risks.

The service undertook audits of patients being cared for in temporary escalation areas to ensure their clinical needs could be met. Data showed an average of 90% compliance with these audits for the last 6 months. Following our assessment, we identified a concern regarding patients being care for in the temporary escalation areas. In response to this the number and frequency of these audits was increased.

Staff we spoke with described the processes to assess and identify patients at risk and how they assessed and documented mental capacity. Alerts on the electronic record systems enabled staff to be aware of specific risks. Staff attended a thorough shift handover where risks were communicated.

Partners, such as psychiatric liaison reported they worked well with department staff. Several members of staff commented on the fantastic support the psychiatric liaison provided, working cohesively to ensure the patient was kept at the centre.

Although patients experienced long waits in ambulances and waiting rooms, patients told us they were well looked after by staff.

The equipment and facilities, in the main, supported the delivery of safe care. When the department was crowded patients were held in areas not designed for long waits where there were no shower facilities available and patients did not have call bells. However, we observed staff seated in the temporary escalation area so could directly observe patients.

We identified other issues relating to equipment and facilities. These included a faulty lock on a cupboard containing substances subject to The Control of Substances Hazardous to Health Regulation. We raised this issue with the senior leadership team following and our assessment and have seen evidence which confirmed the faulty lock was fixed the following day.

Planned preventive maintenance and electrical appliance tests were completed and recorded centrally. All electrical equipment we checked had undergone electrical safety checks within the last 12 months.

The department’s fire safety equipment and emergency systems such as call bells, were tested and maintained appropriately. Fire exits were not blocked, evacuation routes were signposted. Environmental risks assessments were completed.

The department had a modern resuscitation area (built 2020). It had 6 bays 2 of which could be used for isolation and 1 was dedicated to care for children and young people. The resuscitation department had a full set of equipment for treating children and late-stage pregnant women. Each bay was large enough to easily allow for a multi-professional team to care for and treat the patient and have access to a vast range of equipment and facilities.

There was a separate area for children and their families which was safe and secure and there were toys to keep children occupied.

At our previous inspection we found the mental health assessment room which was due for updating as it did not conform to the guidance of the Psychiatric Liaison Accreditation Network (PLAN). At this assessment we found the room had been updated and now had Psychiatric Liaison Accreditation Network (PLAN) accreditation.

At the ambulance entrance, a red and green light system was in operation. If the light was green, the paramedics were able to immediately bring the patient into the department for assessment. If it was red, they needed to liaise with the team, or their hospital ambulance liaison officer (HALO) before bringing the patient through about next steps. An ambulance bay for critical patients was kept free directly outside the entrance.

In the Care Quality Commission’s 2024 national patient survey the results for the hospital Urgent and Emergency Care environment and facilities was similar to other trusts.

There were not always enough skilled and experienced staff in the department.

There was not always the required numbers of children's nurses on each shift. According to the current establishment for paediatric nurses there were no vacancies, however some paediatric nurses had been seconded into other roles outside the Children's ED leaving a shortfall.

The lack of children's nurses was mitigated by other staff with children's nursing competencies. Data showed that between 31 December 2024 and 14 April 2025, 23% of shifts did not have two paediatric trained nurses and 9% of shifts did not have an adult nurse with paediatric competencies. All staff working in the children's ED were triage trained and updated with requirements of paediatric triage. Staff told us that the paediatric ED was short staffed at times for senior paediatric nurses and medical staff.

The consultant cover did not meet the recommendations of the Royal College of Emergency Medicine. Consultant cover was between 8am and 11pm and then on call, national guidance states consultant cover should be between 8am and midnight then on call. Additionally, the department was some distance away from the Children's ward meaning that support from the wards would take time to arrive. Consultant staffing levels were significantly lower on weekends compared to weekdays, with only 3 consultants on shift between 10am and 11pm. This was a known risk and was included on the department's risk register with a risk score of extreme, however it was unclear what mitigations were in place to reduce the risk.

