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Our quality and safety standards

This page was last updated: October 7th, 2022

At Royal Cornwall Hospitals, the quality and safety of your care are our highest priorities. There are national and local standards, policies and procedures to ensure you have the best possible outcomes and experience.

We adhere to the NHS Constitution for our standards and waiting times. We are inspected and regulated by national and local organisations who ensure we provide services to expected levels and meet our commitments within the National Health Service. We also take very seriously the feedback we get from patients and visitors and respond to concerns when they arise.

How are we doing?

At each Trust Board meeting in public we provide an ‘Integrated Performance Report’ which is a summary of how are we are doing on all the main standards and covers our performance on quality and safety as well as finances and workforce information. You can find our Integrated Performance Reports in the ‘Trust Board meetings and papers’ toggle in the Trust Board section.

You may also want to read how the Care Quality Commission rate our services and you can read their assessments of our services on CQC’s website.

Patients and visitors often leave feedback on the NHS Choices website and again you can check there for other views on our care:

If you have any questions about our standards of care or want to make a compliment or complaint please get in touch.

More detail can also be found in our Quality Accounts for 2021-22.

Frequently Asked Questions

Do you offer single sex accommodation?

We are committed to providing every patient with same sex accommodation, because it helps safeguard their privacy and dignity when they are often at their most vulnerable. This means making sure you don’t have to share accommodation, toilets or washing facilities with patients of the opposite sex.

In exceptional cases, when clinically necessary, a patient of the opposite sex who needs very specialised or urgent care might take priority. If this happens, we’ll make sure the time a patient spends in this environment is kept to an absolute minimum; extra care will be taken to protect the patient’s privacy and dignity.

We ask all our patients to respect the privacy and dignity of others, and expect you to show the kind of respect to others as you’d expect yourself, particularly when using toilets and washing facilities. If you have any concerns, please let us know.

Same sex-accommodation means:

The room where your bed is will only have patients of the same sex as you

Your toilet and bathroom will be just for your gender, and will be close to your bed area
There may be both men and women patients on the ward, but they will not share your sleeping area. You may have to cross a ward corridor to reach your bathroom, but you will not have to walk through opposite-sex areas.

Communal space, such as day rooms or dining rooms may be shared and it is very likely that you will see both men and women patients as you move around the hospital (eg on your way to X-ray or the operating theatre).

It is probable that visitors of the opposite gender will come into the room where your bed is, and this may include patients visiting each other.

It is almost certain that both male and female nurses, doctors and other staff will come into your bed area.

If you need help or assistance to use the toilet or take a bath (such as a hoist or special bath) then you may be taken to a unisex bathroom but a member of staff will be with you and no other patient will be able to access the bathroom whilst you are in there.

How are you working to improve identification of sepsis?

Sepsis, also known as blood poisoning or septicemia, claims 44,000 lives a year in the UK – more than bowel, breast and colon cancer combined, and can occur at any age. Many of those lives could be saved, and in a similar way that we battled MRSA a decade ago and have campaigned to act FAST on the signs of stroke, there is now a major drive to increase awareness of sepsis among both health professionals and the general public.

Signs of sepsis

  • Slurred speech
  • Extreme muscle pain
  • Passing no urine
  • Severe breathlessness
  • I feel I might die
  • Skin mottled or discoloured

How we’re working to improve outcomes for sepsis at the Royal Cornwall Hospitals Trust

At the Royal Cornwall Hospitals Trust, we have introduced a number of measures, and tough targets, to improve the screening of patients and identification of sepsis. These really are life-saving changes that we can and need to make in order to prevent unnecessary deaths from Sepsis.

