The Care Quality Commission
  • Hospital
  • NHS hospital

The Christie Main Site

Overall: Good read more about inspection ratings

550 Wilmslow Road, Withington, Manchester, Lancashire, M20 4BX 07960 520160

Provided and run by:
The Christie NHS Foundation Trust

All Inspections

11 October 2022 to 12 October 2022

During a routine inspection

The Christie NHS Foundation trust provides specialist oncology services. There are around 3,400 staff employed at the trust. It is a the largest single site cancer centre in Europe, treating more than 60,000 patients a year. Around 95% of patients receive ambulatory care on an outpatient basis.  

Based in Manchester, the trust serves a population of 3.2 million people across Greater Manchester and Cheshire; more than a quarter of the patients are referred from elsewhere across the UK. 

From the main hospital site, the trust provides radiotherapy, chemotherapy, outpatient and acute oncology, complex surgical care, research and education, specialty diagnostics and other regional and national services. The UK’s largest brachytherapy (internal radiation) service is on the main site. The trust was the first NHS organisation in the UK to deliver high energy proton beam therapy. 

Other sites, closer to some patients’ homes, are known as the ‘Christie@Salford’ and the ‘Christie@Oldham’; these provide radiotherapy, chemotherapy and acute and outpatient oncology. The ‘Christie@Macclesfield’ provides radiotherapy, chemotherapy, haematology and outpatient services in addition to oncology services.  The trust also gives chemotherapy care in ten community locations and offers outpatient appointments and blood tests closer to people’s homes. There is a 24 hour, 365 days a year telephone ‘hotline’ for patients, families and professionals to use; there are around 35,000 hotline contacts each year. 

We carried out an unannounced inspection of the acute medical services on 11 and 12 October 2022, as part of our continual checks on the safety and quality of healthcare services.

This inspection relates to the medical care division, at the Christie hospital medical care was part of the Acute and Supportive Cancer Services.

Our rating of this service ​went down​. We rated it as ​good​ because:

  • The service had enough staff to care for patients and keep them safe. Staff understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff kept good care records. The service managed safety incidents well and learned lessons from them.
  • Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available seven days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

  • The service provided mandatory training but not all staff completed it on time including mandated annual updates. Medical staff did not always complete life support and safeguarding training in a timely manner.
  • Staff did not always complete and review risk assessments for patients in a timely manner.
  • The service did not always manage medicines well.
  • Some essential policies were passed their review date.  

How we carried out the inspection

During our inspections we spoke with a variety of staff, including allied health professionals, nurses, doctors, research staff, health care support staff, and consultants. We also spoke with patients and relatives. We visited clinical areas and non-clinical areas across the hospital site. We reviewed patient records, regional and national data and other information. We also reviewed other information sent to us from external sources.

We held several staff focus groups to enable staff to speak with inspectors. The focus groups included nursing staff, allied health professionals, research and innovation teams, junior doctors and consultants.

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

3 to 26 July 2018

During a routine inspection

Our rating of services stayed the same. We rated them as outstanding because:

  • The culture across all the services we inspected was extremely positive. Staff at all levels were very proud of their organisation and the work they did.
  • The trust ensured that there were sufficient numbers of staff who possessed the right skills and experience deployed at all times.
  • The trust valued patients consistently as individuals; we saw and heard examples of staff going the extra mile to meet the needs of patients and their families.
  • The services provided care and treatment in line with national guidance and evidence based practice. The hospital was a leader in the field of cancer care and pioneered new initiatives and procedures.
  • The trust services were tailored to meet the needs of individual people and delivered in a way to ensure flexibility, choice and continuity of care.
  • The trust leaders were prominent and respected in cancer treatment and procedures. The trust provided expertise and guidance for other members of the healthcare economy. They worked in collaboration with leaders of cancer care locally and nationally.
  • The trust engaged with people well. There were many engagement opportunities for staff and the public. These opportunities were varied and substantial. There was evidence of consistently high levels of constructive engagement with staff and people who use services.

