West Cornwall Hospital

Royal Cornwall Hospitals NHS Trust provides acute hospital services from West Cornwall Hospital, Royal Cornwall Hospital, St Michael’s Hospital and St Austell Hospital. The trust employs approximately 8,000 staff.

We carried out an unannounced focused inspection of West Cornwall Hospital’s urgent treatment centre on 8 and 9 March 2022.

As this was a focused inspection at West Cornwall urgent treatment centre, we only inspected parts of five our key questions. We inspected parts of safe, responsive, caring and well led using our focused inspection framework. We did not inspect effective at this visit but would have reported any areas of concern. We did not rate the service as part of this inspection.

This inspection was carried out to evaluate how the organisation was responding to patient’s needs; we had not inspected the urgent treatment centre since September 2018. The urgent treatment centre was previously rated as good overall.

We looked at the experience for patients using urgent and emergency care services at West Cornwall.

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 West Cornwall Hospital.

• The service mostly had enough staff to care for patients and keep them safe. Staff understood how to protect patients from abuse and acted on any concerns. Patients had an assessment of their infection risk and other clinical risks on arrival at the centre and were treated according to their priority of need. Clinical areas were visibly clean and staff managed safety well.
• Staff were empathetic and caring when treating patients and demonstrated an understanding of how patients may be feeling when receiving treatment. Patients felt informed of their treatment choices and praised staff for care they received. Staff worked together as a team to benefit patients. They supported each other to provide good care. Key services were available seven days a week to support timely patient care.
• The service planned care to meet the needs of local people, including times of extreme capacity pressures to help staff provide safe care and treatment for patients. Staff worked hard to meet individual needs of patients and made co-ordinated care with other services and providers.
• Leaders managed the service well and used reliable systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact. They were focused on needs of patients receiving care. Staff were clear about their roles and felt supported by local and trust-wide managers.
• Local managers demonstrated the skills and abilities to run the services. They understood and managed the risks and issues the services faced. Level of capacity pressure for the service was communicated to executive leaders and across the trust. They were supportive and caring for patients and staff.

However:

• There was a risk of patient needs not being met when the urgent treatment centre changed to a minor injuries and illness unit at 8pm each day. This was particularly concerning when acutely unwell patients were cared for overnight in the urgent treatment centre because there were no available ambulances to transfer them to the Royal Cornwall Hospital.
• There was a risk to patients when safeguarding concerns were not assessed and addressed on discharge. Staff did not consistently complete the adult safeguarding checklist prior to patient discharge.
• There were not always enough nursing staff to cover the planned rotas for each shift in the service. However, managers regularly reviewed staffing levels and skill mix to maintain patient safety as much as possible.

How we carried out the inspection

At West Cornwall Hospital, we spoke with nine patients and their families, eleven staff, including nursing, medical, administration staff and service leads. We observed care provided, reviewed relevant policies, documents and patient records.

You can find further information about how we carry out our inspections on our website: https://www.cqc.org.uk/what-we-do/how-we-do-our-job/what-we-do-inspection.