These include:

  • A dedicated Lead Nurse for Sepsis, whose role is to ensure those involved in patient care are spotting the warning signs which can lead to major organ failure and taking action in the vital first hour. Every hour’s delay increases mortality by almost 8%.
  • A Trust Lead for Sepsis who works to ensure that a culture of sepsis screening and identification of sepsis is embedded within our hospitals with assistance from clinicians in the key areas of Emergency Department and the Medical Admissions Unit.
  • There is a big emphasis on education, too. Education and training is offered to all levels of clinical staff, and includes:
    • Sepsis Champion Study Sessions – educating members of the MDT to pass on their knowledge to others
    • Sepsis simulation with the Simulation Team and as part of the AIMS & ALS courses,
    • HEAC332 & HEAC334 courses
    • Mandatory Training – from January 2017
    • Ward/department-based teaching sessions.
  • Throughout the trust, patient notes are audited to see that nurses are screening appropriately for Sepsis on the Trust’s NEWS chart and on E-Obs. Compliance with the use of Sepsis 6 is also audited.
  • We compile weekly audits in the Emergency Department to monitor our compliance and effectiveness. This review identifies if patients are being appropriately screened and where necessary that the correct steps are then taken. The data is then fed back to the clinical leads in each area to let them know how well they are doing.
  • We also submit monthly data for our sepsis screening and compliance to qualify for CQUIN (Commissioning for Quality and Innovation) money. This money can then be used to improve patient care.
  • Where sepsis is identified, we aim to ensure that all patients receive an appropriate antibiotic within the hour of identifying sepsis as part of the one-hour Sepsis 6 care-bundle pathway; and a three-day review of those antibiotics.

Sepsis Awareness Contacts

Trust Lead for Sepsis

Dr Mike Spivey

Sepsis Lead for the Emergency Department

Dr Mark Jadav

Sepsis Lead for the Medical Admissions Unit

Dr Sanjeev Gupta

Sepsis Lead Nurse

Helen Winn
01872 252856
Bleep: 3993
Helen is based in the Quality, Safety and Compliance Department in the Knowledge Spa. Her hours of work are Monday to Friday, 8am to 4pm, but these can vary dependent on the needs of the role.

Further information about sepsis

How do you make sure equipment is sterile and safe for use?

The Royal Cornwall Hospitals Central Sterile Services Department makes sure all of our medical devices, equipment and instruments are sterile and safe for use.

We use state-of-the-art machinery and techniques to decontaminate, clean and sterilise medical items. We’re also responsible to keeping detailed records, making sure sterile supplies are undamaged and in date and that the medical staff have sterile supplies on hand when they need them.

How do you maintain food standards?

our-care-promise-how-do-you-maintain-food-standardsWe take nutrition for our patients seriously, and we understand the positive impact a healthy, nutritious diet can have on our patients’ recovery.

All of our food is produced by Cornwall Food in Redruth. This state-of-the-art facility opened in 2008 and now produces more than 175,000 meals per month, from soups and main meals to desserts, sandwiches and cakes, all tested by dieticians at Royal Cornwall Hospitals NHS Trust to guarantee that they provide a balanced, nutritious diet.

We stick rigorously to the NHS Cornwall Food Programme principles, aiming wherever possible and feasible to use local ingredients; to create sustainable jobs and to support the local economy. At present over 85% of produce used is sourced locally and Cornwall Food has been nationally recognised as a leader in sustainable purchasing.

Our food preparation is based upon tried and tested “old fashioned” techniques. We do not use any chemicals or additives in our food and everything we produce is done so using the same techniques you’d use at home. Our meals are then blast frozen before heading to our hospitals.

On site, our catering teams use innovative meal delivery trolleys to cook main meals from frozen and make sure patients get their meal at the perfect temperature. Salads and cold desserts to accompany main meals are made fresh at each site. The catering team also runs a snack box service for patients who have missed meals.

You can find out more information out Cornwall Food and their commitments to optimum nutrition and sustainability on the Cornwall Food website.

How do you manage health records for transsexual patients?

When you make the decision to transition from one gender to another, we will need to know what you want to happen with your health records. To make sure that you receive safe, effective and inclusive care in a way that suits you, there are some things you’ll need to consider and tell us about.

