The Royal Marsden - Sutton

The Royal Marsden Hospital NHS Foundation Trust is split over two principal sites, in Chelsea and Sutton, and 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 Royal Marsden Sutton hospital has 106 patient beds.

Overall we rated this location as good. We rated both the radiotherapy and chemotherapy services as outstanding. This was because the radiotherapy service was a patient centered service; care was provided in line with national standards, with radiotherapy services participating in national and international research programmes. Within the chemotherapy service, 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.

We further rated the hospital as outstanding for the key question of caring. Staff across all professions and grades were observed to be compassionate and truly championed the practice of putting patients needs first and foremost. 

Our key findings were as follows:

• There was an open and transparent approach to incident reporting. Staff were encouraged to report incidents and learning from incident investigations was largely embedded.

• The hospital had taken action to minimise risks to patients but had not implemented the World Health Organisation safety checklist in the outpatients department.

• Most staff followed infection prevention and control procedures to minimise the risks of patients acquiring infections. All the wards/clinical areas we visited were clean and well maintained.

• Medicines, including chemotherapy, in the majority of areas were managed safely with the support of pharmacists. The storage of controlled drugs in the outpatient department was improved during the inspection.

• Staff had access to all the equipment they needed to keep patients safe. Resuscitation equipment was checked daily.

• Patients who presented unwell to the hospital were always seen by a nurse or a doctor however the hospital did not have a dedicate acute oncology service.

• Staff were aware of the safeguarding procedures including action to take to protect children and adults but not all staff had completed the required training.

• There were sufficient nursing and medical staff to provide safe care for patients.

• Space in the outpatients department was limited and insufficient to cope with the increasing number of patient. On some occasions staff found it difficult to find an area to care for unwell patients.

• Staff had ready access to and followed protocols and guidelines driven by national guidelines and best practice.

• Departments, such as radiotherapy, were involved in the development of best practice guidance for paediatric radiotherapy.

• The hospital participated in national and local research. The quality of care was monitored through a programme of audits.

• There was a good culture of multidisciplinary team working involving a full range of health and social care professional and underpinned care and treatment.

• Patients had their pain regularly assessed and managed effectively.

• A full range of food and drinks were available to meet the differing needs and preferences of patients. Dieticians and speech and language therapists were available to provide advice and nutritional support.

• Patients were cared for by highly competent staff who were encouraged and supported to continue with their professional developed.

• Documentation of consent was good. Children were involved in giving consent when they were at an age to have a sufficient level of understanding

• Patients and carers were overwhelmingly positive about the care they received from staff. Our observations indicated a caring and compassionate approach in the delivery of care.

• Patients told us they were treated with dignity and respect and involved in decisions about their care and treatment. Staff worked creatively to engage children through the use of play sessions.

• Staff valued patients as individuals and we were told of examples where staff had gone beyond expectations to provide individual care.

• Services were designed to provide emotional support to patients and carers with had access to counselling and spiritual support.

• Services were planned to meet the needs to local people and there were processes for patients to access care for non-cancer related health problems in other hospitals.

• Patients were treated in a timely manner and largely within national access standards, however some patients were not referred to the end of life care team in a timely manner.

• Services were designed to meet the individual needs of patients including support for patients who had dementia or a learning disability.

• Information leaflets were available in English and in other languages on request. “Easy read” copies of the trust’s information leaflets were available.

• Overnight facilities were available for parents in services for children and young people.

• The hospital received few complaints and tried to resolve problem before they escalated to a formal complaint.

• Many of the clinical services were well led with good governance and risk management processes to monitor and evaluate care and report performance back to staff and to the trust board.

• Staff were proud to work at the hospital and we saw the trust’s values reflected in their work.

• Leadership was visible and supportive with effective working relationships between managers and clinicians.

• The culture of the hospital was centred on the needs of patients and promoted the delivery of high quality, person-centred care.

• There was good engagement with staff who felt valued and their work was appreciated. Although staff in the outpatients department felt their service was less of a priority than other services

We saw several areas of outstanding practice including:

• Hospital staff from all professional backgrounds provided care, therapy and treatment that reflected the most recent evidence from international and national research findings, and from local audits and pilot studies.

• There were exceptional opportunities for staff development, which contributed to a highly skilled and competent workforce.

• 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.

• In radiotherapy the development of best practice through constant innovation and change of practices and the way in which these were shared nationally with other departments.

• Management of the paediatric patient pathway with consideration to the needs of children through the traumatic radiotherapy pathway. This included the interactions with staff, the play sessions before radiotherapy and the way in which they were engaged throughout the process.

• The contribution made by the radiotherapy physics team to engage with school children to pursue a career in medical physics and the recognition of the department as a result of its contribution with the annual schools science conference.

• The children and young people’s service sent families flowers on the first anniversary of a child’s death and sent families cards for five years after a child’s death.

• A youth support worker provided activities, games and other media to engage and occupy young people while in hospital.

• The process for both site specific and technique multidisciplinary meetings across both the Chelsea and Sutton sites linked through the use of technology and a shared understanding of the process by all parties.

• The accreditation the radiotherapy department has received from ISO 9001/ 2008, IPEM, HEE, and the academy of healthcare sciences for training.

• The plethora of research and publications released having an impact on both national and international practice Including the development of the Heartspare for breast radiotherapy (which has been rolled out nationally).

• The trust had the largest paediatric inpatient drug development programme in the UK. The programme was set up with the objective of improving survival rates for children and young people with cancer.

• The rapid access and diagnosis service provided a one stop shop for patients with suspected cancer .

• The use of patient information prescriptions which provided patients with information about their condition, using sources approved by the Department of Health.

Importantly, the trust must:

• Implement and embed surgical safety checklists in the outpatients department

In addition the trust should:

• Continue with their redevelopment plans for the outpatient department.
• Provide an acute oncology service in line with best practice guidance.
• Ensure that extravasation and cytotoxic spillage kits in all clinical areas are checked in accordance with trust policy.
• The hospital should improve the compliance with the high dusting audit and ensure that process are in place for all clinical areas to be cleaned appropriately.
• Ensure that staff always follow effective hand hygiene practice including the use of alcohol gel when caring for patients.
• Ensure systems for controlling access to medicines in the outpatient department are secure at all times.
• Take steps to ensure clinics are not overbooked and there is sufficient medical staff available to reduce the time patients wait to be seen in clinic.
• Reduce delays in referring patients, where appropriate, to the end of life care service
• Develop a consistent approach across the trust for recording and logging cadaver storage temperatures.

Professor Sir Mike Richards

Chief Inspector of Hospitals