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The Royal Marsden - London Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 19 January 2017

The Royal Marsden Hospital NHS Foundation Trust is split over two principal sites, one in Chelsea and the other in Sutton. The Trust also has a day-case unit on the site of Kingston Hospital. As a specialist trust, the Royal Marsden receives referrals from beyond the immediate areas, and the population covered by acute services cannot therefore be meaningfully estimated. However 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.

The Chelsea, Fulham Road hospital has 112 inpatient beds and 81 used for day case admissions.

This report describes our judgement of the quality of care at this hospital. It is based on a combination of what we found when we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from patients, the public and other organisations.

Overall we rated this location as outstanding.

We rated the radiotherapy service as outstanding. This was because the radiotherapy service was patient centered service placed patients at the centre of the their care. Care was provided in line with national standards, with radiotherapy services participating in national and international research programmes.

We further rated the hospital as outstanding for the key question of caring.

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 shared with staff and applied in practice.
  • Staffing arrangements supported the delivery of safe diagnostics, treatment and care.
  • 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.
  • Vulnerable individuals were identified and protected under safeguarding practices.
  • Staff were enabled to perform their duties through the provision of professional standards and guidance.
  • 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.
  • All staff recognised the uniqueness and the diversity of patients and responded appropriately with support and advice as required.
  • 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.
  • Staff encouraged participation from those close to people who used the services, including carers and dependents. People were encouraged and supported to manage their own health, care and wellbeing and to be as independent as able.
  • Patient flow from admission, to discharge was managed effectively and ran smoothly.
  • Services were organised to meet people’s treatment needs in relation to their cancer, as well as their wider holistic needs for spiritual and psychological support and for relaxation.
  • There was some flexibility in appointment times to meet the needs of patients who were working or had care responsibilities.
  • Patients had the option of having their blood tests, consultation and treatment on a single day (known as one stop) or of attending the medical day unit on two separate days, one for assessment, and one for treatment.
  • Arrangements were established with other hospitals where patients were treated for non-cancer related conditions.
  • There was clear information and additional culturally appropriate support services for international patients receiving private treatment.
  • There were responsive arrangements for treating patients with possible neutropenic sepsis both within the hospital and for those admitted to A&E departments in other trusts.
  • There were few complaints and those that were received were addressed in a proactive manner.
  • Staff understood and respected the trust’s vision to be leaders in cancer care. They shared the objectives of the wider trust to provide safe, effective and high quality care to all patients.
  • Staff were proud to work for the hospital and would want their friends and family to be treated there should the need arise.

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 provide 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.

However, the trust should:

  • Theatre staff should ensure de-briefing are recorded after surgical activity.
  • The trust should ensure medicines are stored securely and in line with legal requirements.
  • Regular checking processes of the resuscitation trolleys must ensure the drawers are locked to prevent unauthorised access to intravenous drugs and fluids.
  • To meet national recommendations the Linear Accelerator replacement programme must be kept up to date.
  • Ensure staff are conversant with the requirements of infection control procedures.

  • Review strategies to enforce compliance with hand hygiene and infection control measures amongst clinical visitors to the critical care unit.
  • Ensure staff understand security arrangements.
  • Review the risk register for items that can be closed.
  • Ensure single-use disposables are managed for expiry dates.
  • Develop a consistent approach across the trust for recording and logging cadaver storage temperatures.
  • Ensure Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) forms always have dates by which they should be reviewed, and these are completed.
  • Consider the introduction of formal bereavement support throughout the hospital.
  • The provider should review outpatient booking rules to ensure clinics are not overbooked to reduce the time patients wait to be seen.

  • The provider should review the waiting area to provide additional space on busy clinic days.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 19 January 2017

Effective

Good

Updated 19 January 2017

Caring

Outstanding

Updated 19 January 2017

Responsive

Outstanding

Updated 19 January 2017

Well-led

Outstanding

Updated 19 January 2017

Checks on specific services

Adult solid tumours

Good

Updated 19 January 2017

We rated the solid tumours service at The Royal Marsden Hospital, Chelsea location as good because:

• The solid tumour services at The Royal Marsden Chelsea had good safety performance, with few serious incidents.

