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The Royal Marsden - Sutton Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 18 September 2018

Our rating of services improved. We rated it them as outstanding because:

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

A summary of services at this hospital appears in the Overall Summary section.

Inspection areas

Safe

Good

Updated 18 September 2018

Effective

Good

Updated 18 September 2018

Caring

Outstanding

Updated 18 September 2018

Responsive

Good

Updated 18 September 2018

Well-led

Outstanding

Updated 18 September 2018

Checks on specific services

Adult solid tumours

Good

Updated 19 January 2017

We rated adult solid tumours service at The Royal Marsden Hospital, Sutton as good because:

  • The service had trained staff and taken action to minimise risks to patients. Staff were aware of the incident reporting procedures and told us learning from incidents was shared with them.

  • There were sufficient staff, with appropriate skills and expertise, in post to care for patients. Clinical areas were clean and tidy and staff adhered to infection prevention and control procedures.

  • Medicines and controlled drugs were managed in line with best practice and controlled drugs were stored in locked cupboards on the wards.

  • Care and treatment was informed by evidence based practice and staff contributed to national and international research and the trust performed well in national audits.

  • Patients received prompt and effective pain relief and staff had access to the consultant led acute and chronic pain support team.

  • Patients were very positive about the way staff cared for them and we observed positive and responsive interactions.The focus was on the individual needs of patients and staff often went the “extra mile” to meet them.

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

  • The hospital worked well with commissioners and other local NHS trusts to plan and provide care for patients.

  • Referral to treatment times were the same or better than the England average.

  • Additional staff could be deployed to support patients with a learning disability or who were living with dementia.

  • The leadership of the service was good with a strong emphasis on learning, involving staff and patients and improving the quality and safety of care.

  • Staff told us they were treated equally regardless of their gender or ethnicity and were proud to work for the trust.

  • There had been an improvement in the training and support for junior doctors.

  • Formal service level agreements were in place for some services e.g. cardiology and others were being reviewed with providing hospitals.

However:

  • There was limited contribution from non-consultant staff to multidisciplinary review of patients’ needs in some specialties.

Chemotherapy

Outstanding

Updated 19 January 2017

We rated the chemotherapy service at the Royal Marsden Hospital Sutton as outstanding overall because:

  • Patients were provided with individual care in a timely and appropriate manner. Staff provided patients with both internal and external opportunities to emotionally cope with both their condition and treatment. Staff often went out of their way to ensure patient care went beyond their remit as healthcare professionals.
  • There were processes in place for reporting of incidents and staff could clearly outline the reporting system used by the trust. Staff reported incidents and the trust ensured there was a system in place to learn from incidents and improve practice including regular meetings for staff.
  • There was an open culture of incident reporting and learning from these incidents was disseminated to all staff through regular meetings. We found that staff felt confident about being candid with patients.
  • We found that the measures used by the chemotherapy service for preventing and controlling infection met national guidance.
  • There was a bespoke chemotherapy prescribing system and specialist pharmacists. The service took part in national and local audit programmes and there were procedures in place to ensure that the correct medicines were provided in the correct location.
  • Staff were aware of the escalation policies around safeguarding concerns, mental capacity act and deprivation of liberties. Deteriorating patients received a speedy response.
  • Patient treatment plans were decided in effective multidisciplinary meetings. Patients told us that they had their pain managed and this followed national guidelines.
  • The service supported staff with access to training and supervision for competencies. There was a programme of staff led audits regarding clinical practice.
  • Dietitians were on hand to provide regular support to patients. Nurses and housekeepers offered patients food and fluids regularly.
  • The trust’s performance in the FFT was consistently higher than the England average. Patients told us that they felt very involved in the decisions regarding their care and treatment. Patients were assessed holistically and psychological support was available on request.
  • The service was responsive to the needs of people using it. The trust understood their limitations regarding not having a critical care unit on site. To lessen the risk there were processes in place to ensure that patients requiring emergency care had access as soon as possible. The service proactively managed discharges.
  • Patients were provided with written up information concerning their treatment plans and had access to a key worker. There was a minimal amount of complaints. The Patient Advice and Liaison Service (PALS) investigated and fed-back learning to the staff dealt with formal complaints effectively.
  • Staff were aware of the vision and strategy for the chemotherapy service. Quarterly governance reports were published and available to staff on the ward. Staff could name members of the executive team and felt there was a friendly and approachable governance structure. The culture of the service was one of openness and staff felt supported by their teams and team leaders.
  • Generally staff were very proud to work at the trust and within the chemotherapy division.

