The Royal Marsden NHS Foundation Trust

The Royal Marsden NHS Foundation Trust is split over two principal sites, in Chelsea and Sutton, and a day-case unit on the site of Kingston Hospital. As a specialist trust, the Royal Marsden receives referrals from beyond the immediate areas, including national and international referrals. The trust also provides community healthcare services at a range of sites throughout the London Borough of Sutton, to a population of approximately 196,000.

We inspected the Royal Marsden NHS Foundation Trust as part of our specialist NHS inspection programme as well as applying our NHS community health service inspection methodology also. We inspected the trust between 19 and 22 April 2016 as well as carrying out additional visits following the announced inspection to collect further information and to corroborate findings.

The Royal Marsden Community Services formed Sutton and Merton Community Services (SMCS) in 2011. Various community health services were provided in the London Boroughs of Sutton and Merton. From 1 April 2016 The Royal Marsden Community Services stopped providing services to Merton and formed Sutton Community Services (SCS). Our reports in to community health services include data from the 12 month period leading up to our inspection which was before the disaggregation of services and therefore contains some data relating to Merton. We have included separate data where it was available. Our site visits during the inspection were limited to Sutton only.

Overall, we have rated the trust as good. We rated it good for providing care which was safe, effective, responsive to the needs of the population, and well-led. We rated the trust outstanding for the caring domain. 

Additionally, we rated the radiotherapy service as outstanding across both hospital locations. This was because the radiotherapy service was patient centred; care was provided in line with national standards, with radiotherapy services participating in national and international research programmes. 

Our key findings were as follows:

• There were robust processes for staff to follow in relation to incident reporting and investigation. Staff understood the importance of being open and honest, as per the duty of candour.
• Learning outcomes, arising from incident investigations, were, in the main, shared with staff and applied in practice. Improvements were required within the adult's community service to ensure that learning from incidents was shared across all teams.
• Staffing arrangements supported the delivery of safe diagnostics, treatment and care within the hospital setting. However, staffing shortages within the community nursing teams meant that the delivery of end of life care fell to more experienced staff who had attended relevant training, this meant that there was limited staff available to deliver end of life care.
• Specialist staff did not feel they were always being contacted quickly enough to support the timely commencement and delivery of end of life care for patients both in the hospital setting and within the community.
• The environment in which people received treatment and care was clean and organised in a manner, which identified and responded to potential or actual infection control risks.
• Medicines, including controlled drugs, and chemotherapy were safely prepared, managed and optimised.
• In the majority of cases, vulnerable individuals were identified and protected under safeguarding practices and through the application of the Mental Capacity Act and associated Deprivation of Liberty Safeguards. Improvements were required within the community adult's services to ensure capacity assessments were routinely recorded. Staff working within community adults services required further support in helping them to understand the concepts of the Mental Capacity Act.
• Staff were enabled to perform their duties through the provision of professional standards and guidance. However, within community services, staff were not consistently following best practice in their approach to wound assessments. This meant that changes to wound presentation were less likely to be accurately recorded and deterioration may not have been addressed as readily. Additionally, community staff were not routinely following the quality standard for nutrition support in adults which required care services to take responsibility for the identification of people at risk of malnutrition and provide nutrition support for everyone who needed it.
• In the majority of care settings, treatment outcomes and other departmental audits enabled staff to monitor the effectiveness of the services provided.
• Strong multidisciplinary team work across disciplines facilitated the delivery of effective services to people.
• A full range of diagnostic and technological equipment was available, and was used by appropriately trained staff to monitor and deliver treatment and care.
• Staff had the right qualifications, skills, knowledge and experience to undertake their roles and responsibilities. They had access to developmental training and were supported by senior staff through a range of approaches.
• Staff had opportunities to receive feedback on their performance.
• People were treated with kindness, dignity, respect and compassion whilst they received care and treatment from staff.
• Staff took into account and respected people’s personal, cultural, social and religious needs.
• Staff were observed to take the time to interact with people who used the service and those close to them in a respectful and considerate manner. They showed an encouraging, sensitive and supportive attitude towards people receiving treatment and care, as well as those close to them.
• People who used the services and those close to them were involved as partners in their care. Staff communicated with people so they understood their care, treatment and condition. They recognised when people needed additional information and support to help them understand and be involved in their care and treatment and facilitated access to this.
• People received appropriate and timely support and information to cope emotionally with their care, treatment or condition.

