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Provider: The Royal Marsden NHS Foundation Trust Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 16 January 2020

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.
  • The effective domain improved by one rating on both sites. At our previous inspection, the rating for effective was good on both sites. At this inspection, the rating for effective improved to outstanding on both sites.
  • We rated well-led for the trust overall as outstanding.
  • Our rating of the trust’s location The Royal Marsden (London) remained the same. We rated it as outstanding because we rated effective, caring, responsive and well-led as outstanding and safe as good.
  • Our ratings for the core service of adult solid tumours at The Royal Marsden (London) improved. Our ratings for this core service improved from good to outstanding. We rated it as outstanding because we rated effective, caring and well-led as outstanding, and safe and responsive as good.
  • Our ratings for the core service of end of life care at The Royal Marsden (London) improved. Our ratings for this core service improved from good to outstanding. We rated it as outstanding because we rated effective, caring and well-led as outstanding, and safe and responsive as good.
  • Our rating of the trust’s location The Royal Marsden (Sutton) remained the same. We rated it as outstanding because we rated effective, caring, and well-led as outstanding, and safe and responsive as good.
  • Our ratings for the core service of adult solid tumours at The Royal Marsden (Sutton) improved. Our ratings for this core service improved from good to outstanding. We rated it as outstanding because we rated effective and caring as outstanding, and safe, responsive and well-led as good.
  • Our ratings for the core service of end of life care at The Royal Marsden (Sutton) improved. Our ratings for this core service improved from good to outstanding. We rated it as outstanding because we rated effective, caring and well-led as outstanding, and safe and responsive as good.

Inspection areas

Safe

Good

Updated 16 January 2020

Our rating of safe stayed the same. We rated it as good because:

  • All staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and all staff knew how to apply it.
  • The service controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept all specialist surgical equipment and equipment on the wards visibly clean.
  • The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use them. Staff managed clinical waste well.

  • Staff completed and updated risk assessments for each patient and removed or minimised risks. Staff identified and quickly acted upon patients at risk of deterioration.
  • The service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Managers regularly reviewed and adjusted staffing levels and skill mix, and gave bank, agency and locum staff a full induction.
  • Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date, stored securely and easily available to all staff providing care.
  • The service used systems and processes to safely prescribe, administer, record and store medicines.
  • The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. Managers ensured that actions from patient safety alerts were implemented and monitored.
  • The service provided mandatory training in key skills to all staff.

However:

  • Mandatory training rates did not always meet the trust target. Not all porters received annual mandatory training updates where applicable. Safeguarding training rates for medical staff across the end of life core service did not meet the trust target.
  • There were occasions when members of the patient advice and liaison team (PALS) were lone workers and staff informed us that the workload was busy at times.
  • Nurse vacancy rates and unfilled shift rates were above the trust target in the end of life core service.
  • Medical records were not always complete or safely stored. In adult solid tumours, we found paper records stored in an open shelf behind the nurses’ desk. However, the ward clerk was at the desk during the daytime, and nursing staff at other times, which mitigated this risk.

Effective

Outstanding

Updated 16 January 2020

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

  • Outcomes for people who used services were better than expected when compared with other similar services. The effectiveness of the treatment provided to patients for specific tumour groups was much better than the national average and in some cases was regional or world leading.
  • The trust’s performance was recognised by credible external bodies. The trust was one of only five NHS trusts in England to hold accreditation for both adults and children’s services from The Joint Accreditation Committee of the International Society for Cellular Therapy and the European Group for Blood and Marrow Transplantation (JACIE) to provide chimeric antigen receptor T-cell (CAR-T) therapy. CAR-T therapy involves taking blood from the patient and ‘reprogramming’ the patient’s own immune cells to fight the cancer.
  • The trust safely used innovative and pioneering approaches to provide evidence-based care. The trust had a strong national and international reputation for research and actively participated in clinical research studies with its joint research partner. Research at the trust had strong patient partnership and national collaboration.
  • The trust set the standards and practice guidelines for cancer nursing nationally through their Royal Marsden Manual of Cancer Nursing Procedures. Over 90% of acute NHS trusts in England used the electronic version of the manual. At the time of our visit, the trust was in the process of launching the updated tenth edition of the manual.
  • Staff, teams and services were committed to working collaboratively. They supported each other to provide excellent care. The trust won the ‘nursing practice award’ at the Laing Buisson awards 2018 for their multidisciplinary team approach to head and neck cancers.
  • Staff gave patients enough food and drink to meet their needs and improve their health. They used special feeding and hydration techniques when necessary. The service made adjustments for patients’ religious, cultural and other needs.
  • Staff assessed and monitored patients regularly to see if they were in pain and gave pain relief in a timely way. They supported those unable to communicate using suitable assessment tools and gave additional pain relief to ease pain.
  • 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.
  • Key services were available seven days a week to support timely patient care.
  • Staff gave patients practical support and advice to lead healthier lives.
  • Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. They knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health. They used agreed personalised measures to limit patients' liberty. Staff protected the rights of patients’ subject to the Mental Health Act 1983.

