Royal Cornwall Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We reviewed the learning culture; safe systems, pathways and transitions; safe environments; safe and effective staffing and infection prevention and control (IPC), quality statements for the safe key question. Care and treatment was not always provided in a safe way. Care and treatment was not always provided in a safe and timely way, or in an area of the department where it was optimal according to the patient’s acuity level. Patients were not always admitted from the emergency department to a ward bed in a timely manner. Patients experienced waits in ambulances and care in temporary escalation spaces when the emergency department was at capacity. However, the department had improved its staff numbers and retention and staff were doing their best to mitigate risk at times of very high occupancy.

This service scored 66 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

While the people we spoke to expressed that they were generally happy with their care, we were told by some patients that there was a lack of communication on what was happening and what they were waiting for. Patients told us they happy to raise concerns with staff and that they were confident they would be listened to.

Staff told us they felt there was a strong and positive safety culture where staff were open and honest. They told us they were listened to when they spoke up about areas of concern and changes were made when they were in the gift of the department or hospital. When things went wrong, they were investigated, points of failure recognised, and learning shared. Risks were not ignored, and staff felt confident about speaking out. In the 2023 NHS Staff Survey, across the whole organisation, 73% of staff said they were confident about raising concerns about unsafe clinical practice. This was 3% above the national average. There were 62% of staff who said they felt safe speaking about anything that concerned them. This was 1% above the national average. There was a positive response from staff to the questions around staff development and opportunities to improve which were mainly above the average result for all trusts.

The trust had processes and policies to foster a learning culture. Senior staff met regularly, and evidence showed staff feedback was documented and taken forward with teams for learning. Safety events were investigated and reported. We saw evidence that duty of candour was consistently applied.

The patients we met in the urgent treatment area (often termed ‘minors’) were mostly those who had self-presented in the department (sometimes termed as “ambulatory”) or may have been brought by ambulance but able to have non-emergency treatment. Most told us they had not waited too long (“around half an hour” was a common response) for someone to see them initially and those in the waiting room at the time we visited had all been seen and were waiting for the next steps. Those patients in one of the cubicles or chairs within the minors area said they were all comfortable and knew what was happening. Some were waiting for tests or receiving treatment. However despite patients that we spoke with indicating that they were happy with their care, we were aware that some patients often spent longer than necessary in the department prior to being moved to a specialty ward, more suited to their condition. Trust data indicated it was in the top 90% for all attendances greater than 12 hours from arrival.

We saw staff work hard to establish and maintain safe systems of care in not always ideal conditions caused by crowding in the department. Patients were often nursed in corridors and had long waits on ambulances. Staff were concerned with the timeliness of review from specialty services. Some specialties, such as medical care, had doctors based in the department for much of the time to provide immediate support and decision making. However, due to the workload elsewhere in the hospital, specialty staff in some disciplines could be delayed or slow in attending the department or taking admission of the patient. On the days of the site visit, we saw the department’s capacity was full with patients being held in overflow areas not designed for long waits. We also observed 11 patients classified as majors in the urgent treatment area. However, we observed clear oversight of the department, including the overflow areas by senior staff in terms of its capacity and responsiveness.

Partners from the Cornwall system, such as the local community trust, GP’s and the local ambulance trust met monthly at the unscheduled care group meeting, to ensure the system was working together and safe for patients. The local ambulance trust was often frustrated at having crews held at the hospital looking after patients due to the lack of beds in the emergency department. This meant ambulances were unable to get to people in the community that required their services. However, we were told the situation at the time of our site visit had improved and all system partners were working together to avoid unnecessary ambulance handover delays. Data from the providers integrated performance report, April 2024 stated there had been a significant reduction in ambulance delays (over 60 minutes) with this being at its lowest since October 2021.

