The Clatterbridge Cancer Centre

Updated 16 April 2019

The Clatterbridge Cancer Centre NHS Foundation Trust is predominantly based at their Wirral site.

At the time of our inspection the trust had 103 beds, based in six wards, including a clinical decisions unit. The trust also had 22 chairs based within the haemato-oncology unit and a further 117 chairs for treatment of patients with solid tumours. The trust ran approximately 370 outpatient clinics per week from a range of locations. From August 2017 to July 2018 the trust had 7,656 inpatient admissions (127% increase on the previous year), 388,923 outpatient attendances (15% increase on the previous year) and 106 deaths (38% increase on the previous year). At the time of our inspection the trust employed 1,126 staff.

We last inspected this hospital in June 2016 and published our report in February 2017. At that inspection the hospital was given an overall rating of outstanding. The hospital were also issued with requirement notices, which impacted on their rating in the safe domain.

Currently the hospital provides chemotherapy, radiotherapy, medicine (including haemato-oncology), outpatients, diagnostics and end of life care.

During our inspection we:

• Spoke with 72 members of staff across different specialisms and grades.
• Spoke with thirty patients.
• Spoke with four relatives or carers.
• Reviewed 22 sets of patient records.
• Reviewed trust policies and standard operating procedures.
• Observed care delivered to patients.

Updated 16 April 2019

Our rating of services went down. We rated them as good because:

• We rated safe, effective, responsive and well-led as good. We rated caring as outstanding.
• We took into account the hospital’s previous rating from our last inspection for three core services. Following our recent inspection the combined ratings meant we rated four services as good and two as outstanding.
• We cannot compare the ratings for outpatients and diagnostics services as at our last inspection we rated these services together. However, we found that areas of concern in these services at our last inspection had been addressed at this inspection.
• Across the trust, services largely performed well. We were not concerned regarding the overall quality of cancer care. Our concerns were linked to important issues that underpin cancer care and ensure there are effective systems and processes within hospitals.
• We continued to rate caring as outstanding. Throughout the organisation staff were committed to delivering patient centred care. Patients were at the heart of what the trust did and decisions it took. Staff respected individuals and supported them practically and emotionally.
• We improved the overall hospital rating in safe to good.
• We continued to rate effective as good. The hospital continued to ensure that patients had good outcomes because they received care and treatment that met their needs.
• We continued to rate responsive as good because most people’s needs were met through the way the services were organised and delivered.
• At core service level, we rated well-led as good because the leadership and culture promoted high-quality person-centred care.

However:

• Our rating in well-led for medicine went down because the hospital did not comply with some legal requirements. Further information can be found in the medicine report.
• We rated safe in diagnostics as requires improvement. We were concerned regarding patient safety, storage of records and mandatory training levels in relation to life support training. The trust did not comply with some legal requirements in relation to these issues. Further information can be found in the diagnostics report.
• The hospital’s governance systems did not enable senior staff to have oversight of issues that impacted on patient care and allow them to address risks sufficiently in a timely way. Further information can be found in the well-led overall report and evidence appendix.
• The hospital did not ensure there were always enough suitably qualified, competent and experienced staff with relevant levels of life support training (including basic, immediate and advanced life support) deployed within the service at all times.
• We had concerns relating to records storage.
• All the concerns relating to legal requirements were raised with the hospital at the time of our inspection and action was taken to address them.

Updated 16 April 2019

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

• The service provided care and treatment based on national guidance and was involved in research trials. Patients were treated with dignity, respect and their emotional needs were considered and supported when needed.
• The service had plans to provide cancer services at an additional location. The views of staff and patients had been used to drive improvements in the planning stage and further work was in progress to finalise plans in preparation for the move.
• Managers within the service monitored patient outcomes and compared results with similar services to identify areas for improvement.
• Staff cared for patients with compassion dignity and respect. All patients and relatives we spoke to felt they were continually respected and treated with care and compassion.
• The service planned and provided services in a way that met the needs of most local people. At the time of inspection, the service was in the process of building new facilities to meet the needs of the local people by relocating closer to the majority of its patients to improve accessibility.

However:

• Mandatory training compliance levels had gone down since our last inspection. We were not assured there were competent staff on each shift in some areas to provide life support.
• Competency compliance training evidence available on inspection was poor. We were not assured there were competent staff on duty each shift in some areas.
• The service did not have effective governance structures in place to assure the service that staff had the required skills, mandatory training and competency for the role they had undertaken.
• Service leads did not collate data from across the service effectively to inform performance monitoring and make improvements. There were different incompatible systems to collate the information from and maintain accurate records across the medicine service.
• Patient records were not always stored securely. This meant that patient information was accessible to the public in some areas.