However:

  • There was no formal training provided to staff who held bereavement meetings with families following a death.

Caring

Outstanding

Updated 16 January 2020

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

  • Feedback from patients, carers and stakeholders was consistently positive about the way staff treated people. The trust was ranked third in England for overall patient experience in the Care Quality Commission Adult Inpatient Survey Results 2018. The trust was ranked number one for specialist cancer centres in the National Cancer Patient Experience Survey 2018.
  • There was a strong and visible person-centred culture. We found numerous of examples of staff going ‘above and beyond’ for their patients. Staff saw people’s emotional and social needs as being as important as their physical needs.
  • Staff provided emotional support to patients, families and carers to minimise their distress. They understood patients’ personal, cultural and religious needs. Staff understood the delicate nature of their patients care needs and supported both them and their families in whatever way they could.
  • Staff supported and involved patients, families and carers to understand their condition and make decisions about their care and treatment. Staff took a holistic approach to caring for their patients. The patients we spoke with spoke very highly of this.

Responsive

Outstanding

Updated 16 January 2020

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

  • The service planned and provided care in a way that met the needs of local people and the communities served. It also led on the work with other healthcare providers and local authorities in the wider system and local organisations to plan care.
  • The service was inclusive and took account of patients’ individual needs and preferences. Staff made reasonable adjustments to help patients access services. They coordinated care with other services and providers. Staff took account of patients’ personal needs.
  • People could access the service when they needed it and received the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were not always in line with national standards.
  • It was easy for people to give feedback and raise concerns about care received. The service treated concerns and complaints seriously, investigated them and shared lessons learned with all staff. The service included patients in the investigation of their complaint.

However:

  • We found that a small percentage of complaints in end of life care were classified incorrectly.
  • We found that there were limited opportunities for quiet spaces or rooms for grieving relatives on the Sutton site.

Well-led

Outstanding

Updated 16 January 2020

Our rating of well-led stayed the same. We rated it as outstanding because:

  • The trust celebrated safe innovation. The trust 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 was a lead participator in global and regional research and clinical trials. The service provided national level support for specific advanced cancers.
  • Staff were proud of the organisation as a place to work and spoke highly of the culture. The trust was one of the best performing in England in the NHS Staff Survey 2018. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and staff could raise concerns without fear.
  • There was a demonstrated commitment to system-wide collaboration and leadership. The service had a vision for what it wanted to achieve and a strategy to turn it into action, developed with all relevant stakeholders. The vision and strategy were focused on sustainability of services and aligned to local plans within the wider health economy. Leaders and staff understood and knew how to apply them and monitor progress.
  • Leaders had the integrity, skills and abilities to run high-quality services. They understood and managed the priorities and issues the service faced. They were visible and approachable in the service for patients and staff. They supported staff to develop their skills and take on more senior roles. Staff at the Sutton site felt senior leaders were less visible and that there was less financial investment than at the Chelsea site. However, we found evidence of regular executive presence at both sites, as well as significant investment at the Sutton site with the building of the Oak Cancer Centre.
  • Leaders operated effective governance processes, throughout the service and with partner organisations. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service.
  • Leaders and teams used systems to manage performance effectively. They identified and escalated relevant risks and issues and identified actions to reduce their impact. They had plans to cope with unexpected events. Staff contributed to decision-making to help avoid financial pressures compromising the quality of care.
  • The service collected reliable data and analysed it. Staff could find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements. The information systems were integrated and secure. Data or notifications were consistently submitted to external organisations as required.
  • Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. They collaborated with partner organisations to help improve services for patients.
  • All staff were committed to continually learning and improving services. They had a good understanding of quality improvement methods and the skills to use them. Leaders encouraged innovation and participation in research.
Checks on specific services

