Royal Cornwall Hospitals NHS Trust

The Royal Cornwall Hospitals NHS Trust is the principal provider of acute care services in the county of Cornwall. The trust is not a Foundation Trust and performance is monitored by NHS Improvement (NHSI). The trust serves a population of around 532,273 people, a figure that can be doubled by holidaymakers during the busiest times of the year.

CQC has previously carried out two comprehensive inspections at Royal Cornwall Hospital NHS Trust. The first being in January 2014 when the Trust was rated as requires improvement. In June 2015 we carried out a follow up to the first inspection and found the trust had not made sufficient progress in all areas and a second comprehensive inspection was initiated, which we carried out in January 2016. At that time, the trust was rated as requires improvement overall. We rated safe, effective, responsive and well led as requires improvement and caring as good.

A further unannounced focused inspection was conducted on 4 and 5 January 2017. We reviewed end of life and urgent care services to review progress against the inadequate ratings for those core services as identified on the previous inspection in January 2016. We reviewed medicine services as continued intelligence had raised concerns with regards to quality and safety of the service. We also looked at the governance and risk management support for the services we inspected. We rated urgent care services as requires improvement, end of life care services and medicine services as inadequate. We did not rate the trust overall as a result of this inspection.

This inspection took place between 4 and 7 July 2017, and was a focused announced inspection. We undertook a further unannounced inspection on 17 and 18 July 2017. We revisited those core services that we had not inspected in January 2017, with the exception of sexual health. We did not revisit medicine or urgent care services, but we did revisit the safe and well led domains in end of life care. We also inspected governance and risk management support for those services we inspected.

This inspection also covered the following sites:

• St Michael’s Hospital (for surgery and outpatients and diagnostic imaging)
• West Cornwall Hospital (for surgery and outpatients and diagnostic imaging)
• Penrice Birthing Centre (for maternity)

We had serious concerns that systems to assess, monitor, and mitigate risks to patients receiving care and treatment were not operating effectively. We also had concerns that governance systems and processes were not operating effectively. We served the trust with a Section 29A warning notice on 29 August 2017. The notice required the trust to make significant improvements by 30 November 2017. There were, however, a number of areas where the trust were required to give evidence of immediate action to ensure risks were being identified and managed in the interim. These included processes being in place for identifying and managing deteriorating women in maternity and systems and processes being in place to monitor and manage non-admitted cardiology and ophthalmology patients. Additionally the trust were required to provide evidence that there were two paediatric trained staff on duty at all times in the paediatric emergency department and that a risk assessment had been completed for paediatric staffing in the emergency department and obstetric theatres.

We rated Royal Cornwall Hospitals NHS Trust as inadequate overall. Surgery, maternity and gynaecology, end of life and outpatient services were rated as inadequate and critical care and children and young people’s services were rated as good. These ratings have been aggregated with the findings from the core services we inspected in January 2017.

There are separate location reports for each of the above sites, although any overarching findings from those location reports are included in this report as relevant.

Key findings:

Safe:

• We rated safety as inadequate overall. Surgery, maternity and gynaecology and outpatients and diagnostic imaging were rated as inadequate, services for children and young people and end of life care were rated as requires improvement, and critical care and St Michael’s Hospital were rated as good. Safety at West Cornwall Hospital and Penrice Birthing Centre were rated as requires improvement.
• When concerns were raised in surgery or things went wrong, the approach to reviewing and investigating causes was unsatisfactory or too slow. There was little evidence of learning from events or action taken to improve safety. When something went wrong, patients or those close to them were not always told and did not always receive an apology.
• The systems and processes for identifying, grading and managing incidents were not effective and were not conducted in a timely manner.
• The threshold for incident reporting was high so not all incidents were reported. This was true in both maternity and gynaecology.
• There was no evidence of oversight or scrutiny of incidents that related to end of life care at the trust. Therefore, there was no evidence of learning or changes in practice that had resulted from such incidents.
• There was not a clear incident reporting process for staff to follow in the event of a delayed fast track discharge in end of life care. There was also no evidence of executive oversight of the problem caused by inconsistent reporting, and a lack of anyone with clear responsibility for the issue.
• Incidents were not always reported promptly for outpatients. This impacted investigation timeliness and delayed potential learning opportunities.
• Safety was not a sufficient priority. There was limited measurement and monitoring of safety performance. There were significant numbers of serious incidents or never events in surgery.
• Staff did not always assess, monitor or manage risks to patients. Some opportunities to prevent or minimise harm were missed in surgery.
• Changes were made to surgical services without due regard for the impact on patient safety. There were inadequate plans to assess and manage risks associated with anticipated future events or emergencies in both surgery and maternity.
• Not all patients with severe sepsis had timely access to intravenous antibiotics.
• Guidance for midwives in critical areas such as escalation of deteriorating women was sometimes conflicting. For example, the escalation instructions on maternal early warning score (MEOWS) charts did not align with the guidance on the policy on managing the severely ill obstetric woman.
• There was no dedicated high dependency area for deteriorating women and no process to ensure that that there was always a nurse or midwife on duty with the necessary competencies to manage high dependency women. The service did not monitor the number of women needing this level of care.
• One theatre on the delivery suite had dedicated staffing. The contingency plans for using the second theatre in an adjoining room were not clearly understood and an additional theatre team was not readily available, which could result in delays and potentially a risk to women and babies. The process for opening and staffing the second theatre were not well communicated and practiced.
• Risk assessment was poor at all levels. We saw inconsistent use of maternal early warning score (MEOWS) charts and partograms (a composite graphical record of key maternal and foetal data during labour) meant there was a risk that staff might miss signs of deterioration in a woman; on the postnatal ward emergency medicines had been taken off the ward because of the heat, without assessing the risk of doing this, should there be an emergency. Some risks such as staffing were not on the corporate risk register.
• Other risks had not been identified or monitored, for example skills required of community midwives lone working in remote locations, suitability of the second obstetric theatre and staffing levels in the emergency paediatric department.
• The delivery suite capacity was insufficient for the number of women giving birth with the result that women laboured on the antenatal ward several times a month, often without one-to -one care from a midwife for the whole of their established labour.
• More women than the agreed number were being induced on some days, and these inductions were not planned to take into account activity or capacity on the delivery suite to ensure that induction was safe.
• Ophthalmology and cardiology follow up appointment waiting lists were too long and patients were coming to harm through delays in treatment. The process for risk assessment was not sufficient to adequately protect patients from harm and there were no clear action plans to manage and reduce the backlogs.
• There was a significant backlog in reviewing some cardiology 24 hour tapes which put patients at risk.
• Patient identifiable information, including the results of pregnancy tests, was found in two unlocked sluice rooms on a surgical ward. Other patient identifiable information was found unattended and accessible to the public.
• The different records about women in the maternity service were not linked. Women’s hand held records and hospital records, and safeguarding information were held on a separate database which made it difficult for midwives to have an overview of women’s health and social history.
• There was not sufficient information or audit for the trust to be assured of the effective use of end of life care documentation. Audits did not address the quality or completeness with which the documentation was completed or understood, and did not contain any follow up action plans to address the issues raised.
• Paper based patient records, including test results in outpatients were not stored securely.
• Due to a different system in operation, the critical care unit did not use the electronic prescription charts used throughout the rest of the hospital. There had been some safety issues for patients discharged from the unit due to staff not always following the correct handover processes for medicines for the patient prior to their discharge.
• Not all staff in the surgery division had received effective mandatory training in the safety systems, processes and practices.
• Multiple mandatory training modules had not been completed by medical staff and therefore did not meet trust targets.
• We could not be assured that community midwives had up to date skills. They did not have training to cannulate women, and not all were up to date with neonatal life support training. We could not be assured that community midwives had the necessary equipment to manage obstetric or neonatal emergencies in the community in the event that the ambulance was delayed.
• Midwives required training and competency assessments in providing epidural top ups, in and in care of high dependency women. The overall 85% target set for training completion in maternity was lower than the trust target for training completion of 95%.
• Completion of some mandatory training was also below trust target for staff in children and young people’s services and required improvement.
• Although safeguarding training compliance had improved in services for children and young people it remained a challenge and required continued improvement.
• At West Cornwall Hospital, we were unable to evidence the completion of simulation scenarios to respond to patient emergencies.
• We could not be assured that community midwives had up-to-date skills. They did not have training to cannulate women and did not have the necessary equipment to manage obstetric or neonatal emergencies in the community in the event that the ambulance was delayed.
• The emergency resuscitation team did not always have immediate access to a member of staff who was able to deal with difficult airway intubation in surgery.
• The service did not always ensure there was adherence to the World Health Organisation (WHO) surgical safety checklist and audits of the checklist did not provide assurance of compliance.
• Some equipment in surgery and at West Cornwall Hospital was not serviced, maintained, tested or calibrated.
• During our inspection, we noticed the critical care unit was not completely free of dust.
• Checks were carried out on the difficult airway trolley in critical care but were not permanently recorded.
• There were insufficient waste bins on the critical care unit which increased the risk of contamination.
• The antenatal ward was not secure. Open access to the Day Assessment Unit (DAU) which was combined with the antenatal ward was a safeguarding risk to women on the ward. There was also a risk to women’s privacy and dignity. These risks were not on the risk register.
• There were environmental risks on the hospital site: the delivery suite had cracked flooring and worn baths which presented an infection risk and the postnatal ward was uncomfortably hot in summer, with trip risks from fans in corridors, and reported problems with drainage and insects. The ambient temperature of rooms where medicines were stored was not always measured.
• There was no clear nursing observation area on the high dependency unit of the children’s ward and this represented a risk to children who were not visible to nursing staff at all times.
• The fracture clinic was a risk to patients due its design, unregulated clinic temperature and poorly maintained furnishings. Arrangements to ensure children were safeguarded whilst in the department were not adequate.
• Staffing levels in surgery were consistently under plan on most wards during the day.
• Safety briefings did not always take place prior to the start of an operation or theatre list.
• There were not enough midwives to provide a safe service in all areas at all times. Staff had to activate the escalation policy frequently to achieve safe staffing in the delivery unit. Staffing concerns were not on the risk register.
• Safe skill mix in maternity was not always achieved. There was no system to ensure that there was always a midwife or nurse on the delivery suite with skills in caring for a woman needing high dependency care.
• The handovers on the delivery suite were not multidisciplinary; there were multiple handovers several times a day, midwives to midwives and doctors to doctors at different times which were inefficient. Handovers did not clearly highlight risks. There were no safety briefs occurring in the maternity service.
• There had been gaps in gynaecology on call cover which was a risk to women.
• There were insufficient numbers of suitably qualified nursing staff in the paediatric emergency department to provide safe care at all times. There were also no formal processes in place to ensure appropriate cover was in place in the department at all times, particularly during periods when the qualified nurse was temporarily absent from the department.
• The specialist palliative care team was too small to meet the demands of the trust as per national guidance. It was only able to provide a five day a week service, and even this stretched capacity of the team with limited cover arrangements to accommodate annual leave and sickness. This issue was reported upon following both the January 2017 and January 2016 inspections.
• Treatment escalation plans were audited and consistently shown not to be completed fully, often missing essential information about whether patients had mental capacity to consent to the plan. Incomplete treatment escalation plans were reported on following both the January 2017, and January 2016 inspections.

