You are here

Provider: Royal Cornwall Hospitals NHS Trust Requires improvement

On 14 December 2018, we published a report on how well Royal Cornwall Hospitals NHS Trust uses its resources. The ratings from this report are:

  • Use of resources: Requires improvement  
  • Combined rating: Requires improvement  

Read more about use of resources ratings

Following a recent review of Royal Cornwall Hospitals NHS Trust, the report below was published. We will update the information on this page to reflect this report shortly.

Following a recent review of Royal Cornwall Hospitals NHS Trust, the report below was published. We will update the information on this page to reflect this report shortly.

We are carrying out checks on locations registered by this provider. We will publish the reports when our checks are complete.

Inspection Summary


Overall summary & rating

Requires improvement

Updated 14 December 2018

Our rating of the trust improved. We rated it as requires improvement because:

  • We rated safe, effective and responsive as requires improvement. Well-led was rated inadequate and caring was rated good.
  • Royal Cornwall Hospital was rated requires improvement. West Cornwall Hospital and St Michael’s Hospital were rated good.

Royal Cornwall Hospital

Our rating of services improved. We rated them as requires improvement because:

  • We rated safe, effective, responsive and well-led as requires improvement. Caring was rated good.
  • Urgent and emergency care remained the same and was rated as requires improvement. Safe and responsive remained the same and were rated requires improvement. Effective and caring stayed the same and were rated good. Well-led improved and was rated good.
  • Medicine improved since our last inspection and was rated requires improvement. Safe and well-led improved and were rated requires improvement. Effective improved and was rated good. Caring remained the same and was rated good. Responsive stayed the same and was rated inadequate.
  • Surgery had improved since our last inspection and was rated as requires improvement. Safe and responsive had improved since our last inspection and were rated requires improvement. Effective and well-led remained the same and were rated as requires improvement. Caring stayed the same and was rated good.
  • Critical care services remained as good overall. Safe went down one rating since our last inspection and was rated as requires improvement. Effective, caring and well-led remained the same as our last inspection and both were rated good. Responsive went up one rating and was rated good.
  • Maternity services were rated as requires improvement. Safe and well-led were rated requires improvement. Effective, caring and responsive were rated good.
  • End of life services had gone up one rating since our last inspection and were rated requires improvement. Safe had stayed the same and was rated requires improvement. Effective, responsive and well-led had improved and were rated requires improvement. Caring remained the same and was rated good.
  • Outpatient services were rated as requires improvement. Safe, responsive and well-led were rated requires improvement. Caring was rated good. Effective was not rated.
  • Diagnostic imaging was rated outstanding. Responsive and well-led were rated outstanding. Safe and caring were rated good. Effective was not rated.
  • Children and young people’s services remained the same and were rated good. Safe remained the same and was rated as requires improvement. Effective, caring, responsive and well-led remained the same and were rated good.

West Cornwall Hospital

Our rating of services stayed the same. We rated it them as good because:

  • We rated effective, caring, responsive and well-led as good. We rated Safe as requires improvement.
  • Urgent and emergency care had not been rated before. Safe, effective, caring, responsive and well-led were rated good.
  • Medicine stayed the same since our last inspection and was rated as good. Safe went down one rating to requires improvement. Effective, responsive and well-led remained the same and were rated as good. Caring went down one rating from outstanding and was rated as good.
  • Surgery remained as good overall. Safe stayed the same and was rated requires improvement. Effective, caring, responsive and well-led stayed the same and were rated as good.
  • Outpatients was rated as good overall. Safe, caring, responsive and well-led were all rated as good. Effective was not rated.

St Michael’s Hospital

Our rating of services stayed the same. We rated it them as good because:

  • We rated safe, effective, caring, responsive and well-led as good.
  • Medicine was rated as good. Safe, effective, caring, responsive and well-led were all rated as good.
  • Surgery remained good overall. Safe, effective, responsive and well-led stayed the same and were rated good. Caring went down and was rated as good.
  • Outpatients was rated good overall. Safe, caring, responsive and well-led were rated good. Effective was not rated.