• Appropriate procedures supported the delivery of safe care.

• There were sufficient staff with a range of skills and expertise, and staff were encouraged to develop.

• Theatres and wards were clean and there were safe practices to minimise the risk of infections arising.

• There were good multidisciplinary team input between surgeons, doctors, nurses and other members of staff to provide a safe patient pathway of care.

• There were good surgical outcomes for the complex high-risk surgery undertaken at the trust, and the trust performed well in national audits.

• Specialist surgery, using the latest equipment and advanced practices were available to patients.

• Patients received timely effective pain relief.

• The trust demonstrated continual improvement, with comprehensive auditing and projects.

• We saw staff being compassionate, kind and caring to patients across the whole trust.

• The trust scored well on the Cancer Patient Experience Survey, being in the top 20% for many statements.

• The trust supplied an extensive range of accessible therapies for patients.

• The use of enhanced care pathway plans for patients and the involvement of staff in designing these.

• Patient flow from admission, to theatre, then on to the ward and finally to discharge was managed effectively and ran smoothly.

• The service was fully accessible to patients with disabilities.

• There was a clear strategic plan and staff demonstrated a shared vision with the trust.

• There was effective leadership, which provided strong support to staff. Leaders were visible and staff felt they were approachable. Matrons and clinical leads were present and supportive of their staff.

Chemotherapy

Good

Updated 19 January 2017

We rated the service at the Royal Marsden Hospital Chelsea location as good overall because:

• Chemotherapy drugs were prepared in an aseptic (germ free) environment, prescribed through an electronic prescribing system. Drug administration was monitored safely, and patients were made aware of potentially life threatening side effects that could occur between treatments and knew what action to take.

• There was a strong culture of multidisciplinary working between nurses, specialist nurses, doctors and allied health professionals. Patient treatment was decided in multidisciplinary meetings (MDTs) and there was regular in-depth MDT patient review.

• There were clear arrangements for responding quickly to patients with possible neutropenic sepsis both within the hospital and for those admitted to A&E departments in other trusts.

• There were established non-cancer pathways and agreements with other hospitals for patients needing treatment for other conditions such as respiratory and neurological conditions. There were formal agreements with some other hospitals where patients were treated for non-cancer related conditions.

• Services were organised to meet people’s treatment needs in relation to their cancer. They also took into account patients wider holistic needs for spiritual and psychological support and for relaxation. Staff treated patients as individuals.

• Patients told us staff at all levels were courteous, thoughtful, and kind in their dealings with them, in many small ways that went well beyond the administration of treatment. The number of compliments far exceeded the complaints.

• The atmosphere of the units was calm and welcoming and patients we spoke with and their families were full of praise for the sensitivity staff showed to their feelings and concerns and to the needs of some patients for emotional support in coping with their treatment and condition.

• Nurses recognised the uniqueness of each patient, and the diversity of patients, and responded appropriately with support and advice as required.

• There was an open culture of reporting and learning from incidents and near misses without blame and patients were protected from avoidable harm because staff understood the risks of treatment and the nature of incidents.

• The chemotherapy day units, the clinical assessment unit and some wards were modern and welcoming, and we observed high standards of cleanliness.

• Staff were clear about the vision for the trust’s services to be leaders in cancer care. They shared the objectives of the wider trust to provide safe, effective and high quality care to all patients. All those we spoke with were proud to work for the hospital and would want their friends and family to be treated there should the need arise.

• There was a very wide range of information available to patients to supplement what they were told by clinical staff, including films for patients to help them look after their CAVD devices. Information was available in other languages.

However;

• The acute oncology service did not operate at weekends.

Critical care

Outstanding

Updated 19 January 2017

Overall we rated critical care as outstanding at the Royal Marsden Hospital, Chelsea location because:

• Consistently good nurse and doctor staffing levels met national benchmarks and best practice guidelines.

