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Provider: The Royal Marsden NHS Foundation Trust Outstanding

Reports


Inspection carried out on 10 Sep to 12 Sep 2019

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.
  • 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.


CQC inspections of services

Service reports published 18 September 2018
Inspection carried out on 8 May 2018 During an inspection of Community health services for adults Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 8 May 2018 During an inspection of Community health services for children, young people and families Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
Inspection carried out on 8 May 2018 During an inspection of Community end of life care Download report PDF (opens in a new tab)Download report PDF (opens in a new tab)
See more service reports published 18 September 2018
Service reports published 19 January 2017
Inspection carried out on 19 - 22 April 2016 During an inspection of Community health services for adults Download report PDF (opens in a new tab)
Inspection carried out on 19 - 22 April 2016 During an inspection of Community health services for children, young people and families Download report PDF (opens in a new tab)
Inspection carried out on 19 - 22 April 2016 During an inspection of Community end of life care Download report PDF (opens in a new tab)
See more service reports published 19 January 2017
Inspection carried out on 8 May 2018

During a routine inspection

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

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

The Royal Marsden (London)

  • Our rating of the trust’s location The Royal Marsden (London) remained the same. We rated it as outstanding because safe and effective were good and caring, responsive and well-led were outstanding.
  • We did not inspect any of the core services at this location as they were inspected in April 2016 and we had no new concerns about the safety and quality of the services.

The Royal Marsden (Sutton)

  • Our rating of the trust’s location The Royal Marsden (Sutton) improved. We rated it as outstanding because safe, effective and responsive were good and caring and well-led were outstanding. The rating for well-led improved and the rating for safe, effective, caring and responsive remained the same
  • We inspected Outpatients during this inspection to check if improvements had been made. Our rating of the service improved. We rated it as good because safe, effective, caring and responsive were all rated as good. The rating of safe and well-led improved since the last inspection and caring and responsive remained the same. We do not rate effective in Outpatients.

The Royal Marsden Community Services

  • Our rating of the trust’s location The Royal Marsden Community Services improved. We rated it as good because safe, effective, caring, responsive and well-led were good. The rating for safe, effective responsive and well-led improved and the rating for caring remained the same
  • We inspected Community health services for adults during this inspection because it had been registered as a ‘new’ service since the last inspection. We rated it as good because safe, effective, caring responsive and well-led were all rated as good.
  • We inspected Community health services for children and young people during this inspection because it had been registered as a ‘new’ service since the last inspection. We rated it as good because safe, effective, caring responsive and well-led were all rated as good.
  • We inspected Community end of life care during this inspection because it had been registered as a ‘new’ service since the last inspection. We rated it as good because safe, effective, caring responsive and well-led were all rated as good.

Inspection carried out on 19 - 22 April 2016

During a routine inspection

The Royal Marsden NHS Foundation Trust is split over two principal sites, in Chelsea and Sutton, and a day-case unit on the site of Kingston Hospital. As a specialist trust, the Royal Marsden receives referrals from beyond the immediate areas, including national and international referrals. 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.

We inspected the Royal Marsden NHS Foundation Trust as part of our specialist NHS inspection programme as well as applying our NHS community health service inspection methodology also. We inspected the trust between 19 and 22 April 2016 as well as carrying out additional visits following the announced inspection to collect further information and to corroborate findings.

The Royal Marsden Community Services formed Sutton and Merton Community Services (SMCS) in 2011. Various community health services were provided in the London Boroughs of Sutton and Merton. From 1 April 2016 The Royal Marsden Community Services stopped providing services to Merton and formed Sutton Community Services (SCS). Our reports in to community health services include data from the 12 month period leading up to our inspection which was before the disaggregation of services and therefore contains some data relating to Merton. We have included separate data where it was available. Our site visits during the inspection were limited to Sutton only.

Overall, we have rated the trust as good. We rated it good for providing care which was safe, effective, responsive to the needs of the population, and well-led. We rated the trust outstanding for the caring domain. 

Additionally, we rated the radiotherapy service as outstanding across both hospital locations. This was because the radiotherapy service was patient centred; care was provided in line with national standards, with radiotherapy services participating in national and international research programmes. 

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, in the main, shared with staff and applied in practice. Improvements were required within the adult's community service to ensure that learning from incidents was shared across all teams.
  • Staffing arrangements supported the delivery of safe diagnostics, treatment and care within the hospital setting. However, staffing shortages within the community nursing teams meant that the delivery of end of life care fell to more experienced staff who had attended relevant training, this meant that there was limited staff available to deliver end of life care.
  • Specialist staff did not feel they were always being contacted quickly enough to support the timely commencement and delivery of end of life care for patients both in the hospital setting and within the community.
  • 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.
  • In the majority of cases, vulnerable individuals were identified and protected under safeguarding practices and through the application of the Mental Capacity Act and associated Deprivation of Liberty Safeguards. Improvements were required within the community adult's services to ensure capacity assessments were routinely recorded. Staff working within community adults services required further support in helping them to understand the concepts of the Mental Capacity Act.
  • Staff were enabled to perform their duties through the provision of professional standards and guidance. However, within community services, staff were not consistently following best practice in their approach to wound assessments. This meant that changes to wound presentation were less likely to be accurately recorded and deterioration may not have been addressed as readily. Additionally, community staff were not routinely following the quality standard for nutrition support in adults which required care services to take responsibility for the identification of people at risk of malnutrition and provide nutrition support for everyone who needed it.
  • In the majority of care settings, 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.
  • 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.

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 provided 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 and drove the quality improvement agenda.
  • Nursing and therapy staff had the commitment and time to provide person-centred care that often went the ‘extra mile’
  • The introduction of ambulatory care had managed to reduce patient bed stays and improve patient experience.
  • The end of life supportive care home team (SCHT) was a part of a Sutton CCG (clinical commissioning group) vanguard relating to improving end of life care in care and nursing homes. Members of the SCHT were involved in developing the service and had been invited to speak about the model and share this development with other services. The end of life supportive care home team (SCHT) was a part of a Sutton CCG (clinical commissioning group) vanguard relating to improving end of life care in care and nursing homes. 

However, there were also areas of practice where the trust needs to make improvements.

Importantly, the trust must:

  • Implement and embed the World Health Organisation Safety Checklist in the outpatients department.
  • When patients (aged 16 and over) are unable to give consent because they lack the capacity to do so, the trust should ensure staff act in accordance with the Mental Capacity Act 2005.
  • Ensure that records contain accurate information in respect of each patient and include appropriate information in relation to the treatment and care provided, particularly with regard to risk assessments.
  • The provider should take action to understand the shortfalls in recording of risk assessments and individualised care plans in the integrated community teams.
  • Review the staff compliment for community adult services to ensure there are sufficient numbers of appropriately skilled staff to meet patient’s needs.
  • The provider should strengthen the reporting on the assurance of effectiveness of governance arrangements to the trust board; this specifically relates to community services.

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.


Joint inspection reports with Ofsted

We carry out joint inspections with Ofsted. As part of each inspection, we look at the way health services provide care and treatment to people.