Community services

  • Sexual health services remained the same and were rated good. Safe, effective, caring, responsive and well-led all remained the same and were all rated good.
Inspection areas

Safe

Requires improvement

Updated 14 December 2018

  • In medicine, incidents were reported, investigated and lessons shared with the team and wider service. Patients were protected from abuse and avoidable harm. Infection control risks were managed. Medicines were managed, stored and administered safely. However, staff in the department were not compliant with mandatory training. Equipment was not regularly maintained and there was a lack of storage space for equipment. Patient records were not always appropriately maintained.
  • In surgery, staffing levels ensured the safe running of the service. The surgical safety checklist was routinely used, and staff had received additional training to manage patients who deteriorated post-operatively. Staff understood the importance of sepsis and the need to manage this to ensure patient safety. Medicines were stored securely, and infection control risks were managed to protect patients from healthcare associated infections. Equipment was regularly maintained. However, mandatory and safeguarding training for the service was not complaint with the trust’s target and a small amount of equipment on the wards was found to be out of date.
  • In outpatients, staff were complaint with safeguarding training. There was adequate staffing and skill mix to safely manage outpatient clinics. Infection control and medicines were safely managed. However, not all staff had received the correct level of child safeguarding training and the traceability system for prescriptions was unclear.

Community services

  • In sexual health services, there was a risk staff were not always protected from infection risks due to the incorrect cleaning materials being used to clean up spillages of bodily fluids. Individual patient records did not always accurately reflect conversations, advice and treatment provided by the service. However, staff received training to provide services to adults and children and the environment and facilities ensured the safety of patients. Risks to patients were identified and managed, and staffing levels and skill mix ensured the safe care and treatment of patents attending the service. The storage, management and administration of medicines ensured the safety of patients and systems and processes ensured patients were protected from healthcare associated infection. Action and learning was taken when incidents occurred.

Effective

Requires improvement

Updated 14 December 2018

Royal Cornwall Hospital

Our rating of effective improved. We rated it as requires improvement because:

  • In children and young people’s services, the lack of alignment of record systems impacted on the service’s ability to provide effective treatment. Additional training in mental health was limited and staff did not always feel confident to manage children with complex mental health conditions. However, care and treatment was based on best practice evidence-based guidelines with performance being benchmarked to identify areas of the service which required improvement. Staff were also engaged with reviewing performance and were encouraged to review outcomes and make improvements to the service where required.
  • In medicine, discharge planning was inconsistent and was impacting on patient flow. Staff handovers did not routinely include information regarding the psychological and emotional needs of the patient and those close to them. Staff were not confident in completing documentation regarding mental capacity and not all staff had received their annual appraisal. However, care and treatment had been developed in line with national guidance and the effectiveness of care and treatment was assessed through regular audit. Staff worked effectively across other healthcare disciplines and other agencies to provide effective care for patients.
  • In diagnostic imaging, the most current evidence-based techniques and technologies were used to deliver care and treatment. Staff were competent to carry out their role and were actively engaged to monitor and improve quality and outcomes. Collaborative working both internally and externally was strong and staff understood their roles and responsibilities in relation the Mental Capacity Act 2005.
  • In end of life care, not all patients deemed to be end of life were identified, particularly those patients in their last year of life. Documentation for end of life care records was variable, with not all patients having their preferred place of care documented in their records. Audit compliance with treatment escalation plans remained poor and continued to challenge the trust. There was a lack of data to review patient outcomes and advanced care planning training was not available to staff, meaning staff did not feel confident to discuss and plan this with patients. However, care and treatment was delivered in line with national guidance and staff working within the specialist palliative care and end of life team had the skills and knowledge required for their role. There was strong multidisciplinary working both internally and externally with other organisations to assess, plan and deliver care and treatment to patients at the end of their lives.
  • In sexual health services, audit was carried out to ensure care and treatment was compliant with legislation and best practice guidelines. Outcome data was collected to ensure the service was effective for patients. Staff worked collaborative both internally and externally to provide care and treatment for patients. Patients were supported to manage their pain and provided with information to support a healthier lifestyle. Consent to care and treatment was sought in line with legislation.
  • In critical care, there were gaps in allied healthcare professional input into the multidisciplinary team and there was limited resource to provide specialist advice for patients with complex nutritional needs. Critical care performance in the National Emergency Laparotomy Audit from 1 December 2017 to 28 February 2018 was worse than average and not all critical care nurses had received an appraisal. However, patient care and treatment was delivered in line with nationally recommended guidance. Care and treatment plans were developed in line with National Institute for Health and Care Excellence guidance on admission to the unit, with patients’ physical and emotional needs featuring as part of the assessment. The unit participated in audit to identify areas which required improvement, staff were competent to provide safe care to patients and were encouraged to develop their knowledge and skills.
  • In urgent and emergency care, audits demonstrated the management of pain was poor and Royal College of Emergency Medicine audit results were not consistently positive. Staff did not always understand the relevant consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act 2005. However, care and treatment was based on national best practice guidance, training was provided to ensure staff were competent to carry out their roles and multidisciplinary working was strong to optimise care and treatment for patients. The department also prompted patients’ independence if the environment was safe to do so.
  • In outpatients, patients continued to wait long periods of time to access care and treatment. However, care and treatment was based on nationally recognised guidance. Staff were competent in their roles and worked closely with other professionals to share their skills and knowledge. Staff worked together to optimise care and treatment for patients and there was strong multidisciplinary working in the pain clinic to effectively manage pain.
  • In maternity services, improvements were needed to improve access and the provision of community-specific guidelines and guidance to support mothers with infant feeding. Work was also required to ensure guidance for the emergency evacuation of the birthing pool was up to date with current practical training. However, pregnant women had their needs assessed and were managed in line with national guidance. All staff contributed to an audit plan to benchmark and improve services and patient outcomes were within expected or better than expected ranges compared to other services. There was strong multidisciplinary working between staff in the department and care and treatment was provided to women at all stages of their pregnancy in a timely way. Staff in the department had the skills and competencies to work in all areas and support women with both high and low risk pregnancies. Staff also understood and followed the relevant consent and decision-making requirements of legislation and guidance.
  • In surgery, completion of consent forms varied, and patients were not always given enough time to make an informed decision. Discussion and communication around resuscitation decisions was not routinely discussed and competency frameworks were not always used to ensure staff were competent and had the skills they required to carry out their role. This was further impacted by the high numbers of medical outliers on the surgical wards, which staff did not feel competent to care for. Appraisal rates for the department were below the trust’s target for all staff groups. However, the effectiveness of treatment was reviewed through local and national audit and outcomes were generally within the expected range when benchmarked nationally. The multidisciplinary team worked together to optimise care and treatment for patients and nutrition, hydration and pain were assessed on admission and managed throughout the patient’s stay on the surgical ward.