The service currently had about 12 full-time consultants. Based on the current staffing establishment data showed a vacancy rate of less than 1% for all grades of medical staff, the highest vacancy rate (6%) was amongst middle grade doctors, this was still below the trust target of 10%. Data showed that nearly 13% of resident doctor shifts were covered by bank additional duty hours and nearly 25% of middle grade doctors shifts were covered by bank, additional duty hours or agency shifts. This indicates that the current staffing establishment for resident and middle grade doctors was less than it needed to be.

Data showed an overall vacancy rate of just over 10% for all staff. The vacancy rate for registered nurses was 14% just over the trust target and 6% for Health Care Assistants. The unfilled shift rate for doctors in ED for the past 3 months was nearly 3%. However, the trust advised this figure did not include consultants as their rotas were annualised so difficult to determine what was unfilled. This meant the trust did not know the number of consultant shifts that were unfilled. The average unfilled shift rate for nurses over the last 3 months was 6%.

The most recent data showed an overall staff sickness rate of 3.61% for all staff which was slightly better than the trust target of 3.75%. The highest sickness rate (4%) was for nursing staff which was slightly worse than the trust target.

There had been a significant effort in recruitment and upskilling of nurses. Administration staff vacancies and nursing shortages was included on the departmental risk register. However, it was unclear how the risks were being mitigated. This meant the trust could not be assured all reasonable actions were being taken to address risks.

There were robust and safe recruitment practices to make sure that all staff, including agency staff and volunteers, were suitably experienced, competent, and able to carry out their role. There was a suite of policies relating to safe recruitment and all new starters received a comprehensive induction.

The service used bank staff when necessary and regular agency staff, and ensured they were familiar with local systems and processes. Data showed between January 2025 and March 2025 the, 7% of all nursing shifts were filled by agency staff.

Staff appraisals were not always completed, the latest appraisal compliance was 77%. This was an improvement since the last inspection when compliance was at 65.6%, however, this still did not reach the trust's own internal appraisal target (90%). A performance appraisal can have many benefits such as to identify individual learning needs, identify continuing development needs of employees and as a tool to identify progression opportunities.

Staff did not always complete mandatory training appropriate and relevant to their role. Overall compliance for all staff was 84% which was less than the trust target (90%).

Data provided to us by the trust showed that 85% of doctors had up to date Advanced Life Support training, 56% of doctors had up to date Advanced Trauma Support Training. Fifty two percent doctors had up to date Advanced Paediatric Life Support Training. Eighty one percent of nurses had Advanced Paediatric Life Support Training. The trust confirmed that the 2 nurses who had not completed the training were booked on the course. The compliance was below the trust target in all modules. All staff working in the Children's ED had completed paediatric life support training.

Not all staff received training on sepsis screening and management. Data showed 90% of nursing staff had completed sepsis training but only 58% of medical staff had completed the training. This had implications for missed opportunities for screening and delays in care. However, during our assessment we found sepsis screening and treatment was undertaken in line with national guidance.

The resuscitation unit had resuscitation practitioners who were dedicated to working solely in the unit, developing and maintaining a unique set of clinical skills related to trauma care

There was a positive culture around nursing education, classes and learning opportunities. We were told there was a culture of supporting staff to develop and progress.

Medical staff were supported by named supervisors. Resident doctors had protected time for teaching. Feedback from resident doctors was positive.

During the assessment, the department was busy with more patients being cared for than the department was built for. This put inevitable pressure on staff. There were nursing staff assigned to temporary escalation areas to ensure patients in this area were monitored and cared for. There was also a nurse allocated to the ambulatory decision lounge where up to four patients could be waiting and being treated so they were not left unattended.

During our assessment we observed that nursing and medical staff worked well under pressure. There was a culture of working together as a team to manage the numbers of patients in the department. We observed staff having positive interactions with patients, despite the capacity demands and patient flow. Senior staff supported junior staff, and all staff worked in collaboration with each other. For example, we saw a consultant undertaking informal teaching with resident doctors.

