The emergency department at Cornwall’s main hospital must continue to improve despite staff being praised for their hard work, dedication and care. Inspectors from the Care Quality Commission last inspected the emergency department at the Royal Cornwall Hospital at Treliske in Truro in March 2022. At the time, A&E was inspected but not rated.
Inspectors returned to Treliske’s urgent and emergency care department in May and July following growing concerns that patients were waiting too long before being seen with many of them having to wait in ambulances parked outside for hours on ends. There was also a concern that there had been too many falls in corridors involving elderly patients.
While the CQC said it was pleased to see some improvement against the areas of concern found during the previous inspection in 2022, inspectors found that patients were not always admitted from the emergency department to a ward bed in a timely manner and the number of stranded patients – the so-called ‘bed blockers’ – was high.
In their report, the CQC wrote: “Patients experienced waits in ambulances when the emergency department was at capacity. The issues found were linked to the crowding of the emergency department and the lack of care packages available in the local community which meant people in the hospital who were fit for discharge remained being cared for in the hospital setting.
“We also found that appraisals for staff were not completed regularly which was also an issue at the previous inspection. The major area of concern was crowding.
“As with other hospitals, due to a crisis in capacity for ward beds, there were often patients being held on ambulances in the care of ambulance staff. This was due to the emergency department being full and patients who needed admission or specialty review being managed in an overflow area.
“Delaying ambulances led to delays for patients waiting in the community. These delays resulted in staff caring for patients longer than required in the emergency department.”
Royal Cornwall Hospitals Trust (RCHT) chief executive officer Steve Williamson said the report on the emergency department was “fair and captures the challenging circumstances our emergency care teams and hospitals face”.
He said: “It is reassuring to see the rating for Safe has improved to Good but we accept that, together with our partners across the health and care system, we have more to do to further improve our ability to provide timely care, even at times of intense pressure, as we are currently seeing.”
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As a result of the inspection, the rating for Treliske’s urgent and emergency care department remained unchanged as ‘requires improvement’ as are the ratings for effective and responsive.
However, it was not all bad news for the RCHT, which runs the hospital along with West Cornwall Hospital in Penzance and St Michael’s Hospital in Hayle. CQC inspectors noted that when it comes to the care provided by staff it is ‘good’, while the department is also ‘well led’ and the rating for safety improved from ‘requires improvement’ to ‘good’.
A report on older people’s care provided on Zennor ward was also assessed as ‘good’. The hospital was rated as ‘inadequate’ in September 2018 but was re-rated as ‘requires improvement’ a few months later after improvements were made. That overall rating remains in place for both the hospital and RCHT.
Catherine Campbell, CQC deputy director of operations in the south, said that “over-crowding in the emergency department created issues that the trust couldn’t solve alone, and further support was needed from the local health and social care system to address”. She also noted how the facilities are in need of updating.
She said: “Throughout our inspection of Royal Cornwall Hospitals NHS Trust’s urgent and emergency care, we saw staff were working hard to provide safe care in challenging conditions.
“The trust faced issues with the high number of people attending the department and with discharging people to the local community, which in turn created a problem of flow around the hospital. We also found people who were fit for discharge were staying in the hospital longer than they needed to because their care outside the hospital wasn’t ready.
“This over-crowding in the emergency department created issues that the trust couldn’t solve alone, and further support was needed from the local health and social care system to address.
“People faced unacceptable delays for care when the department was at capacity, people could also face lengthy waits in ambulances. This had an impact on the ambulance trust’s emergency response times in responding to other people. We saw people being cared for in one of the corridors of the department. While they were treated with kindness, people and staff told us it was difficult to maintain privacy in such conditions.”
She added: “We found the senior leadership team was open to challenge and understood the problems the service faced. They were supporting staff to manage the priorities and issues and deal with difficult circumstances.
“In medical care, we found a good safety culture where staff regularly discussed people’s care. Staff highlighted people’s conditions when things got worse and provided safe care and treatment, using well-defined procedures to assess risks and select a personalised care plan. The environment was clean and tidy, but in need of modernisation and adjustments to make it dementia friendly.