We saw several areas of outstanding practice including:

• Critical care staff worked with a specialist in aromatherapy massage as part of a trial to identify if this type of therapy would result in better sleep patterns amongst patients. This trial was in progress at the time of our inspection and aimed to find if non-pharmacological intervention could be an effective alternative to support sleep to high doses of drugs.
• The Critical Care Unit’s (CCU) research programme was well structured and there were multiple safety nets in place for staff conducting this. The Committee for Clinical Research had oversight of every project and only approved them after a positive peer review and ethics approval. The research profile was internationally recognised and staff represented the unit at the NHS National Institute of Health Research and the National Critical Care Research Group. Senior research staff worked academically and clinically, which meant they could ensure critical care projects were conducted according to established multi-professional best practice.
• Staff in CCU prescribed patients who were considered high-risk for complications a pre-rehabilitation programme before they underwent surgery. A physiotherapist led this programme and provided patients with an exercise regime and diary. This helped them to prepare for rehabilitation and to support their health to improve their condition after surgery.
• The environmental adaptations in the Chelsea CCU demonstrated exemplary focus on individual care and attention to detail. This included adapted environments for patients with dementia, bariatric patients and teenagers.
• Senior staff actively promoted staff welfare and had provided tai chi, complementary therapies and meditation sessions to promote wellbeing and relaxation.
• The Marsden is the only NHS hospital to have the updated version of the da Vinci Xi surgical robot. This less invasive surgery allowed improved patient recovery. The 10 year fellowship programme meant that 30 surgeons would be trained by the trust to operate the robot.
• There was an extensive range of information, including films for patients, which provided detailed support.
• The trust had direct access to electronic information held by community services, including GPs. This meant that hospital staff could access up-to-date information about patients, for example, details of their current medicine.
• Staff demonstrated high care, arranging patient transportation and accommodation for those that did not live near to the hospital.
• The investment by the trust ensured that staff were developed and highly trained. Many staff had studied for master degrees and specialist courses in cancer.
• Research, ongoing quality improvement projects and auditing were of a high level and drove the quality improvement agenda.
• Nursing and therapy staff had the commitment and time to provide person-centred care that often went the ‘extra mile’
• The introduction of ambulatory care had managed to reduce patient bed stays and improve patient experience.
• The end of life supportive care home team (SCHT) was a part of a Sutton CCG (clinical commissioning group) vanguard relating to improving end of life care in care and nursing homes. Members of the SCHT were involved in developing the service and had been invited to speak about the model and share this development with other services. The end of life supportive care home team (SCHT) was a part of a Sutton CCG (clinical commissioning group) vanguard relating to improving end of life care in care and nursing homes. 

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

Importantly, the trust must:

• Implement and embed the World Health Organisation Safety Checklist in the outpatients department.
• When patients (aged 16 and over) are unable to give consent because they lack the capacity to do so, the trust should ensure staff act in accordance with the Mental Capacity Act 2005.
• Ensure that records contain accurate information in respect of each patient and include appropriate information in relation to the treatment and care provided, particularly with regard to risk assessments.
• The provider should take action to understand the shortfalls in recording of risk assessments and individualised care plans in the integrated community teams.
• Review the staff compliment for community adult services to ensure there are sufficient numbers of appropriately skilled staff to meet patient’s needs.
• The provider should strengthen the reporting on the assurance of effectiveness of governance arrangements to the trust board; this specifically relates to community services.

Professor Sir Mike Richards

Chief Inspector of Hospitals

We rated the service as requiring improvement overall because:

• There was a shortage of experienced nursing and therapy staff in the integrated community teams and insufficient time to complete holistic assessments.

• Learning from incident reporting was shared within the relevant teams however systems to share learning across teams were not embedded.

