We undertook this focused inspection to follow up on the concerns identified in a Section 29A Warning Notice served on the Trust in June 2015. The inspection in June 2015 was to follow up concerns found at the comprehensive inspection of the trust in January 2014.

The warning notice related to a failure to comply with Regulation 18 (1) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Staffing.

Compliance with the Section 29A Warning Notice was required by 7 October 2015. The inspection was conducted on 21 October 2015 and was unannounced.

Our inspection focused on the issues identified in the emergency department and the Higher Care Bay on Wellington ward, which were:

• In the main emergency department on occasions there was insufficient staff to provide a safe environment for patients. In the children’s emergency area there was one nurse on duty, who was not always a registered sick children’s nurse.
• The levels of sufficiently skilled staff, in the high care bay on Wellington ward (where patients who may require higher levels of care or requiring non-invasive ventilation were co-horted) were of concern where we observed occasions when non registered nursing staff were left for periods of time caring for patients requiring high levels of care.

Our key findings of the inspection carried out on 21 October 2015 were as follows:

• Staffing levels for Wellington ward Higher Care Bay had been increased. This meant there was 24 hour registered nurse presence on the Higher Care Bay at all times including when staff had to leave the bay to prepare medications or for their break.
• There were regular processes and audits in place to assess patient dependency and to ensure staffing levels and skill mix met the care and treatment needs of the patients in the Higher Care Bay.
• We found that nursing staffing levels in the emergency department (ED) had been increased, using an evidence-based model to inform numbers and skill mix for the main and children’s emergency areas.
• Additional registered children’s nurses had been appointed to ensure the ED had one on duty every shift.
• The whole hospital discussed staffing issues at the bed meetings, held three times a day.
• We found the concerns raised in the warning notice had been met.

Professor Sir Mike Richards

Chief Inspector of Hospitals

The inspection was carried out on 28 and 29 May 2013 with two compliance inspectors, a national professional advisor and an expert by experience. We looked at five outcome areas. In particular; clinical care quality assurance processes, follow up of children’s services inspection reports from 2011 and 2012, disabled access and staff support systems.

We spoke with 15 patients and observed staff and patients on a variety of wards and departments including the maternity department, gynaecology department and ward, cardiology wards, trauma wards, gastroenterology wards, children’s wards and the dermatology department, which included day surgery. Comments from patients we spoke with were positive and they praised the care, support and treatment they had received. One patient told us “the nurses have got a lot to do, little time to do it and they’ve got to do the best they can” the same patient also said “the girls here are marvellous and compassionate with each other”. On another ward a patient told us “the staff on X are brilliant, though they generally need more staff”. A different patient told us “the nurses have a very good attitude.

We spoke to over 50 staff including the medical director, interim nurse executive, head of quality and safety and quality improvement manager, tissue viability consultant nurse, speciality director and governance lead in dermatology, psychiatric liaison nurse, divisional general manager and divisional director of surgery, trauma and orthopaedics, head of learning and organisational development, learning and development nurse, divisional nurse for anaesthetics and theatres, the responsible officer for revalidation, divisional director of women, children and sexual health, child protection named nurse, divisional nurse – head of midwifery, cardiac catheter laboratory manager, coronary care unit manager, matron for child health, head of estates operations and head of human resources business partners. On the wards and departments we visited we also spoke to nurses, midwives, healthcare assistants and housekeeping staff.

People who used the service were protected from the risk of abuse, because the trust had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

The trust has taken steps to provide care in an environment that was suitably designed and adequately maintained. We found that disabled parking provided could cause difficulties for people with mobility problems due to the distance from the spaces to the pay and display machines.

People were cared for by staff who were supported to deliver care and treatment safely and to an appropriate standard.

The hospital had appropriate quality assurance processes in place to monitor and improve the services they provided. However a number of the patients we spoke with had not been advised of the process to follow if they had any concerns about treatment or staff.

