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 assessed six quality statements. 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.

There was not a clear system of risk management based around delivering safe and good quality care and treatment.

There was an inclusive and positive culture of continuous learning and improvement. Leaders were capable, compassionate and inclusive and supported their staff in challenging and stressful times. There was a strong desire to meet the needs of the whole population and to provide safe, integrated person-centred care. However, we had concerns regarding the fragility and sustainability of those leading the service to deliver the significant changes at the current pace.

Leaders felt they did not have the autonomy to lead and make decisions about changes that impacted their services. Staff told us they were unable to influence change and contribute to decision-making in the department which impacted them. There was a disconnect between the clinical teams and operational corporate decision making and staff felt a loss of autonomy and influence.

Most staff were aware of the freedom to speak up service and were confident in raising concerns. The service worked in partnership with stakeholders and communities.

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 board approved the trust strategy in November 2022 for 2022-2032. The strategy described their overarching vision as a Trust of Outstanding Care for One and All, and this was underpinned by 3 key strategic objectives: Safe, High-Quality Care, Supported and Valued People and Journey of Improvement. The trust had recently undertaken a refresh of the strategy to provide an opportunity to ensure the strategic priorities continue to reflect their current operating environment and the opportunities and challenges faced.

The service had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. The vision and strategy were focused on sustainability of services and aligned to local plans within the wider health economy. The service had emergency department (ED) strategy 2022-2027. There were different mechanisms for staff to feedback on the proposed strategy.

There was mixed feedback from staff regarding culture and implementation of the vision and strategy alongside other changes. Some staff describing a difficult culture in the context of operational decision making and pressure to place patients on the ward. Staff described the negative impact it had on staff wellbeing and morale. Some staff told us that they were not engaged in changes that were made that impacted them. Not all staff were aware of the vision and strategy of the service and how this fitted into the overarching trust strategy. There had been work undertaken to improve this including increased senior oversight and presence, professional role modelling and increased staffing and support as well as engagement. This had improved the culture though senior staff were aware there was still more to do to embed the change.

There was a good safety culture where events were investigated, and learning was embedded to promote good practice. Staff said raising concerns was encouraged and valued. In the 2024 staff survey results 87% of staff working in the ED either agreed or strongly agreed that the organisation encourages staff to report errors, near misses or incidents.

The trust values of respect, compassion, honesty and teamwork, were displayed around the trust and department. We saw staff lived these values.

Leaders had a shared purpose and strived to deliver and motivate staff to succeed. However, we were concerned about the negative impact it had on their wellbeing. Generally, there were high levels of satisfaction amongst staff, despite the challenges they faced. However, in the 2024 staff survey results only 50% of staff working in the ED agreed or strongly agreed that if a friend or relative needed treatment they would be happy with the standard of care provided by this organisation.

Staff told us they felt supported by managers and had opportunities for development. 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 give safe care and treatment.

There was a triumvirate leadership structure with medical, nursing, and operational leads. There was a strong, committed and capable leadership team in the department. The leadership team had the skills, experience and knowledge to lead the department effectively and with credibility. They were open, honest and willing to learn and improve. However, the Emergency Department and medical care services were in the same care group and was therefore the same leadership team. We were concerned that, whilst they had capability, they might not have capacity and the wellbeing of the triumvirate leadership team was impacted given the number of significant changes being made at pace.

There was a disconnect between clinical decision making and operational decision making. Senior clinical staff told us that they were not engaged or involved in decisions that directly impacted them.

Staff told us leaders in the service were approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the practice. The leadership team worked with other departments and also the ICS the development of emergency care services within the region.

The leadership in the department included the clinical director, the head of nursing and general manager. They described a positive working relationship and were well sighted on the demands and challenges of the department. They recognised the risks in the department and shared strategies and plans to address these. However, the biggest risk they identified was over crowding in the department and it was not clear how the risk was being mitigated. They could not be assured all reasonable actions were being taken to address risks.

Senior leaders were aware of the impact that the crowded department has had on staff and that this increased stress. There were support services in place and actions to support culture had been implemented. However, leaders acknowledged there was still more to do.

Leaders were able to demonstrate how they worked as part of a multidisciplinary team within the service and how they collaborated with partners such as local NHS ambulance and mental health trusts. They told us they worked well together and there was regular engagement to review performance and identify improvements to services. Leaders had various initiatives to aid flow, virtual wards, community assessment and treatment units, urgent community response services and minor injury units.

Leaders had effective support and opportunities to develop and maintain their skills. The roles of staff and leaders were clear, and they understood their responsibilities and accountabilities. The trust had processes to encourage talent management, career progression and succession planning. The Safe and Compassionate Leadership programme formed part of the trusts commitment to support and equip leaders and make positive steps towards culture improvement. This programme aims to support leaders in their challenging roles.

