Our quality and safety standards

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’re 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 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 on the Board Meetings page.

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.

Our care promise

Being open with you

We recognise that sometimes, sadly and despite our best efforts, things can go wrong. In these circumstances, and in line with the Trust’s Being Open policy, we promise to:

  • acknowledge that something has gone wrong
  • make sure that patients, their relatives and carers are made aware at the earliest opportunity
  • recognise any distress the incident may have caused and offer a sincere and compassionate apology
  • explain that we will investigate fully, involve you in the investigation and keep you informed at every stage
  • provide a full and comprehensive explanation of what went wrong and why
  • explain what will be done to prevent it happening again
  • offer support and counselling services as needed
  • respect your confidentiality
  • ensure the continuity of your care

Please help us to make our hospital as safe as it can be – if you are anxious, or have concerns about your care and treatment, please do raise them with the healthcare professionals looking after you. We assure you this will not compromise your future care and you will be treated with respect.

We also expect and encourage all our staff to raise any concerns they have to help us do our best for patients, keep them safe and ensure that we continue to learn.

If you feel uncomfortable discussing your concern with the staff providing your care, please contact the Patient Experience Team on 01872 252793 or by email at rcht.patientexperience@nhs.net.

Patient Safety

Patient safety incidents are any unintended or unexpected incidents which could have, or did, lead to harm for one or more patients receiving healthcare.

We aspire to be among the safest hospitals in the country, providing Brilliant Care to our patients. Every patient safety incident offers us an opportunity to learn and improve patient safety in our organisation.

All incidents are recorded on our electronic incident log and have a level of review proportionate to the event. This aims to establish what happened, and why, so that actions can be taken locally to improve safety for our patients.

Learning from, and responding to, patient safety incidents

In September 2022, we approved our second Patient Safety Improvement Response Plan (PSIRP). We have worked with colleagues the trust, our local commissioners, and our Patient Safety Partner.

Our PSIRP represents a further shift in the way the NHS responds to patient safety incidents and is a major step towards establishing a safety management system across the NHS. It is a key part of the NHS patient safety strategy, which supports the development and maintenance of an effective patient safety incident response system that integrates four key aims:

  1. Compassionate engagement and involvement of those affected by patient safety incidents.
  2. Application of a range of system-based approached to learning from patient safety incidents.
  3. Considered and proportionate responses to patient safety incidents.
  4. Supportive oversight focussed on strengthening response system functioning and improvement.

Our plan sets out how we will review, investigate, and learn from patient safety incidents to make improvements based on organisational priorities related to patient safety. It also explains how we will continue to involve and support those affected, including patients, families, carers, and staff, alongside building knowledge of patient safety science. Our plan is rooted in a safe and just culture, which encourages everyone to raise safety concerns that are then responded to in a compassionate and fair way.

Patients involved in incidents

Keeping patients safe is our most important responsibility and we will do everything we can to ensure we cause no harm. However, we are all human and despite our best efforts, sometimes things do go wrong and harm is caused.

As a patient or patient’s next of kin, you may be contacted if you are identified as being involved in care where an incident has occurred. This is known as ‘being open’ and our commitment to you is to be open, honest and to say sorry.

When an incident occurs that causes harm of a certain level, we have a legal requirement to use Duty of Candour to tell you what has happened and what we are going to do. Duty of Candour is all about being open and honest with patients and their relatives.

This means we will:

  • apologise and tell you in person what has happened,
  • work closely with you to investigate why it happened; and
  • meet with you to discuss what we found.

During each step we will explain what will happen next in the investigation process so that you will know what to expect.

Simple steps to keep you safe during your hospital stay

You may be feeling anxious about being in hospital but keeping you safe and well is a priority for the staff looking after you. There are also some simple things you can do to help keep yourself safe during your hospital stay, such as asking for help when needed, protecting yourself from slips and falls and helping to prevent blood clots.

Please see the NHS England videos and leaflets for more information.

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 (e.g. 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 have 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.

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?

We 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 Sustenation 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 Sustenation 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 Sustenation 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.

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

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 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 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?

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?

We 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.

"Disability confident employer" badge

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, diversity and inclusion 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 gov.uk 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

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:

Page last reviewed: 28 February 2024

Alert: Infected Blood Products Inquiry

If you are concerned following news coverage of the Infected Blood Products Inquiry, you can find help and support on the NHS website: Infected blood support (nhs.uk)

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