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The Clatterbridge Cancer Centre Good

Reports


Inspection carried out on 10 Dec to 17 Jan 2019

During a routine inspection

Our rating of services went down. We rated them as good because:

  • We rated safe, effective, responsive and well-led as good. We rated caring as outstanding.
  • We took into account the hospital’s previous rating from our last inspection for three core services. Following our recent inspection the combined ratings meant we rated four services as good and two as outstanding.
  • We cannot compare the ratings for outpatients and diagnostics services as at our last inspection we rated these services together. However, we found that areas of concern in these services at our last inspection had been addressed at this inspection.
  • Across the trust, services largely performed well. We were not concerned regarding the overall quality of cancer care. Our concerns were linked to important issues that underpin cancer care and ensure there are effective systems and processes within hospitals.
  • We continued to rate caring as outstanding. Throughout the organisation staff were committed to delivering patient centred care. Patients were at the heart of what the trust did and decisions it took. Staff respected individuals and supported them practically and emotionally.
  • We improved the overall hospital rating in safe to good.
  • We continued to rate effective as good. The hospital continued to ensure that patients had good outcomes because they received care and treatment that met their needs.
  • We continued to rate responsive as good because most people’s needs were met through the way the services were organised and delivered.
  • At core service level, we rated well-led as good because the leadership and culture promoted high-quality person-centred care.

However:

  • Our rating in well-led for medicine went down because the hospital did not comply with some legal requirements. Further information can be found in the medicine report.
  • We rated safe in diagnostics as requires improvement. We were concerned regarding patient safety, storage of records and mandatory training levels in relation to life support training. The trust did not comply with some legal requirements in relation to these issues. Further information can be found in the diagnostics report.
  • The hospital’s governance systems did not enable senior staff to have oversight of issues that impacted on patient care and allow them to address risks sufficiently in a timely way. Further information can be found in the well-led overall report and evidence appendix.
  • The hospital did not ensure there were always enough suitably qualified, competent and experienced staff with relevant levels of life support training (including basic, immediate and advanced life support) deployed within the service at all times.
  • We had concerns relating to records storage.
  • All the concerns relating to legal requirements were raised with the hospital at the time of our inspection and action was taken to address them.

Inspection carried out on 07, 08, 09 June 2016

During a routine inspection

The Clatterbridge Cancer Centre is one of the biggest cancer centres in the country and treats patients from across Merseyside, Lancashire, Cheshire, the Isle of Man and North Wales. The trust also provides specialist care and treatment to patients from all over the United Kingdom.

The trust completed the year with an income and expenditure surplus of £56.5 m. However, the trust will be moving to a new site in the centre of Liverpool in 2018, and £49m funding will be reinvested into the cost of the building of the new hospital. The new hospital will make treatment more accessible for those who live in the more deprived areas of Merseyside and the surrounding areas. Some services will remain at the Clatterbridge site including the proton service for eyes.

Oncology services are provided at the hospital there are 74 inpatient beds over three inpatient wards at the hospital and a four bedded young peoples’ unit that was found on Mersey Ward. They had a total of 3,760 admissions between April 2015 and March 2016 and had a low number of deaths during the same period (74).

Chemotherapy services are provided by the trusts Systematic Anti-Cancer Therapy (SACT) Service at the Clatterbridge Cancer Centre and at eight peripheral satellite clinics at a range of locations, which include acute general hospitals, primary care centres and other sites managed by the trust. The service also provides certain types of chemotherapy in patient’s homes. This service is provided by staff employed and trained by the Clatterbridge Cancer Centre. The adult day-case Delamere chemotherapy unit is open Monday to Friday between the hours of 8.30am and 6.30pm. Between April 2015 and April 2016, the unit delivered 46,974 doses of chemotherapy. Of these 19,979 were delivered at the Clatterbridge Cancer Centre, 26,247 were delivered in the outreach sites and 748 of these doses were delivered in patient’s homes.

There are seven linear accelerators for the delivery of radiotherapy treatment at the Clatterbridge site and there is a radiographer led service from a purpose built unit in Aintree with three linear accelerators. The trust delivered 97,926 radiotherapy treatments in the period April 2015 to March 2016. There is a brachytherapy treatment known as Papillon which can provide an alternative to surgery for some rectal cancers. There is a proton beam therapy service for the treatment of cancers of the eye that treats patients from all over the country and from abroad. The low energy proton beam therapy unit is the only one in the country.