• Patient records were not completed in a consistent or thorough way. 50% of those we viewed did not have the appropriate risk assessments in place. This meant that before visiting nursing staff did not always have a clear understanding of a patient’s health status when giving treatment

• Safety information provided by the trust identified they had a high prevalence of patients with pressure ulcers. We found staff were not consistently following best practice in their approach to wound assessments. This meant that changes to wound presentation were less likely to be accurately recorded and deterioration may not have been addressed as readily.

• Baseline recordings of patient observations were not always completed.

• Deprivation of Liberty Safeguards were not always understood and mental capacity was not always appropriately assessed and recorded for patients who may lack capacity. Staff were knowledgeable about the need to act in patient’s best interest but were not clear about who could consent on the patient’s behalf and how this information should be recorded in patients’ records.

• Staff did not consistently use outcome measures to monitor patient progress. For example: key outcome measures such as the assessment of pressure ulcer risk and nutrition scoring.

• Staff were not following the quality standard for nutrition support in adults which required care services to take responsibility for the identification of people at risk of malnutrition and provide nutrition support for everyone who needed it.

• Few of the records we looked at documented people had been involved or encouraged to be partners in their care when assessing their emotional needs. However we found that in discussions with staff they gave examples and referred to practice that demonstrated they had considered the patients emotional needs although this was not always well documented.

• The arrangements for governance and quality performance did not always operate effectively. Not all risks and issues were known and those that were known were not always recorded.

• The approach to service delivery and improvement was sometimes reactive and improvements were not always identified or action taken.This meant the impact on the quality of care for patients was not always effectively monitored.

• Operational organisational processes impacted on continuity of care. We were not assured systems and processes were in place to effectively identify risks to patient care.

However we also found:

• There was a clear incident reporting system in place and staff were encouraged to report incidents.There was evidence of learning from incidents and evidence of improvements being made as a result of reporting and sharing the outcomes of incidents.

• Community staff were knowledgeable about safeguarding procedures and knew who they would report any concerns to.

• Community nursing staff had access to specialised equipment to meet patients’ needs when required.

• Staff with specialist skills and knowledge were used by community teams to provide advice or direct support in planning or implementing care. Teams worked together in a coordinated way and mad appropriate referrals on to specialised services to ensure that patients’ needs were met.

• Services were delivered in line with evidence based practice. Staff used clinical guidelines and protocols to inform their decisions about care and treatment

• The service participated in national audits and developed action plans to make improvements

• Patients were given a choice of options to manage their pain.

• Patients received a caring service from staff that were kind and respectful toward them.

• Nursing and therapy staff treated patients with dignity, involved patients and their families in their direct care and supported them during times of crisis.

• The services provided a range of specialist therapeutic interventions.

• The trust was aware of the diverse needs of the people who used the service and they provided a range of support as required.

• The trust worked closely with commissioners, local authorities, people who use services, primary care services and other local providers to ensure it understood the needs of the population it served in order to plan and deliver services.

• Staff considered the needs of people who may have difficulty accessing services and adapted their care approach to show respect for cultural factors. There was evidence of learning from the complaints received from patients and families.

• Patients reported that they were satisfied with how to make a complaint and how they were dealt with.

• Leaders encouraged and supported staff so they felt respected valued and supported.

Overall rating for this core service GOOD

We rated the service as being good overall

• Parents we spoke with were positive about the staff that provided their care and treatment. They told us they had confidence in the staff they saw and the advice they received.

• The friends and family (FFT) test for Sutton and Merton children’s and families’ services for the period April 2015 to March 2016 showed that 95.3% of patients would recommend the service.

• Staff knew how to report incidents; team meeting minutes demonstrated that incidents were discussed as part of the meetings.

• Staff working with children had access to regular safeguarding supervision and were able to attend further training provided by the Local Safeguarding Children’s Board (LSCB).

• 89% of staff had completed level 2 and 88% had completed level 3 which was against the trust target of 90% for safeguarding levels 2 and 3.

• The trust target for completing mandatory training was 85%; however, this target was stretched to 90% for the community division in December 2015. For completion of the five core elements of mandatory training 92.1% of staff in Sutton and Merton community services had been trained.