West Cornwall Hospital

Our rating of effective stayed the same. We rated it as good because:

  • In urgent and emergency care, information and protocols were displayed in the resuscitation room to support staff. Staff underwent additional training to make sure they had the necessary knowledge and skills to carry out their role. Staff also completed training in the Mental Capacity Act 2005. However, the department did not participate in the Royal College of Emergency Medicine audits and not all staff in the department had received their annual appraisal.
  • In medicine, national guidance was used to support the delivery of care and treatment and staff were able to access further advice from specialist nurses if required. Staff supported patients to meet their nutrition and hydration needs and multidisciplinary working on the unit and with staff in the community functioned well. However, nursing care plans were not individualised and lacked detail about how to care for the individual patient’s needs. There was no structured clinical supervision for nurses. Mental capacity assessments for patients were not always completed when there was a requirement to do so.
  • In surgery, audit was used to review and monitor the effectiveness of care and treatment and collected outcomes were in the expected range when benchmarked nationally. Teams worked together to optimise treatment for patients and staff were competent to provide treatment for patients within the boundaries of their role. Consent was sought in line with national guidance and pain, nutrition and hydration were managed for patients during their stay. However, not all staff had received their annual appraisal.
  • In outpatients, care and treatment was based on national guidance and best practice standards. Additional in-house training was provided to staff to ensure they were competent to carry out their role in different speciality clinics. There was effective multidisciplinary working and staff understood the consent and decision-making requirements under the Mental Capacity Act 2005. However, patient outcome data collected from each clinic was not used effectively to identify where improvements to the service could be made.

