Royal Cornwall Hospital

Updated 27 February 2023

Pages 1 and 2 of this report relate to the hospital and the ratings of that location, from page 3 the ratings and information relate to maternity services based at Royal Cornwall Hospital.

We inspected maternity services at Royal Cornwall Hospital as part of our national maternity inspection programme. The programme aims to give an up-to-date view of hospital maternity care across the country and help us understand what is working well to support learning and improvement at a local and national level.

We will publish a report of our overall findings when we have completed the national inspection programme.

The service provides maternity care for women across Cornwall and the Isles of Scilly, approximately 3800 babies are born at the trust each year. The maternity unit contained an antenatal ward, maternity day assessment unit and triage, delivery suite, co-located midwife-led birth centre, and postnatal ward, where transitional care was provided for babies with more complex needs. The delivery suite was located on the first floor and comprised of 6 high risk labour rooms, 4 high-dependency rooms and 2 theatres. There was a bereavement suite located on the ground floor.

We carried out a short notice announced focused inspection of the maternity service, looking only at the safe and well-led key questions.

Our rating of this location did not change at this inspection. The previous rating of requires improvement remains.

We also inspected two other maternity services locations run by Royal Cornwall Hospitals NHS Trust. Our reports are here:

Penrice Birth Centre: https://www.cqc.org.uk/location/REF81

Helston Birth Centre: https://www.cqc.org.uk/location/REFZ1

How we carried out the inspection

We inspected the service using a site visit where we observed care on the wards, spoke with staff, managers and service users, and attended meetings. We interviewed leaders and members of the executive team remotely after the site visit. We looked at online feedback from staff and service users submitted via the CQC enquiries process. The service submitted data and evidence of their performance after the inspection which was analysed and reviewed for use in the report.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.

Updated 26 February 2020

• The service did not have enough medical staff in all areas and staff mandatory training was not fully completed.
• Not all staff were fully aware of the rights of patients under the Mental Health Act 1983.
• Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not all in line with national standards.

However:

• The service had enough staff to care for patients and keep them safe. Staff understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed most risks to patients, acted on them and kept good care records. The service continued to recruit staff with the right qualifications, skills, training and experience to keep patients safe.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Some services were available seven days a week.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service and received the care and treatment but sometimes experienced delays.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

Updated 14 December 2018

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

• Staff adhered to infection prevention and control policies and protocols.
• The units were clean, organised and suitable for children and young people.
• Incidents were reported and acted upon with feedback and learning provided to staff.
• Treatment and care were effective and delivered in accordance with best practice and recognised national guidelines.
• There was good multidisciplinary team working within the service and with other agencies.
• Children and young people were at the centre of the service and the priority for staff.
• Children, young people and their families were respected and valued as individuals.
• Care was delivered in a compassionate manner. Parents spoke highly of the approach and commitment of the staff who provided a service to their children.
• Children received excellent care from dedicated, caring and well-trained staff who were skilled in working and communicating with children, young people and their families.
• Staff understood the individual needs of children, young people and their families and designed and delivered services to meet them.
• There were clear lines of local management in place and structures for managing governance and measuring quality. The leadership and culture of the service drove improvement and the delivery of high-quality individual care.
• All staff were committed to children, young people and their families and to their colleagues. There were high levels of staff satisfaction with staff saying they were proud of the units as a place to work. They spoke highly of the culture and levels of engagement from managers.
• Innovation, high performance and the high quality of care were encouraged and acknowledged.

However:

• There was poor compliance with mandatory training levels.
• Safeguarding training compliance remained a challenge and required continued improvement. We were not assured there was a consistency of understanding of processes and policies at the named lead doctor level.
• The location of the high dependency unit and the nursing observation arrangements remained a risk to children who were not visible to the main nursing station.
• Some staff had little training in mental health beyond their mandatory training. There was no further formal training to manage children and young people with complex mental health conditions who were in a crisis. Some staff said they did not feel adequately equipped to deal with these patients.
• Risk assessment and decision-making processes for children and young people with mental health needs were not always documented and some staff did not understand the requirements.
• There was a lack of coordination between patient record systems and this hampered delivery of effective care and treatment.