• Staff told us they participated in the appraisals process. The trust reported 87.4% of staff within the Sutton children’s and young people’s services had received an appraisal as of April 2016, which was higher that the trust target of 85%.

• There was evidence of good MDT working across different the different services and with other health care professionals. The safeguarding team had good working relationships with the Sutton Multi Agency Safeguarding Hub (MASH) and Multi Agency Risk Assessment Conferences (MARAC).

• Clinics and services were located in places where people could access them and the school nursing service also ran drop in clinics outside school times in different locations including voluntary sector provision for young people.

• The service experience low level of complaints, learning from complaints led to improvements in the service. However, guidance on how to make complaints was not readily available in the clinics we visited.

• Governance structures were in place within community services there were divisional management meetings which fed into children’s services managers’ operational meeting and cascaded into team meetings

• Risks were identified on the risk register and action was being taken to mitigate the risks. Most staff were aware of what was on the divisions risk register.

• Senior staff within children and young people’s service had clear visions on how the services were to develop and move forward, this included opportunities to share learning across services.

• Staff reported that they were proud to work for children’s and young people’s community services and liked being part of the Royal Marsden NHS Trust. They were enthusiastic about the care and treatment they provided for the people who used their services.

However

• Children did not have timely access to some therapies following a referral for treatment.

• Guidance on how to make a complaint about the service was not readily available in many of the clinics that we visited. The service did not did not meet their target for responding to complaints.

• Care leavers did not have relevant health information and health summaries were not being routinely completed. Health assessments for ‘looked after’ children were not being completed within time scales and there was lack of coordination in the monitoring quality of care for ‘looked after’ children who lived out of the area.

• There was a lack of disabled parking at some of the clinics that services operated from which presented access difficulties for wheelchair users.

• The trust undertook infection control audits at different locations where community services were based and operated from. A score of 75% and below demonstrated minimal compliance. In one of the four locations children’s and young people’s services operated from scored 59.1% in February 2016.

• For completion of the other mandatory training which was not part of the core programme, 89.1 % staff in Sutton and Merton community services had completed the training as of April 2016. Training was below the trusts target of 90% for Equality and Diversity (87.4%), medicines management (77.1%), moving and handling patient handling (82.4%), and paediatric basic life support (87.7%).

Overall we rated the trust as GOOD for community end of life care services because:

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.

• Medicines were managed safely in relation to end of life care, including the use of “just in case” anticipatory medication to support the management of symptoms quickly and effectively.

• There was good prioritisation of the needs of patients at the end of life.

• There was a clear vision and strategy for the work of the specialist care home team (SCHT) and there was evidence of a positive impact on patients living in care homes experiencing improved end of life care as a result of supportive care home service.

• There was good multi-disciplinary working through the GSF and specialist staff were available to support the work of the community nursing teams.

• Patients were treated with dignity, kindness and compassion and there was consistently positive feedback from patients and their relatives about the service.

• Staff worked had to ensure that patients at the end of life were given the support that they need, including staying beyond the end of their shift to make sure patients had in place what they needed.

• We observed good use of advance care planning with a uniform approach across services and adapted tools for use when patients did not have capacity and decisions were made in their best interest.

• There was a culture of quality end of life care across all community end of life care services.

However,

• It was unclear what guidance was being used to support the delivery of end of life care in patient’s homes as there was no evidence based end of life care plan in use within the service.

• It was unclear how the service was monitoring a range of patient outcomes specific to end of life care when patients were supported by community nurses in their own homes.

• Staffing shortages within the community nursing teams meant that the delivery of end of life care fell to more experienced staff who had attended relevant training.

• There was no completed end of life care strategy for community end of life care implemented and the development of this service in relation to the trust-wide strategy was unclear.

• Quality measurement in relation to community end of life care services was limited and did not cover all aspects of the service. There was no clear plan for measuring or improving the quality of end of life care for patients receiving care in their own homes.

• In the absence of a community end of life care strategy and clear processes for measuring the quality of services it was unclear how specialist palliative care and end of life care input was influencing the development of services for patients receiving end of life care in their own homes.