St Michael’s Hospital

Our rating of effective stayed the same. We rated it as good because:

  • In medicine, national guidance was used to support the delivery of care and treatment and a small amount of patient outcome data was collected for national comparison. Multidisciplinary working was well established, and staff understood consent and decision-making requirements under the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards. However, there was no formal supervision for staff and monitoring of nutrition was not always effective to identify associated health implications.
  • In surgery, outcomes were collected and monitored through national audit to identify the effectiveness of care and treatment for patients. Staff worked effectively to optimise treatment for patients and staff had the knowledge and skills to carry out their role competently. Enhanced training was provided to give staff the skills to manage patients who may deteriorate post-operatively. Staff supported patients to improve their health and wellbeing to be in an optimal position for surgery. However, not all staff had received their annual appraisal.
  • In outpatients, care and treatment was delivered in line with national guidance. In-house training ensured staff were competent to work across all the different speciality clinics located in the department. There was strong multidisciplinary working across the department. However, compliance against evidence-based guidance was not always audited. No patient outcome data was collected from the various outpatient clinics to identify areas which were working well and areas which required improvements.

Caring

Good

Updated 14 December 2018

Royal Cornwall Hospital

Our rating of caring stayed the same. We rated it as good because:

  • In children and young people’s services, children and their parents were treated with kindness and compassion. Children and young people were encouraged to ask questions and take an active role in their care and treatment and be as independent as possible.
  • In medicine, staff were supportive and compassionate to patients and those close to them. The provision of emotional support was considered and included during staff handovers.
  • In diagnostic imaging, patients were treated with compassion and were actively involved in decision making about their care and treatment. Staff were aware of the emotional impact care and treatment had on individual patients’ wellbeing and worked to support patients emotionally.
  • In the end of life service, patients were positive about the care and treatment they had received. Counselling and psychological support were accessible for patients and the bereavement service provided supportive and compassionate care. Patients were involved with decision making about their care and treatment, staff supported patients emotionally and understood the impact their diagnosis and care and treatment had on their wellbeing.
  • In sexual health services, care was compassionate and empathetic towards patients. Patients were provided with additional emotional support or signposted to the best service to help them. Patients took an active role in making informed choices regarding their care and treatment.
  • In critical care, staff took the time to build relationships with patients and were compassionate towards them. Staff worked hard to alleviate patients’ fears and anxieties and provided emotional support to patients and those close to them. Patients and their relatives were involved in discussions regarding care and treatment and were kept informed about treatment plans.
  • In urgent and emergency care, staff were described as attentive and caring by patients. Staff were compassionate with patients and spoke in a way which both adults and children could understand. This engaged patients and helped to relieve their fears and anxieties. The positive relationships between nurses and ambulance staff demonstrated a positive impact on patient anxiety when attending the department. However, patients’ privacy and dignity were not always respected, particularly during busy periods. Patients regularly waited for staff to respond to requests or concerns and call bells were sounding for prolonged periods of time in the department.
  • In outpatient services, patients were treated with compassion, dignity and respect. We observed positive interactions between patients and staff and patients spoke highly of the care they received. Staff explained information clearly to patients and supported them to make their own decisions. Additional support was provided to patients when staff had to break bad news.
  • In maternity, patients were positive about the care and treatment they received from the department and sensitive and compassionate care was provided to patients who experienced miscarriage or still birth. Women spoke positively of the emotional support they received and felt both they and their partners had received good communication from staff on the unit and had been involved with their care.
  • In surgery, patients were treated with kindness and respect. The multidisciplinary team interacted positively with patients and emotional support was provided. Staff communicated with patients so they could understand their care and treatment. However, some patients felt the amount of communication and updates they received about their care and treatment could be improved.

West Cornwall Hospital

Our rating of caring stayed the same. We rated it as good because:

  • In urgent and emergency care, nurses reassured patients when they were upset or distressed and worked hard to reduce patients’ anxieties before, during and after treatment. The department had scored better than the England average on the NHS Friends and Family Test between July 2017 and July 2018.
  • In medicine, staff interacted with patients in a kind and compassionate way and respected their personal, cultural and religious needs. Staff supported patients emotionally to relieve their anxieties and patients were supported to understand their care and treatment, including the risks and benefits.
  • In surgery, people were treated with kindness and respect and patients were positive about the care and treatment they received. Staff interacted positively with patients and provided emotional support when required. Staff made sure they communicated with patients in a way they could understand. However, there was limited capacity for single sex care in the treatment centre recovery area.
  • In outpatients, there was a patient-centred culture and patients were treated compassionately. Staff explained information to patients in a way they could understand and gave them opportunities to ask questions and be involved in their care and treatment.