However:

• Staff were aware of their responsibility to report incidents in critical care and services for children and young people. The electronic reporting system had been improved since our previous inspection. Individual reporting of incidents specific to end of life care had improved since our last inspection and the ability of staff to identify such events was good in many of the areas we visited.
• There was good engagement in morbidity and mortality meetings in surgery, which led to service improvement.
• Surgery ward safety briefings held every morning were well attended, with good communication where safety concerns were aired openly.
• There was an improvement month on month in the number of patients with an end of life care plan based on the five priorities of care.
• Safeguarding was well-managed in maternity as part of an integrated hospital safeguarding team. New safeguarding paperwork had been introduced to improve the quality of safeguarding records and a database enabled midwives to check safeguarding referrals.
• Staff we spoke with in services for children and young people were knowledgeable about the trust safeguarding process and were clear about their responsibilities.
• Safeguarding policies and procedures were available to staff in outpatients who knew how to access and follow these.
• A new electronic maternity information system due in October was planned which would enable more comprehensive records to be kept and improve the accessibility of information.
• Nursing and medical records had been completed appropriately and in line with each individual child’s needs.
• Medicines, including controlled drugs were stored safely in critical care, and accurate records of use were maintained.
• Systems were in place in children and young person’s services for the safe storage and administration of medicines and appropriate audit trails were in place for controlled drugs.
• There were effective arrangements in place around the prescription of anticipatory medications to ensure that end of life patients’ symptoms could be managed in a timely way.
• Audit compliance scores for the cleanliness of the critical care unit environment were high, which reduced the risk of patients developing unit acquired infections.
• Accommodation in maternity was visibly clean and equipment was well-maintained. There had been no incidents with a contributing factor relating to maintenance in the twelve months to June 2017.
• The children and young people’s units were clean and well organised. Staff adhered to infection prevention and control policies and protocols.
• Cleanliness and infection control were found to be well audited and compliant in outpatients. Staff adhered to infection control procedures.
• World Health Organisation (WHO) surgical safety checklists were used in the obstetric theatre and gynaecology theatres and we saw evidence of good compliance.
• Equipment, such as syringe drivers and specialist mattresses were readily available for end of life patients who needed it.

• Staff in maternity reported the quality of training was high. Funds had been secured and dedicated for enhanced training over the coming year

• Nurse staffing levels on the critical care unit had improved and agency use had reduced since our last inspection. Further recruitment of nurses had taken place and was ongoing to ensure the critical care unit was compliant with the Faculty of Intensive Care Medicine Core Standards for nurse staffing levels.
• Medical staffing levels had also improved and further recruitment was taking place at the time of our inspection.
• There was 60 hours consultant cover on the delivery suite which met the recommendations of the Royal College of Obstetricians and Gynaecologists for a maternity unit of this size.
• We found the time taken for diagnostic images to be reported was maintained by increasing staffing levels to meet demand.
• Areas we visited were proactively managing risks, both in and out of hours to meet the needs of patients who were at the end of life.

Effective

• We rated effective as requires improvement overall. Surgery and maternity and gynaecology were rated as requires improvement, and critical care and services for children and young people were rated as good. We did not rate the effectiveness of the outpatients and diagnostics service. West Cornwall and St Michael’s Hospitals were rated as good, and Penrice Birthing Centre was rated as requires improvement.
• Systems and processes for identifying, sharing and implementing new or updated guidance were not operating effectively.
• Clinical audits across the trust were not always planned or carried out in a systematic or timely way to ensure compliance and identify risks or learning. Results of clinical audits were not always shared with relevant staff.
• There was a maternity audit schedule for 2017 but no effective process to ensure that cyclical improvement was established and ongoing. Audit plans did not include audit of risks rated as high on the risk register. Changes were made in response to external factors and the service did not always plan these systematically.
• Outcome data for outpatients was confused and prevented staff from measuring clinic performance.
• We were not assured that all staff were up to date with recent guideline changes, particularly community midwives who did not have remote access to the guidelines. Some guidelines, such as the use of a partogram to show the progress of labour were not followed in many women’s deliveries.
• Not all staff had up to date training to use specialist equipment and the system for monitoring competence was not effective.
• Children and young people’s staff working in the community did not have access to the electronic records system used by another provider of community health care in the county. Staff said it was difficult to coordinate between the two systems and this could hamper delivery of effective care and treatment.
• Post inpatient follow up reviews did not always take place, which may result in a patient being readmitted for further care and treatment.
• There was limited support from some services at weekends, including pharmacy and physiotherapy.
• There were gaps in management and support arrangements for staff in some areas, such as appraisal, supervision and professional development.