Updated 1 February 2017

We rated the chemotherapy service outstanding because:

• The service had a clear focus on safety and patient centred care. Safety was a high priority throughout the service and there was routine measurement and monitoring of safety and performance within the service. Risks were appropriately and identified.
• We found that the care delivered to patients was evidence-based and in line with key documents such as National Institute of Health and Care Excellence guidance. There was routine monitoring of patient outcomes of care and treatment, and patient feedback was actively sought on a regular basis.
• The training for staff involved with the delivery of chemotherapy was appropriate to their role and provided on a regular basis. Staff appraisals were completed. All teams within the service worked effectively and engaged with other professionals to ensure patients received the required level of care and support. Staff spoke very positively about the support they were given by leaders and management. Managers within the service lead by example and staff told us they were inspirational.
• Staff treated patients as partners in their care and treatment and empowered them to make choices about their treatment plan and direction. Staff were passionate and committed to providing outstanding care. Staff were observed providing care to patients with kindness, compassion and dignity. Staff at all levels routinely went the extra mile to provide outstanding care to patients.
• Individual needs were identified and responded to appropriately. The service also provided an innovative and comprehensive chemotherapy program in patients own homes and were considering offering this service in workplaces. Psychological support, counselling and complementary services were all provided free of charge for patients and their relatives.
• The service had introduced an innovative ‘rapid chair’ initiative in response to issues with patients experiencing delays. This meant that patients who were receiving short periods of chemotherapy did not experience delays. This service was introduced in direct response to patient feedback.
• The service had a comprehensive strategy and business plan, which took into account sustainability for the future. The service was responsive to patients’ needs and fully took into account the needs of the population they served. The service had adapted to meet the needs of the patients using their services and was actively engaging with the public regularly to ensure that they provided services that met their needs. Patients could access treatment and care in a timely way. All patients we spoke with told us that they had experienced no delays in accessing chemotherapy and eight out twelve patients told us they were surprised at how quickly their treatment had been commenced.
• All patients we spoke with told us that the care they received from the service exceeded their expectation.

Updated 16 April 2019

• The service had acted on areas for improvement identified during the last inspection.
• There were systems in place to safeguard people from abuse and neglect. Staff were aware of how to raise safeguarding concerns.
• The service had implemented a quality assurance programme across all modalities and this process had been subject to external review.
• There was a positive culture around reporting of safety incidents. Lessons learned following incidents were shared effectively.
• Staff treated patients with compassion and respect. Patients we spoke with provided positive feedback in this regard.
• Staff worked with patients and those close to them to meet the needs of individuals and provide additional support when necessary.
• Leaders within the service had the support of staff working within the department who were confident in their ability to drive improvement.
• The service had a vision and strategy for how this would be achieved. Service leads had engaged with staff in the creation and implementation of this strategy.

However;

• We observed that radiographers carrying out computed tomography scans did not routinely carry out a ‘pause and check’ in line with best practice. We escalated this to the trust at the time of our inspection and they took action.
• Records were not always stored appropriately. Diagnostic images were not automatically archived so that they were accessible for reporting or for use at a later date. We escalated this to the trust at the time of our inspection and they took action.
• There was not always enough radiologist capacity to produce imaging reports in a timely manner.
• There was a system in place to prioritise reporting of patient’s images which included a target for reporting of non-urgent scans however staff we spoke to were not always certain what this was. This represented a safety risk to patients which we escalated at the time of our inspection.
• Due to reduced radiologist capacity within the service, new clinical trials had been suspended. This limited the services offer to patients and diminished opportunities for research and clinical excellence.

• There were systems in place to identity and manage risk within the service although we found examples when some actions to mitigate risk had been delayed.

Updated 1 February 2017

We rated end of life care services as ‘good ‘ overall because;

• End of life services were led by a dedicated specialist palliative care consultant and a team of specialist nurses who were dedicated to providing the best possible care and treatment.

• The SPC team had developed a clear vision and strategy which was supported by an end of life care work programme which were aimed at improving the current services provided further.

• The SPC consultant was involved in a number of different projects to improve end of life services not only at the trust, but also nationally.

