The Royal Cornwall Hospitals NHS Trust is the principal provider of acute care services in the county of Cornwall. The Trust serves a population of around 532,273 people, a figure which can be doubled by holiday makers during the busiest times of the year.

West Cornwall Hospital is a registered location of Royal Cornwall Hospitals NHS Trust and is located in Penzance. It provides medical inpatient, day surgery, urgent care and outpatient services. This was an announced focused inspection of West Cornwall Hospital. We inspected both surgery and outpatient services as part of this inspection. We visited West Cornwall Hospital on 5 July 2017.

We rated West Cornwall Hospital as good overall.

Our key findings were as follows:

• Staff reported incidents and demonstrated knowledge of how to do this. They could explain the learning and actions which had resulted from incidents, near misses and never events. They were confident in the processes to identify and report incidents.
• The environment was well maintained and was visibly clean and tidy. Staff adhered to infection control policies and procedures.
• Equipment was in working order and had been serviced/calibrated as required. Resuscitation equipment was checked regularly.
• There were arrangements to safeguard vulnerable adults and children from abuse, which reflected the relevant legislation and local requirements.
• Staff monitored patients for signs of deterioration and were confident in the process to follow and escalation route should a patient deteriorate or be identified for sepsis.
• Compliance with the five steps to safer surgery World Health Organisation checklist was observed in theatres. Checklists were appropriately adapted to suit the procedure.
• Care and treatment was delivered in line with relevant evidence-based best practice guidance and standards.
• All outpatient staff were competent to carry out their roles. Learning needs were identified during their annual appraisal and the trust encouraged and supported continued professional development.
• Patients were positive about the care and treatment they had received. We observed staff treating patients with compassion and kindness. We saw staff did everything possible to ensure that patients’ privacy and dignity was respected.
• Staff understood and respected patients’ personal, cultural, social and religious needs.
• Staff showed a supportive attitude to patients. When patients showed discomfort or emotional distress, staff responded in a compassionate, timely and appropriate way.
• Staff kept patients well informed throughout the pathway, ensuring their understanding and consenting patients verbally and with written consent.
• Patient flow from admission to discharge was timely, with minimal delays. However, the full capacity of theatres at West Cornwall Hospital was not being fully utilised.
• Information about the needs of the local population was used to inform how services were planned and delivered.
• Patients’ individual needs were taken into account, For example, people with learning difficulties, patients living with dementia, mobility problems, hearing difficulties and visual impairment may be given longer appointment times.
• There was a clear vision for surgical services at West Cornwall Hospital, however the strategy for achieving this was dependent on the review of the current infrastructure.
• There was a very positive culture in surgical services and all of the outpatient departments we visited. The local management teams were well respected. Managers supported their teams and promoted good quality care and were comfortable in raising concerns and issues. The departments we visited appeared well organised and were running smoothly.

We also saw areas of outstanding practice, including:

• There was a very positive culture in all the departments we visited. Staff described good teamwork and flexibility within the staff groups.
• Staff across all of the outpatient departments and we visited, including reception staff were very patient-centred and made great efforts to ensure patients were supported, given time to ask questions and understood the information they had been given.
• The department had six volunteers. We saw them helping people around the department and to different parts of the hospital. We saw them spending time with patients who were waiting, helping to relieve their anxiety. The volunteers also provided drinks to patients who were waiting for their appointments. The outpatient department manager spoke very highly of their volunteers and the positive effect they had on patients who visited the department.

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

Importantly, the trust must:

• Review all equipment in the surgical unit and theatres at West Cornwall Hospital and ensure it is serviced in line with manufacturer guidance. The asset registers should ensure a clear audit trail is maintained of date of last service and date due for next service.

In addition the trust should:

• Ensure all staff are aware of the local procedure at West Cornwall Hospital for managing patients requiring overnight stay or transfer for escalation of care and ensure this process is well embedded and staff are able to access advice immediately if a patient is at risk. The surgeon and anaesthetist should be reminded to visit the ward to check all patients prior to them leaving site and handover to the medical team on site in line with the local procedure. The arrangements with the ambulance service and timely transfer of patients should be reviewed to ensure there are no risks to the patient and staff are not left feeling vulnerable.
• Ensure staff are confident in the response to emergencies through the use of simulation scenarios and use these to identify learning needs for processes and staff.
• Review the use of fabric reusable curtains in the surgical unit and the diagnostic imaging department and their implications on infection prevention control within the hospital.
• Consider a formal process for clinical supervision to ensure improvements in nurse practice and reflective learning.
• Continue to review the capacity at West Cornwall Hospital and the opportunities to increase theatre lists for the benefit of improving flow at Royal Cornwall Hospital and ensuring patients receive timely operation dates.
• The trust should ensure there are processes in place for induction and orientation when West Cornwall Hospital staff are relocated to Royal Cornwall Hospital for their shift. Consideration should be given to the safe staffing provided when staff are required to work on wards or departments which they have never experienced or are not comfortable to work in.
• Review the process for recording and managing risks relevant to theatres and the surgical unit at West Cornwall Hospital.
• Monitor the risks and practices put in place to reduce the risks for radiography staff when lone working out of hours.
• Make better use of the cardiology clinic capacity available at West Cornwall Hospital.
• Make data available, trust-wide, to show the proportion of patients that waited more than 30 minutes to see a clinician or what percentage of clinics started late.
• Display information about chaperones being available in all outpatient areas.

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 the Trust Development Authority (TDA).

The Trust serves a population of around 450,000 people, a figure that can be doubled by holidaymakers during the busiest times of the year.

This is the second comprehensive inspection we have carried out 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 required.

