Mount Vernon Cancer Centre

Mount Vernon Cancer Centre (MVCC) is part of East and North Herts NHS Trust and provides a specialist non-surgical cancer service. It is situated in Hillingdon, Middlesex on a large site owned by Hillingdon NHS Trust and is some 33 miles from East and North Herts Trust’s main hospital in Stevenage.

It serves a wide area of 2 million people across Hertfordshire, Bedfordshire, Northwest London and parts of the Thames Valley.

The cancer centre has never been inspected by the Care Quality Commission before and was inspected on this occasion as a specialist stand-alone unit as part of the comprehensive inspection of East and North Herts NHS Trust.

We inspected five core services, chemotherapy, radiotherapy, medicine, outpatients and end of life care. Radiotherapy and outpatients were rated good. However, end of life care and chemotherapy required improvement. Medicine was rated as inadequate.

Overall, we rated MVCC as requiring improvement on two of the five key questions which we always rate. The areas that required improvement were responsiveness and well led. Safety was rated as inadequate overall.

Overall caring and effectiveness were good. In chemotherapy, caring was rated as outstanding, where it was evident staff were encouraging and supportive and went the extra mile to ensure that patients were cared for in the best possible way.

Our key findings were as follows:

• The environment had not been always been well maintained and there were areas of risks that had not been addressed by the service. These concerns were brought to the attention of senior staff during the inspection.
• Infection rates were low. There had been no reported incidents of MRSA or Clostridium Difficile (C.Difficle) in the six months prior to our inspection. Clinical waste was disposed of safely. This included chemotherapy waste.
• There was a low recording of incidents by staff in some areas.
• Urgent transfers out of the hospital were not reported on the trust wide incident reporting system. They were recorded in a diary type format, but this lacked detail with regards to the reason for transfer and patient outcomes. There was no trend analysis or evidence of learning.
• There was no process in place to follow up these patients so the service was not updated on whether the patients’ cancer treatment had been maintained. Therefore, the trust was unsighted on this risk and no actions had been taken to address this concern.
• There was limited completion of observation and fluid balance, especially for patients receiving intravenous therapy or fluid irrigation. In patient nursing assessments were often incomplete and actions were not reviewed with the patient.
• The wards duplicated documents for recording and administering blood transfusions. On observation we found that standards of hand-washing did not meet the infection control national guidance standards.
• We found that there were sufficient doctors and registered nurses on duty, and nursing numbers were monitored daily. Patients who were deteriorating were seen by medical staff and care reassessed promptly.
• Most staff had good access to training and appraisal systems, although some reported that travelling to the trust’s main site in Stevenage for training, was difficult.
• There was evidence of local clinical audits and action required at ward level. Intentional rounds were carried out to assess patients’ pain and symptom relief.
• There was a daily multidisciplinary (MDT) handover and a weekly in-depth MDT patient review. We found that there was a strong culture of multidisciplinary working between nurses, specialist nurses, doctors, allied health professionals and social workers. The service was covered by a consultant seven days per week and interventions were carried out at weekends.
• Patients received compassionate care, were treated with dignity, respect and reported they felt safe. Both patients and their relatives were positive about their experiences of care and kindness offered to them. We observed a supportive volunteer system adding strength to the clinical teams’ positive approach. Patients told us that they were involved in decisions about their care and treatments and were given appropriate information
• Staff had limited awareness of the trust’s vision and values. The reported culture amongst some of the nursing staff was a resistance to change and some staff members not taking the responsibility that their grade denoted. New nursing leadership was beginning to address this.
• There was a process in place to obtain rapid treatment for patients who were suspected of having neutropenic sepsis. There was a procedure in place to minimise chemotherapy being given via the incorrect route. Only 30% of patients who were suspected of having neutropenic sepsis received antibiotics within two hours of admission. However, not all these patient were admitted to MVCC.
• The hospital was meeting the 31 day target for treating patients who required chemotherapy and radiotherapy for most tumour types.
• All the consultants specialised in treating one or two tumour sites only.
• There was almost always long queues in the outpatients department for patients to be checked in, although patients who were nervous, for example, if they were needle phobic, were seen and reassured as soon as possible. There were always long waits for treatment, whether the patient chose to have a one stop option or blood tests on one day and treatment the next. Patients who required daily treatment, but did not need an in-patient bed, were able to stay in the hospital’s on-site hostel.
• Patients often needed to go outside the main building to access other services. Often their individual needs were not always met with regards to keeping warm and dry.
• Patients who required specialised treatment by a plastic surgeon for extravasation, needed to be transferred off site.
• The service to insert PICC lines operated three days per week. This meant patients sometimes had their first treatment without the PICC line in situ.
• Although each division within the hospital had local objectives and there were objectives for the cancer centre, there was no principal cancer strategy, nor was there a director with sole responsibility for cancer. There was no strategic oversight of the chemotherapy service.
• All the staff we spoke with were proud to work for the Cancer Centre and would want their friends and family to be treated there should the need arise.
• The radiotherapy service had a strong reputation nationally as a major contributor to clinical trials. There was clear evidence of both staff and patient engagement in service provision and development. The trust had a replacement for the Liverpool Care Pathway (LCP) called the Individual Care Plan for the dying person (ICP).
• The end of life service did not collect information of the percentage of people achieved discharge to their preferred place within 24 hours. Without this information, we were unable to monitor if the service was honouring peoples’ wishes and if the trust needed to make any improvement on this.
• Staff had limited awareness of the trust’s vision and values. The leadership team could articulate their plans for the future, but did not have a clearly defined cancer strategy in place.

We saw several areas of outstanding practice including:

• The radiotherapy service provides IMRT (Intensity Modulated Radiotherapy) to a higher percentage of patients than the England average. The service provided a good range in IGRT (Image Guided Radiotherapy). Together these are indicators of a high quality radiotherapy service.
• The radiotherapy service had a strong reputation nationally as a major contributor to clinical trials.
• The radiotherapy service was accredited to the ISO 9001 quality standard.
• The cancer centre is one of the top ten centres in the country for research and innovation.
• Care shown to patients undergoing chemotherapy was outstanding.
• Effective multidisciplinary working was evident throughout all departments.
• All staff were proud to work for MVCC and many described it as a special place to work.

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

Action the hospital MUST take to improve:

• Ensure that patients who require urgent transfer have their needs met to ensure their safety and that there is an effective process in place to handover continuing treatment.
• Ensure there is oversight and monitoring of all transfers.

Action the trust SHOULD take to improve:

• Consideration given to patients’ needs are responded to when they are transported outside the building.
• Consideration should be given towards using one system for recording and administrating blood transfusions. Standards of hand-washing did not meet the infection control national guidance standards.
• Consider that urgent transfers out of the hospital are recorded on the trust’s incident reporting system, so that there is an oversight for the reasons for transfer.
• Consider ways of resolving long waits in outpatients and for chemotherapy.
• Consideration should be given to unwell patients having to queue for their outpatient appointments.
• Ensure that all staff are aware of their responsibilities with regards to DoLs and MCA.
• Consider a more effective way of ensuring the environment in Michael Sobell House (MSH) is clean and safe.
• Consider collecting information of the percentage of people who achieved dying in their preferred location.

Professor Sir Mike Richards

Chief Inspector of Hospitals