Royal Cornwall Hospitals NHS Trust (RCHT) is the main provider of acute hospital and specialist services for most of the population of Cornwall and the Isles of Scilly, 587,000 people. The population can more than double during busy holiday periods. The trust delivers care from three main sites – Royal Cornwall Hospital in Truro, St Michael’s Hospital in Hayle and West Cornwall Hospital in Penzance. The service employed 5,683 staff as at September 2021.
We carried out an unannounced focused inspection of Royal Cornwall Hospital urgent and emergency care services (also known as accident and emergency - A&E) and medical care services (including older people's care) between 8 and 10 March 2022. We had an additional focus on the urgent and emergency care pathway across Cornwall and carried out a number of inspections of services over a few weeks. This was to assess how patient risks were being managed across health and social care services during increased and extreme capacity pressures.
As this was a focused inspection at Royal Cornwall Hospital emergency department (ED), we only inspected parts of four key questions: safe, responsive, caring and well led and did not inspect effective. In medicine we inspected all five key questions.
Our inspection had a short announcement of around 30 minutes to enable staff to arrange to meet with us and for us to carry out our work safely and effectively.
For this inspection we considered information and data on emergency department performance and medical care.
We looked at the experience of patients using urgent and emergency care and medical care services in Royal Cornwall Hospital. This included the emergency department but also areas where patients in that pathway were cared for while waiting for treatment or admission. We also visited wards where patients from the emergency department were admitted for further care. This was to determine how the flow of patients who started their care and treatment in the emergency department was managed by the hospital. During the inspection the trust had an outbreak of COVID-19 which resulted in several medical wards and some bays on other medical wards were closed. We were not able to visit these wards and bays during this inspection.
A summary of CQC findings on urgent and emergency care services in Cornwall.
Urgent and emergency care services across England have been and continue to be under sustained pressure. In response, CQC is undertaking a series of coordinated inspections, monitoring calls and analysis of data to identify how services in a local area work together to ensure patients receive safe, effective and timely care. We have summarised our findings for Cornwall below:
Cornwall
The health and care system in this area is under extreme pressure and struggling to meet people’s needs in a safe and timely way. We have identified a high level of risk to people’s health when trying to access urgent and emergency care in Cornwall. Provision of urgent and emergency care in Cornwall is supported by services, stakeholders, commissioners and the local authority and stakeholders were aware of the challenges across Cornwall; however, performance has remained poor, and people are unable to access the right urgent and emergency care, in the right place, at the right time.
We found significant delays to people’s treatment across primary care, urgent care, 999 and acute services which put people at risk of harm. Staff reported feeling very tired due to the on-going pressures which were exacerbated by high levels of staff sickness and staff leaving health and social care. All sectors were struggling to recruit to vacant posts. We found a particularly high level of staff absence across social care resulting in long delays for people waiting to leave hospital to receive social care either in their own home or in a care setting.
GP practices reported concerns about the availability of urgent and emergency responses, often resulting in significant delays in 999 responses for patients who were seriously unwell and GPs needing to provide emergency treatment or extended care whilst waiting for an ambulance. GPs also reported a lack of capacity in mental health services which resulted in people’s needs not being appropriately met, as well as a shortage of District Nurses in Cornwall.
A lack of dental and mental health support also presented significant challenges to the NHS111 service who were actively managing their own performance but needed additional resources available in the community to avoid signposting people to acute services. The NHS111 service in Cornwall worked to deliver timely access to people in this area, whilst performance was below national targets it was better than other areas in England.
Urgent care services were available in the community, including urgent treatment centres and minor illness and injury units and these services were promoted across Cornwall. These services adapted where possible to the change in pressures across Cornwall. When services experienced staffing issues, some units would be closed. When a decision was made to close a minor injury unit (MIU) the trust diverted patients to the nearest alternative MIU and updated the systems directory of services to reflect this. However, this carried a potential risk of increased waiting times in other minor injury units and of more people attending emergency departments to access treatment. This had been highlighted on the trust’s risk register.
Due to the increased pressures in health and social care across Cornwall, we found some patients presented or were taken to urgent care services who were acutely unwell or who required dental or mental health care which wasn’t available elsewhere. Staff working in these services treated those patients to the best of their ability; however, patients were not always receiving the right care in the right place.
Delays in ambulance response times in Cornwall are extremely concerning and pose a high level of risk to patient safety. Ambulance handover delays at hospitals in the region were some of the highest recorded in England. This resulted in people being treated in the ambulances outside of the hospital, it also meant a significant reduction in the number of ambulances available to respond to 999 calls. These delays impacted on the safe care and treatment people received and posed a high risk to people awaiting a 999 response. At the time of our inspection, the ambulance service in Cornwall escalated safety concerns to NHS England and NHS Improvement.
Staff working in the ambulance service reported significant difficulties in accessing alternative pathways to Emergency Departments (ED). When trying to access acute assessment units, staff reported being bounced back and forth between services and resorting to ED as they were unable to get their patient accepted. Many other alternative pathways were only available in specific geographical areas and within specific times, making it challenging for front line ambulance crews to know what services they could access and when. In addition, ambulance staff were not always empowered to make referrals to alternative services. The complexity of these pathways often resulted in patients being conveyed to the ED.