A range of outpatient cancer services are provided by the trust and a number of outpatient appointments are also offered in satellite clinics at hospitals throughout Cheshire, Merseyside and the Isle of Man. They offer a combination of consultant and nurse-led clinics including clinical and medical oncology and phlebotomy. A number of therapy led appointments are provided including physiotherapy, speech and language therapy and occupational therapy. There were 99,394 outpatient appointments offered across the trust between July 2015 and April 2016 with 43,318 offered at Clatterbridge Cancer Centre, Wirral.

The diagnostic imaging department consists of two direct radiography (DR) rooms (one of which includes a orthopantomogram (OPT) machine), one computed tomography (CT) scanner, one gamma camera, one positron emission tomography–computed tomography (PET CT) scanner, two magnetic resonance imaging (MRI) scanners, and ultrasound.

End of life services were provided and led by a team of specialist palliative care nurses and a consultant in palliative care medicine, who provided direct care and treatment to patients and supported staff throughout the hospital.

We visited the Clatterbridge Cancer Centre and the Aintree Radiotherapy site as part of our announced inspection during 7 to 9 June 2016. We also carried out an unannounced inspection on 21 June 2016. During this inspection, the team inspected the following core services:

• Medical care services (Oncology)

• End of life

• Outpatients and diagnostic services

• Chemotherapy

• Radiotherapy

Overall, we rated The Clatterbridge Cancer Centre NHS Foundation Trust as outstanding. We have judged the service as ‘good’ for safe, effective and responsive. We rated the domains of caring and well-led as ‘Outstanding’.

Our key findings were as follows;

Vision and strategy

  • There was a clear trust strategy plan for 2014 to 2019 which had been refreshed in February 2016. This was supported by the establishment of a Transformation Programme Office to support the delivery of the transformation agenda. The plan was linked to other external plans including the Five Year Forward View (5YFV) [Published October 2014]; the 2016/17 planning guidance (particularly the opportunities provided by the requirement for the development of health economy sustainability and transformation plans (STPs) that cover the same planning period). Published December 2015 and the Report of the cancer taskforce (Achieving World Class Outcomes: a strategy for England 2015-2020)
  • All services had local plans which linked to the trust strategy.

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.
  • There was effective teamwork and clearly visible leadership within the services and decision-making was patient centred and clinician led.
  • Leaders understood the challenges to good quality care and identified actions to address them.
  • Staff felt involved in decision making, and felt that they were able to influence the vision and strategy of the organisation.
  • The NHS staff survey 2015 showed the trust performed better than the national average for 12 indicators and as expected in a further seven. The overall staff engagement score for the trust was 3.98, which was in line with the national average score of 3.94 for specialist acute trusts.

Culture

  • The trust had “the Clatterbridge Culture Programme” in place which was a five year strategy to create a culture in which positive behaviours are experiences consistently throughout the organisation. This contained a culture recipe and clear measurement of each of the culture dimensions.
  • All the staff we spoke with were proud, highly motivated and spoke positively about the care they delivered. Staff told us there was a friendly and open culture. They told us they received regular feedback to aid future learning and that they were supported with their training needs by their managers.
  • All leaders appeared to be competent, knowledgeable and experienced to lead their teams and understood the challenges to good quality care and what was needed to address those challenges. Leaders strived to deliver and motivate staff to succeed and to continue to improve. Managers sought to improve the workforce culture to engage with staff to achieve advances in care and quality.
  • We saw that a very positive and supportive culture across all wards and departments. Staff were very proud of their hospital and the work they did. They were enthusiastic and passionate about the care they provided and the achievements they have accomplished. There was a tangible sense of willingness to go the extra mile and do the very best for their patients.
  • There was an open and honest culture within the organisation and staff were candid about the challenges they faced.
  • Staff morale was reported to be good although in outpatients the amount change the department had experienced in a short period of time had affected morale.

Governance and risk management

  • We found all policies to be clear, accessible and up to date.
  • The trust had been awarded significant assurance by Mersey Internal Audit for the last two years regarding information governance (IG). The IG Toolkit was reported as 80% compliant for 2015/16.
  • Clinical governance managers were integrated in to directorates, attending and reporting to directorate meetings and providing leadership with root cause analyses.
  • Local risk registers were seen to be relevant and up to date; however in oncology the process required strengthening. The use of monitoring including dashboards and audits was seen in all areas.