However:

  • The surgical directorate did not always demonstrate effective learning from incidents. They did not always recognise and share learning in a timely way. The governance systems in place meant critical information was not always shared across disciplines and did not reach some staff who might benefit and who might be in a position to prevent similar incidents from reoccurring in the future.
  • Some audit systems were not robust enough to identify potential safety issues. The Association for Peri-operative Practice (AfPP) audit tool and the World Health Organisation (WHO) checklist audits did not provide adequate assurance in some high risk processes.
  • Patients’ records were not integrated, different disciplines entered information in different places, some electronically and some hand written. This meant all the patients information was not available in one place and posed a risk that some information may be missed.
  • The management team had not fully implemented the Local Safety Standards for Invasive Procedures (LocSSIPs) based on the National Safety Standards for Invasive Procedures (NatSSIPs) as recommended by the National Patient Safety Agency.

May 2016

During a routine inspection

The Christie NHS Foundation Trust is a 188 bed (including critical care) comprehensive cancer centre serving a population of 3.2million people across Greater Manchester and Cheshire, with 26% of patients being referred to us from across the UK.

NHS activity is commissioned by the specialist commissioners of NHS England with over 90% of activity being ambulatory care. There is an annual turnover of £230 million, operating with 2,500 staff, 350 volunteers, 27,500 public members and have one of the largest hospital charities.

The Christie NHS Foundation Trust has one of the largest clinical trials portfolios and are part of Manchester Cancer Research Centre working in partnership with the University of Manchester and Cancer Research UK. They are also one of seven partners in the Manchester Academic Health Science Centre.

The Networked Services division provides clinical and medical oncology services across Greater Manchester & Cheshire, clinical haematology and transplantation, teenage and young adult services and specialist endocrinology. The clinical and medical oncology services include the delivery of radiotherapy on the Withington site and at two satellite centres at local provider sites. The Cancer Centre Services Division includes surgery (including anaesthetics and theatres), the surgical day case unit, critical care, oncology assessment unit and outpatients and diagnostics.

There are currently 13 service linear accelerators providing service radiotherapy treatment, which includes external beam, brachytherapy, image guided radiotherapy and stereotactic radiotherapy. Chemotherapy treatment is delivered on the Withington site and through 9 outreach sites and a mobile unit across Greater Manchester and Cheshire. At the Withington site there are 50 chemotherapy treatment chairs and beds providing up to 135 treatments per day. The Christie Medical Physics and Engineering division provides expertise, local and national in medical physics which includes PET-CT scanning and nuclear medicine.

We visited the Christie main site, Oldham and Salford as part of our announced inspection during 10 to 13 May 2016 March 2016. We also carried out an unannounced inspection on 25 May 2016. During this inspection, the team inspected the following core services:

  • Medical care services

  • Surgery

  • Critical care

  • End of life

  • Outpatients and diagnostic services

  • Chemotherapy

  • Radiotherapy

  • Our key findings were as follows:

    Leadership and management

    The hospital was led and managed by a visible executive team. This team were well known to staff, and staff spoke highly of the commitment by leaders to continually improve services putting patients and people close to them at the centre of decision making.

    Staff felt involved in decision making, and felt that they were able to influence the vision and strategy of The Christie NHS Foundation Trust.

    There was effective teamwork and clearly visible leadership within the services.

    Both trust and local leadership sought continuous improvement and innovation and research in both services and procedures they delivered. There was significant involvement in research and clinical trials programmes in order to improve the care and treatment provided for patients.

    The NHS staff survey 2015 showed the trust performed better than the national average for 11 indicators. The overall staff engagement score for the trust was 4.03, which was better than the national average score of 4.01 for specialist acute trusts.

    Access and flow

    • There was a 24-hour telephone helpline service (hotline) for patients and carers for advice on the side effects and complications of cancer treatments, such as chemotherapy. Advice was given by nurse practitioners with consultant and registrar support if needed.

    • The oncology assessment unit (OAU) had 20 inpatient beds and rapid access clinic beds (open Monday to Friday) to accommodate urgent and unplanned medical and surgical admissions to the hospital.

    • Patients could be admitted to the OAU directly following an outpatient appointment, via the 24-hour hotline service or transferred from other hospitals. Patients requiring admission to the hospital were transferred to the hospitals wards from the OAU.