Updated 14 December 2018

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

• Staff followed best practice with regards to the prevention and control of infection. In general, there were good systems for staff to keep people safe and safeguarded from abuse. Most risks to patients were assessed and their safety was monitored. Staff had all the information they needed to deliver safe care and treatment. Staffing levels for nurses and doctors were provided at safe levels. Staff managed medicines safely. The service had a good track record on safety. When things went wrong, the team shared learning from investigations and made improvements.
• In general, the team provided care based on the best available evidence. The service monitored care and treatment using data from internal and external audits. Patient outcomes were mostly good compared to other services. Staff had the skills, knowledge and experience to deliver effective care. They were competent and had good opportunities for development. Staff worked well together and involved other services and organisations to deliver effective care and treatment.
• Staff were consistently caring and treated patients with kindness, dignity, respect and compassion. Patients were given the emotional support they needed. Patients and relatives felt involved in treatment decisions.
• In general, patients received personalised care responsive to their needs. Patients could usually access treatment in a timely way. Staff ensured the individual needs of complex patients were met. Consent to care and treatment was always sought in line with legislation and guidance. Patients complaints and concerns were listened to and used to improve quality of care.
• The local leadership team had the capacity and capability to deliver high quality sustainable care. Leaders understood the challenges to care and there was a strategy for improvement. There were clear roles, responsibilities and systems of accountability to support good governance and management. The culture of the unit was focussed on patient safety. Staff worked together to deliver good quality care.

However:

• Some safety systems were not well monitored, such as mandatory training compliance. Not all risks to patient safety were assessed and well managed, such as the routine maintenance of medical equipment and the use of bed rails for patients.
• Not all necessary staff were involved in assessing, planning and delivering care and treatment. There were gaps in the multidisciplinary team which reduced patients’ access to rehabilitation and specialist nutritional advice.
• Not all care was responsive to patients’ needs. Patients sometimes were not admitted to the unit or discharged at the right time due to the demand for beds on the unit and the wider hospital. Complaints were not always handled in a timely way.

Updated 14 December 2018

We previously inspected diagnostic imaging jointly with outpatients, so we cannot compare our new ratings directly with previous ratings.

We rated this service as outstanding because:

• People’s needs were met through the way services were organised and delivered. Patients could access the service when it suited them, and staff ensured the individual needs of complex patients were met. Consent to care and treatment was always sought in line with legislation and guidance. Patients’ complaints and concerns were listened to and used to improve quality of care.
• The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care. Risk was understood and managed and there was a proactive and collaborative approach to reviewing and improving quality and safety.
• People were protected by a strong comprehensive safety system, and a focus on openness, transparency and learning when things go wrong. There were safe levels of staff who were trained to provide safe care. Patient records, infection control practices, systems, and staff recognition and management of risks to patients assured us of a safe service.
• The team provided care based on the best available evidence. The service monitored care using data from internal audits. Staff had the skills, knowledge and experience to deliver an effective service. They were competent and had good opportunities for development. Staff worked well together and involved other services to support them in providing effective care.
• Staff were consistently caring and treated patients with kindness, dignity, respect and compassion. Staff made every effort to minimise any distress for patients.

However:

• Some parts of the estate were not suitable for patient care and needed updating.

Updated 26 February 2020

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients and acted on them and managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service. Staff were working towards keeping good care records using a process of audit and improvement programmes.
• We saw staff provided care and treatment which was suitable for patients at the end of their life. Staff gave patients enough to eat and drink and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it.
• Staff had the skills, knowledge and experience to lead the service. Leaders ran services well, were developing information systems and supported staff to develop their skills. Specialist end of life staff understood the service’s vision and values, and how to apply them in their work. Most staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

• Documentation did not always provide assurances that suitable, individualised care was provided for patients at the end of their life.

Updated 27 February 2023

Updated 26 February 2020

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse and managed safety well. Staff assessed risks to patients and acted on them. Staff completed comprehensive records and managed medicines well. Staff kept themselves and patient equipment clean. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
• Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information.
• Staff treated patients with compassion and kindness. Staff listened to patients and their carers and helped them understand their conditions. They provided emotional support to patients, families and carers.
• The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. Some patients could access the service when they needed it and did not have to wait too long for treatment.
• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

• Not all records in cardiology were stored securely. Staff were not always aware of learning from incidents in other clinics. There was a risk of cross infection because staff did not follow trust policy for cleaning the play equipment in outpatient clinics. Staff did not always complete safety checks on emergency equipment. Essential fire safety equipment was not available or was out of date.
• Not all key services were available seven days a week.
• Not all staff took care to maintain patient privacy and dignity in outpatient clinics.
• There were delays for treatment in some specialties. Patients waited longer than expected for their complaints to be investigated and resolved.

Updated 12 May 2016

We judged sexual health services as good overall because:

• Patients were protected from avoidable harm. Openness and transparency about safety was encouraged. Staff understood their responsibilities and were encouraged to report incidents and near misses.

• Safeguarding vulnerable adults, children and young people was managed proactively and effectively by staff trained to recognise early signs of abuse.

• Staff were employed in sufficient numbers to run the service effectively. A daily briefing ensured all staff were aware of any potential risks or concerns regarding the operation of the clinics.