Services for children & young people

Good

Updated 19 January 2017

We rated services for children and young people Royal Marsden Hospital Sutton as overall good overall because:

  • Children, young people and their families were unanimously positive about the care they received.
  • Sensitive emotional support was provided to children, young people and their families.

  • There was a children’s psychology care service and bereaved families were offered a post bereavement meeting to discuss their child’s care and treatment and ask any questions.

  • There were enough nurses and doctors with the right skills and knowledgeable and experience to care for children and young people.

  • There was an effective system for learning and reporting from incidents. The majority of incidents reported between February 2015 and February 2016 were graded as either low harm or no harm.
  • The service had reported no serious incidents during the preceding twelve months leading up to the inspection. There was robust evidence that where such incidents had previously been reported, actions had been taken to mitigate the risk of such incidents being repeated.

  • All of the areas we visited were clean and spacious and entrances were secure.
  • Although the service did not have a paediatric intensive care unit, children or young people who required intensive care were transferred to St George’s University Hospitals Foundation Trust without compromising safety.

  • The service used the Paediatric Early Warning Score (PEWS) to monitor children and the National Early Warning Score (NEWS) whose condition changed or deteriorated. Staff we spoke with were aware of the action to take should a child or young person’s condition deteriorate and this was supported in the patient notes we reviewed.

  • A specialist telephone helpline was available for 24 hours seven days a week for children and young people and health care staff who were looking after them once they had been discharged. Call details and actions taken were recorded on the patients' electronic patient record. This process was audited on an annual basis to ensure that information was recorded and actioned appropriately and that appropriate communication between relevant persons had taken place.

  • Care and treatment was provided in line with best practice and by a multidisciplinary team involving nurses, doctors, therapists, social workers and an activities coordinator. Staff told us “we work as part of a team”.

  • There were some audits but information about outcomes was limited.

  • Pain was monitored using age specific tools and a range of options for controlling pain were available including analgesia, physiotherapy and relaxation therapy.

  • A dietician supported children and young people to maintain a healthy diet before, during and after treatment.

  • Children had access to play areas and toys and books and for young people there were separate social areas where they could to play pool, watch TV, make a snack or play games.

  • For children or young people with a learning disability a needs assessment was carried out and staff worked closely with their families. Their care was reviewed at a weekly meeting along with plans to support them in the longer term.

  • There was a clear vision and set of values which staff were aware of.

  • There was a strong clinical governance structure with mechanisms for reporting upwards and providing feedback to staff. Risks were reviewed and managed effectively.

  • Staff spoke positively about the local management team, they were visible and supportive along with the trust executive were visible. Support was available to help staff cope with the emotional challenges of the work.

  • Children and young people and their families were involved in developing the service through a range of consultations. Staff felt valued by the hospital and were passionate about caring for children and young people.

  • Staff described the hospital as a “learning organisation” which saw incidents and complaints as a way to improve the service. Staff felt valued by the hospital and were passionate about caring for children and young people.
  • Staff spoke positively about their managers and the senior team. They felt they were visible and approachable and staff were proud to work at the hospital.

However:

  • The Royal Marsden CYP service shared care with multiple POSCUs, posing a challenge to information sharing and governance.  The configuration of services and their governance across the network should be reviewed.

Haematology

Good

Updated 19 January 2017

We rated the haematology service at The Royal Marsden Hospital, Sutton as good because:

  • Ambulatory care proved to be a valuable innovation both in terms of enabling patients to benefit from more time at home and reducing hospital costs.

  • Staff were enthusiastic to work at the trust and within their division. There was a culture of openness and staff said their managers supported them. The vision of the service was embedded into practice on the unit.

  • The environment was clean and staff complied with infection prevention and control procedures.