Hospital wards were frequently being adapted to meet changes in demand and due to the impact of COVID-19. There was a significant number of people who were medically fit for discharge but remaining in the hospital impacting on the care delivered to other patients. The hospital had created additional space to accommodate patients who were fit for discharge but were awaiting care packages in the community; however, staff were stretched to care for these patients.
Delays in discharge from acute medical care impacted on patient flow across urgent and emergency care pathways. This also resulted in delays in handovers from ambulance crews, prolonged waits and overcrowding in the Emergency Department due to the lack of bed capacity. We found that care and treatment was not always provided in the ED in a timely way due to overcrowding, staffing issues and additional pressure on those working in the department. These delays in care and treatment put people at risk of harm.
In response to COVID-19, community assessment and treatment units (CATUs) had been established in Cornwall. These wards were designed to support patient flow, avoid admission into acute hospitals and provide timely diagnostic tests and assessments. However, these wards were full and unable to admit patients and experienced delayed discharges due to a lack of onward care provision in the community.
Community nursing teams had been recently established to support admissions avoidance and improved discharge. This work spanned across health and social care; however, at the time of our inspections it was in its infancy so we could not assess the impact.
The reasons for delayed discharge are complex and we found that discharge processes should be improved to prevent delays where possible. However, we recognise that patient flow across the Urgent and Emergency Care pathway in Cornwall is significantly impacted on by a shortage of staffed capacity in social care services. Staff shortages in social care across Cornwall, especially for nursing staff, are some of the highest seen in England. This staffing crisis is resulting in a shortage of domiciliary care packages and care home capacity meaning many people cannot be safely discharged from hospital. A care hotel has been established in Cornwall providing very short-term care for people with very low levels of care needs; this is working well for those who meet the criteria for staying in the hotel, however this is a relatively small number of people.
Without significant improvement in patient flow and better collaborative working between health and social care, it is unlikely that patient safety and performance across urgent and emergency care will improve. Whilst we have seen some pilots and community services adapted to meet changes in demand, additional focus on health promotion and preventative healthcare is needed to support people to manage their own health needs. People trying to access urgent and emergency care in Cornwall experience significant challenges and delays and do not always receive timely, appropriate care to meet their needs and people are at increased risk of harm
Summary of CQC findings on services at Royal Cornwall Hospital.
Urgent and emergency care
- The service controlled infection risk well;
- Staff assessed patients and completed risk assessments for each patient as quickly as practically possible;
- Treatment of stroke within the emergency department was compared nationally with other trusts;
- Staff treated patients with compassion and kindness and took account of their individual needs;
- The trust had successfully recruited to four consultant grade posts and will be fully established for consultant grade staff within the emergency department;
- Leaders and teams used systems to manage performance effectively.
Medical care
- The service controlled infection risk well. Staff assessed risks to patients, acted on them. They managed medicines well.
- Staff worked well together for the benefit of patients. 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.
- The service planned care to meet the needs of local people and took account of patients’ individual needs.
- Leaders ran services well using reliable information systems. Risk to the service provision were identified and actions devised to help minimise these.
However:
Urgent and emergency care
- The Trust faced challenges with access and flow which meant they could not always ensure patients accessed the emergency department when needed, or ensure they received timely treatment;
- Patients were not receiving timely treatment; for example, some patients were not assessed or triaged within 15 minutes of arrival as per the national standard and some patients identified as being at risk of developing sepsis were not receiving antibiotics within one hour;
- Patients were waiting for long periods in the emergency department.
- Patients, experiencing chest pains, did not always receive an electrocardiogram (ECG) as soon as possible as per recommendations of the National Institute for Health and Care Excellence (NICE).
- Staff were not receiving mandatory training or appraisals;
- The environment that was designed to look after patients with minor injuries was being used for patients of greater acuity and was not suitable for this purpose. It was not always staffed to manage the level of the patient’s acuity;
- The mental health assessment room was being used to treat clinical patients and therefore the trust did not have a dedicated available room that was equipped to provide a safe and private environment for psychiatric assessments;
- There was a high turnover of ED nursing staff, leaving the department struggling for experienced nurses.
Medical care
- The service did not always have enough staff to care for patients and keep them safe. Some staff were moved to wards they were not familiar with to help maintain safer staffing levels. When capacity within services was pressured, they used areas that were not always suitable for patients and lacked some facilities.
- Outcomes for stroke patients did not always meet national standards. Information about some patients care needs was not shared with care or nursing homes on discharge which places patients at risk of unsafe care.
- People could access the service when they needed it but did not always receive the right care promptly due to pressures on bed capacity. There were significant numbers of patients unable to leave the hospital as they were waiting for onward care packages to be set up. Patients were being moved sometimes multiple times, sometimes at night, in order to admit them to the right place once a bed became available. Some patients were needing longer stays while they awaited treatment. Delays for patients waiting for cardiology investigations impacted on the demand for beds.
- Changes in the executive leadership team of the trust had impacted negatively on the staff. Some staff felt the new senior leadership for the trust did not visit the medical areas impacted by demand sooner. Morale was low for some staff in the service due to the immense and unrelenting pressures which had been ongoing for a number of years.