Clinical areas were visibly clean and had suitable furnishings which were clean and well-maintained. Issues with defective equipment and cleanliness had been resolved since our previous inspection. The cleaning schedule set out by the service was followed. Disposable curtains labelled with the date they were last changed. Cleaning records were up to date and demonstrated all areas and equipment were cleaned regularly. Clinical waste was disposed of safely.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly. Staff followed infection prevention and control (IPC) guidance. Data showed that compliance with level 1 IPC training exceeded the trust target for all staff groups. However, overall compliance with level 2 IPC training was only 75% which was less than the trust target.

We observed staff maintained standards of hygiene and cleanliness. Staff washed hands in line with infection control policies and adhered to the uniform policy. We observed staff complied with ‘bare arms below the elbows’ policy, in accordance with National Institute for Health and Care Excellence (NICE) guidance. Personal protective equipment and handwashing facilities were mostly available. However, in the Children’s ED there was not a handwashing sink. Since our assessment the trust has supplied information confirming a handwashing sink will be installed.

The service had an effective approach to assessing and managing the risk of infection, which was in line with current relevant national guidance. An IPC policy set out key information for staff to support maintaining infection, prevention and control standards. Hand hygiene, local cleaning and infection prevention and control audits were undertaken by the service. For example, between January and March 2025 hand hygiene audits showed 90% compliance.

Domestic staff were visible within the department. We observed both clinical staff and the cleaning staff diligently cleaning equipment and the environment.

Isolations rooms were designated as part of the resuscitation area of the department and a large tent was available outside of the service for any incidents requiring decontamination.

Staff did not always store and manage medicines securely or safely. Medicines were stored in dedicated secure storage areas with access restricted to authorised staff. However, within these areas a few of the medicine’s cupboards were broken. The trust had since provided evidence which confirmed the locks have been repaired.

Medicines that had a revised expiry date once opened generally lacked, either the date of opening or the revised expiry date.

The department held To Take Out (TTO) packs. These packs were pre-labelled with standardised information including directions. However, the completeness of the pre-labelling was variable.

Whilst controlled drugs were stored securely, and records kept the trust's procedure for disposing of small volumes of part-doses was not being followed.

Concern was raised by staff in paediatric ED about the work surface they had to use when preparing medicines. It was not located in a secure clinical area and was at child height. Which meant there was a risk that if medicines were not closely monitored during preparation, for example if staff were called away to respond to an emergency, children may be able to access the medicines. This was on the department’s risk register, and we saw quotes for the required changes to the environment had been obtained.

Piped medical gases were available in the emergency department. Following a national safety alert the trust had reviewed the accessibility of piped medical air. At the time of the inspection, staff were reviewing the equipment requiring piped medical air and were fitting caps to the piped medical air outlet in areas where anaesthetic machines were unlikely to be used.

Emergency medicines and equipment were available. There were tamper evident seals in place to ensure they were safe. Staff recorded weekly safety checks on emergency medicines and equipment to ensure they were safe to use if needed in an emergency. All expiry dates checked were in date.

During triage medicine for pain relief and other symptoms were prescribed by doctors or administered by nurses via homely remedies procedures or patient group directions (PGDs). PGDs were also available for the initial treatment of suspected sepsis by the nurses.

We reviewed the e-prescribing and medicines administration records for 5 patients. These indicated medicines were administered in a timely manner.

The trust had contributed to the Royal College of Emergency Medicines (RCEM) ‘Time Critical Medicines’ quality improvement project work relating to time critical medicines in Emergency Departments. At the time of the inspection the pharmacy service to the emergency department had been reduced due to vacancies and was based on the medical assessment unit. The trust was reviewing clinical pharmacy staffing levels and seven day working to support hospital admissions via ED against the RCEM staffing recommendations.

Patients being discharged from ED requiring medicines in working hours would have a prescription dispensed by the on-site outpatient and ED pharmacy. Outside of working hours TTO packs were prepared by the ED nurses.

Staff described quality improvement work that had been undertaken to improve the adherence to prescribing guidelines for antibiotic and pain relief. Staff told us that not all medicines dispensed by the outpatient and ED pharmacy were collected by patients and work was being undertaken to reduce the frequency of uncollected medicines. Following a change of provider the turnaround time for the outpatient and ED pharmacy had improved.