However:

• We could see evidence from audits in some areas where the results triggered change, and evidence that some treatment provided was in line with best practice and national guidance, for example in critical care, gynaecology and children and young people services.
• We saw strong relationships between most multi-disciplinary teams.
• There was good compliance with NHS England’s standards for seven-day working in hospitals.
• In critical care and children and young people’s services, patients had good outcomes as they received effective care and treatment which met their needs. High quality performance and care were encouraged and acknowledged and all staff were engaged in monitoring and improving outcomes

Caring:

• Caring was rated as good overall and good for each core service. At St Michael’s Hospital, caring was rated as outstanding.
• In surgery feedback from patients and relatives was positive overall. For example, the NHS Friends and Family Test scores were mostly above 90% for surgical wards between March 2016 and February 2017. However, the response rate was only 11%, compared to around 25% nationally.
• Patients and their families spoke almost entirely positively about the care they received while in the surgical division. Staff worked hard to uphold patients’ dignity, individuality and human rights. We observed staff acting in a respectful, kind and compassionate way to patients and those close to them.
• Staff on the critical care unit were compassionate, kind and sensitive. Patients, relatives and visitors were complimentary about the compassion and kindness they had been shown.
• Communication with patients was effective as they were kept informed of their condition, progress and treatment. Patients’ privacy and dignity was maintained throughout their treatment and staff took all steps to protect confidentiality.
• Those close to patients in critical care were involved in their care and were kept updated on any progress or deterioration in condition.
• Care delivered in maternity was kind and compassionate. Women we spoke with and their families spoke well of the care they received. Specialist midwives, helped women understand the specific needs of managing conditions such as diabetes alongside pregnancy.
• The Friends and Family test results were generally good both in maternity and gynaecology.
• Women had reasonable continuity of care before and after birth from a local team of community midwives which enabled them to establish trusting relationships.
• Staff were kind and non-judgemental in the unplanned pregnancy unit.
• Children and young people were treated as individuals and as part of a family. Feedback from children, young people and parents had been consistently positive. They praised the way the staff really understood the needs of their children, and involved the whole family in their care.
• Parents said staff were caring and compassionate, treated them with dignity and respect, and made their children feel safe. Staff ensured children and young people experienced high quality care. Staff were skilled to be able to communicate well with children and young people to reduce their anxieties and keep them informed of what was happening and involved in their care.
• Parents, siblings and grandparents were encouraged to be involved in the care of their children as much as they wanted to be, whilst young people were encouraged to be as independent as possible. They were able to ask questions and raise anxieties and concerns and receive answers and information they could understand.
• We observed staff treating patients with kindness and warmth. The neonatal unit and the paediatric wards and the outpatient department were busy and professionally run, but staff always had time to provide individualised care.
• Staff talked about children and young people compassionately with knowledge of their circumstances and those of their families.
• Staff in outpatients adopted the “hello my name is” by way of introduction to all patients.
• We found people were supported, treated with dignity and respect and were involved as partners in their care.
• We observed outpatient receptionists talking to patients in a respectful way.
• Patients told us nursing staff and doctors explained clearly what options were available to them.
• Patients were empowered and supported to manage their own health, care and wellbeing.

However:

• Some patients we spoke with in surgery did not feel well informed about their care, particularly in terms of when their operation was to take place.

• The critical care unit was not using patient diaries but there were plans to introduce them later in the year.
• There were no formal arrangements for counselling services in the critical care but the unit had developed close ties to the trust’s chaplaincy service which provided patients with spiritual support.
• Although there was supportive care for women in maternity immediately around the time of bereavement, there was no follow up or counselling provided by hospital staff.
• Women were less satisfied with their experience of care on the postnatal ward, particularly during the high temperatures that prevailed during our inspection.
• Privacy and dignity was not always fully maintained as two delivery rooms on the delivery suite did not have blinds for privacy when the lights were on at night.
• The fracture clinic cubicles were small and close together. Private and confidential conversations in adjoining cubicles could be overheard.

Responsive:

• We rated responsiveness as inadequate overall. Surgery was rated as inadequate, critical care, maternity and gynaecology and outpatients and diagnostic imaging were rated as requires improvement and services for children and young people were rated as good. West Cornwall Hospital, St Michael’s Hospital and Penrice Birthing Centre were also rated as good.
• Surgical services were planned to meet local needs but lack of capacity and resources meant that plans were not always delivered in a way which met patients’ needs.
• The facilities and premises used did not always meet patients’ needs or were inappropriate, with admission lounges used for surgical and medical patients overnight.
• Surgical patients were unable to access the care they needed at the right time, and referral to treatment times for incomplete pathways had been worse than average from March 2017.
• Pressures from non-elective admissions and delayed transfers of care led to significant levels of cancellations of elective operations. Twelve patients with cancer had their operation cancelled from January to May 2017, seven on the day of their booked operation.
• Patients were not always operated on in the correct operating theatres, and assessments to identify patient risks were not always carried out.
• Patients did not always have access to services in a timely way for an initial assessment, diagnosis or treatment. Patients experienced significant waits for some services. A high number of patients were not treated within 28 days of their operation being cancelled at short notice.
• There had been too many occasions when patients had to stay in recovery overnight because there were no available beds.
• Due to the lack of capacity within the hospital for beds, critical care patients did not always receive optimal care at the right time. There were frequent delayed admissions, delayed discharges and discharges which took place out of hours.
• At times, level two patients were kept in the recovery area following surgery instead of being admitted to the critical care unit, due to the lack of bed capacity on the critical care unit.
• Patients were not always cared for in separate single sex areas due to patient flow issues.
• The critical care unit did not routinely screen for patients living with dementia when admitted onto the unit.
• In maternity there were regular delays in transferring women to the labour ward because of capacity on the delivery suite, both from limitations of accommodation and staffing.
• The service did not run a dedicated elective caesarean list. This could mean woman scheduled for elective surgery had to wait if there was an emergency underway on the day they were admitted.
• The day assessment unit only had two scanning slots a day. As a result, some women who attended for reduced foetal movements had to return for scanning on another day.
• Not all women were able to give birth in the community as planned as there was a low threshold for transferring women into the main consultant led unit.
• There was a risk to women’s privacy and dignity on the antenatal ward as some women gave birth on the ward. The ward did not have closed doors and was merged with the day assessment unit.
• Few partners were able to stay overnight on the postnatal ward as space was limited.
• Some maternity services had to be closed at times because of staffing, such as the homebirth service, birth centres, early pregnancy unit and emergency gynaecology unit.
• There were long waiting times for referral to treatment for some (non-cancer) gynaecology procedures.
• There were delays in completing discharge summaries on the children’s wards and performance required improvement.
• The temperature in the neonatal unit was not always at a suitable level.
• There were capacity and demand issues in ophthalmology and cardiology. These demands had led to increased waiting times and unacceptably long waits for follow up treatment.
• Action plans put in place had failed to reduce the number of people waiting for follow up appointments in cardiology and ophthalmology.
• The fracture clinic did not meet patients’ needs and issues identified following our January 2016 inspection continued.
• Patient’s told us that directional and information signage for moving through the hospital were challenging.
• The outpatients’ transformation programme had not managed to improve patent flow through the outpatient clinics.
• There were a high number of cancelled appointments for avoidable reasons.
• Not all outpatient clinics had been designed to be dementia-friendly.
• The surgery service consistently missed targets to respond to complaints within 25 working days. There was little evidence to show lessons had been leaned and practice changed to demonstrate people who complained were listened to.

