The Clatterbridge Cancer Centre NHS Foundation Trust

The Clatterbridge Cancer Centre is one of the biggest cancer centres in the country and treats patients from across Merseyside, Lancashire, Cheshire, the Isle of Man and North Wales. The trust also provides specialist care and treatment to patients from all over the United Kingdom.

The trust completed the year with an income and expenditure surplus of £56.5 m. However, the trust will be moving to a new site in the centre of Liverpool in 2018, and £49m funding will be reinvested into the cost of the building of the new hospital. The new hospital will make treatment more accessible for those who live in the more deprived areas of Merseyside and the surrounding areas. Some services will remain at the Clatterbridge site including the proton service for eyes.

Oncology services are provided at the hospital there are 74 inpatient beds over three inpatient wards at the hospital and a four bedded young peoples’ unit that was found on Mersey Ward. They had a total of 3,760 admissions between April 2015 and March 2016 and had a low number of deaths during the same period (74).

Chemotherapy services are provided by the trusts Systematic Anti-Cancer Therapy (SACT) Service at The Clatterbridge Cancer Centre and at eight peripheral satellite clinics at a range of locations, which include acute general hospitals, primary care centres and other sites managed by the trust. The service also provides certain types of chemotherapy in patient’s homes. This service is provided by staff employed and trained by The Clatterbridge Cancer Centre. The adult day-case Delamere chemotherapy unit is open Monday to Friday between the hours of 8.30am and 6.30pm. Between April 2015 and April 2016, the unit delivered 46,974 doses of chemotherapy. Of these 19,979 were delivered at The Clatterbridge Cancer Centre, 26,247 were delivered in the outreach sites and 748 of these doses were delivered in patient’s homes.

There are seven linear accelerators for the delivery of radiotherapy treatment at The Clatterbridge site and there is a further three at the radiographer led service which is delivered from a purpose built unit in Aintree. The trust delivered 97,926 radiotherapy treatments in the period April 2015 to March 2016. There is a brachytherapy treatment known as Papillon which can provide an alternative to surgery for some rectal cancers. There is a proton beam therapy service for the treatment of cancers of the eye that treats patients from all over the country and from abroad. The low energy proton beam therapy unit is the only one in the country.

A range of outpatient cancer services are provided by the trust and a number of outpatient appointments are also offered in satellite clinics at hospitals throughout Cheshire, Merseyside and the Isle of Man. They offer a combination of consultant and nurse-led clinics including clinical and medical oncology and phlebotomy. A number of therapy led appointments are provided including physiotherapy, speech and language therapy and occupational therapy. There were 99,394 outpatient appointments offered across the trust between July 2015 and April 2016 with 43,318 offered at The Clatterbridge Cancer Centre, Wirral.

The diagnostic imaging department consists of two direct radiography (DR) rooms (one of which includes a orthopantomogram (OPT) machine), one computed tomography (CT) scanner, one gamma camera, one positron emission tomography–computed tomography (PET CT) scanner, two magnetic resonance imaging (MRI) scanners, and ultrasound.

End of life services were provided and led by a team of specialist palliative care nurses and a consultant in palliative care medicine, who provided direct care and treatment to patients and supported staff throughout the hospital.

We visited The Clatterbridge Cancer Centre and the Aintree Radiotherapy site as part of our announced inspection during 7 to 9 June 2016. We also carried out an unannounced inspection on 21 June 2016. During this inspection, the team inspected the following core services:

• Medical care services

• End of life

• Outpatients and diagnostic services

• Chemotherapy

• Radiotherapy

Overall, we rated The Clatterbridge Cancer Centre NHS Foundation Trust as outstanding. We have judged the service as ‘good’ for safe, effective and responsive. We rated the domains of caring and well-led as ‘Outstanding’.

Our key findings were as follows;

Vision and strategy

• There was a clear trust strategy plan for 2014 to 2019 which had been refreshed in February 2016. This was supported by the establishment of a Transformation Programme Office to support the delivery of the transformation agenda. The plan was linked to other external plans including the Five Year Forward View (5YFV) [Published October 2014]; the 2016/17 planning guidance (particularly the opportunities provided by the requirement for the development of health economy sustainability and transformation plans (STPs) that cover the same planning period). Published December 2015 and the Report of the cancer taskforce (Achieving World Class Outcomes: a strategy for England 2015-2020).

• All services had local plans which linked to the trust strategy.

Leadership and Management

• The hospital was led and managed by a visible executive team. This team were well known to staff, and staff spoke highly of the commitment by leaders to continually improve services putting patients and people close to them at the centre of decision making.

• There was effective teamwork and clearly visible leadership within the services and decision-making was patient centred and clinician led.

• Leaders understood the challenges to good quality care and identified actions to address them.

• Staff felt involved in decision making, and felt that they were able to influence the vision and strategy of the organisation.

• The NHS staff survey 2015 showed the trust performed better than the national average for 12 indicators and as expected in a further seven. The overall staff engagement score for the trust was 3.98, which was in line with the national average score of 3.94 for specialist acute trusts.