The service had established Freedom to Speak up arrangements. Staff were aware of how to raise concerns.However,the Freedom to Speak up annual report covering the time period between April 2024 and March 2025, showed trust wide the experience of staff raising concerns had declined. The report showed that just over 70% of staff felt secure raising concerns about unsafe clinical practice which was in line with the national average. However, only 51% of staff felt confident that their organisation would address their concerns which was worse than the national average of 56%.

In the same report there were 81 speak up cases raised in total trust wide. Of these cases 47 were raised direct to the Freedom to Speak Up Guardian (FTSUG) and 34 via the anonymous app. The numbers of anonymous concerns had continued to fall, this may suggest staff are feeling safer to speak more locally in their care groups and to champions and the Guardian. However, the number of anonymous concerns raised was 42% which was much higher than the national average of 9.5%. The greatest number of cases raised related to behaviours and relationships. Nurses were raising the largest number of concerns in this time period followed by administration staff. The Acute Emergency Medicine care group raised 6 concerns.

Leaders encouraged staff to raise concerns and promoted the value of doing so. However, not all staff felt empowered to speak up or that their concerns would be listened to.

Call 4 Concern was available to staff, patients and those close to them to raise concerns and these were listened to and addressed by the team.

Patients knew how to make a complaint or raise concerns. The service clearly displayed information about how to raise a complaint. Managers investigated complaints, identified themes and shared feedback with staff. Learning from these was used to improve the service. Staff understood the policy on complaints and were able to give examples of learning from complaints.

When something went wrong, people received a sincere and timely apology and were told about any actions being taken to prevent the same happening again. We reviewed learning responses which showed Duty of Candour was completed appropriately.

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.

The service did not always have effective systems to enable oversight of risk. The department risk register was monitored and included risks for adult and paediatric emergency departments. However, the ED specific risk register did not include timelines for review or mitigations. This meant we could not be assured all reasonable actions were being taken to address risks. An additional risk register provided by the trust which included medical care services risks included some risks relating to the ED but were not on the ED specific risk register. For example, on the joint risk register there was a risk pertaining to overcrowding and the use of the corridor as a temporary escalation areas but this risk had not been reviewed since 15 March 2023.The ED specific risk register included a similar risk relating to overcrowding but did not include mitigations and when the risk was reviewed.

There was a good range of accurate and timely data and information available to understand performance and quality and improvements were made as needed. For example, the service compared itself to national published research in relation to the increased risk of patient's dying by experiencing delays in the ED crowding.

Audits undertaken included clinical effectiveness and compliance with guidance from the National Institute of Health and Care Excellence (NICE). Performance against national guidance was shared with staff to highlight areas of improvement. For example, the April 2025 ED Governance newsletter included performance against national guidance for the management of patients having a stroke.

There were regular and effective meetings for safety, audit, quality, and governance. These discussed and addressed key areas of performance, risk, audit, culture, and workforce. Minutes recorded areas of concern were identified and actions were taken to learn and improve. Once a month, the team reported and presented a summary of their incidents and staffing metrics to the care group for the wider group to be aware of the departmental pressures and emerging risks.

Information on governance was shared via a newsletter emailed to all staff; a poster was also displayed. Staff received feedback from incident reporting and risks during handover and safety huddles.

Staff were part of the emergency preparedness network, and they had the strategies and guidance to respond to major incidents. Good practice was recognised and celebrated.

Staff understood their role and responsibilities, what they were accountable for, and to whom. Leaders mostly operated effective governance processes, throughout the service and with partner organisations. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service. However, we had concerns around the challenges for the department leads and staff around the increased pressures and the impact this may have on patients.

Staff and leaders worked in partnership with key organisations to support care provision, service development and joined-up care.

A range of Improvement training courses were available via the QI website and were delivered in both virtual & face to face settings. The trust invited external stakeholders such as Integrated Care Board (ICB) colleagues to join to provide and foster engagement with improvement, science education and shared peer to peer learning.

The trust held bi-monthly Learn and Share events which were open to Cornwall System-wide stakeholders and provided an opportunity to showcase improvement endeavours at varying stages, drive the improvement mindset and provide networking & collaborative opportunities.

People's views and experiences were gathered and acted on to shape and improve the services and culture. This included people in a range of equality groups. People who used services, those close to them and their relatives were actively engaged and involved in decision-making to shape services and culture. For example, the accessibility advisory group which had a range of stakeholders including iSight Cornwall, Mobility and DisAbility Cornwall were engaged with developing the hospital estate.