However:

• There were good arrangements for supporting patients with a learning difficulty going into theatre.
• The critical care unit had introduced measures to ensure patient flow in and out of the unit did not deteriorate. New systems for assessing bed capacity had been introduced which increased efficiency in the admission and discharge processes.
• Since our last inspection a critical care matron had been appointed which had increased the profile of the unit at daily bed meetings. The coordinators were now more aware of the capacity issues on the unit, which assisted in securing beds for critical care patients to be admitted to.
• The chief operating officer visited the critical care unit or had daily conversations with the critical care matron to assess the unit’s bed capacity.
• Antenatal and postnatal services were provided in community locations as far as possible, reducing women’s need to travel to the hospital.
• Women deemed low risk could choose to birth at home, at freestanding birth centres or at the hospital delivery suite.
• Midwives assessed women’s mood during antenatal visits and were able to signpost women to sources of help for anxiety and depression.
• The unplanned pregnancy service was discreet. Staff were non-judgemental and women gave very good feedback about their care and treatment. Women could access the service in both Truro and Penzance.
• There was a good range of information leaflets for women with early pregnancy problems detailing ways of managing these.
• Good use was made of Facebook to communicate with women and young people.
• Services were tailored to meet the needs of individual children and young people and were delivered in a flexible way.
• There were good facilities for babies, children, young people and their families.
• The environment for the neonatal service had improved considerably with the opening of the new unit in May 2017. Staff had been involved in the design and planning phase of the development of the unit
• There were no barriers for those making a complaint. Staff actively invited feedback from children and their parents or carers, and were very open to learning and improvement. There were, however, few complaints made to the service and those that had been made were fully investigated and responded to with compassion.
• Children and young people of all ages had timely access to care and treatment
• A new wide bore scanner was soon to be available to meet the needs of larger patients.
• We found the time taken for diagnostic images to be reported was adaptable and managed demand.
• Imaging was performing well and managing many of its key waiting times.

Well led:

• Well led was rated as inadequate overall. Maternity and gynaecology, end of life care and outpatients and diagnostic imaging were rated as inadequate, surgery was rated as requires improvement and critical care and services for children and young people were rated as good. West Cornwall and St Michael’s Hospitals were rated as good, and Penrice Birthing Centre was rated as requires improvement.
• The arrangements for governance and performance management in surgery did not always operate effectively. Risks, issues and poor performance were not always dealt with appropriately or in a timely way.
• Not all leaders in surgery had the necessary time to lead effectively. The need to develop leaders was not always identified or action was not always taken. Leaders were not always clear about their roles and their accountability for quality.
• The sustainable delivery of quality care was put at risk by financial challenges facing the trust.
• There was no clear vision or strategy for service development in either the maternity or gynaecology service.
• Management of the maternity service was reactive in response to external reports or adverse events. At times the service focused on solving immediate issues without risk assessing the consequences of these actions on the wider service.
• The governance processes in maternity did not ensure quality, performance and risk were managed. The maternity dashboard held predominantly clinical information with no staffing information included.
• There was an absence of comprehensive performance and quality audit plan. Several significant risks were identified which were not on the register and risk assessments had not been undertaken.
• There was very little evidence of improvements by self-examination or benchmarking with other similar maternity services. The limited range of audits restricted the scope of quality monitoring and meant there could be little assurance that practices followed guidelines.
• There was some uncertainty concerning the flow of data about the maternity unit’s performance to the hospital’s executive team. The unit was not holding regular nursing meetings.
• There was poor communication at executive level about the future plans for the end of life service at the trust and a lack of consultation on the business plan that lay behind these plans.
• We saw a business plan for the development of end of life care at the trust going forward. However we saw little evidence that there had been any tangible improvements in end of life care with the exception of the increase in use of the end of life care documentation.
• There was a lack of any systematic audit programme relating to end of life care, and few measures that addressed risk and quality. This issue had been reported following the inspection in January 2017.
• There was no evidence that the end of life care strategy was being monitored or taken forward since the departure in May 2017 of the end of life facilitator. Key tasks such as training needs analysis within the strategy had not been completed.
• There was no scrutiny or interrogation of, delayed fast track discharges, or the achievement of preferred place of care, for end of life patients and so no learning could be taken from these.
• In outpatients governance procedures to monitor waiting lists, waiting times, frequency of cancelled clinics, and referral to treatment timelines for patients were not robust enough which meant the impact on patients was not fully known.
• A programme of rolling improvements in the outpatient service was not delivering sufficient results in a timely manner and significant challenges remained.
• Accountability for decision making was unclear in several speciality clinics. Leaders, including the board and divisional management, were not visible within the outpatients department.
• In the surgical division the culture was dictated by senior and executive management. It was not one of fairness, openness, transparency, honesty, challenge and candour. We found there was a disconnect between the executive team and frontline staff.
• Decisions in the maternity service were traditionally made at the top and then communicated to staff. Staff had become accustomed to a top down leadership style, however, efforts were being made to effect a change in this.
• Some staff continued to feel the culture of the maternity services was punitive despite actions to involve more staff in open discussions about the service culture.
• Bullying and undermining behaviour towards other staff, peers or juniors appeared to have been insufficiently challenged in the maternity service. This meant that there was not a clear reporting line of key clinical issues affecting the maternity service. The operational decision-making group for midwifery did not feed into either the obstetrics and gynaecology meeting or the maternity forum.
• A significantly high number of outpatients staff at all levels felt the culture within the trust was one of intimidation, bullying and discrimination and several staff had left or been signed off with stress.
• The critical care unit risk register did not highlight all risks identified by the service and some ongoing risks had been closed. There were also issues with the way in which risks were added and removed from the register.
• We were not assured of sufficient oversight and management of the risk register relating to end of life care.
• Staff and public engagement was not given sufficient priority in most of the core services. There was a limited approach to obtaining the views of patients who used services and other stakeholders. Feedback was not always reported or acted upon in a timely way. We saw few mechanisms for capturing feedback from patients, their families and carers, or from staff. There had therefore been no input from these groups into the end of life service. This issue had been reported following both the January 2017 and January 2016 inspections.
• There were low levels of staff satisfaction, high levels of stress and work overload. Staff did not feel respected, valued, supported and appreciated. Staff did not always raise concerns or they were not always taken seriously or treated with respect when they did.

However:

• We found nursing, theatre and medical staff to be committed to the hospital and dedicated and caring to deliver care and treatment to patients.
• Most managers we spoke to in surgery said they were overwhelmingly proud of the teams they led. There was alignment between the recorded risks and what staff said was on their worry list.
• Innovation and improvement was encouraged within the surgical directorate.
• There was clear vision for the critical care unit and a realistic strategy for achieving it.
• There was an effective governance framework to support the delivery of the strategy and good quality care within the critical care unit.
• All staff working on the critical care unit shared values which promoted the delivery of treatment that was safe and of the highest quality.
• There was good nursing and medical leadership on the critical care unit. Managers were visible and approachable. Staff felt they could bring any concerns to their supervisors and they would be acted upon.
• The service was taking steps to ensure the sustainability of the critical care unit so that it continued to provide safe care and treatment to patients
• New management appointments in maternity had the potential to change the culture and involve staff more in decision making over time. A senior leadership programme for all senior managers had taken place which was in the process of being rolled out to other staff to strengthen staff understanding of leadership and develop skills.
• The leadership, governance and culture of the services for children and young people were used to drive and improve the delivery of high-quality care. The clinical managers were committed to the children and young people in their care, their staff and the unit. Frontline staff and managers were passionate about providing a high quality service for children and young people with a continual drive to improve the delivery of care.
• In end of life care we saw excellent examples of leadership within the specialist palliative care team and the mortuary which meant that staff working within these services benefitted from the support and commitment of their leaders.
• Substantial funding had been agreed which aimed to improve education and provision of end of life care at the trust. There had been some improvement in the profile of end of life services since our last inspection.
• The specialist palliative care team were held in extremely high regard across the trust in all areas we visited.
• In diagnostic imaging we found the leadership to be visible and supportive. The culture in imaging was open and staff felt able to raise concerns.
• Children and young people were able to give their feedback on the services they received; this was recorded and acted upon where necessary.
• A variety of staff engagement activities following from the cultural review in maternity had tapped into staff views about the service and opportunities for improvement, and staff were taking forward some of these.
• There was a high level of staff satisfaction with staff saying they were proud of the children and young people’s units as a place to work. They showed commitment to the children and young people, their responsibilities and to one another. All staff were treated with respect and their views and opinions heard and valued.