The provider had processes and escalation plans to manage increased pressures on the service. The expectation for effective triage was to see patients arriving on foot within 15 minutes of their booking to reception. This was a recognised time limit to ensure any urgent clinical treatment could be provided safely without further delay. At the time of our visit, not all patients were being seen within 15 minutes, but there were no serious delays. In the early morning of the second day we visited, the safety briefing heard there were no patients in the urgent treatment area waiting for triage. This can often be the case in these units and pressure tended to build during the day as we saw more patients arrive on our first day as the day went on. Data from the providers integrated performance report for April 2024 indicated an improving trend and that the time to initial assessment was 27 minutes. This was an improvement from 50 minutes in December 2023 but still not within the 15 minute expectation.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

Although patients experienced long waits in ambulances and waiting rooms, patients told us they were well looked after by staff. Patients we spoke with agreed that the department was clean and well maintained.

The equipment and facilities, in the main, supported the delivery of safe care. As previously mentioned under ‘safe systems’ when the department was crowded patients were held in areas not designed for long waits. Staff reported in the main there was no issue with accessing equipment, but several staff members were concerned about the provision of the MRI service. The emergency department in Royal Cornwall Hospital was the only one in the county and many miles from the next department located in Plymouth, Devon. The MRI scanner and interpretation of results were unavailable from 7.30pm until 7am the next morning. A senior member of the medical team said they felt “incredibly uncomfortable” with this lack of provision, and it was seen as “a significant risk.” Four ED consultants we spoke with separately raised this as a major concern. The clinical director of the department had studied the risk and concluded how providing the service at least until midnight would reduce the safety risk by a considerable factor. This was discussed at a senior leadership meeting. We fed this back to the executive team at the end of our visit.

The department had a modern resuscitation area (built 2020). This had increased the capacity for patients needing this emergency treatment from three in the previous small unit, to six bays, two of which could be used for isolation. There was a new protocol between the department, critical care and acute medicine designed to avoid patients who might fall between certain clinical priorities being held for too long in resuscitation. The resuscitation department had a full set of equipment for treating children and late-stage pregnant women. Each bay was large enough to easily allow for a multi-professional team to care for and treat the patient and have access to a vast range of equipment and facilities. The unit also had resuscitation practitioners who were dedicated to working solely in the unit, developing and maintaining a unique set of clinical skills related to trauma care. There was a mental health assessment room which was due for updating as it did not entirely conform to the guidance of the Psychiatric Liaison Accreditation Network (PLAN). At the time of our visit to the department, staff had needed to place a trolley in the room so the patient could lie down. This resulted in the second doorway required by PLAN being obstructed and ligature points being introduced. The staff told us they had risk assessed the situation and decided this was an acceptable plan in the circumstances and provided extra supervision of the patient to ensure their safety. Otherwise, the chairs in the room were not secured and were part of the safety refurbishment. Our concern, and that of the staff (which was on the risk register) was due to excessive delays in transferring patients with mental ill health to ward admission, they were waiting for too long in a room not designed for comfort and could exacerbate their symptoms. At the last inspection we also found the mental health room was being used for acute patients.

There was a relatively new system operating to help ambulance crews arriving have immediate insight into the capacity in the department. At the ambulance entrance, a red and green light system had been installed which was activated by the team managing the ambulance assessment area. If the light was green, the paramedics were able to immediately bring the patient into the department for assessment. If it was red, they needed to liaise with the team, or their hospital ambulance liaison officer (HALO) before bringing the patient through about next steps. Patients who were pre-alerted (a patient who was critically ill) were brought to the department immediately on arrival regardless of the red and green light status. An ambulance bay for critical patients was kept free directly outside the entrance.

Patient’s stated that the staff were all lovely, friendly and introduced themselves. They agreed that staff all seemed to get along together and there is a nice environment.