    • Records between April 2015 and March 2016 showed average bed occupancy rates were; OAU (80%), ward 4 (91%), ward 11 (93%), ward 12 (91%) and Palatine ward (90%). Bed occupancy rates varied across the medical wards.

    • We did not see significant numbers of medical patients admitted to the surgical wards (medical outliers) during the inspection. We identified two medical patients that were located in the surgical wards. There were instances where medical patients were placed in other medical specialty wards due to capacity issues. However, the numbers we observed were not significant. For example, the lead nurse on the Palatine ward told us there had been six patients placed on wards 11 and 12 during the past week due to bed availability issues.

    • Records between February 2015 and January 2016 showed 7,734 patients (95.3%) did not move wards during their hospital stay and 382 (4.6%) had one or more ward moves following their admission. The overall number of patients that had one or more ward moves during their admission (382) had improved from 493 during the previous 12 months. Ward staff told us they avoided moving patients once admitted and one of the main reasons for bed moves was ward refurbishment activities.

    • The rate of delayed discharges based on the proportion of occupied bed days per month ranged between 0.3% and 1.8% from April 2015 to March 2016. This showed the majority of patients were discharged from the medical wards in a timely manner.

    • The referral to treatment (RTT) incomplete pathway standard is that at least 92% of patients should have to wait less than or equal to 18 weeks of referral for their treatment. Hospital records showed compliance against the incomplete pathway standard was 98.5% between April 2015 and March 2016 (i.e. 2015/16).

    • In June 2015, NHS England abolished the RTT standard that at least 90% of admitted and non-admitted patients should start treatment within 18 weeks of their referral. Records showed the hospital achieved 98.6% compliance for non-admitted patients and 96% compliance for admitted patients during 2015/16.

    • The NHS 31-day cancer waiting time standard is for at least 96% of patients who are newly diagnosed with a cancer to receive their first treatment within 31 calendar days from the date of the decision to treat. Hospital records showed compliance against the 31-day standard was 98.4% during 2015/16.

    • During this period, the hospital achieved 99.8% compliance against the standard for at least 98% patients to experience a maximum wait of 31 days for a second or subsequent anti-cancer drug treatment.

    • The NHS 62-day cancer waiting time standard is for at least 85% of patients who are urgently referred by their GP with a suspicion of cancer and are subsequently diagnosed with cancer should wait no longer than 62 calendar days from the date the referral is received by the hospital to the date of their first treatment. Records showed compliance against the 62-day standard was 88.5% during 2015/16.

    • During this period, the hospital achieved 88.0% compliance against the standard for at least 80% patients to experience a maximum wait of 62 days

    • The hospital also achieved 97.6% compliance against the standard for at least 90% patients to experience a maximum wait of 62 days for first treatment following referral from an NHS cancer screening service during 2015/16.

    • 99% patients were seen within 24 hours of being referred to the specialist palliative care team.

    Cleanliness and infection control

    • Clinical areas at the point of care were visibly clean.

    • The trust had infection prevention and control policies in place, which were accessible to staff and staff were knowledgeable on preventing infection and minimising risks to patients, visitors and staff.

    • There was enough personal protective equipment available, which was accessible for staff and staff used this appropriately, however we observed that local policy related to insertion of invasive lines and personal protective equipment was not always followed.

    • Staff generally followed good practice guidance in relation to the control and prevention of infection in line with trust policies and procedures.

    • There had been no MRSA bacteraemia infections and 17 Clostridium difficile (C.diff) infections relating to the hospital between April 2015 and March 2016. Of the 17 infections, all were classed as ‘unavoidable’ which meant they were not caused as a direct result of lapses in the care provided by the hospital.

    Staffing

    • Nurse staffing was calculated, reviewed and audited bi-annually using a recognised patient acuity and dependency tool the ‘safer nursing care tool' (SNCT).

    • The matrons and ward managers carried out daily staff monitoring and escalated staffing shortfalls due to unplanned sickness or leave. The ward managers told us staffing levels were based on the dependency of patients and this was reviewed daily.