We saw several areas of outstanding practice including:

• The critical care unit had arranged for an external provider to provide shiatzu massage to patients on the ward to help with muscular pain. The service was also available to staff.
• The unit was using a local private ambulance to enable patients to go on day trips to local destinations. Nurses and doctors from the critical care unit would accompany them on these visits following a thorough risk assessment process.The patients suggested the destination and the unit endeavoured to grant their wish. Payment for the use of their services comes from the Charitable Fund.
• Emotional support and information was provided to those close to patients. Following the participation in the Provision of Psychological Support to People in Intensive Care (POPPI), three nurses from the unit had undertaken training to enable them to deliver psychological support to improve outcomes for patients being discharged from the unit. The nurses in question were delivering this support to patients during our inspection. The nurses were also able to provide support to colleagues when required.
• An initiative was put forward to deliver additional support to bereaved children. We saw many tools to help children to cope with their loss. For example, the unit had invested in story books surrounding death. There were also puppets, colouring books and toys which could be used to distract and comfort children.
• The outpatient department had introduced an improved treatment option for the rapid removal of blood clots from veins and arteries following the purchase of new equipment. In some instances this prevented patients having emergency surgery and reduced length of stay.
• The development and implementation of “RADAR” by Royal Cornwall Hospitals NHS Trust improved monitoring of referral to treatment, delays and clinic cancelations. It had won several national awards for innovation.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

• Improve the approach to identifying, reviewing and investigating incidents and never events.
• Adopt a positive incident reporting culture where learning from surgical incidents is shared with staff and embedded to improve safe care and treatment of patients.
• Ensure there is an effective system in place to monitor and scrutinise incidents relating specifically to end of life care ensuring subsequent learning can be implemented.
• Take immediate steps to improve incident reporting timeliness, consistency, investigation, learning and sharing of learning processes.
• Review and implement the systems and processes to ensure staff follow the principles of duty of candour.
• Review the security of the antenatal ward to ensure the privacy and security of women who were inpatients.
• Take immediate steps to address the fracture clinic environmental issues that have been present since the January 2016 inspection, including adequate safeguarding systems for children.
• Ensure safety checks on surgical equipment are carried out by the planned dates.
• Provide surgical patients with sepsis with timely access to intravenous antibiotics.
• Securely and confidentially manage all patient information.
• Ensure that patient records are stored securely across the trust. Patient confidentiality must be maintained in accordance with the Data Protection Act.
• Ensure that the causes of incomplete treatment escalation plans are addressed and compliance is improved in critical care.
• Ensure patients are risk assessed and operated on in the correct theatre with the correct equipment and staff available.
• Ensure emergency resuscitation teams have immediate access at all times to a member of staff who is able to deal with difficult airway intubation.
• Ensure full compliance with the Five Step to Safer Surgery World Health Organisation (WHO) checklist to prevent or avoid serious patient harm.
• Meet expected levels of medical and nurse staffing levels on surgical wards to keep patients safe.
• Ensure there are sufficient numbers of midwives and nurses, with the right skill mix on duty at all times to deliver safe care.
• Ensure inductions of labour are safe in relation to capacity, activity and staffing on the delivery suite.
• Ensure there are sufficient numbers of suitably qualified nursing staff in the paediatric emergency department and formal processes in place to ensure appropriate cover was provided at all times.
• Improve compliance with the use of surgical patient care bundles.
• Ensure better quality data about processes and outcomes within the maternity services is available for analysis and to support improvement.
• Ensure the maternity dashboard includes sufficient information to provide a comprehensive overview of maternity performance. Proactively benchmark processes and outcomes in the maternity service against comparable trusts in rural areas.
• Ensure all surgical staff receive annual appraisals, mandatory training, appropriate supervision and professional development.
• Ensure all midwives update their training to a level where they all have the skills needed for their roles, and set targets for completion of training in line with trust targets of 95%.
• Ensure there are clearly articulated and understood processes in place for identifying and managing deteriorating women and that the processes are monitored.
• Review the risks and contingency plans for opening and staffing the second theatre and ensure there is a robust process in place that is well communicated and practiced.
• Identify, analyse and manage all risks of harm to women in maternity services, ensuring local risk registers are maintained in all discrete units and feed into the divisional and corporate risk register.
• Review and improve the high dependency processes and facilities for managing high dependency care in maternity services ensuring there are adequately skilled and trained staff on duty at all times.
• Take immediate steps to ensure the privacy and dignity of patients using the fracture clinic cubicles
• Improve the incomplete referral to treatment pathway compliance for surgical patients.
• Review the arrangements on the antenatal ward to ensure one-to-one care and women’s privacy and dignity when giving labouring and giving birth there in the absence of additional capacity on the delivery suite
• Ensure all patients have their operations at the right time, whether in an emergency or for a planned procedure.
• Ensure surgical facilities are appropriate to meet patients’ needs.
• Improve bed management, and discharge arrangements to ensure a more effective flow of patients across the hospital to improve cancellations of patient’s operations.
• Ensure access and flow into the critical care unit is improved to ensure delayed admissions, delayed discharges and discharges out of hours are reduced so patients receive the right care at the right time and in the right place.
• Take immediate steps to ensure that the backlog of patients awaiting cardiology procedures is eradicated.
• Take immediate steps to ensure that the backlog of 24 hour cardiac recordings and echocardiograms are reviewed.
• Take immediate steps to ensure that the backlog of patients awaiting WARM ophthalmology procedures and glaucoma service is eradicated.
• Improve the response times for patients’ complaints.
• Ensure governance processes are embedded in practice to provide assurance that surgical services are safe and effective and provide quality care to patients.
• Ensure that systems are in place so that governance arrangements, risk management, and quality measures in maternity are effective. Ensure audits are aligned to incidents and identified risks.
• Ensure governance systems and processes are established and operated effectively to ensure the trust can assess, monitor and improve the quality and safety of the services provided to patients receiving end of life care.
• Ensure action is taken to address behaviours and performance which are inconsistent with the vision and values of the hospital, regardless of seniority.

Professor Edward Baker

Chief Inspector of Hospitals

The Royal Cornwall Hospitals NHS Trust is the principal provider of acute care services in the county of Cornwall. The Trust is not a Foundation Trust and performance is monitored by NHS Improvement (NHSI). The Trust serves a population of around 415,783 people, a figure that can be doubled by holidaymakers during the busiest times of the year.

CQC has previously carried out two comprehensive inspections at Royal Cornwall Hospital NHS Trust. The first being in January 2014 when the Trust was rated as requires improvement. In June 2015 we carried out a follow up to the first inspection and found the trust had not made sufficient progress in all areas and a second comprehensive inspection was initiated, which we carried out in January 2016. At that time, the trust was rated as requires improvement overall. We rated safe, effective, responsive and well led as requires improvement and caring as good.