The service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. There were 4 substantive vacancies for middle grade doctors however, the trust used locum middle grades to fill these gaps and maintain safety. In terms of nursing staff, there were some vacancies however, this was partly due to a successful business case to increase the nursing numbers in the ED in the year 2023. There were 9 substantive vacancies for Band 5 however, the trust was actively recruiting to these posts. Bank and agency staff were used to staff the unfunded roster, such as corridor care and the ambulatory decision lounge. There was a positive culture around nursing education, classes and learning opportunities. At the time of the last inspection essential training was often cancelled to meet staffing shortfalls in the department, staff we spoke with at this inspection said that this no longer happened which was a significant improvement that helped to retain staff working at the trust. We met a trainee nurse associate who came into the acute sector following a career in the military medical services. They spoke highly of the training they had received and their supervision and mentorship. There was a welcomed pathway for future advancement of staff training in the nursing professions. After a two-year programme in the nursing associate role, and a year in the substantive role, the member of staff was enabled and supported to study to train as a registered nurse.

When we were on site, the department was busy with more patients being cared for than the department was built for. This put inevitable pressure on staff. However, staff said they felt able to respond to increasing demand and were authorised to increase staffing levels to meet patient need and acuity. This included, for example, nursing staff being located on the corridor where patients were waiting and having responsibility for monitoring and caring for them. There was also a nurse allocated to the ambulatory decision lounge where up to four patients could be waiting and being treated so they were not left unattended. We spoke with a patient who had been in the waiting room since the previous evening and had waited an hour to be triaged. They were subsequently returned to the waiting room awaiting a scan, with no pain relief until the following morning. Following the administration of pain relief the patient was not rechecked until CQC staff intervened and alerted staff to them.

Mandatory training was required of all staff and was monitored. Compliance with mandatory training had improved since the previous inspection and was at 83.7%. There was evidence of leadership development and training for staff. Staff appraisals were not always completed. Appraisal compliance as at March 2024 was 65.6%. This was an improvement since the last inspection where compliance was at 50.9%, however, this still did not reach the trust’s own internal appraisal target. We have requested the trust to complete an action plan to ensure staff have regular appraisals. A performance appraisal can have many benefits such as to identify individual learning needs, identify continuing development needs of employees and as a tool to identify progression opportunities.

Patients and carers said they had no concerns around the department being clean and processes for infection control. We were told by one patient how “there seems to always be someone cleaning and it does all look spotless.”

There were regular audits for infection prevention control and action plans to drive improvement should these audits indicate it was necessary. From the infection prevention and control environment audit taken in August 2024, the service scored over 85% compliance with the majority of areas inspected. Staff we spoke with understood how to care for suspected infectious patients.

Most of the patient areas were visibly clean and most of the equipment used was in good condition, although some of the seating used by the staff was worn and had tears which could lead to ineffective cleaning. We observed both clinical staff and the cleaning staff diligently cleaning equipment and the environment. The floors were clean despite heavy foot traffic and the constant movement of people and equipment. The privacy curtains were in good condition and there was no visible dust at height. However, in some areas we found examples of cleaning being missed. In the area behind the clinical desks in majors 1 was excessive dust on both the surfaces and the rear of the computer screens. This was a busy area and hard to access for cleaning staff, but it was clear it was not on anyone’s rota to tackle. We also found the two toilets used by staff to be in a poor state of repair with chipped and missing paint and damaged laminate. There were plenty of examples of notices stuck to walls with sticky tape, which should not be used as it was a risk to the spread of infection. There was a machine used for eye tests which had not been effectively cleaned. We gave feedback to the senior team during our visit around these areas of concern. In the patient toilet in majors 1, there was no hot water in the sink as the tap was ineffective and no hand towels. Staff were unaware of this and commented how there was a gap in regular and ongoing checks of facilities. One of the staff toilets also had no hand towels. We observed staff using hand gel and washing their hands between patients. When we observed a session in triage, the nurse made sure to clean any equipment they had used, such as the blood pressure monitor, between patients. They washed their hands and wore gloves when required. We observed a trainee nursing associate efficiently and effectively cleaning a bay after a patient had been discharged. They cleaned the equipment and made sure the room was entirely fit for use.

The department’s training team included IPC in all training and staff competencies were checked. Mandatory training data showed ED staff as 89.8% compliant with IPC training. The service had regular audits for infection control prevention and the environment.

We did not look at Medicines optimisation during this assessment. The score for this quality statement is based on the previous rating for Safe.