The Royal Marsden - London

Updated 16 January 2020

The Royal Marsden (London) has a total of 113 inpatient beds.

Patients receiving end of life care are cared for throughout the hospital. There are no dedicated end of life care beds but the trust tries to manage the majority of these patients on Horder ward, where nursing staff are experienced managing patients with complex symptom control and end of life needs. The specialist team at the trust is comprised of a multi-professional team providing a 24/7 visiting, advisory service to patients and staff at across the trust. Across the whole trust, there were 236 deaths between February 2018 and January 2019.

Solid tumours at The Royal Marsden Hospital Chelsea, comprises of, urology, gastrointestinal, breast, gynaecological, head and neck, sarcoma, melanoma, lung, plastic surgery, skin, thyroid, neuro oncology and other rare cancers. As a recognised centre for the treatment of cancer, The Royal Marsden provides a specialist tertiary service for complex surgery and treats patients referred from all over the country and abroad.

There are seven operating theatres at The Royal Marsden, Chelsea. The trust provides surgery for upper gastrointestinal, lower gastrointestinal, liver resections, head and neck cancers, intra-abdominal and retroperitoneal sarcomas, plastics, breast, gynaecology and urology.

There are seven wards in total; five are divided into tumour type. Burdett Coutts is a male only ward for gastrointestinal and genito-urinary treatment. Ellis Ward is female only, for treatment of breast, gynaecological, urological and gastrointestinal. Wilson Ward is a male and female ward for patients with sarcoma, melanoma, head and neck, lung and haematology cancers. The private wards of Granard House and Wiltshire Ward cater for patients with surgery and medical treatment.

Updated 16 January 2020

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

• We rated effective, caring, responsive and well-led as outstanding.
• We rated safe as 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.

Updated 16 January 2020

Our rating of this service improved. We rated it as outstanding because:

• The service was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation. The service had been recognised for innovative practices which had proven results in positively impacting safety, care and outcomes.
• The service engaged well with patients, staff, the public and local organisations to plan and manage appropriate services. The service was focussed on using views gathered from engagement to drive improvement efforts.
• Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. The culture was positive with a primary focus on patient care and experience.
• Staff monitored the effectiveness of care and treatment. They used the findings to make improvements and achieved leading outcomes for patients.
• The service provided care and treatment based on national guidance and evidence-based practice. Managers checked to make sure staff followed guidance. The service had been accredited under relevant clinical accreditation schemes.
• The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and development
• Staff of different kinds worked together as a team to benefit patients. They supported each other to provide good care.
• Staff were exceptionally kind and caring and provided holistic patient centred care. They went the extra mile to ensure their patients felt their experience was the best they could provide and the patient was at the centre of care for the whole person.
• Feedback from people who used the service was continuously positive. Patients felt their care was delivered with exceptional kindness and patience. They believed that staff went above and beyond their expectations and without exception demonstrated compassion and empathy in their roles.
• The service provided a substantial and effective network of emotional support for patients. They anticipated and provided an array of services that may have been of benefit to patients and their support network. These considerations were given high value and implemented in a positive and proactive way, this support was embedded and integral to the care that was delivered.
• Patients and their relatives were treated as active partners in the planning and delivering of their care and treatment. We saw that staff were committed to working with patients and their relatives, gave them appropriate information and encouraged them to make joint decisions about their care.

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.

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.

Updated 16 January 2020

Our rating of this service improved. We rated it as outstanding because:

• The profile of the service had improved greatly since the previous inspection, with all staff across the trust invested in the importance of ensuring patients received a good end of life care experience. There was a strong emphasis on evidence-based end of life care, supported by data, audits and performance metrics.
• At the time of the last inspection, there was a feeling amongst many staff that we spoke to that referral to the specialist team could be made earlier in the patient pathway, with the majority of patients referred to the specialist team in their last month of life. Since the previous inspection, much work had taken place across the trust and there was now greater recognition that early involvement of palliative care could be beneficial to patients throughout their illness.
• The “triggers” project had been rolled out and was now available to patients with lung, gynaecological, renal and upper gastrointestinal cancer. The aim of this service was to offer patients attending these oncology clinics early proactive referral to the specialist team to enhance their quality of life.
• In the National Audit of Care at the End of Life (NACEL) 2018/19, the trust scored above the national average in all but one measure.
• The service had enough staff to care for patients and keep them safe. Clinical staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service-controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. 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, 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, and took account of their individual needs. They provided emotional support to patients, families and carers. We were given multiple examples of arrangements being made for patients at the end of life to support their needs and wishes, as well as feedback that staff routinely went above and beyond for their patients.
• The service planned care to meet the needs of the patient population, took account of patients’ individual needs, and made it easy for people to give feedback. Waiting times from referral to achievement of preferred place of care and death were in line with good practice.
• 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 end of life 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.

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.

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.