This inspection was a responsive, unannounced focused inspection and was conducted on 4 and 5 January 2017. We reviewed end of life and urgent care services to review progress against the inadequate ratings for those core services as identified on the previous inspection in January 2016. We reviewed medicine services as continued intelligence had raised concerns with regards to quality and safety of the service. We also looked at the governance and risk management support for the services we inspected. On 2 March 2017, we returned to the trust to review the fit and proper person’s process. This was announced to the trust the day before we attended.

Only those services provided at the main Royal Cornwall Hospital site in Treliske were inspected. We did not inspect:

• St Michaels Hospital
• West Cornwall hospital
• Penrice birthing unit

We did not rate Royal Cornwall Hospitals NHS Trust overall at this inspection because we only reviewed three core services and well led at provider level, and because the previous inspection was more than 12 months earlier.

Key findings:

Safe:

• There was a system in place for capturing incidents, however the system was not being used in a reliable way, and the processes around incident reporting were not robust enough, or implemented in terms of identifying, capturing, reporting or reviewing incidents. Although staff did complete incident forms and they were encouraged to do so, there was little evidence of actions or learning resulting from these.
• The classification of incidents was not effective, for example we found multiple examples of incidents (where harm had resulted) classified as ‘no harm’. This meant not all incidents were investigated or escalated appropriately, and opportunities to learn and improve were missed. It also meant that the trust were not able to produce accurate reports for analysis or accurately identifying risks or trends, for example, there was no reliable process for establishing which incidents related to end of life patients.
• Not all incidents had action plans associated with them, and those that did, were not always robust or monitored to ensure they had been completed, and learning had taken place.
• As the level of harm had not always been correctly established or recorded, there was no assurance that duty of candour had always been applied appropriately.
• There was inconsistency with the quality of serious incident investigation reports and evidence of learning from patient deaths. There was no evidence to show actions identified following serious incidents were reviewed for progress and led to improvements. In addition, we found examples of serious incidents that had not been reported as such.
• In some medical wards there were known staff shortages. However, the trust assured us that detailed meetings took place across the day to ensure the safe staffing of wards. Some staff told us that the process for booking agency staff was complicated.
• Neurology did not have sufficient staffing capacity to provide a seven day service.
• The number of consultants in the emergency department and the hours they worked were below recommended levels, although there was active recruitment, and good coverage from junior doctors. The overcrowding in the department meant there were times when the nursing staff levels were not adequate. Levels of nursing staff were rising towards planned numbers, but staff raised concerns about cover in the minor injuries’ area at night being adequate.
• The specialist end of life team did not have enough medical or nursing staff to provide a service seven days a week and cover arrangements were limited. However, specialist advice on end of life medicines to treat pain and other symptoms was available to any clinical staff 24 hours a day, seven days per week.
• An electronic alert system set up to notify doctors of patients needing to be seen meant that on occasion, doctors were inundated with messages and updates which meant they found it hard to prioritise patients.
• The Trust had set itself a challenging 100% target for Safeguarding training. Although there had been an increase in compliance rates, there were still some areas where compliance remained low. In some ward areas less than 50% of the staff were sufficiently trained in children’s safeguarding. Training for both adult and children’s safeguarding was not meeting trust targets.
• Many consultants did not have the required levels of mandatory training to keep people safe. Insufficient numbers of consultants had training in infection control, manual handling, fire safety, health and safety or information governance. Nurse mandatory training was much improved in the emergency department and coming up towards targets. There was an impressive length of time given over to nurse mandatory and continuous developmental training.
• There was inconsistent understanding across wards regarding which nursing staff had in date syringe driver training and competency to safely set up and monitor equipment. This had been raised during the last inspection, but progress was not apparent.
• There was no up-to-date record of review of equipment skills for staff in the emergency department, and a number of pieces of equipment were indicating they were overdue for servicing.
• Resuscitation trolley checks on the Medical Admissions Unit and Tintagel ward were frequently missed which meant that there was an increased risk to the patient if the equipment was needed.
• The overcrowding in the emergency department was causing reduced access to some areas, including the resuscitation room. Emergency evacuation may also be impeded.
• Not all patients were able to reach their call bells. These were not provided in some areas, or within patients’ reach in others.
• We found that medicines were not stored securely in the Medical Assessment Unit and despite raising our concerns found that medicine security got worse as the inspection went on.
• There were delays in medicine administration which had not been resolved. There were two incidents during our inspection of a lack of security with the drug cupboard keys. There were some issues with medicines’ management and storage in some areas, although this was mostly well managed.
• There had not been a sustained improvement in the timeliness of observations, and management of sepsis in the emergency department.
• There was still further progress to be made, but a much improved assessment and response to patient risk, triage and urgent treatment, although not all patients were receiving a timely electrocardiogram (ECG) test when presenting in the emergency department with chest pain.
• Risks to people who used end of life services were assessed, monitored and managed on a day-to-day basis. These included signs of deteriorating health, medical emergencies or behaviours that challenged. The specialist end of life team and ward staff reviewed end of life patient care every day in order to respond to changeable conditions and risks, although improvements were required to how treatment escalation plans were completed by doctors to ensure compliance with policy.
• Although infection control practices were generally good they were unsafe on the Medical Admissions Unit. Not all cleaning of equipment was recorded in the emergency department.
• We observed a lack of hand hygiene at times among the staff in the emergency department.
• There was a variable level of completion of emergency department patient records from comprehensive to poor, although audit work in the department demonstrated this was improving.
• On regular occasions on the medical wards we found that records trolleys were left unlocked and unoccupied. We also found zip locked bags containing records left unattended by the ward entrances awaiting collection.

Effective:

• The Royal College of Emergency Medicine audits were not given a satisfactory priority in the year in which they were to be undertaken. The results of the asthma audit were poor although they had used an insufficient dataset, and the audit was done outside of the required period. The emergency department had however, excelled in the timeliness, care and treatment of patients suffering a stroke or trauma.
• We asked for, but were not provided with up to date audit information for some national audits. The results of these in the previous inspection were worse than the national average. However, we saw that there had been improvement in the national stroke audit. The trust had gone from a level E to a level D, which is the national average.
• There was a lack of ongoing audit information to evidence quality and progress in the delivery of effective end of life services. End of life service did not participate in any national audit.
• There was evidence that people’s care and treatment was planned and delivered in line with current evidence-based guidance, standards, best practice and legislation.
• During December 2016 a revised end of life strategy and patient care documents were launched based on national guidance. The strategy lacked accompanying staff training and emphasis to ensure all doctors understood what their roles and responsibilities would be.
• Whilst new end of life care plans were being rolled out across the trust, there remained a lack of recorded evidence to show end of life care provided was holistic and person centred. There was a reliance on the patient or relatives of the patient initiating and articulating any personalised wishes in order for any actions to be taken, and documentation did not always reflect this to ensure patients were safe at all times.
• A continuously funded secondment post for generic hospital staff to work with the specialist end of life team to increase their skills and knowledge was available but not fully utilised.
• There was little evidence of advance end of life care planning being undertaken. Most of the staff we spoke with did not recognise end of life as relevant during the last twelve months of life.
• In medicine, there was evidence people had comprehensive assessments of their needs, which included consideration of clinical needs, mental health, physical health and wellbeing, and nutrition and hydration needs.
• Discharge was not done in a timely way and there was not robust multi-disciplinary working around discharge. All patients were subject to standards set in the SAFER care bundle. Achievement in standards of discharge was significantly lower than the trusts target. Examples of these targets included the timeliness of discharge and discharge on the patient’s clinically stable date. Staff told us this was due to delayed transfers of care and delays with external assessments.
• There was no seven day consultant cover for neurology patients. This increased the risk to patients at weekends. The use of a consultant of the week model had an impact on the effectiveness of treatment. Staff were not supported well and patients were missing important medicines as a result of a lack of accountability under this model. The end of life service did not provide seven day services, and there was limited out of hours cover. All services needed to provide effective care were available seven days a week in the emergency department.
• The link end of life care meetings were a productive forum for learning and sharing clinical and policy updates and were valued by those staff who attended.
• Records maintained by the specialist end of life team showed they were prompt to respond to referrals, although these were increasing and staff were already stretched. Staff throughout the hospital told us they understood how to contact the team and highly valued the expertise, guidance and support provided.
• There was a strong ethos in the emergency department for multidisciplinary working and we saw some good examples of this. When people received care from a range of different staff, teams or services, it was coordinated. All relevant staff, teams and services were involved in assessing, planning and delivering people’s care and treatment.
• Many consultants did not have the required levels of mandatory training to keep people safe. Very few consultants had training in infection control, manual handling, fire safety, health and safety or information governance. In the emergency department, staff had the right competencies, experience and skills and professional development and competency training had improved. There was an excellent range of training for medical staff, including outstanding simulation training and production of high-quality case studies, teaching materials, guidance and protocols.
• Appraisal rates in medicine were not meeting targets. Only two wards had appraisal rates higher than the 95% trust target. Some wards were significantly lower with Kerensa ward having 56% compliance and Tintagel ward having 65% compliance. In the emergency department, staff appraisals had improved and were heading towards target.