Cleanliness and Infection control

  • Clinical areas at the point of care were visibly clean.
  • The trust had infection control and prevention policies in place, which were accessible to staff and staff were knowledgeable on preventing infection and minimising risks to patients, visitors and staff.
  • The local Infection Control Committee met regularly and covered all expected areas.
  • In April 2016 the committee reported that the C.Diff objective for the year remained at one case. There had been no MRSA bacteraemia infections.
  • Staff were observed to comply to bare below the elbow standards and hand washing procedures were adhered to. The use of personal protective equipment was of a good standard.

Staffing

  • Medical, nursing and radiographer staffing was good and in line with the expectations at a specialist trust. Staff told us that they felt well-staffed and they felt that they had enough time to care for patients and medical response was timely when required.
  • Nurse staffing levels were based on an acuity tool. Staff sickness and turnover rates were as expected. Staff told us that they felt well-staffed and they felt that they had enough time to care for patients. Staff vacancies were noted on the risk registers and actions had been identified to mitigate these risks. There was a reliance on temporary staffing on some of the wards but there was a buddy system in place to make sure they were well supported.
  • Concerns were found around staffing in the diagnostic imaging service. 

Mortality rates/ Patient outcomes

  • As a specialist cancer trust, it is inevitable that many patients with advanced cancer spend their final weeks as patients of Clatterbridge Cancer Centre, and whilst acknowledging the desire of the most terminally ill patient to die at home, for some, symptom control issues or social difficulties mean that their end-of-life care is delivered within a hospital.
  • Between April 2014 and March 2015 there were 50 deaths at the centre.
  • Accordingly a significant number of deaths occurring within the trust were "expected”. The Trust Management Group reviewed the 99 inpatient deaths occurring between April 2014 and January 2016, only 5 were deemed to be unexpected. The palliative care team had significant input into the management of in-patients with advanced disease, and often patients had been on the Amber Care Bundle or an end-of-life pathway in the days or weeks prior to their death.
  • The service participated in the National Chemotherapy Multi-Disciplinary Team (MDT) Peer Review (2014) being compliant with 35 out of 36 standards and scoring 97.6% overall. The service scored 100% overall compliance with the 19 standards for intrathecal chemotherapy in the National Chemotherapy MDT Peer Review (2014).
  • Data contributions to the National Care of the Dying audit showed that the service had performed better than others nationally in the ten key clinical performance indicators.

We saw several areas of outstanding practice including:

In the End of Life Service;

  • The service had developed a simulation based training programme to develop the skills and knowledge of staff throughout the hospital. This involved simulating difficult situations so that staff developed their confidence when dealing with patients and relatives at the end of life.
  • All staff were committed to facilitating the requests of patients at the end of life. For example, there had been a number of weddings organised within a short period of time at the request of patients. Several staff were involved in facilitating these.
  • The service had responded to NICE guidance by developing a day after death service which met the needs of the bereaved in that a number of risk assessments were undertaken to ensure their welfare.
  • The SPC consultant was involved in a number of projects. For example, the serious illness programme UK was being piloted collaboratively with one organisation from the United States and had been designed in response to services recognising the challenging situations that clinicians faced when dealing with patients and relatives at the end of life.

In the Outpatients and Diagnostics service;

  • Individual needs of patients were identified through completion of a Holistic Needs Assessment at varying times during treatment and surveillance. Following completion a care plan was formulated to summarise any concerns and identify actions to address them.

In the Radiotherapy service;

  • The development of the advanced practice radiographer posts that enabled consultants and registrars to do the more complex work.
  • The uses of skill mix across the department for staff at all levels including health care assistants
  • The continuing development of the Papillon service as an alternative to radical surgery.
  • The proton beam service for the treatment of eye cancers and its continuing development and training of staff from other centres.
  • Radiographers able to prescribe medicines for head and neck cancer patients to alleviate their pain.
  • The development and use of the vac bags to help to immobilise patients during treatment and the making of individual head rests to make patients more comfortable.