Our key findings for West Cornwall Hospital were as follows:

Safe

• There was a positive approach to incident reporting with evidence of learning from within and external to the ward and hospital. Patients were informed by staff when things went wrong and given an apology.

• There were reliable systems in place to prevent and protect people from a healthcare associated infection and equipment was checked and maintained.
• There were sufficient nursing and medical staff to meet patient needs

Effective

• Staff provided evidenced care and treatment. The endoscopy unit had received JAG accreditation and the renal unit had started to deliver haemodiafiltration to improve patient outcomes.
• There was a strong focus on multidisciplinary working.
• Staff had a good understanding of the mental capacity act and its application in practice.

However,

• Not all staff had received annual appraisals with one ward reporting only 8% of staff having had an appraisal in the previous twelve months.

Caring

• Staff were seen to deliver care that was kind and compassionate and at times went the extra mile to care for both patients and relatives. Emotional and spiritual needs were met.
• Patients were highly positive about the care and attention they received.

Responsive

• Services were planned to meet the needs of patients and visitors to the area.
• Discharge planning commenced on admission.
• Staff at the hospital went to great lengths to plan, deliver and coordinate care and services in a way that took into account patients’ complex needs.

However

• It was not clear how patients or relatives could raise a concern or a complaint.

Well led.

• There were governance systems in place that ensured activity was monitored, risks were reflected on the risk register and findings were fed into the trustwide governance system.
• There was an open culture with a visible leadership where staff felt able to raise concerns.
• There was innovative working and close engagement with the local community. Recruitment and retention strategies were in place.

We saw several areas of outstanding practice including:

• The hospital worked closely with Age UK to provide additional services to patients on discharge. This ensured their home was ready for them when they returned. Their presence within the hospital also supported the care of patients living with dementia.
• Staff went the extra mile for example by providing a ‘memory café’ in the day room on a weekly basis. Patients and family members could attend for free and were invited to engage in singing, quizzes and games to help engage people living with dementia. Patients received tea and homemade cakes made by the nurses, along with prizes.

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

The trust should:

• Ensure the decontamination room and storage room used by the endoscopy service is kept secure at all times.
• Ensure there is a system to monitor staff accessing clinical supervision.
• Ensure all staff receive an annual appraisal.
• Ensure the process is clear on how patients or relatives could raise a concern or a complaint.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We spoke with patients about the service they received when we visited the two medical wards, outpatients, operating theatres, day surgery unit, renal dialysis unit and the Urgent Care Centre at West Cornwall Hospital.

We had a large number of comments, both from patients at the time of the inspection and also comments left by patients who had used the service on the NHS Choices website. This was further supported by the comments received from the enthusiastic and knowledgeable staff. The staff told us they enjoyed working at the hospital, and they felt supported, both by their colleagues and also by Royal Cornwall Hospitals NHS Trust (RCHT).

Comments received from patients included “We both know what's happening and we’re kept fully informed”, “I was fully informed about the reason for the X-ray” and “The consultants are friendly but professional and put you at your ease. I felt very much included in the whole process”.

Patients were protected by the hospital’s management of medicines, its robust recruitment procedures and the tools and methodology used to monitor practices and outcomes for patients.

We spoke with people about the service they received when we visited two medical wards and the Urgent Care Centre at West Cornwall Hospital.

People told us they had confidence in the staff and the service offered. People said they were satisfied with the care provided and the kindness and politeness of the staff. All the comments received from people at the time of the inspection were positive, and this was further supported by the comments received from the enthusiastic and knowledgeable staff. The staff told us they enjoyed working at the hospital, and they felt supported, both by their colleagues and seniors and also by Royal Cornwall Hospitals NHS Trust (RCHT).

One patient described their experience at West Cornwall Hospital in August 2012 on the NHS Choices website: “Excellent service - I really felt like the staff cared about me. They were attentive, helpful, thoughtful, considerate and patient. They listened to my concerns and addressed them properly. When I went for my booking appointment they did everything there and then - I saw five departments in an hour, so I wouldn't have to come back. And they were concerned about keeping me for an hour, they kept apologising, checking on me, chatting, bringing me drinks - I almost didn't want to go home! They really took care of me”.

We spoke with people about the service they received. They told us that they have confidence in the staff and the service offered. People said they were satisfied with the care provided and the kindness and politeness of the staff. One patient described the nursing staff as “wonderful”. Someone who visited West Cornwall Hospital in December 2010 said "This is a vital and excellent hospital". Another said “This is an excellent hospital where my son received vital life saving treatment over Christmas. I can't thank the staff enough especially the two junior doctors on duty who made all the right decisions”.

One person using West Cornwall Hospital in December 2010 made comment on the NHS Choices website that “the ward was exceptionally clean and well maintained”, and another earlier in the year said “…ward was spotless and I was very impressed”.

Our rating of services stayed the same. We rated it them as good because:

• Urgent and emergency care has not been rated before. Safe, effective, caring, responsive and well led have all been rated good.
• Medicine has stayed the same since our last inspection and was rated as good. Safe was found to be worse and went down one rating to requires improvement. Effective remained the same and was rated as good. Caring went down one rating from outstanding and was rated as good. Responsive and well led remained the same as our last inspection and were rated as good.
• Surgery remained as good overall. Safe stayed the same since our last inspection and was rated requires improvement. Effective, stayed the same and was rated as good. Caring stayed the same since our last inspection and was rated good. Responsive and well-led both also both stayed the same since our last inspection and were rated good.
• Outpatients was rated as good overall. Safe, caring, responsive and well led were all rated as good. Effective was not rated.