Caring:

• Feedback from patients and those close to them was mostly very positive about the way staff treated people. People were treated with dignity, respect and kindness during their stay.
• People are involved and encouraged to be partners in their care and in making decisions. Staff spend time talking to people, or those close to them and we witnessed staff in the emergency department at a very busy time, taking care to help patients understand what was happening to them.
• Staff had the skills and compassion to communicate effectively to patients during times of distress. This was particularly apparent in the coronary care unit, and in the emergency department.
• Feedback was overwhelmingly positive on Wellington ward. Staff were enthusiastic about the care they were giving. Patients felt that staff went the extra mile and exceeded their expectations.
• Patients and their relatives told us they had been consulted about end of life treatment and care, this was also evidenced in some of the care plans we reviewed, although there was a lack of detailed written information in care records to show what had been discussed with patients and how they had been included and involved in treatment and care. This meant that when staff changed shift, these needs would not always be clear.
• The new cancer resource centre provided a wide range of resources, counselling and support to any person affected by cancer.
• Friends and Family response rates were not good across the medicine directorate. For example on Carnkie ward, Tintagel ward and Kerensa ward response rates were below 10%. In the emergency department, although improving the response rate was also very low, but the trust was recommended, in those responses received, by a higher number of people than the England average. For end of life care, there was a lack of survey or other evidence to show patients’ needs were being consistently met.
• Due to overcrowding in the department, it was difficult to avoid breaches of privacy and dignity for some patients.

Responsive:

• Although processes were in place to support flow within the hospital there were not enough beds to meet the demand of the service. Bed capacity was full and escalation areas (such as theatres and day case surgery) were regularly being used. Additionally there were 40 medical outliers in surgical wards. This took up 16% of the surgical bed base. On the day of the inspection the trust had sought external help and support by the use of escalation (Gold Call) to address the system risk and attempt to reduce bed occupancy.
• The emergency department had moved up the national rankings in terms of accident and emergency target waiting times, and the time taken to first treat patients was consistently better than the standard of 60 minutes, with care and treatment appropriately prioritised. However, demand on the service and the way it had been required to operate meant too many patients were, at times, waiting on trolleys to be admitted to a ward, and flow was not timely; the department had not met the target to admit, discharge, or transfer 95% of patients within four hours for at least the last two years. At the time of our inspection, this was running at around 77%. People in the emergency department were kept informed about waiting times and alternative access to treatment in the county.
• People were frequently and consistently not able to access services in a timely way due to the over occupancy and the issues with flow. This included delays for an initial assessment, diagnosis or treatment and people experienced unacceptable waits for some services. During the inspection over 100 patients were delayed in hospital due to inability to access community services. Between April 2016 and December 2016 over 1700 bed days were lost as a result of inadequate hospital flow. This was a worsening picture since the last inspection.
• On average 97 patients a month were waiting longer than seven days for discharge. This increased the risks of patients deteriorating, prevented patients who required medical care accessing wards, and caused crowding in the emergency department. An external agency had recently undertaken a comprehensive review of the discharge systems and processes and work had been initiated to implement their recommendations.
• Staff in the end of life service told us discharge delays were frequent and resulted from a lack of community resources. There was no information to evidence this. Whilst there were issues regarding the availability of community resources, there were no apparent plans in place to address these issues with community providers in order to make service improvements to meet patients’ discharge needs. In some areas there was confusion regarding who had overall responsibility for processing fast track patient discharges through to discharge.
• There was a waiting list for cardiac procedures within the hospital with some patients not being seen by their ‘see by’ date, due to staff capacity and cancellations of clinics. There was evidence to show this had been getting worse over time, and since the last inspection. However, we were informed of the Trust’s active work plan to recruit more staff and the oversight of the risk in Cardiology.
• There was a lack of processes in place to evidence if the end of life care provided was responsive to patient’s needs and wishes. Ward staff primarily relied on the patient or relatives to initiate and communicate any requests.
• There was inconsistent feedback and evidence to show if patients spiritual and cultural needs had been reviewed and any needs addressed. Patient’s personal choice as to where they preferred to receive their end of life care was not routinely monitored and reviewed.
• The medicine and emergency department services were planned to meet the needs of local people. People using the service could all do so on an equal basis. We found that some reasonable adjustments had been made to manage the needs of patients with individual vulnerabilities. This included patients living with dementia and patients with a learning disability. We found that there had been significant improvements in the stroke service which ensured that the design of services were tailored to meet their needs.
• The cancer resource centre provided a wide range of services, support, training and information based on the needs of patients and people close to patients. The centre also provided training information and information for trust staff and other professionals who provided any services to patients with cancer.
• Complaints in medicine were not being handled in a timely way and in all areas, there was insufficient evidence to show complaints led to changes and improvements.
• A third of complaints in medicine were resolved beyond their timescales. However, we found that it was easy for patients to raise a concern or a complaint. There was openness, transparency, and a will to learn from complaints on the wards, although this learning was not shared more widely. We found examples where learning from complaints had resulted in changed practice locally.
• There had been a drive for the complaints team to hold early resolution meetings with complainants, and these had resulted in fewer complaints progressing through to formal complaints.

Well led:

• Although staff understood what the vision and values were, they felt they were not able to fully live by them due to the pressures of the job.
• Strategic objectives were aligned to a degree to the vision and values, however due to ongoing work and involvement with the county’s sustainability and transformation plans, the detail underpinning the strategic aims had not yet been formulated or articulated, and staff across all areas we visited were unsure of the impact this would have on their roles and services. Service level strategies were at different stages of development.
• Recommendations from an external governance review undertaken in July 2015 had been accepted, but progress in implementing the changes had been limited, and the governance arrangements currently in place were unclear.
• There was confusion around senior leader’s accountability portfolios which had yet to be formally agreed, and below board level, the subcommittee and divisional reporting structures were not clear. Some governance committees had been suspended due to operational pressures.
• The processes in place to meet the Fit and Proper Persons Requirements for Directors (FPPR) were not sufficient to meet the requirements of the regulations and did not provide appropriate assurances that adequate checks were being made and recorded to confirm directors were suitably ‘fit and proper’.
• Reports to the board did not consistently set out the key issues or risks facing the services, and some areas had not reported as expected, or at all during 2016 due to capacity, for example, end of life services.
• There was concern about the level of oversight, challenge and scrutiny at board level and assumptions being made that sufficient scrutiny occurred at subcommittee level, which some leaders told us, it did not.
• The risk registers that were in place at the time of the inspection did not accurately reflect the risks to patient safety and the quality of care and treatment. The corporate risk register similarly did not reflect all known risk and appropriate mitigations. There was confusion around the newly reset risk tolerances, which had not been documented.
• There was no effective assurance system in place for identifying, capturing and managing risks between ward and divisional level. There was no assurance that risks were being escalated and actioned appropriately. There was a lack of capacity to recognise and respond proactively to emerging risks given the focus on urgent priorities. There was some confusion as to who had ownership of incidents and risk between the central team and the divisions, and the divisional teams did not always have the required access to manage their incidents.
• The emergency department risk register had few clinical risks; concentrated on mostly potential environmental risks; and beyond the ongoing situation with crowding, did not address known or current concerns. The end of life service did not have a specific risk register.
• Safety and quality meetings at divisional level were of a variable standard. Whilst all departments indicated the occurrence of meetings, some departments demonstrated a lack of escalation. It was also reported by staff in some divisions that the escalation of issues was futile, with little recognition, feedback or action from executive level meetings.
• There was not a holistic approach to the monitoring of safety and performance data, supported and informed by robust, ongoing clinical audits in all services underpinned by robust action plans to drive improvements. There were a number of areas not being considered through this mechanism, or not demonstrating sufficient priority, for example the RCEM audits.
• There was a lack of audit and quality measures to fully evidence quality and risk management issues for end of life patients to maintain and make service improvements. There was no routine engagement with patients or those people close to them to gather feedback in order to make service improvements.
• Quality improvement was not embedded across the organisation.
• There was a conflict between delivering high quality patient care, and the time to commit to good governance and risk management. Operational pressures compounded this.
• Available funds and training available for the development and sustainability of a skilled end of life workforce throughout the trust had not been fully utilised.
• There was an established pattern of increased referrals to the specialist end of life team but there were no plans in place to ensure the team who were already stretched, had the capacity to cope with it.
• The issues identified in the core services inspected and the lack of significant and sustained progress since the previous inspection raised questions about the capacity and capability of the trust leadership team. There has been a prolonged period of instability at board level, and some evidence to show this has impacted on patient care and staff morale. There was widespread anxiety about the effect and impact of the sustainability and transformation plan (STP), and the potential dilution of leadership with the chief executive spending more time in her role as lead officer for the STP.
• There was a lack of support from the wider system which led to delays in the management of key risks, such as patient flow. Leadership of the end of life service was not fully effective and coordinated.
• In medicine, there were low levels of staff satisfaction, high levels of stress and work overload. Staff did not feel respected, valued, supported and appreciated. This was particularly apparent on Tintagel ward. More work was needed to improve the continuing poor staff engagement and staff survey results.
• All staff we met were focused to continually improve the care they were giving. This was particularly apparent on Wellington ward where innovate schemes had been introduced to develop skills further.
• The specialist end of life team was held in high regard by staff we spoke with on the wards and other services we visited, and in the emergency department, there was experienced, committed, caring and strong local leadership. The leaders understood the challenges they faced and had ambitions for improvements and innovation. Staff in the emergency department felt respected and valued. There was encouragement of openness, candour and collaborative working.

We saw several areas of outstanding practice including:

• There was an outstanding commitment to medical simulation training in the emergency department and this extended to the production of detailed and valuable case studies. This provided education for staff, but also awareness of human factors in a busy environment, and how staff might react to those.
• There had been an outstanding response to trauma and stroke patients in the emergency department. The department was among the top hospitals in the country for providing timely and appropriate care.
• There was an outstanding commitment to mandatory training for the nursing staff in the emergency department with three-day sessions held to cover this and other key topics for continuous professional development.
• Despite unprecedented overcrowding, the emergency department was calm and professional during our unannounced inspection.
• MASH up Monday training on Wellington ward – this was small training sessions on the ward led by the ward sister and other relevant staff and was being extended to cover something each weekday. The ward sister had won a trust pride and achievement award in November 2016 for this.
• Clinical Matron for the cardio-respiratory directorate was nominated for a Nursing Times award for ‘Matrons Rounds’ – promoting safe, effective, caring, responsive and well led care in January 2016.
• One of the respiratory doctors had organised a respiratory day for staff at an external venue that included training, lunch and discussion about respiratory care. The matron said the doctor was very enthusiastic and staff were looking forward to the day.
• The use of an electronic pharmacy system to ensure detailed exchanges of communication to community GP’s and pharmacists. This ensured that the community teams were up to date in dose changes, new medicines, discontinued medicines, and those that were to continue but were temporarily stopped.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

• Review, document and implement the governance processes, subcommittee structures and reporting lines to and from the board and ensure this is communicated to staff.
• Review the governance in the emergency department and across medicine to ensure it has evidence that recognises and addresses risks, safety, and quality of care. This needs to include actions from avoidable patient harm, progress with audits, and demonstrable learning and improvements when there are incidents, complaints, and other indications of emerging or existing risks.
• Review and improve governance processes to fully evidence all quality and risk management issues for end of life patients, and ensure these are reported in line with the risk management policy and processes.
• Review and implement the systems and processes for managing corporate, divisional and local risk registers and ensure that all staff are clear about their roles and responsibilities. The risk register must be improved to recognise all risks, particularly clinical risks, and consider where there are gaps in what is reported and how they are reviewed.
• Review the incident reporting systems and processes and provide assurance this is a fair reflection of the risks in the trust at all times. Ensure any categorisation of an incident is accurate in order to ensure learning and appropriate escalation from all incidents, including ‘near miss’ events. In addition, to ensure that duty of candour is correctly applied in all cases.
• Review how end of life patient care is captured within the trusts incident reporting system to ensure incidents reported in all categories can adequately identify if they also involve end of life patients, and improve and educate staff trust wide to recognise what end of life issues could or should be reported as an incident.
• Present incident information with more prominence in safety reviews and governance committees with a responsibility for risk, and embed and demonstrate learning and improvement.
• Address timeliness and inconsistencies in the quality of investigation reports for all serious incidents.
• Demonstrate learning across the trust from patient deaths, particularly, but not limited to, any that were unexpected or avoidable.
• Ensure that actions to improve on performance measures are robust, are actioned appropriately and are discussed at the relevant meetings to ensure senior level and board oversight as necessary.
• Ensure a holistic approach to the monitoring of safety and performance data, supported and informed by robust, ongoing clinical audits in all services underpinned by robust action plans to drive improvements.
• Ensure that staff receive appropriate safeguarding training to protect both adults and children.
• Ensure that both nursing and medical staff have appropriate mandatory training to keep people safe.
• Continue to review and put in place measures to address and manage patient access and flow, and ensure patients are appropriately discharged, working closely with system partners to achieve workable solutions to the current barriers, including a review of the effectiveness of system wide GOLD calls and the steps taken in advance of anticipated busy periods to plan for this.
• Ensure that designated leaders have the time and capacity to lead effectively and manage governance within their divisions, departments and teams.
• Review using the emergency department as an access point for medically expected and surgical patients to relieve pressure on the whole system, reduce breaches of patient privacy and dignity, and improve the response to patients.
• Ensure that there is appropriate medical oversight and accountability for neurology patients on Tintagel ward including at weekends.
• Find a workable solution to delays in the administration of medicines to patients in the emergency department, and ensure that medicines in the medical division are stored safely and securely.
• Ensure there is a sustained and effective improvement in the management of sepsis in the emergency department.
• Ensure there is evidence in the emergency department of governance for equipment and the environment, which includes staff competence, cleaning regimes, availability of call bells in all areas, and maintenance being undertaken when required.
• Ensure that resuscitation trolleys in the medical division are checked appropriately so they are safe to use.
• Ensure that medical records remain secure and locked away throughout the medical division.

Professor Sir Mike Richards

Chief Inspector of Hospitals