• We found that the numbers of nursing staff on inpatient wards were adequate to provide care and treatment to patients at the end of life.

• We found that both the SPC team and general staff on the inpatient wards were keen to tell us how proud they were of the service that they provided. All staff were committed to high quality, compassionate care.

• End of life services had been developed and were delivered in line with current best practice guidance. The service had responded to the Liverpool care pathway being withdrawn by implementing an individual communication record which had been designed to meet individual needs of patients at the end of life.

• The service made regular contributions to the National Care of the Dying Audit and the most up to date records from January 2016 showed that the service performed better than other services nationally in all ten clinical indicators.

• We saw some positive examples of multi-disciplinary team working. End of life services were everybody’s responsibility and the SPC team provided a good level of support to nursing and medical staff on the inpatient wards.

However,

• The SPC team were not currently able to provide a seven day service. There were plans in place to introduce this in September 2016.

• End of life care training had been included as part of the mandatory training programme for all staff. However, there was currently a low level of compliance with this.

• The service did not currently use advanced care planning and were not part of the gold standard framework accreditation scheme.

• There was limited evidence of incidents and complaints being discussed in governance meetings which meant that it was unclear how lessons were being learnt and improvements were being made.

• The trust had a service level agreement in place with another hospital for the provision of on-site mortuary services. However, we found that there was no assurance that this was being monitored appropriately through key performance indicators.

Updated 16 April 2019

We previously inspected outpatients jointly with diagnostic imaging in June 2016, so we cannot compare our new ratings directly with previous ratings.

We rated it as good because:

• Services had suitable premises and equipment. They were kept clean to minimise the risk of infection.
• There were enough staff with the right qualifications, skills and training so that patients were seen and assessed in a timely way and within the prescribed targets.
• The service provided care and treatment based on national guidance. There were processes in place to ensure that guidance was promptly reviewed, disseminated and embedded.
• The effectiveness of care and treatment was monitored regularly and reported to the trust board. Services were involved in the annual clinical audit programme. Audit results and patient outcome monitoring were used to drive improvements.
• Staff received role-specific training. They were encouraged to take up external training courses that were relevant to their roles.
• Staff worked collaboratively with GPs, NHS trusts in the region, support and therapy services and other stakeholders to deliver effective care and treatment.
• The staff provided holistic care to the patients. Patient feedback about their care was very positive. Staff delivered care that was individually tailored to the needs of the patient. Patients were treated with privacy and dignity at all times.
• There was strong emotional support for patients and their physical, mental and spiritual needs were considered always.
• Staff worked to empower patients and their relatives and respected their wishes. They were involved in decisions and staff ensured that they were fully informed and made time to answer any additional questions or concerns, even if this meant the patient and their family returning to the clinic without an appointment.
• Complaints and concerns were treated seriously and lessons were learned and shared with staff.
• The service had a vision for what it wanted to achieve and workable plans to turn it into action. The views of staff and patients were used to drive improvements.
• Staff were valued and supported by managers and a positive culture and the wellbeing of staff was promoted.

However:

• There were some mandatory training courses where completion rates were well below the target level of 90% set by the trust, for example, resuscitation level three (adult immediate life support) where there had been a delay in delivering training courses due to staff sickness. Managers told us that relevant staff were booked on future courses to complete the training.

Updated 1 February 2017

We rated the radiotherapy service outstanding because:

• Services were safe and there was a good and open culture of incident reporting. Lessons were learned and the duty of candour was applied appropriately.
• Patients commented on the cleanliness of the departments and audits were carried out to ensure that equipment was clean. There were infection control processes in place which were also audited.
• The equipment and techniques used for radiotherapy were some of the most advanced in the country.
• There was a comprehensive audit system in place and a culture of continuous learning, development and improvement across radiotherapy and medical physics.
• Staff development was good for all grades of staff and radiographers were taking on new roles that enabled consultants to undertake more complex work.
• Patients were extremely complementary about the service and there were good interactions between staff and patients. Patients and their carers were supported. There was a self- help group for patients who had completed their treatment at the Aintree site and a wide range of complementary therapies were available for patients.
• Patients were given a full schedule of appointments at their first appointment.
• The governance of the department was very effective and the department had participated in an external quality management standard and had done for several years.
• Leadership was robust, which contributed to a culture of improvement and a focus on improving short and long term outcomes for patients.
• The department had consistently achieved their referral for treatment targets though some patients waited more than 31 days to start their treatment. The department cancelled very few clinics.