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Provider: The Christie NHS Foundation Trust Outstanding

Reports


Inspection carried out on 3 to 26 July 2018

During a routine inspection

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

We rated effective, caring, responsive and well-led as outstanding, and safe as good. We rated four of the trust’s seven services as outstanding and three as good. In rating the trust, we took into account the current ratings of the four services not inspected this time.

We rated well-led for the trust overall as outstanding.

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

However:

  • The processes for ensuring effective learning from incidents was not always robust.
  • Some audit systems within the surgical directorate were not robust enough to identify potential safety issues.


CQC inspections of services

Inspection carried out on 10 11 12 13May 2016 and 25 May 2016

During a routine inspection

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

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

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

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

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

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

  • Medical care services

  • Surgery

  • Critical care

  • End of life

  • Outpatients and diagnostic services

  • Chemotherapy

  • Radiotherapy

Our key findings were as follows

Leadership and Management

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

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

  • There was effective teamwork and clearly visible leadership within the services and decision-making was patient centred and clinician led.

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

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

  • Leaders worked closely with other directorates and departments, offering a truly joined up and integrated approach to the treatment of cancer. This achieved advances in the care and treatment, improved the patients journey and experience.

Culture

  • 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.

  • Staff spoke positively about the organisational support they received. For example, services for patients such as ‘look good, feel better’ and complimentary therapies were also made available for staff at a discounted rate. We spoke with two volunteers and they spoke positively about the support they received from ward staff.

  • We saw that a very positive 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.

  • A ‘freedom to speak up guardian’ was in the process of being appointed as per national recommendations, this individual was to encourage staff to raise concerns where they something that concerns them. Staff told us they were supported and free to express their concerns and speak openly about issues that concerned them. Staff felt there was a supportive ‘no blame culture’.

Equality and Diversity

  • We found that the trust had a positive and inclusive approach to equality and diversity. We found that staff were committed and proactive in relation to providing an inclusive workplace.

  • As part of the new Workforce Race Equality Standard (WRES) programme, we have added a review of the trusts approach to equality and diversity to our well led methodology. The WRES has nine very specific indicators by which organisations are expected to publish and report as well as put action plans into place to improve the experiences of it Black and Minority Ethnic (BME) staff. As part of this inspection, we looked into what the trust was doing to embed the WRES and race equality into the organisation as well as its work to include other staff and patient groups with protected characteristics.

  • We analysed data from the NHS Staff survey regarding questions relating to the Workforce Race Equality Standard (WRES). The results for the trust were positive for the trust in most areas.

  • Where the trust was performing worse in the standardof staff experiencing harassment, bullying or abuse from staff in the last 12 months, the trust had acted upon findings by introducing a range of interventions to strengthen mechanisms for staff to raise concerns at work, including any concerns of harassment or bullying. This included revised policies, guidance for staff and managers, films indicating good practice, new intranet page and staff newsletters.

  • The trust had strong links within local communities, promoting employment opportunities. This included a new programme of work “Healthcare Horizons work experience programme” in partnership with local schools.

  • There were programmes in place to support staff development, and there were procedures in place to ensure that this was fair and representative of all staff working at The Christie.

  • In April 2016, 96% of staff employed by The Christie NHS Foundation trust self declared ethnicity, which supported equality and diversity monitoring.

  • The trust had introduced unconscious bias training as part recruitment training and key Skills for Managers, which staff said was helpful.

Governance and risk management

  • Governance and risk management structures were embedded in the trust.

  • There was a robust committee structure in place that supported challenge and review of performance, risk and quality.Mechanisms were in place to ensure that committees were led and represented appropriately, to ensure that performance was challenged and understood.

  • The Board Assurance Framework (BAF) was aligned to strategic objectives and we saw evidence that it was linked appropriately to divisional risk registers that were regularly reviewed.

  • There was evidence of effective clinical governance procedures and quality measurement processes, these enabled risks to be captured, identified and escalated through different committees and steering groups. This supported the dissemination of shared learning and service improvements and an avenue for escalation to the trust board.

  • The trust used collaborative initiatives such as the “Christie Quality Standard” to provide assurance related to a standardised delivery of services.

  • The directorate maintained and reviewed a risk register. Managers and staff were aware of departmental risks, performance results, serious incidents

Cleanliness and Infection control

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

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

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

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

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

Staffing

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

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

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

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

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

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

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

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

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

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

Mortality rates

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

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

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

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

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

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

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

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

Nutrition and hydration

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

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

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

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

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

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

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

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

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

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

We saw several areas of outstanding practice including:

Medical care services

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

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

    Surgical services

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

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

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

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

End of life services

  • The SCT team used an innovative approach to their structure, which was recognised by NHS England and is now being rolled out across cancer centres throughout the country.

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

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

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

Chemotherapy

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

Radiotherapy

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

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

Professor Sir Mike Richards Chief Inspector of Hospitals

Intelligent Monitoring

We use our system of intelligent monitoring of indicators to direct our resources to where they are most needed. Our analysts have developed this monitoring to give our inspectors a clear picture of the areas of care that need to be followed up.

Together with local information from partners and the public, this monitoring helps us to decide when, where and what to inspect.


Organisation Review of Compliance