• Patients’ care and treatment was planned and delivered in line with current national recommendations and legislation.

• The service participated in local and national audits and used the outcomes to inform,develop and improve care pathways and patients’ care and treatment.

• Staff worked well together as part of a multidisciplinary team to coordinate and deliver patients’ care and treatment effectively.

• Patients were provided with sufficient information regarding their care and treatment needs to be able to give consent prior to procedures or treatments being carried out.

• The sexual health service provided a caring service to patients.

• The privacy, dignity and confidentiality of patients’ was protected and they were treated respectfully by the staff.

• Patients we spoke with provided us with positive feedback regarding their experience of using the sexual health service.

• The service was planned and delivered in various locations and at different times of day times, in order to meet the needs of the local population.

• The facilities and premises we visited were fit for purpose.

• The booking system for appointments was easy to use and supported patients to attend an appropriate clinic to meet their care and treatment needs.

• Patients were advised on how to make a complaint, were listened and responded to and action was taken in response to complaints and suggestions received.

• Staff were aware of a clear vision and strategy for the service in that the aim was to become a fully integrated sexual health service. However, this was dependent on future commissioning arrangements which lay with an external organisation.

• There were effective governance systems within the service and the wider trust. The service was able to identify current and future risks and the actions required to address these issues.

Updated 26 February 2020

• The service did not have enough staff to care for patients and keep them safe. Nursing staffing in the surgical division remained a challenge and had been for some time. The service provided mandatory training in key skills, however, we were not assured all staff were fully compliant with their training, particularly medical staff. Staff were working towards keeping good care records using a process of audit and improvement programmes.
• The management of medicines could be improved to ensure best practice. Not all controlled drug records were completed in accordance with trust policy.
• The service did not always have suitable premises. On Trauma 1 ward, we found a room which was used for both storage of equipment and as a patient waiting area, because of a lack of storage area. There was not enough space in the St Mawes lounge, we observed three patients having their observations taken in the waiting area, with one patient standing up to have their observations done as no chair was available. However, the surgical admissions lounge was used as an escalation area and not adequately staffed with appropriately trained nurses. Surgical nurses were not trained to look after the acutely unwell medical patients on the surgical admissions lounge.
• The service did not always plan care to meet the needs of local people or take account of patients’ individual needs. Medical outliers were regularly in the surgical bed space and this impacted on patient flow throughout the hospital. At the time of our inspection there were 44 medical outliers on surgical wards including the surgical admission lounge and Wheal Coates. On one day of the inspection we saw 16 medical outliers (out of a total of 18 surgical inpatient beds and four day-case beds).
• Not all staff understood the service’s vision and values, and how to apply them in their work. In some areas we found that this had a negative effect on morale and on staff retention.

However:

• Staff understood how to protect patients from abuse. Staff we spoke with understood the trust’s safeguarding policy and processes and were clear about their responsibilities. Staff had access to a safeguarding lead nurse and told us they gave good support.  
• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.  Staff worked well together for the benefit of patients, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week. 
• ​Leaders ran services well using reliable information systems and supported staff to develop their skills. The leadership team felt supported by the executive team to drive progress and make improvements. They had a good awareness of risks and the challenges to the service. We found the leaders highly energised and enthusiastic about shaping the future of surgical services in Cornwall, focusing on patient experience.

Updated 26 February 2020

• Not all staff had completed or refreshed mandatory and safeguarding training at the required level for their role. Safety checklists were being used although recording of ongoing monitoring was not as frequent as it should have been.
• The mental health assessment room did not meet required standards for patient safety.
• The service did not meet the Department of Health’s standard for patients to be admitted, transferred or discharged within four hours of arrival, although it had been mostly better than the England average. Patients were not always assessed promptly and within 15 minutes of arrival in the emergency department. The percentage of patients waiting more than four hours from decision to admit to admission was also high.
• The response time for complaints was not in line with trust policy and the average was more than twice the required time limit.
• Some emergency equipment was not consistently checked.
• The resuscitation room was too small to accommodate current demand and on occasion, some patients had to be transferred and treated elsewhere. However, there was a plan to upgrade this area.
• Some staff did not have all the skills or tools to support them to communicate with people with sensory impairment, dementia or learning difficulty.

However:

• The department was visibly clean, and most medicines were managed well.
• There were enough staff with the right qualifications, skills and experience who were supported to develop.
• Leaders understood the challenges to quality and sustainability.
• Patient feedback was good while we were on site, though survey results showed some deterioration over the past nine months.
• Nursing staff vacancy rates were reducing.
• There was a structure of governance, which provided accountability and quality assurance.