    • The wards we inspected had sufficient numbers of trained nursing and support staff with an appropriate skills mix to ensure that patients were safe and received the right level of care.

    • Records showed the average shift fill rates for nursing and care staff on the medical wards were consistently above 95% between January 2016 and April 2016.

    • The nursing staff were supported by a number of advanced nurse practitioners (ANP’s) that worked across the medical services. For example, there were five ANP’s covering the oncology assessment unit (OAU).

    • The proportion of consultants and registrars across the medical services at the hospital was greater than the England average. The proportion of middle career doctors was below the England average (4% compared with the England average of 6%). The proportion of junior doctors was also below the England average (1% compared with the England average of 22%).

    • There were separate medical rotas in place to cover specific specialties, such as head and neck and gastroenterology, chest and gynaecology, and urology, lymphoma and melanoma.

    • There was sufficient on-site and on-call consultant cover over a 24-hour period including cover outside of normal working hours and at weekends. The on-call consultants were free from other

    • Daily medical handovers took place during shift changes and these included discussions about specific patient needs.

    • Whilst radiography staffing was good at Salford and Oldham radiotherapy services, staffing at the Christie site on the treatment floor was challenging and staff were working additional hours on a daily basis to ensure that all patients received their treatment and morale was low. Radiography staffing in other areas of the department was better. There were also problems with staffing on the reception areas, however the newly appointed manager of the service was aware of all the staffing issues and plans were in place to review departmental needs.

    Mortality rates

    • The overall five-year survival rate for patients diagnosed with showed significant improvements for the majority of patients between 2005 and 2015.

    • The overall survival rate for patients with brain and central nervous system (CNS) tumours varied by tumour type with patients with glioblastoma (GBM) showing the worst outcomes.GBM is the most common and aggressive primary malignant brain tumour in adults. A report from July 2015 showed the rate for patients with GBM was 27.4%, which was comparable to the England average of 28.4%.

    • The head and neck cancer report from February 2015 showed one year survival from diagnosis for cancer of the larynx among patients who received their first treatment at the hospital was 88%, which was better than the estimated England average of 85%.

    • One year survival for prostate cancer for all patients receiving primary treatment at the hospital was approximately 98%, compared to the estimated England average of 93.6%.

    • Audit reports from 2015 and 2016 showed the overall survival rates for patients with skin melanomas; Hodgkin lymphoma and cancer of the bladder were also comparable to estimated England averages based on Cancer Research UK data.

    • The Christie stem cell transplant programme annual report for 2015 had not yet been published. Data from the 2014 annual report showed one-year survival rates for autologous ( and allogeneic (other person’s marrow or stem cells)transplants remained largely unchanged over the last decade. The one year survival rates were also equivalent or better than national figures from the British Society of Blood and Marrow Transplantation (BSBMT) 2013 report.

    • The trusts major surgery 30 day survival rate from 1 January 2015 to 31 December 2015 was 100%.

    • The national bowel cancer audit (2015) showed the trust performed better than the England average for adjusted 90 day mortality, adjusted two year mortality, adjusted 90 day readmission rates and data completeness; this is despite Christie patients being recorded as having more distant metastases. The Christie undertook less laparoscopic procedures 46% against an England average of 57% and 77% of Christie patients stayed in hospital longer than five days in comparison to 69% on average across England. The Christie excised 14 lymph nodes on average against an England average of 17.

    Nutrition and hydration

    • Patient records included assessments of patients’ nutritional requirements. Where patients were identified as at risk, there were fluid and food charts in place and these were reviewed and updated by the staff.

    • Where patients did not eat enough, this was addressed by medical staff to ensure patient safety and comfort. Patient records also showed that there was regular dietician involvement with patients who were identified as being at risk.

    • Patients with difficulties eating and drinking were placed on special diets or provided with ‘finger foods’ to facilitate their eating. We also saw that the wards used a ‘red tray’ system so patients living with dementia could be identified and supported by staff during mealtimes.

    • Patients told us they were offered a choice of food and drink and spoke positively about the quality of the food offered.

    • Wards had access to a dietician with core hours who provided advice and input for those people who were highlighted to be at risk of dehydration or malnutrition. We saw evidence that this process was followed.