  • There were clear arrangements for responding to whose condition deteriorated including if they developed sepsis.
  • Staff were aware of the signs of potential and actual abuse and knew what action to take.
  • There were sufficient staff with the right skills and expertise to care for patients.
  • Staff used national and local guidance to care for patients and the transplant unit had been accredited by the Joint Accreditation Committee of the International Society for Cellular Therapy (JACIE).
  • Weekly multidisciplinary meetings took place to review patients care and treatment.
  • Patients told us the food was good and where needed support was given with eating.
  • Patients received appropriate pain relief and staff through a range of methods and analgesia and they also had access to psychological support.
  • There was good multidisciplinary team working with all staff contributing at multidisciplinary team meetings.
  • We observed staff treating patients with kindness and compassion and care was individualised with patients saying they felt “at home” on the ward.
  • Patients’ care was coordinated with care for non-cancer conditions provided at other hospitals.
  • The ambulatory inpatient care (AMBIN) service for transplant patients enabled patients to be cared for at home with frequent visits to the unit for review.
  • All patients were allocated a key worker who acted as the point of contact for patients and answer any questions they had.
  • Patients with a specific need, such as a learning disability had their care tailored to meet their needs. Patients at risk of falling were provided with non-slip socks and an interpreter service was available for patients for whom English was not their first language.
  • The service received very few complaints
  • Quality and safety meetings took place and the risk registers were up to date.
  • Staff described the culture as “open” and said their managers and senior managers within the trust were visible and approachable.

However;

  • Space on the wards was limited and there was no relative’s room on the haemto-oncology unit.
  • Junior doctors had limited time to attend training due to their workload.

End of life care

Good

Updated 19 January 2017

We rated the end of life care (EoLC) services at The Royal Marsden Hospital Sutton as ‘good’ overall because:

  • The specialist palliative care team (SPCT) were highly skilled and knowledgeable to meet the needs of patients and work cohesively with ward staff.
  • They provided a seven day 24 hour service and demonstrated a multidisciplinary approach to delivering patient care.
  • There was an open and transparent approach to reporting and learning from incidents and staff were aware of safeguarding procedures and how to recognise if someone was at risk or had experience abuse. The SPCT provided training and education to other staff in the hospital including junior doctors, nurses and porters.
  • Care and treatment was delivered in line with best practice such as NHS guidance Priorities for the Care of the Dying Person and One Chance to get it Right – developed by the Leadership Alliance for the Care of Dying People (LACDP). It also referred to the NICE quality standards for end of life care.
  • The SPCT worked closely with the acute pain service and many patients we spoke with said their pain was well controlled.
  • The majority of ‘Do not attempt cardiopulmonary resuscitation' forms we reviewed had been completed in full.
  • We saw patients were treated with dignity and respect and all staff provided compassionate care. Patients and their families were involved in discussions and decisions about their care and treatment.
  • Facilities were available for relatives to stay overnight, either on fold-out cots by the patient’s bed or in specific accommodation.
  • Patients had access to emotional support from two registered mental health nurses and a consultant psychiatrist, although due to increasing demand patients sometimes had to wait up to six weeks for this support.
  • A new clinical leadership model had recently been introduced to strengthen the leadership and improve accountability for quality and reporting to and from the trust board. Senior staff were positive about the changes as they felt it would improve access to therapies and psychological support for patients.
  • The trust had an end of life care strategy supported by an action plan and key milestones.
  • Many staff had worked at the hospital for a number of years and told us there was a flattened hierarch and an open culture in which everyone’s opinion was considered.
  • Staff engagement was good with quarterly forums where staff could share their experiences with colleagues.

However;

  • For some patients there was a delay in referral to the service. 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.
  • 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.
  • Body store fridge checks were not retained, and there was a lack of consistent approach across the trust sites for this.
  • There was a lack of quiet or private space on some wards for grieving relatives.

Outpatients and diagnostic imaging

Requires improvement

Updated 19 January 2017

We rated the outpatient and diagnostic imaging service at The Royal Marsden Hospital Sutton as requires improvement overall because:

  • Surgical procedures were being carried out in the OPD however staff were not using the WHO safety checklist.
  • There was no acute oncology service.  Although there were areas to care for patients who presented or who became unwell they were also used for clinical procedures.  This meant that staff sometimes had difficulty finding an area to care for unwell patients and had to care for them in clinic rooms until an inpatient bed could be found or the patient was transferred to another hospital.
  • Systems for controlling access to medicines in the OPD 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.
  • The trust was aware of the capacity problems in the OPD but had only recently taken started to take action to address them. Plans included a new outpatient department within the Centre for Clinical Care and Research.

  • A transformation project had been established to improve performance and patient experience but was still in the early stages.

However:

  • Staff in both the outpatient and diagnostics imaging service were caring and involved patients and their carers in discussions about their care and treatment.
  • At the time of the inspection the OPD had experienced a high vacancy rate but temporary staff were used to fill the vacancies.
  • There were adequate levels, with relevant skills and experience, of radiography staff and a recent recruitment drive had been successful in recruiting more staff.
  • Staff in OPD and diagnostics and imaging had access to, and used, evidence based guidance.
  • Clinics were organised so that patients could access services together for example breast and plastic surgery clinics were organised on the same day.
  • Diagnostics and imaging provided a rapid diagnostic service for breast, skin and urology cancers.