“The trust knows where it needs to make improvements to ensure the safety of people needing urgent and emergency care. CQC will continue to engage with the trust and partners and will return to check on progress.”
Mr Williamson said that in the seven months since the emergency department inspection, a great deal has been done to improve urgent and emergency care pathways, not least in the expansion and introduction of more community-based services offering alternatives to the emergency department or hospital admission.
He said that these include same day emergency care units in Bodmin, Camborne-Redruth and Penzance, and a new single point of access advice line for GPs, ambulance crews and other health professionals to support them in directing patients to the nearest community services that can meet the individuals’ needs.
He added: “Most recently at RCHT we have launched our ‘Home for lunch’ initiative which aims provide a safer discharge from hospital by getting patients home and settled earlier in the day, and at the same time freeing up beds sooner to admit new patients. This will avoid long waits and over-crowding in the emergency department and consequently, ambulance queues and handover delays.”
Inspectors findings in urgent and emergency care:
- There was a strong safety culture with staff feeling confident to raise concerns.
- The department had passports for people with learning disabilities and made adaptions to try and reduce any possible distress such as moving them to a quieter area of the department or an area where lights could be dimmed.
- The service now had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
- Members of the NHS ambulance service spoke highly about the camaraderie and teamwork in the department. The paramedics and ambulance technicians said they felt part of the team and were respected by staff in the department.
- The service accessed a translation service for people whose first language wasn’t English and there was an induction loop fitted at the reception desk to help people with hearing aids.
- The service had also improved its staffing levels since the last inspection to support this.
- There was good external partner engagement, including with the local mental health trust, but the mental health trust had its own capacity issues which caused significant delays for people needing transfers.
The areas that need improvement:
- MRI services were unavailable between 7.30pm and 7am the next day with some staff telling inspectors they saw this as a significant risk.
- There was a mental health assessment room which was due for updating as it did not entirely conform to the national guidelines. Staff had needed to place a trolley in the room so a person could lie down. This resulted in a second doorway being obstructed and ligature points being introduced.
- Essential staff training had been frequently cancelled due to staffing pressures.
- Staff said they were worried about the pressure they were under and how this affected their ability to provide safe and quality care. Inspectors recognised this had been relentless and with the summer months when the tourist population arrived, this was unlikely to be easing.
RCHT’s chief medical officer Merry Kane said: “Like many parts of the country, we are experiencing a challenging start to 2025. Whilst Norovirus and flu have stifled our progress in recent weeks, the work we began in late November to get patients ‘Home for lunch’ had seen a reduction in ambulance delays and is helping us to contain those at a lower number, despite the current pressure.
“We’re also working to ensure we get patients home as soon as they are medically fit, particularly frail and elderly people, to avoid the hospital acquired deconditioning that can prevent them regaining their mobility and independence.”
Bernadette George, the director of nursing, midwifery and allied health professionals, added: “None of us want patients to experience delays in any part of their emergency care pathway and our own staff and colleagues across health and care services are working tirelessly to prevent that happening.
“What does shine through the CQC’s report is the kindness and compassion of our staff who assessors observed were ‘doing their best to mitigate risk at times of very high occupancy.’ It is also reassuring to see acknowledgement of the high calibre of leadership across the team and the open and honest culture that is so important to patient care and safety.”
Bernadette added: “The report on Zennor ward, following the CQC’s inspection last July, is an overwhelmingly positive one, with the team recognised for their attention to patient safety, risk assessments and well-documented individual care plans. Whilst it was acknowledged the ward is well-staffed, the environment, in the oldest part of the Royal Cornwall Hospital is tired.
“The good news is we starting on a refurbishment next week which will include work to make the ward a more dementia friendly setting. It was great to see the team acknowledged for their work which has successfully reduced falls and to read the feedback from patients talking of kind and competent staff who supported and listened to them.”
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