• A robust incident reporting system was in place, which staff spoke enthusiastically about as a key feature of their ability to develop and progress. There was a clear track record of detailed investigations into incidents and learning as a result.

• There was consistent input from a multidisciplinary team of cancer and other medical specialists, including pharmacy, occupational therapy, dietetics and microbiology. On-site pharmacists and technician support ensured a high standard of medicines management and equipment readiness. Such specialist teams also provided staff with teaching and learning opportunities on a regular basis.

• Critical care services fully met the National Institute for Health and Care Excellence guidance on the rehabilitation of patients. This included a follow-up clinic led by highly experienced clinicians who constantly strived to improve the service by asking for feedback from patients and their relatives and acting on this.

• A well-developed rolling programme of clinical audits was overseen by a clinical lead, outreach matron and clinical nurse lead. Unit staff were involved in the discussion of results and contributed to re-audits, which established improved care pathways for patients. The audit programme was in addition to expected national data contributions such as the Intensive Care National Audit Research Centre.

• There was a focus on providing individualised care based on feedback from patients and their relatives. This included use of a patient experience survey and a culture of openness and collaboration in which staff acted on informal feedback.

• Staff responsiveness to individuals needs was evident in the design and resources of the unit, which demonstrated attention to detail in areas that could make a material difference to patients. This included photosensitive glass, modified bed spaces for patients living with dementia and obesity as well as adapted spaces for teenagers.

• Governance and risk management processes were robust and fit for purpose and demonstrated a very positive working relationship between all staff teams in the unit and the trust’s senior executive team. The team focused on service innovation and sustainability and had a number of strategies to achieve this. This included an extensive specialist education programme for nurses and a range of nurse-led service improvement teams who had accountability for changes in practice and policy in specific areas.

However;

• There was room for improvement in infection control practices and hand hygiene audit results were variable. Senior clinical staff demonstrated appropriate action to improve the outcomes of such audits.

• A dedicated clinical nurse educator ensured staff remained up to date with mandatory training although the unit was slightly short of the trust’s target figure.

End of life care

Good

Updated 19 January 2017

Overall we rated the End of Life Care (EoLC) at the Royal Marsden Hospital, Chelsea site as good because:

• The specialist team were highly skilled and knowledgeable throughout the hospital and provided effective support to clinical staff.

• Patients were provided with good quality and safe care at the end of their life. Patients were cared for in a caring and compassionate manner by staff at all levels. Their privacy and dignity was maintained throughout their stay in hospital.

• Staff ensured patients and their relatives were fully informed and involved in their treatment decisions. Consent and capacity were considered appropriately.

• There was an extensive education programme to support staff in delivering this care in line with appropriate national standards and best practice guidance.

• Regular and meaningful clinical audits were carried out in a variety of topics relating to EoLC. Information and learning points relating to incidents and complaints were shared across the trust. Improvements had been made across the service because of this, and staff were able to describe these changes.

• Patient care records and risk assessments were thorough and complete, with appropriate consideration given to different aspects of holistic care at the end of life.

• The needs of individuals were considered and largely met by the service. The majority of patients achieved their preferred place of death.

• Pain relief, nutrition and hydration were considered in nearly all cases and patients were happy in regard to these outcomes. Symptom control was considered and well managed, using both traditional medical methods and complementary therapies.

• The trust had a clearly defined vision and strategy to improve palliative care provision.

• Regular meetings and forums took place that addressed issues in EoLC with various stakeholders with a view to strengthening this provision.

• Senior staff were supportive and approachable, encouraging an open and transparent culture.

However;

• Referral to palliative care was not always made earlier in the patient pathway. This affected their access to psychological support and advanced care planning at the end of life. Psychological support often carried a long waiting time and there was no formal bereavement support offered to bereaved families through the hospital. There was a lack of quiet or private space in the wards for grieving relatives.

• Porters were broadly unaware of the procedures to follow in terms of infection control and escalation of potential problems in relation to the body store.