  • The trust was aware of the capacity problems in the OPD but had only recently taken started to take action to address them. Plans included a new outpatient department within the Centre for Clinical Care and Research.

  • A transformation project had been established to improve performance and patient experience but was still in the early stages.

Radiotherapy

Outstanding

Updated 19 January 2017

We rated the radiotherapy service at The Royal Marsden Hospital Sutton as overall outstanding because;

  • There was a clear culture or providing safe care and incident report and learning from incidents was embedded in the service.
  • Staff were aware of safeguarding procedures for both adults and children.
  • There were enough radiographers, physics and engineering and medical staff to provide a safe service.
  • Many staff were up to date with all aspects of mandatory training.
  • Equipment was checked and maintained and there was a replacement programme for equipment.
  • Care and treatment was delivered in line with national guidance and best practice and the service led nationally on the development of best practice guidance particularly in paediatric radiotherapy.
  • The service provided a range of treatments including stereotactic body radiation therapy (SBRT), which is a highly focused radiation treatment that gives an intense dose of radiation concentrated on a tumour, while limiting the dose to the surrounding organs.
  • Intensity modulated radiotherapy (IMRT) is known to provide better outcomes and the percentage of IMRT delivered by the service was significantly higher than other services.
  • Staff were supported to develop their knowledge and skill and all staff has either had an appraisal or had one booked. There was good multidisciplinary working involving a range of staff.
  • Patients and families were overwhelmingly positive about the service. They told us staff were compassionate and gave examples of where they had gone the “extra mile”.
  • Staff treated patients as individuals and recognised the importance of building a relationship with them. Patients were involved in decisions about their treatment and given information about the risks and benefits of treatment.
  • To help children become familiar with the processes involved in radiation and had several play sessions before their treatment started. Play specialists and their parents were involved in helping children become accustomed to the environment.
  • The service was response to the individual needs of patients and patients received their treatments within national targets.
  • The service had dementia champions and was directly involved directly involved in the development of the trust’s dementia strategy and the trusts dementia board.
  • Following an audit of the suitability of the radiotherapy department signage had been improved along with more clocks to help patients orientate themselves.
  • There were separate waiting areas for children and adults and the service recognised that young people needed their own area and had secured funding to develop a waiting area for young people.
  • The leadership of the service was outstanding. There was an innovative strategy which staff were aware of. Staff could describe the trust values and we saw evidence of them translated into practice.

Outpatients

Good

Updated 18 September 2018

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

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

The ratings of safe and well led improved.

The ratings for effective, caring and responsive remained the same.

  • We found that there had been improvements to the outpatient service to make services safer and to strengthen the service’s leadership. This has been reflected in change of rating from requires improvement to good.
  • The service had improved the security of medicines. Access to the treatment room was controlled by the use of smartcards.
  • A clinical assessment unit was opened in August 2016. A pathway had been developed to support patients who became unwell in outpatients. Patients assessed on the clinical assessment unit returned home, were admitted to a bed on the Sutton site or transferred to the Chelsea site or to another suitable hospital.
  • The number of nurse staffing vacancies had reduced.
  • The service had introduced surgical checklists for procedures carried out in outpatients.
  • Clinic utilisation was being monitored to improve the effectiveness of clinics and reduce patient waiting times.
  • A transformation project was underway. Follow up care after treatment for some cancers was planned according to the risk of disease recurrence. Follow up consultations over the phone or using skype were being introduced. A new building for outpatients and research was planned which was due to open in 2021. Staff and patients’ views were taken into account during the planning stage.
  • As part of the trust’s closer to home strategy, a mobile chemotherapy unit was providing services for patients in their local community, reducing the number of times patients had to travel to hospital.

However,

  • Patients often waited for blood tests. The waiting area and blood taking areas were both small and staff wrote test requests and test tube labels by hand which led to delays if these were difficult to read or information was missing.
  • Phlebotomy staff were not always following best practice on infection control standards. Staff used one cuff and did not use single use tourniquets. When we brought this to the attention of the sister staff were reminded they should use single use tourniquets.
  • Staff told us the availability of the electronic records system had improved. When we last inspected staff told us the system was often unavailable. We saw three incident reports relating to problems with the system, the most recent incident was reported in March 2018.