Changing your gender and name on your health records

If you would like your gender and/or name changed on your health records, we will need to see a copy of your Statutory Declaration or Deed Poll for your change of name.

Things to think about

We’ll also need to know how you want your records to be managed. Your “gender flag” will now change but you’ll need to think about your historical records. You have a couple of options:

  1. They can be locked so that staff can’t see them and know that you have/are changing gender
  2. You can leave them in place and just have your future records showing your present preferred gender.

When making this decision, you’ll need to think about the following:

  • The system is designed to identify gender-specific health screening, such as, prostate screening or cervical screening (smear test). You may still need access to these health screening checks, either in the short term or permanently, therefore we’ll need to override the system to allow you to be included.
  • If you lock your historic records, a clinician would not be aware of physiological body differences that may cause misdiagnosis, for example, blood results can be affected by gender.

Telling us your preferences

Once you have made a decision, or if you would like further help or advice about managing your health records, please contact our Data Quality Team.

Data Quality Team Leader

Kerensa Downing
01872 254648

Data Quality Officers

Jenna Bailey
01872 254542

Lynda Coventry
01872 254589

Data Quality Team

The Kedhlow Building
Royal Cornwall Hospital

We can also share this information with other health organisations in Cornwall so they can ensure your health records are current. Please let us know if you would like us to do so.

How do you maintain safe staffing levels?

From April 2014 all hospitals are required to publish information about the number of nursing and midwifery staff working and planned to work on each ward. Royal Cornwall Hospitals display a daily poster for patients and visitors in all of our wards that shows the planned and actual staffing available during day and night shifts.

Where will our staffing levels will be published?

Information about staffing levels will be published here monthly as well as on the NHS Choices website. Details will be reported monthly at our public Board meetings with a full review of staffing levels undertaken every six months.

Published information will show staffing levels for each ward during both day and night time for each month. The information will show separately registered nursing and midwifery staff as well as healthcare support workers by hours actually worked against those planned.

Why do our staffing levels may sometimes look high or low?

Monthly ‘fill-rate’ averages will be displayed showing the percentage of shifts meeting planned staffing levels. If a ward meets a 100% fill rate this will indicate that actual staffing levels exactly met those hours planned.

Where fill rates exceed 100% this indicates more staff on duty than was planned, as there are times when we have a higher number of patients requiring more complicated care or requiring individual care on a one-to-one basis.

When the fill rate is less than 100% this indicates fewer staff on duty than planned. We can safely operate our wards with less staff as the staffing levels are reviewed several times a day and staff can be moved or extra staff called in to ensure we meet the needs of our sickest patients.

Information about nursing and midwifery staffing levels for our wards is published here.

How do you prevent and control infection?

We take the prevention of infection very seriously. Every day, thousands of people; patients, staff and visitors, pass through our hospitals. We have a number of infection prevention and control procedures in place to minimise the risk of infection in this busy environment.

But we also need the help of our patients and visitors to help prevent the spread of infection. There are two simple things you can do that will help hugely:

Hand washing is one of the simplest and most effective ways to prevent the spread of infection. There are hand washing stations at the entrances to all of our wards. Hand sanitiser gel is also available at the entrances and exits of all our hospitals. Please use these whenever you come in or out, and always after you have eaten or used the toilet.

Don’t visit the hospital if you have a cold, flu, vomiting, diarrhoea, a high temperature or aches and pains. These illnesses can easily be passed onto our patients, staff and other visitors.

Our infection prevention team provides a 24-hour advice and guidance service. Please speak to the Nurse in Charge for more information.

See the Infection Prevention and Control Clinical Guidelines.

How do you source goods and services?

The Clinical Procurement team supports patient care by ordering goods and services on behalf of the Royal Cornwall Hospitals wards and departments. Each year, we place more than 300,000 orders, totalling around £45 million.

We make sure all goods and services are sourced from responsible suppliers and provide the best possible value for the Trust and our patients.

The organisations we work with are required to comply with European and UK law. This often requires us to issue tenders and requests for quotes so that we achieve value for money in a transparent and fair way.