Community end of life care

Good

Updated 18 September 2018

Our rating of this service stayed the same. We rated it as good because:

  • We rated safe, effective, caring, responsive and well-led as good.
  • The ratings of safe, effective, caring and responsive remained the same. The rating for well-led improved.
  • Since our last inspection there had been a focus on the trust wide understanding and development of end of life care. There was now a strategy and governance programme in end of life care with a clear structure of leadership and accountability.
  • There had been a focus on continuous improvement across the service since our last inspection. There are now clear audits and key performance indicators structures for delivering end of life care.
  • Appropriate measures were in place to keep patients safe from avoidable harm. Incidents and safety monitoring results were collated and shared to improve the service.
  • Policies, procedures and ways of working had been brought into line with local and national guidance. Advanced care planning for patients at the end of life had improved since the last inspection.
  • Patients were provided with compassionate and person centred care, which took account of their individual differences and needs. Relatives and friends were involved in care planning wherever appropriate and recognised as part of the caring team.
  • Staff across the service worked effectively with external agencies and attended Gold Standard Framework meetings with others in the borough to coordinate care for patients and improve pathways.

However:

  • The community staff did not have rights to prescribe medication or verify patient death so were reliant on others in the community, more often than not, GPs.
  • The service provided mandatory training in key skills to all staff but some completion rates were below the Trust target.

  • Staff did not always have access to up-to-date, accurate and comprehensive information on patients’ care and treatment. This was particularly the case with regards to the non-transferable DNACPRs from some of the local trusts.

Community health services for adults

Requires improvement

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 safe and well-led domains improved since our last inspection; effective, caring and responsive stayed the same.
  • The service underwent appropriate changes after the last inspection and managers had implemented required improvements.
  • Record keeping and documentation had been much improved and the service undertook audits to check quality and compliance.
  • Staff had training on Mental Capacity Act and Deprivation of liberty safeguards and knew how to apply them in practice.
  • The service had processes in place to ensure there were enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • Staff were competent and had access to training to enhance skills and support to progress in their personal career development.
  • We saw good multidisciplinary team working in different areas of adult community services.
  • The trust took an active approach to deliver services, that met the needs of the local population and to reduce waiting times.
  • The trust actively sought regular patient and staff feedback and took actions in response to results.

However:

  • Mandatory training completion rates were below trust target.
  • We found facilities and equipment were not always kept clean and tidy.
  • Vacancy rates were above trust target.
  • There was long referral to treatment time for community neuro therapy.
  • Staff felt disconnected to the trust and trust leadership and did not find good communication between senior management and staff.
  • Staff survey results demonstrated majority of staff working extra hours.

Community health services for children, young people and families

Good

Updated 18 September 2018

Our rating of this service stayed the same. We rated it as good because:

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

The rating for responsive improved since the last inspection. The ratings for safe, effective, caring and well-led remain the same as at the last inspection.

  • The service managed patient safety incidents well.
  • The service controlled infection risk well.
  • Staff kept appropriate records of patients’ care and treatment.
  • Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
  • The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
  • The service provided care and treatment based on national guidance and evidence of its effectiveness.
  • The service made adjustments for patients’ religious, cultural and other preferences.
  • The service monitored the effectiveness of care and treatment and used the findings to improve them.
  • Staff of different kinds worked together as a team to benefit patients. Health visitors, school nurses and other healthcare professionals supported each other to provide good care.
  • Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
  • Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
  • Staff involved patients and those close to them in decisions about their care and treatment.
  • Staff provided emotional support to patients to minimise their distress.
  • The trust planned and provided services in a way that met the needs of local people.
  • The service took account of patients’ individual needs.
  • The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.
  • The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.
  • The service had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff and key groups representing the local community.
  • The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
  • The service engaged well with staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.