• The arrangements for checking temperature storage in the mortuary were not sufficiently robust.

• Body store fridge checks were not retained, and there was a lack of consistent approach across the trust sites for this.

• When asked staff were not aware that there was a lay member with responsibility for EoLC on the trust board, there was also little knowledge of items relating to EoLC on the trust risk register, and no awareness that items should be added that presented a potential issue affecting patient care

Outpatients and diagnostic imaging

Good

Updated 19 January 2017

​We rated the outpatient and diagnostic imaging service at the Royal Marsden Hospital, Chelsea site as good overall because:

• The outpatient and diagnostic imaging departments were providing safe, effective, caring and responsive services, and was well led.

• There were sufficient staff with appropriate skills in the outpatients and diagnostic imaging departments to provide safe services. Staff in both departments felt well supported and had access to training and development opportunities.

• The outpatient service was using the London Cancer Alliance holistic needs assessment process to assess patient’s care and plan the treatment they received.

• There was good patient information in outpatients and diagnostic imaging about the treatment options available.

• Staff in outpatients and diagnostic imaging understood the importance of reporting and learning from incidents. Information about incidents was passed on to staff in a variety of ways including staff meetings in the morning before outpatient clinics started, and at departmental meetings.

• An outpatient transformation project was underway to respond to areas where there were recognised problems with waiting times.

However;

•           Systems for controlling access to medicines in the outpatient department were not robust. When we brought these issues to the attention of managers, they immediately put measures in place to improve the storage and security of medicines.

Radiotherapy

Outstanding

Updated 19 January 2017

Overall we rated the Radiotherapy service at the Royal Marsden Hospital, Chelsea as outstanding because:

• Safety was embedded across all areas involved in the radiotherapy pathway from the maintenance of equipment to the delivery of accurate complex radiotherapy treatments.

• Incident reporting played a major part in the safe and effective delivery of the service. Clinical, non-clinical and radiation incidents were reported through the appropriate mechanisms, investigated and learnings were shared across all multi professional groups of staff.

• The department submitted radiotherapy error reports (RTE) to Public Health England (PHE) Towards Safer Radiotherapy data set. This disseminated learning from RTE’s across the radiotherapy community to influence local practise and improve patient safety.

• The clinical equipment available in the pre-treatment, physics planning, and treatment areas allowed high standards of treatments to be planned and delivered. This included Intensity Modulated Radiotherapy (IMRT), Image Guided Radiotherapy (IGRT) and Stereotactic radiotherapy. All of which followed national recommendations as best practice to deliver improved outcomes to patients.

• The radiotherapy service was a major contributor to local and national clinical trials with 33 trials open. With this high level of engagement, the department supported the implementation and evaluation of new radiotherapy techniques such as adaptive radiotherapy and IMRT.

• All professional groups of staff were very well supported by the trust through mandatory and continuing professional development training, (CPD). High percentages of staff had postgraduate qualifications, which enriched their knowledge, allowing high levels of care to be delivered.

• There was a comprehensive system for ensuring and measuring competencies, which supported the continuing development of all the staff groups. There was a strong multidisciplinary teamwork, which supported improved patient pathways.

• Electronic patient records and a quality management system ensured staff could access clinical information, protocols, and procedures to support the delivery of evidenced based good care.

• We observed staff being caring and compassionate to patients, relatives and all staff groups. We observed patients being treated as a person and not a group of symptoms. All relatives were actively included, with patients’ consent, in the patient centred care delivered.

• The service performed well against the 31 day waiting time standard for definitive and subsequent treatments. Data confirmed all patients were seen within 20 minutes of their scheduled treatment time unless unforeseen circumstances developed. All patients started their radiotherapy within the time constraints recommended in the Manual of Cancer Standards.

• A strong, visible, and approachable senior management team led the service with a strong governance structure, which ensured a safe and effective service. Staff felt fully supported and presented at national and international conferences with the work they were undertaking across the service.