The Royal Marsden - London

The Royal Marsden Hospital NHS Foundation Trust is split over two principal sites, one in Chelsea and the other in Sutton. The Trust also has a day-case unit on the site of Kingston Hospital. As a specialist trust, the Royal Marsden receives referrals from beyond the immediate areas, and the population covered by acute services cannot therefore be meaningfully estimated. However 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.

The Chelsea, Fulham Road hospital has 112 inpatient beds and 81 used for day case admissions.

This report describes our judgement of the quality of care at this hospital. It is based on a combination of what we found when we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from patients, the public and other organisations.

Overall we rated this location as outstanding.

We rated the radiotherapy service as outstanding. This was because the radiotherapy service was patient centered service placed patients at the centre of the their care. Care was provided in line with national standards, with radiotherapy services participating in national and international research programmes.

We further rated the hospital as outstanding for the key question of caring.

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 shared with staff and applied in practice.
• Staffing arrangements supported the delivery of safe diagnostics, treatment and care.
• 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.
• Vulnerable individuals were identified and protected under safeguarding practices.
• Staff were enabled to perform their duties through the provision of professional standards and guidance.
• 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.
• All staff recognised the uniqueness and the diversity of patients and responded appropriately with support and advice as required.
• 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.
• Staff encouraged participation from those close to people who used the services, including carers and dependents. People were encouraged and supported to manage their own health, care and wellbeing and to be as independent as able.
• Patient flow from admission, to discharge was managed effectively and ran smoothly.
• Services were organised to meet people’s treatment needs in relation to their cancer, as well as their wider holistic needs for spiritual and psychological support and for relaxation.
• There was some flexibility in appointment times to meet the needs of patients who were working or had care responsibilities.
• Patients had the option of having their blood tests, consultation and treatment on a single day (known as one stop) or of attending the medical day unit on two separate days, one for assessment, and one for treatment.
• Arrangements were established with other hospitals where patients were treated for non-cancer related conditions.
• There was clear information and additional culturally appropriate support services for international patients receiving private treatment.
• There were responsive arrangements for treating patients with possible neutropenic sepsis both within the hospital and for those admitted to A&E departments in other trusts.
• There were few complaints and those that were received were addressed in a proactive manner.
• Staff understood and respected the trust’s vision 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.
• Staff were proud to work for the hospital and would want their friends and family to be treated there should the need arise.

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 provide 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.

However, the trust should:

• Theatre staff should ensure de-briefing are recorded after surgical activity.
• The trust should ensure medicines are stored securely and in line with legal requirements.
• Regular checking processes of the resuscitation trolleys must ensure the drawers are locked to prevent unauthorised access to intravenous drugs and fluids.
• To meet national recommendations the Linear Accelerator replacement programme must be kept up to date.
• Ensure staff are conversant with the requirements of infection control procedures.
• Review strategies to enforce compliance with hand hygiene and infection control measures amongst clinical visitors to the critical care unit.
• Ensure staff understand security arrangements.
• Review the risk register for items that can be closed.
• Ensure single-use disposables are managed for expiry dates.
• Develop a consistent approach across the trust for recording and logging cadaver storage temperatures.
• Ensure Do Not Attempt Cardio Pulmonary Resuscitation (DNACPR) forms always have dates by which they should be reviewed, and these are completed.
• Consider the introduction of formal bereavement support throughout the hospital.
• The provider should review outpatient booking rules to ensure clinics are not overbooked to reduce the time patients wait to be seen.
• The provider should review the waiting area to provide additional space on busy clinic days.

Professor Sir Mike Richards

Chief Inspector of Hospitals