Leaders understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement. For example, the Cornwall Partnership NHS Foundation trust, intermediate care service provided a Mental Health Crisis Assessment Hub, which incorporated Acute hospitals, GP's, Urgent Treatment Centres and Same Day Emergency Care units. The service was available 24 hours a day 7 days a week for patients in experiencing a mental health crisis with no acute medical need. This was an alternative to an attendance at the emergency department.

The trust had a West Cornwall Hospital development group. This group brings together representatives from the public, clinicians and managers, primary care network and other organisations as partners in the restoration and further development of West Cornwall Hospital. The group hosted a number of events including an outpatient workshop and developed a booklet addressing concerns and identifying improvements regarding West Cornwall Hospital.

The trust's strategy aligned to local plans in the wider health and social care economy, and services were planned to meet the needs of the relevant population. The ICB recommended that all Cornwall Isle Of Scilly providers held regular provider to provider meetings to address the challenges across the system given the degree of interdependencies. Seven pillars or Urgent and Emergency Care priorities were developed and the ICB transformation support hub supported the coordination / oversight of each 7 pillars for action plan development and exception reporting. Four of the pillars were the responsibility of the trust. There was a performance dashboard aligned to key performance indicators to monitor the impact. There were weekly ICB clinically led oversight meetings, each pillar had accountable leads, was clinically driven, had clear governance, a designated action plan and trajectory.

Partners from the Cornwall system, such as the local community trust, GP's and the local ambulance trust met monthly to ensure the system was working together and safe for patients. Policies and pathways such as same day emergency care were aligned with other key partners to drive improvements for patient care and treatment.

Partners we spoke with advised there were no concerns in relation to staff working together, inclusivity and partnership working.

Alerts on the IT system enabled staff to be aware of and follow specific care plans if a patient had needs that required additional support. There was a frequent and high intensity users lead. They led monthly multi agency meetings. This was in line with The Royal College of Emergency Medicine (RCEM), Best Practice Guideline.

The emergency department had regular meetings other stakeholders such as the mental health trust to improve shared learning, oversight of clinical issues and performance and to enable joint service development and provision to progress in collaboration.

Staff focused on continuous learning, innovation and improvement across the organisation and the local system. They encouraged creative ways of delivering equality of experience, outcome, and quality of life for people. The service actively contributed to safe, effective practice and research. The trust have a Quality Improvement (QI) team and hub (QIdeas) on the staff intranet where staff could submit ideas for improvement programmes via a short form and received a response usually within 48 hours. It was expected that staff raised small-scale improvement ideas directly to their line manager and teams for action. Through these suggestions, the leadership identify themes. For example, food availability for staff.

Staff told us that the trust was building QI into the culture with the understanding that in the future, they will not need a QI team as each staff member will be empowered to take on QI initiatives. The trust offered positive opportunities for staff to discuss QI including QI cafes, let's talk monthly sessions with executive team with one session focusing on QI, and an annual QI conference.

As part of the response to ongoing operational pressures, an improvement project was to expand the range of pre packed to take out (TTO) medications within ED to facilitate faster discharges was implemented. This included use of pre-packs `in hours' to help patients be discharged from ED faster. A piece of work was undertaken to identify the most commonly prescribed items in ED that would be useful to hold as TTO packs. Feedback following implementation of the packs included: reduced the amount of medicines given to patients that could be bought cheaper by patients, increased stock levels of high frequency TTO's and a wider range of medicines as TTO's.

There was a Clinical Vision for Flow Improvement programme recently established. This programme focussed improving operational and clinical performance within the department. For example, achieving the average ambulance handover time to under 40 minutes by September 2025 and improve performance in the management of patients with sepsis.

A new triage system supported by a new standard operating procedure had commenced shortly before our assessment. The principle aims were reduced triage times as well as ensuring patients had early clinical review and oversight. Staff had been involved in the development and an evaluation was planned.

The service had strong external relationships that supported improvement and innovation. Staff and leaders engaged with external work. There was a trust wide flow improvement programme with 4 workstreams: ED, sick frail patients, sick general patients, and short stay patients. Each workstream had an action plan.

The department's senior nurse was developing a chart for patients to provide information for them and their families on what was happening and the next steps. This would be updated by staff and form a `live' and personalised source of information.

The trust implemented a ward accreditation program called Aspire (named voted for by staff). It was developed and implemented by the trust and aimed to improve the quality of care by evaluating and accrediting wards based on specific standards. The program was revised and expanded to incorporate evidence-based metrics and new elements, like direct registered nurse care time and ward climate, to ensure a more robust and reliable assessment of patient safety and quality. The program was seen as a tool for continuous quality improvement at the ward level, encouraging staff ownership and pride in their work, while also reducing variation and improving team working.