In the Chemotherapy service;

  • The innovative introduction of the rapid chair initiative in the Delamere unit had improved the experience and waiting times for patients receiving shorter treatments.
  • The introduction of the Adjuvant Zoledronatec service was innovative and market leading. The introduction of this service meant that patients with breast cancer were receiving the very latest evidence based treatment to reduce their risk of death and reoccurrence.
  • The Chemotherapy at Home project was outstanding and provided patients with treatment in their own homes. This service embodied the overall trust and service vision of providing the best cancer care to their patients.
  • The positivity and compassion shown by staff and reflected in the feedback from patients was outstanding. It was clear that all levels of staff continuously strived to provide outstanding care to their patients.
  • The interaction and utilisation of the Maggie’s Merseyside charity was excellent. It meant that patients could access all the advice, support and treatment in one place at one time.
  • The support offered to patients throughout their treatment was outstanding. This included the implementation of the end of treatment bell, the PAT therapy dog and handler, massages and relaxation techniques for patients and the program of activities provided in the Maggie’s centre. All of which contributed to patients receiving an excellent level of emotional and practical support.

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

Importantly, the trust must:

  • Improve the staffing within the diagnostic imaging service.
  • Ensure that concerns were raised regarding the protection documentation (as required by the Ionising Radiation Regulations 1999 (IRR) and Ionising Radiation (Medical Exposure) Regulations 2000 (IR(ME)R)) which was overdue for review or did not reflect current clinical practise such as a risk assessment from 2013, and local rules from 2014 are addressed.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection carried out on 27 September 2013

During a routine inspection

During our inspection we visited the Mersey Ward, Conway Ward and Sulby Ward, including the teenage and young adults unit. We spoke with patients and staff on all the wards we visited. We spoke with 16 staff of different grades. We spoke with eight patients and some of their relatives.

Patients spoke positively about their experience at the Clatterbridge Cancer Centre NHS Foundation Trust. One said �The staff have been great at helping me to overcome my embarrassment, and I�m not used to needing any help�. Others told us staff treated them with sensitivity, and one patient commented that staff �could be good fun� but said they were very careful when assisting them and helped them relax �because they are good at this work�. One nurse told us �If anyone asks where I work I feel so proud when I tell them�.

Patients understood the care and treatment choices available to them and were given appropriate information and support regarding their care or treatment.

We saw that staff were well supported and had regular personal development reviews. Training was monitored and we saw evidence that staff had the opportunity to attend more specialist training courses when appropriate. There were enough staff on duty at the time of our inspection and we saw that additional staff could be accessed at short notice if required.

Records were kept securely and could be located promptly when needed.

Inspection carried out on 11 October 2012

During a routine inspection

During our inspection at The Clatterbridge Cancer Centre NHS Foundation Trust we visited all three inpatient wards; Sulby ward, Mersey ward and Conway ward. We spoke with eight staff members, including ward managers, nurses and a psychologist. We also spoke with two patients on each of the wards we inspected.

The patients we spoke with were very positive about all aspects of their care and treatment. They said that prior to being admitted they had met their consultant who had explained everything and asked for their consent to the suggested treatment. They said they were asked for their consent again after they were admitted and prior to their treatment commencing. Patients told us that staff regularly checked they were all right and not in any pain. They said staff fully explained everything that was happening with regard to their treatment and support.

Comments from patients included �[The staff] treat you as an individual not as a number or a disease�, �I can�t fault anything to do with the oncology department�, and �[The staff] are amazing, absolutely amazing�.

Staff told us that they felt well supported at work and received regular training. They said they had the opportunity to increase their knowledge of their area of work and extra training courses were well advertised.

We saw that the trust carried out regular checks on all aspects of the service they provided. Where improvements could be made action plans were put in place and monitored.

Inspection carried out on 16 March 2011

During a themed inspection looking at Dignity and Nutrition

Patients and relatives interviewed expressed that they were very satisfied with the care and treatment given to them during their stay at Clatterbridge Centre for Oncology. They told us that they were treated with respect and dignity, their needs were assessed and they were given plenty of information in a form they could understand to help them make choices regarding their care and treatment.

The hospital�s own patient survey results and results from the NHS patient survey corroborated this evidence. A large proportion of inpatients expressed satisfaction within both surveys with care and treatment, privacy, dignity, information and treatment with respect.

Patients told us at interview and within surveys that generally they were very satisfied with the care given in respect of meeting their nutritional needs. They also told us that the food choices, availability, presentation, and special diets were of good quality. We were told that staff support and assist patients where required and that mealtimes were protected and well organised.