    • The nutritional requirements of individual patients were highlighted during handovers, ward rounds and multi-disciplinary meetings to ensure a holistic approach to care. Those who were on fluid or food charts and those who needed assistance or encouragement with eating and drinking could be highlighted by notes above their bed.

    • Wards had access to a diabetes specialist nurse who was available for advice for patients and staff.

    • Patients told us they were happy with the quality and choice of food and that was provided.

    • Guidelines were in place for initiating nutritional support for all patients on admission to ensure adequate nutrition and hydration.

    • A nutritional screening tool was used to assess the needs of the patient.

    We saw several areas of outstanding practice including:

    Medical care services

    • The availability and accessibility of services for patients and their relatives, such as the complimentary therapies, food voucher service and were identified as outstanding practice.

    • The trust was named, by the National Institute for Health Research (NIHR), as one of the best hospitals providing opportunities for patients to take part in clinical research studies. The Christie School of Oncology was established to provide undergraduate education, clinical professional and medical education and this was one of the first its kind nationally.

      Surgical services

    • The surgical division demonstrated an outstanding approach to treatment by the multidisciplinary cancer team who offered bespoke multi-speciality treatments, together with multi-modality therapy to patients, which improved survival rates, outcomes and quality of life for those patients.

    • The trust had an outstanding programme of alternative and complimentary therapies on offer to help patients with their holistic health and wellbeing which surgical patients could access.

    • The surgery directorate and wider trust displayed outstanding support and engagement for their staff. They used many different ways to engage with staff to keep them involved and included in decisions, changes and improvements within the trust. This in turn motivated and encouraged staff to improve their skills, qualifications and experience and become invested in the success of their organisation about which they were very proud.

    • The surgery directorate uses the very latest state of the art surgical robots which allows surgeons to work with greater vision, precision, dexterity and control and which provides many positive outcomes and less complications for patients.

    End of life services

    • The Specialist Supportive Care Team (SCT), an overarching team that includes the pain service and palliative care team, used an innovative approach to their structure, which was recognised by NHS England and is now being rolled out across cancer centres throughout the country.

    • GPs within Greater Manchester could access their patients’ information electronically. Other GPs had to access the Christie Portal to view their patient’s information.

    • The service was initiating the ‘goals of care’ approach to help ensure that clinicians and patients truly understood each other’s expectations regarding treatment and outcomes. At the time of our inspection, a small number of conversations had been trialled with patients. Clinicians told us that they found the approach ensured that conversations were easier to have and that they truly understood what their patients expected from them in their patient journey. Service leads were preparing to present this to the Cancer Vanguard for consideration for ‘goals of care’ being rolled out across the country.

    • The team had worked to develop the ‘Enhanced Supportive Care’ initiative. This is a new initiative aimed at addressing more fully the needs of cancer patients. The doctor is the national lead for this initiative, which is now being rolled out by NHS England. The service received a national QiC (Quality in Care) patient care pathway award in February 2016 for this service.

    Chemotherapy

    • With the increase of outreach services highlighted in the five year strategy, quality was seen as paramount. To ensure standards did not fall, the Christie Quality Mark was introduced in 2014. With representatives from governance, nurses, governors, consultants and managers from the Christie and other trusts locally formed a working group to ensure consistency in standards was maintained.

    Radiotherapy

    • The opt-in physiotherapy lymphoedema service at Salford for patients who had breast cancer was extremely good practice to address the needs of patients who were unaware if they would develop lymphoedema following treatment.

    • The world class research in radiotherapy and the development of the proton beam service.

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

    Importantly, the trust should

    Medical services

    • Take appropriate actions to maintain temperatures within treatment rooms where medicines are stored.

    • Take appropriate actions to improve staff appraisal rates and mandatory training compliance.

    Surgical services

    • Ensure that trust policy concerning the disposal and ‘wasting’ of controlled drugs, where the full contents of a vial are not prescribed and administered are adhered to in theatres and recovery.

    • Ensure full compliance with all aspects of the National Patient Safety Agency (NPSA) ‘five steps to safer surgery’ and the completion of the World Health Organisation (WHO) checklist, in particular the introduction of all staff members.