St Michael’s Hospital

Our rating of caring went down. We rated it as good because:

  • Overall, staff remained caring. However, we did not see evidence to demonstrate this was ‘above and beyond’.
  • In medicine, patients were treated with compassion and emotionally supported by staff. Patients were involved in decision making processes regarding their care and treatment and staff kept patients well informed.
  • In surgery, patients were positive about their experiences on the surgical wards and interactions between staff and patients were positive. Staff supported patients emotionally and communicated with patients in a way they could understand.
  • In outpatients, a patient-centred culture ensured patients were treated compassionately and respected. Staff understood the importance of involving patients in their care and treatment, ensured they communicated in ways patients could understand and encouraged them to ask questions.

Responsive

Requires improvement

Updated 14 December 2018

Royal Cornwall Hospital

Our rating of responsive improved. We rated it as requires improvement because:

  • In children and young people’s services, services had been designed to meet the needs of children and young people. The service reflected the needs of children and young people in the local population and systems and processes ensured each child’s individual needs were met.
  • In medicine, systems to enable patient flow through the hospital were not always effective due to demand outweighing capacity. Bed management plans had not been fully confirmed despite winter pressures already being evident. Capacity issues in the service were having an impact on the surgical division. However, individual patient need was assessed on admission and there were systems to ensure patients who required additional support received this.
  • In diagnostic imaging, patients were given a choice as to where and when they accessed care and treatment. The service met the needs of the individual patients accessing it and those of the local population. Waiting times were well-managed and the clear majority of patients were seen within national standards.
  • In end of life care, the service was unable to meet the demands of the local population due to the lack of facilities, space and medical cover. Patients were not always supported to make informed choices about their care. Facilities were not available for patients of different religions and there was no evidence of learning from complaints or how this information was used to improve services. However, systems and processes were followed to determine at what point care and treatment was withdrawn. The service had a good relationship with the local hospice to ensure patients who had identified this as their preferred place of care could assess this in a timely way.
  • In sexual health, patients were not provided with information about how they could make a complaint. However, complaints received by the services were listened and responded to. Services were personalised to the individual and planned and delivered to meet the needs of the local population. Patients could access treatment in a timely way and they were provided with a choice of locations and times at which they could access care and treatment.
  • In critical care, patient admissions to the unit were sometimes delayed due to other services not consistently predicting post-surgery critical care needs for patients. The resolution of the one complaint received by the unit had not met with the trust’s timeframes. However, the service was looking to develop to meet the unmet needs of patients. Performance was better than the national average for numbers of non-clinical transfers, and non-delayed out-of-hours discharges from the wards. Patients’ individual needs were met, for example patients with sensory loss and patients with complex emotional and mental health problems.
  • In urgent and emergency care, the facilities available to the department were not always appropriate for the needs of the service being delivered. Demand frequently impacted on the availability of clinical space to assess and treat patients. Systems to promote patient flow were not always effective and the department consistently failed to meet Department of Health standards for admitting or discharging patients within four hours. During busy periods patients had to wait in the corridor, which did not ensure their comfort or privacy. However, there were pathways to stream patients into primary care services and access to support for adults and children with mental health problems was available. The number of patients leaving the department before being assessed and receiving treatment was better than the England average and complaints were taken seriously, investigated and learning shared with all staff.
  • In outpatient services, referral to treatment (RTT) was variable and still not meeting national standards. Facilities were not always appropriate for the services which were being delivered. Patient confidentiality was not always maintained, and the number of car parking bays did not meet demand. Patients did not always receive communication about follow up appointments. The trust’s plan to run additional clinics to reduce speciality waiting lists was not always possible in practice. However, patients were given a choice about the location they could access care and treatment. There were systems and processes to notify staff if patients required additional support and staff had access to a mental health and learning disability team who could provide additional support and advice if required. The cancer services team had systems and processes to ensure patients were not at risk of breaching cancer waiting times and there had been an increase in the number of clinics to improve patient flow and reduce waiting time into the service.
  • In maternity, staff were not familiar with the abduction policy. Learning and actions taken following complaints was not always documented clearly and the investigation process was not compliant with timeframes set out in the trust’s policy. However, maternity services delivered reflected the needs of the local population and there were systems to ensure the flow of patients through the department. The service was designed to meet women’s individual needs. There were processes to support women with mental health needs and a bereavement suite which could be used by women and their relatives who had experienced a loss.
  • In surgery, winter pressures had impacted on the delivery of surgical services meaning a high number of elective patients had been cancelled. There were a high number of patients who had waited longer than 52 weeks for their surgery in some specialities and medical outliers on surgical wards impacted the flow of patients within the hospital. Escalation facilities on Newlyn Unit were not an appropriate environment for patients due to the lack of hygiene facilities and bays were not dementia friendly to support the needs of patients attending the department with dementia. However, changes were being made to the delivery of the orthopaedic service to benefit the local population and staff were aware of understanding patients individual needs to ensure they received personalised care. There were systems and processes to monitor theatre efficiency, despite the still being unused theatre sessions and emergency patients were being seen in line with key performance indicators.