We spoke with people about the service they received when we visited an elderly care ward, a trauma ward, an oncology ward and the emergency department at the Royal Cornwall Hospital.

People told us they had been looked after well and had confidence in the service offered. One person said “everyone is very kind and caring”, “nothing is too much trouble for them”. One person said the staff “know what they are doing”. Another added that the various staff had “explained everything” and all “knew what each other were doing”.

The staff told us they enjoyed working in their particular departments, and they felt supported, both by their colleagues and the senior management team.

Staff throughout the hospital confirmed that they knew how to report any incidents of perceived abuse. They also told us that they had access to training both mandatory training and training relevant to their particular job role.

All of the wards and departments we visited were clean. They had hand washing facilities available and access to aprons and gloves as required.

We saw that the trust had a number of internal and external audit systems in place to monitor the quality of the service provided. We were reassured that they responded appropriately when they were given information of concern. They reviewed their own processes as a result of concerns raised and made amendments to their systems if required.

We carried out a responsive review of the Royal Cornwall Hospital on 23 May 2012 between 4pm and 8pm. This followed safeguarding concerns about the care of vulnerable people who may not be able to speak for themselves. We visited Wheal Agar ward (from where the concerns had first been bought to our attention), Carnkie ward, Grenville ward, Phoenix ward, Roskear ward and the Medical Assessment Unit. The inspection team consisted of two compliance inspectors and a specialist nurse.

On Wheal Agar ward we observed people being assisted to stand up and move about appropriately. We saw that people were being offered a choice of meal and an explanation of what the meals were. We also saw staff chatting with people in an adult manner and at eye level with the patient.

One person on Carnkie Ward told us that they had been treated with respect and kindness throughout their 11 day stay. She added that the staff were completely flexible in responding to her needs. This view was reiterated by a patients on Roskear Ward and the Medical Admissions Unit who described the staff as “kind and caring”, “brilliant in the night” and “can’t speak highly enough” of them.

People, on all the wards we visited, told us that they did not have to wait too long to have the bell answered. This view was supported by our observations. Apart from on Wheal Agar Ward where the provider might like to note that we were told by a visitor that their relative had had to wait so long for assistance they had soiled themselves already before anybody arrived..

We saw staff on Wheal Agar ward struggling to meet the demands of the patients. Many of the patients needed two staff to help them and others were wandering around with no focus. One person was observed picking up a piece of electronic equipment from the nurse station. This warranted a staff member to quickly go to the lady to take the item off her. The equipment might have been harmful to her or become damaged by her meaning that the equipment would then not be available for other perople to use.

One person on Carnkie Ward told us that the staff had been very supportive to her through a difficult time and that she never felt rushed. Another person told us that the staff had been “excellent” and that they had “no complaints”. They added that they had been “fully involved” in their discharge plans and had had lots of information.

Patients we spoke to on the Medical Assessment Unit spoke very highly of the staff. Patients on both Medical Assessment Unit and Roskear ward told us that noise at night was an issue and this coupled with the medicine round sometimes happening at 11.30 pm often prevented them from getting proper rest.

One patient and two visitors on Phoenix ward told us that the “care couldn’t be better in a private hospital”. They added that “staff are excellent. And they keep us informed every step of the way”.

Two patients on Grenville ward told us that they had seen other patients wait for a long time to have their bells answered when they rang for assistance.

People on Carnkie Ward told us that the food was “brilliant”. Another person said that what they had chosen they had enjoyed. They were pleased that small portions were available as they did not have big appetite.

When we arrived on Wheal Agar ward it took over five minutes for anybody to answer the bell to let us in. Staff told us that staffing levels go in “peaks and troughs” as often agency staff bought in to help did not always have the relevant skills and experience to look after people with dementia. We were told that the directors of nursing have been very supportive and they were aware that recruitment specifically for Wheal Agar ward was underway.

One relative told us that there were “not enough staff” and whilst they were usually polite and helpful they were “a bit thin on the ground”.