We also provide advice and support to other health organisations in Cornwall.
The team is based at Carlyon House, Royal Cornwall Hospital, and the office is open from 9am to 5pm Monday to Friday.

What is your equality policy?

Logo - disability confident employerWe are committed to playing our part in contributing towards the NHS vision of providing a fair service that meets the needs of our patients, staff and wider community and is equally available to all.

The Trust is also committed to being a fair employer and is currently accredited by the Disability Confident Scheme.

Our equality statement is:

Royal Cornwall Hospitals Trust is committed to delivering inclusive health services for all in a dignified and respectful way by a workforce which is equally respected. We recognise that all patients, staff and members of the public are individuals and we will strive to meet their needs.

As an organisation, we will endeavour to ensure that no one is discriminated against or treated unfairly due to: age, disability, race, religion or belief, gender, sexual orientation, gender reassignment, marriage/civil partnership or pregnancy/maternity. Where necessary we will make every effort to ensure adjustments are made to prevent less equitable experiences occurring.

Discriminatory behaviour is not acceptable and, in relation to the characteristics above, may be unlawful. RCHT will not tolerate discrimination from anyone – staff, the public or patients.

Read our full equality, inclusion and human rights policy.

How we make sure we achieve this

The Equality Act 2010 legally protects people from discrimination in the workplace and in wider society.

The categories in the Act – Age, Disability, Gender reassignment, Race, Religion or belief, Sex, Sexual orientation, Pregnancy and maternity and Marriage/civil partnership – apply to everyone (except Gender Reassignment, which applies exclusively to transgender & non binary individuals), not just minorities. We all have a gender, a sexual orientation, a race, a belief (including Atheism or Agnostic).

Every policy and service at Royal Cornwall Hospitals has an Equality Impact Assessment completed. This will highlight if there will be a negative impact for any of these nine protected characteristics.

The Equality Act also introduced a Public Sector General Equality Duty that requires public sector organisations to positively promote equality. This is measured by the Equality Delivery System (EDS) gradings, which are published annually alongside an annual Equality, Diversity and Human Rights report

Find out more about your rights under the Act on the website.

What should you do if you feel you have been disadvantaged or treated less favourably

If you feel you have been disadvantaged or treated less favourably because of one of these aspects of who you are you can question the legality of this under the Act. If you feel that there is a negative impact for you or someone else please contact our Human Rights, Equality & Inclusion Lead, Debby Lewis, on 01872 258128.

Our Equality Reports

Feedback and Contact Details

We always welcome opportunities to improve so if you want to become involved or have any suggestions on how we can improve then please contact:

Human Rights, Equality and Inclusion Lead

Debby Lewis
The Knowledge Spa
Royal Cornwall Hospital
Truro TR1 3HD
01872 258128

How do we ensure equality in care for veterans and the armed forces community?

We are committed to ensuring that those who serve or who have served in the armed forces, and their families, are treated fairly.

As part of this commitment, we are among the first NHS trusts awarded Veteran Aware accreditation by the Veterans Covenant Hospital Alliance (VCHA).

This means we are leading the way in improving NHS care for veterans and members of the armed forces community by:

  • Raising awareness among staff to be aware of veterans’ specific needs;
  • Making past and present servicemen and women aware of charities or NHS services beneficial to them, such as mental health services or support with financial and/or benefit claims;
  • Ensuring that the armed forces community is never disadvantaged compared to other patients, in line with the NHS’s commitment to the Armed Forces Covenant.

As part of this, we display posters in our clinics and public waiting areas, urging anyone who has served in the armed forces to make themselves known to staff.

In addition, we work with Step Into Health and the Employer Recognition Scheme to ensure that we are ‘forces friendly’ employers.

When fully utilised, these services will enhance the recovery pathway for veterans in NHS hospitals.

Where can I view your clinical guidelines?

All of the Royal Cornwall Hospitals NHS Trust Clinical Guidelines are available in our documents library:

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