West Cornwall Hospital

Our rating of responsive stayed the same. We rated it as good because:

  • In urgent and emergency care, complaints were investigated thoroughly, and lessons were shared with staff. Patients had access to mental health services and additional information and support to ensure their individual needs were met. However, the emergency department’s facilities were not always appropriate to deliver the care and treatment required to patients.
  • In medicine, services were planned and delivered to meet the needs of the local population and patients could access the service when they needed it. Discharge planning was timely and waiting times to admit, treat and discharge patients were in line with national averages. However, some patients remained in hospital even when they were medically fit for discharge due to internal and external factors impacting on their timely discharge.
  • In surgery, care was individualised and responsive to patients’ needs. Patients had their needs assess and planned for as part of the pre-operative assessment stage. Services were accessible and coordinated to account for the needs of individuals. The average length of stay for patients in the department was lower compared to the England average. However, there were a high number of patients waiting 52 weeks or longer for urology surgery and complaints were not always responded to in a timely way.
  • In outpatients, the service reflected the needs of the local population and brought care closer to home for patients. Individual patient need was met, and alternative arrangements were made if required. The ‘did not attend’ rate was better than the England average for the department.

St Michael’s Hospital

Our rating of responsive stayed the same. We rated it as good because:

  • In medicine, services met the rehabilitation needs of the local population. Access to the service was timely and the majority of waiting times for treatment and discharge were in line with good practice. However, some medically fit patients had their discharge delayed due to waits for suitable accommodation.
  • In surgery, individualised care and treatment was provided for patients. This was assessed and planned as part of the pre-operative assessment. Services were accessible to meet the needs of individual patients and those in vulnerable circumstances. Action had been taken to improve patient access to services and changes to the infrastructure of St Michael’s Hospital were being made to support this. There were good processes for monitoring theatre efficiency. However, patients did not always have access to care and treatment in a timely way. This was due to patients waiting 52 weeks or longer for their surgery in trauma and orthopaedics.
  • In outpatients, the service provided brought care closer to patients in their community. Reasonable adjustments were made to meet the individual needs of patients attending outpatient clinics and the ‘did not attend’ rate was better than the England average.

Well-led

Inadequate

Updated 14 December 2018

Royal Cornwall Hospital

Our rating of well-led stayed the same. We rated it as inadequate because:

  • In children and young people’s services, leaders had the skills and experience to carry out their role. Risks within the service were understood and managed and the governance and culture were used to drive and improve the delivery of high quality care. There was a high level of staff satisfaction due to them being well respected and valued members of the team.
  • In medicine, leadership from ward to board was not always evident. There had been much change with board leadership and staff were tired of the instability. Staff felt their pride in the work they carried out was undermined by the higher-level management instability. Staff and managers did not feel empowered to make changes and did not feel listened to by the board. There was no clear direction for staff to enable them to effectively manage patients with mental health problems. However, leadership at ward and unit level was mostly strong and staff were familiar with the local vision and strategy. Assurance systems ensured services were monitored to enable improvements to be made to services. Realtime data was available around performance, safety and quality to identify risk and areas requiring service improvement.
  • In diagnostic imaging, leadership was inclusive and effective at all levels. The service was committed to system-wide collaboration, and the strategy and objectives, while challenging, were achievable. Staff were proud to work for the organisation and there was a positive working culture. There was a common focus on improving the quality and sustainability of care and people’s experiences. Leaders strived to deliver and motivate staff. Performance was regularly reviewed and there was continual learning to ensure staff had the skills to use systems and processes effectively.
  • In end of life services, the leadership was not adequate to support staff to care for patients in the last year of their life. The mortuary services lacked investment and we were not assured there was sufficient oversight or management of the issues faced by the department. The end of life risk register did not provide assurance that risks were being managed and mitigated and there was no systematic programme of audit to monitor quality safety or performance of the service and to identify areas which required improvements. There was also little engagement with the public to gain feedback to drive service improvement. However, staff felt the leadership was visible and that leaders worked collaboratively with them. Staff were encouraged to develop their skills and the specialist palliative end of life care team were highly regarded among staff for their support and guidance.
  • In sexual health, the leadership ensured the delivery of high quality care and treatment and there were clear responsibilities, roles and systems of accountability which supported good governance and management. Risk was effectively identified and managed, and staff felt respected and valued. Patients, staff and external partners were engaged and involved to improve the quality of the service provided.
  • In critical care, not all risks affecting the delivery of safe care were identified, monitored and managed effectively. However, the leadership team was held in high regard by the staff and divisional management. Leaders were visible and had the knowledge and skills to lead the service. There were effective governance structures to support the delivery of good quality, sustainable services and reliable pathways to escalate concerns and to provide accountability for performance. Leaders understood the challenges to quality in the service and identified actions to address these. A programme of audit helped leaders to manage performance of the service. The culture centred on the needs of patients and staff wellbeing was highly prioritised. Feedback from patients was encouraged to drive service improvements.
  • In urgent and emergency care, leaders understood the challenges to quality and sustainability within the department and were enthusiastic and energetic about the actions identified to address them. Staff felt the addition of two new members of staff and a regular governance meeting had improved the culture of the department and staff were motivated to play their role in the governance of the unit. There was a culture of strong support from senior doctors in the department. The governance structure ensured accountability for the safe delivery of the service and there was oversight and management of risk within the department. The department worked well to encourage learning, continuous improvement and innovation through quality improvement projects.
  • In outpatient services, not all leaders had the skills, knowledge, experience and integrity they needed to lead their departments. There was a variable level of understanding of both the acute processes for governance and how they integrated into the wider health economy. Staff were not engaged with the governance of the service. Some nursing staff spoke unfavourably of senior leadership and their style of management and a culture of intimidation and fear remained in several outpatient departments. Leaders were not always visible and approachable, and some staff felt disengaged from the board and felt they had to manage issues alone. However, there was improved oversight and management of risks to patients. Some teams worked collaboratively, resolved conflicts quickly and constructively and shared responsibility to deliver good quality of care. There was an improving governance framework to support the delivery of quality patient care and there were procedures to maintain clinical governance and risk management. Governance procedures to monitor waiting lists, waiting times, frequency of cancelled clinics and RTT timelines for patients were improving but still had room to progress. The outpatient transformation programme had been re-started to better address the challenges faced by the departments.
  • In maternity, the impact of changes across the senior leadership team were being felt and not all staff felt leaders were effective. There were mixed reports regarding the culture in the department with regards to communication and leadership styles. Governance processes also needed to be embedded within the department to ensure a safe and high-quality service was delivered. However, improvements had been made to how risks were identified, monitored and managed and senior staff demonstrated they had the knowledge, skill and experience to carry out their role. Leaders of the department felt supported by the trust board and this was demonstrated by an agreement at board level to increase the numbers of governance and risk-related midwifery posts. A recently introduced ‘improve well’ smartphone application had been introduced to the department to enable staff to put forwards ideas for service improvement.
  • In surgery, governance processes were still in the early stages and needed to embed. There was no focus on sepsis as part of surgical governance. Management and oversight of the risk register was unclear and did not provide assurance around effective risk management. There was a gap in medical leadership due to longstanding clinical director vacancies. However, leaders for the surgical department were clear about divisional priorities and were committed to ensuring sustainable improvements were made. Staff were proud to work for the trust and felt engaged and involved with surgical governance appropriate to their level and role.