Three staff on Carnkie ward told us that due to the high number of intravenous drugs that have to be given they often felt that there were not enough trained nurses on duty. On the day of our inspection they were managing with one less trained nurse due to sickness. Two of the staff said that the ward had recruited two trained nurses with previous relevant experience and felt that once they started the pressures would ease.

One member of staff on Roskear ward told us that she had had concerns about staffing levels in the past. As a result she had made an untoward incident report. These reports are seen by senior staff in the hospital and fed into national patient safety data.

Two patients on Grenville ward told us that the staff were very busy all of the time.

The nurse in charge on Grenville ward told us that he thought they were fully staffed at the moment. He told us that as the ward has a variety of patients, some of whom have dementia, he was the ward dementia lead. He was supported by two health care assistants. We observed him advising a relative about completion of a ‘This Is Me’ booklet, designed to help staff understand the needs of people who may not be able to speak for themselves and describe their likes and dislikes.

Staff on Phoenix ward told us that staffing numbers go down to four overnight even though the needs of the patients are still high with many of them needing two staff to assist them.

Staff on Wheal Agar ward told us that they had recently met with senior staff regarding poor staffing levels. They told us that they are reassured that this was being actively addressed. They said that they were receiving support and regular visits from the nurse consultant and other senior nursing staff. They said this was to ensure that the skill level and numbers of staff would enable the staff to tailor the care to meet patients individual needs.

On the medical admissions unit staff told us that flexibility of staffing was required to meet the fluctuating demand. They explained that they used an electronic rostering system and had access to bank staff and funding for agency staff if required. They said that new staff had recently been recruited and would be joining the team soon.

The nurse in charge on Carnkie ward told us that the ward had recently gone through a difficult period but there were lots of improvements planned. She felt very positive about the development plan and thought it was realistic and achievable. She added that the need for annual appraisals and regular supervision (one to one) to take place had been added to the plan and were due to start taking place very soon.

We spoke to an assistant practitioner (a role developed from the health care assistant role to provide more complex support to the trained nurses). She told us that they carried out extensive training over a two year period. She added that the role has not been completely defined and so an educator had been appointed for three months to ensure the correct protocols were in place to define what an assistant practitioner can and cannot do. She felt supported by this move and enjoyed the role very much.

Staff on Phoenix ward told us that annual appraisals were taking place. They added that if you physically had to attend training there was no problem being released, but if the training was via e-learning then it was more difficult to get protected time to complete it.

The nurse in charge on Grenville ward told us that their annual appraisals take place. He added that the ward managers had an open door policy and encouraged staff to raise any concerns with them at any time.

We did not speak to people who used this service as part of this review. We looked at a random sample of medical records. This was to check that current practice ensured that treatment for the termination of pregnancy was not commenced unless two certificated opinions from doctors had been obtained.

People told us that the staff are always very busy but despite that they cannot praise them enough. They added that ‘everyone is lovely’, ‘staff are wonderful’, ‘wonderful staff and Doctors’ and that they are ‘looked after well’. One person, on the Surgical Receiving Unit, said that they had been waiting for a wash for over an hour. One person said that they had once been nil by mouth for four days because the list kept getting cancelled and that an intravenous drip was not quite the same as eating.

People who use the service and staff consistently told us that there were not enough staff.

People said that staff communicated with them well and they felt informed about their conditions and what would be happening to them.

People told us that (especially on the Medical Assessment Unit and Wheal Agar Ward) that it is noisy at night, with staff making a lot of noise with no effort to be quiet. They added that some of the equipment is also noisy.

We were told by patients, on Wheal Agar Ward, that there is no access to a television and that they sit by their bed all day with not a lot to do.

People using the service said although the staff are busy they can ask them questions or speak to them if they have any concerns. Relatives we spoke to said they had felt included for example when their relative had returned from the operating theatre.

Because we were reviewing practice in the operating theatres we did not speak to many people who use the service.

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

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