    • Ensure full compliance with trust CVC insertion infection control precautions.

    • Seek to improve the legibility of handwritten surgery consent forms.

    • Ensure a consistent and compliant approach to the requirements of the Mental Capacity Act 2005 regarding the two stage assessment of a patient’s capacity to consent to treatment.

    • Improve the temporary environment used for the pre-operative clinic, until the new facilities become available.

    • The service should consider increasing the numbers of staff with competency based qualifications in gaining consent.

    • They should continue to work towards meeting all of the recommendations of the ‘Implementation of the Faculty of Pain Medicine’s Core Standards for Pain Management (2015)’.

    Critical care

    • Ensure information related to patients physical and psychological needs assessments in critical care are relayed to the staff on the ward on discharge.

    End of life care

    • The trust should consider implementing a way that individuals’ faith needs can be met by the mortuary service.

    Chemotherapy

    • Improve mandatory training where there are pockets of low compliance

    • Ensure rooms storing medicines are below 25°C.

    • Review the attendance at divisional governance meetings to ensure staff attendance is adequate.

    • Ensure that where required (sluice room on the ground floor of the Palatine Centre) is secured and that chlorine based cleaning products and hand sanitisers are stored securely at all times.

    Radiotherapy

    • Review the staffing level requirements for treatment radiographers.

    • The trust should review the management structure and the skill mix in the radiography department and to consider roles for radiographers that include routine treatment delivery and review for patients and allows specialist registrars and consultants to treat more complex patients.

    Professor Sir Mike RichardsChief Inspector of Hospitals

23 December 2013

During an inspection in response to concerns

During this inspection we checked that all appropriate pre-employment checks were carried out for staff working at The Christie NHS Foundation Trust.

We saw that a recruitment and selection policy was in place to follow when any new staff member was being recruited. A policy was also in place regarding the needs for staff to have a Disclosure and Barring Service (DBS) check.

We saw evidence that the trust carried out the required pre-employment checks for staff. They also had a system in place to ensure all relevant checks, such a DBS and the right to work in the UK, were carried out.

10 January 2013

During a routine inspection

During our inspection we visited the Young Oncology Ward (YOU), ward 4 (clinical oncology ward for patients receiving radiotherapy and chemotherapy), ward 10 (surgical oncology ward) and ward 12 (for patients receiving radiotherapy and chemotherapy). We spoke with 11 staff members, including ward managers, nurses and healthcare assistants. We also spoke with seven patients.

The patients we spoke with commented positively about all aspects of their care and treatment. Their comments included 'I ask lots of questions and they don't make you feel stupid', 'You cannot fault the nurses. They do over and above what should be done' and 'It is a specialised hospital, I am getting the best'.

We saw evidence that doctors fully discussed patients' options with them and gave them time to consider what their preferred treatment option was. In the records we looked at we saw patients had given their consent prior to any treatment or procedure commencing.

The staff we spoke with said they felt well supported at work, and they had an annual appraisal meeting with their manager. We saw that their mandatory training was usually up to date, and they had the opportunity to attend other training courses to increase their skills. Ward managers said they were able to access staff at short notice, and these would usually be from their team on the ward or trust bank staff.

5 October 2011

During a routine inspection

We reviewed information that we hold from patient surveys. The majority of information reviewed was rated as better than expected (compared to similar organisations).

We visited the hospital on 5th October 2011 and spoke to a number of patients.

Those whom we spoke to told us that they felt they were always treated with dignity and respect, that staff always spoke to them and explained what was happening and asked permission before carrying out any care.

Comments were made by patients that we spoke to such as:

'They always draw the curtains when staff want to speak to you or give care'

'Everything regarding care is explained and if I do not understand then it is repeated to ensure that I do. Sometimes the information is backed up with leaflets but I look for guidance from them (they are the experts) to make my decision'

' I am very satisfied with the care that my child receives and appreciate that I am kept informed and can seek further clarification'

It was noted that all the patients we spoke to said that they were not aware of their care plan. They also told us that they were never anxious about their care nor did they ever feel unsafe.