West Cornwall Hospital

Our rating of well-led stayed the same. We rated it as good because:

  • In urgent and emergency care, leadership of the services was strong, and the risks, quality and sustainability of the service were understood. There were supportive relationships between staff and an open and transparent approach when things went wrong.
  • In medicine, the leadership team had the skills and qualifications to carry out their role effectively. There was a positive culture where staff felt valued and supported and the staff were aware of the trust’s vision. A systematic approach to governance was used to improve the quality of services and develop standards of care where required. The department liaised well with patients, staff, the public and local organisations to provide a streamlined and well-managed service for patients. There was a drive to improve the service by learning from when things went wrong, and the service was due to trial a new initiative to help improve delayed transfers of care.
  • In surgery, leaders were clear about the priorities for the division and the need to ensure sustainable improvements. Staff felt supported by leaders and there was a positive culture within the service. However, it was unclear whether leaders had the capacity and capability to deliver and drive high quality care. Management posts continued to be covered on an interim basis and staff felt senior leaders were not visible. Staff did not feel engaged or involved with the developments within the service. Management and oversight of risk was unclear and reporting of incidents and management of risk relating to post-operative consultant cover needed improving.
  • In outpatients, the governance framework ensured the delivery of good quality care and there were processes to identify and manage risks effectively. Staff spoke highly of the culture and the team. However, staff felt there was a lack of integration between the department and the outpatient department at the main Royal Cornwall Hospital site.

St Michael’s Hospital

Our rating of well-led stayed the same. We rated it as good because:

  • In medicine, staff were supported to carry out their role and felt supported by their managers. Managers were capable of leading the service and had recognised accreditations and qualifications to ensure their competence in their leadership role. Governance processes were used to improve the quality of services and risks to the service were managed appropriately. The unit was involved in trust-wide working groups to develop a strategy for patients with spinal injuries and were proud of how proactive they were to improve services.
  • In surgery, leaders were visible and approachable and had the capacity and capability to deliver high quality care. Leaders were clear about the future priorities and the development of surgical services at St Michael’s Hospital. Quality and performance was monitored to identify areas for improvement. Staff felt engaged with the governance of the surgical division at an appropriate level for their role. However, the oversight and management of risk within the service was unclear.
  • In outpatients, systems and processes to identify and manage risk were understood and there was a programme of audit to monitor quality and compliance with systems and processes in the department. Staff spoke highly of their local manager and felt there was a positive working culture in the department. However, there was a lack of oversight of safety, quality and performance from senior managers. Some staff felt they worked in silo at the hospital with limited involvement with the wider organisation.
Checks on specific services

Community health services for adults

Good

Updated 14 December 2018

Our rating of this service stayed the same. We rated it as good because:

  • Safe, effective, caring, responsive and well-led all remained the same and were rated as good.
  • The service had robust procedures in place to safeguard adults and children against abuse and staff were trained to deliver sexual health services to adults and children.
  • The environment, maintenance and use of facilities and premises kept patients who visited the service safe. Medicines were stored, administered and dispensed safely.
  • Risks to patients were assessed and their safety monitored and managed so that patients and staff were safe. The service ensured action was taken and learning taken when things went wrong.
  • The service carried out internal and external audits to ensure the care and treatment was in line with recognised legislation and best practice. The service collected appropriate data to ensure that patients received a good outcome.
  • Staff worked well within and across the trust and with external organisations to deliver effective care and treatment.
  • The service ensured consent to care and treatment was always sought in line with legislation and guidance.
  • Patients received a caring, compassionate and empathetic service and were able to make informed choices about their care and treatment. Staff provided or signposted patients to appropriate emotional support.
  • Patients were able to access care and treatment in a timely way in a variety of locations.
  • The leadership and management of the service ensured high quality care and treatment was delivered. There were clear responsibilities, roles and systems of accountability which supported good governance and management.
  • The strategy and forward planning for the development of the sexual health service was under review at the time of our inspection.

However:

  • Staff were not fully protected from the risk of infection as they did not use appropriate equipment or cleaning materials when cleaning spillages of bodily fluids.
  • Staff did not always have access to supplies of single use equipment when required.
  • Information maintained in patient records was not always an accurate reflection of the conversations, advice and treatment provided.
  • At times patients could not receive all required care and treatment at one clinic. This was due to not all nursing staff being trained to provide contraception and genitourinary care, despite this being an integrated service.