Culture

• The trust had “the Clatterbridge Culture Programme” in place. This was a five year strategy to create a culture in which positive behaviours are experiences consistently throughout the organisation. This contained a culture recipe and clear measurement of each of the culture dimensions.

• All the staff we spoke with were proud, highly motivated and spoke positively about the care they delivered. Staff told us there was a friendly and open culture. They told us they received regular feedback to aid future learning and that they were supported with their training needs by their managers.

• All leaders appeared to be competent, knowledgeable and experienced to lead their teams and understood the challenges to good quality care and what was needed to address those challenges. Leaders strived to deliver and motivate staff to succeed and to continue to improve. Managers sought to improve the workforce culture to engage with staff to achieve advances in care and quality.

• We saw that a very positive and supportive culture across all wards and departments. Staff were very proud of their hospital and the work they did. They were enthusiastic and passionate about the care they provided and the achievements they have accomplished. There was a tangible sense of willingness to go the extra mile and do the very best for their patients.

• There was an open and honest culture within the organisation and staff were candid about the challenges they faced.

• Staff morale was reported to be good although in outpatients the amount change the department had experienced in a short period of time had affected morale.

Equality and Diversity

• The trust has an overall Equality and Diversity Strategy (EDS) in place and there were clear monitoring processes for the EDS2 plan. However the EDS2 plan was not readily visible to staff, the equality plan published on the intranet was dated 2012-16 and was not the same as the current EDS2 action plan.

• A governance process was in place to ensure that equality impact assessments were carried out for major service changes and policies, but this did not extend to organisational strategies.

• There was a strong communication relationship between corporate diversity lead and staff side chair.

• Equality and diversity training was included as mandatory training for all staff every three years. Overall trust rates of compliance are 84%.

• The trust’s staff survey result in relation to discrimination at work was 7%, which was better the 9% sector average.

Governance and risk management

• The trust had commissioned an external governance report which had reported in March 2016. This had made 36 recommendations to strengthen the governance in the organisation and the trust had a robust action plan in place with actions to be completed by October 2016.

• The Board Assurance Framework (BAF) had been revised in May 2016 in response to the governance report and there were good processes in place for the management of the BAF.

• There was a robust committee structure in place that supported challenge and review of performance, risk and quality.Mechanisms were in place to ensure that committees were led and represented appropriately, to ensure that performance was challenged and understood.

• We found all policies to be clear, accessible and up to date.

• The trust had been awarded significant assurance by Mersey Internal Audit for the last two years regarding information governance (IG). The IG Toolkit was reported as 80% compliant for 2015/16.

• Clinical governance managers were integrated in to directorates, attending and reporting to directorate meetings and providing leadership with root cause analyses.

• Local risk registers were seen to be relevant and up to date; however in oncology the process required strengthening. The use of monitoring including dashboards and audits was seen in all areas.

Patient experience

• Relationships between staff and patients and their families were strong, caring and supportive. The staff throughout the hospital were highly motivated and committed to providing holistic, high quality, compassionate care to patients and those around them. A Holistic Needs Assessment was completed before and during patient treatment and surveillance to identify emotional and spiritual need. We saw staff communicating with patients and relatives in a compassionate and respectful manner and the privacy and dignity of patients and relatives were maintained consistently. These relationships were highly valued by the staff and promoted by leaders.

• Feedback from patients through comment cards during the inspection was 97% positive. We spoke with patients and families who told us they had experienced “nothing but kindness”, that staff had been “lovely” and they had time to ask questions. Patients we spoke with said that they were treated as an individual and were extremely positive about the staff. Patients told us that staff helped them to feel safe and secure during treatment

• There were many free services for patients and their families which improved the patient experience ranging from free car parking and beverages to complementary therapies and PAT therapy. There were examples of staff making sure acutely ill patients were involved in major life moments despite their illness and treatment and where staff had gone the extra mile. For example, a number of weddings had been facilitated at short notice. They also facilitated for one patient, who was acutely unwell, to be present at the birth of their child and arranged for the family to be together at the hospital for the first few important days of family life. This demonstrated a commitment in understanding and responding to the wishes of patients at the end of life.

• Between December 2015 and April 2016 results from the NHS Friends and Family Test showed the percentage of patients that would recommend the centre ranged from 97 to100%, above the national average of around 95%.

• In the cancer patient experience survey for inpatient stay 2013/2014, the trust ranked within the top 20% of all trusts for seven of the 34 areas.

• The trust performed better than similar trusts in seven of the 12 areas of the 2014 CQC inpatient survey.

Cleanliness and Infection control

• Clinical areas at the point of care were visibly clean.

• The trust had infection control and prevention policies in place, which were accessible to staff and staff were knowledgeable on preventing infection and minimising risks to patients, visitors and staff.

• The local Infection Control Committee met regularly and covered all expected areas.

• In April 2016 the committee reported that the C.diff objective for the year remained at one case. There had been no MRSA bacteraemia infections.

• Staff were observed to comply to bare below the elbow standards and hand washing procedures were adhered to. The use of personal protective equipment was of a good standard.

• In the 2015 patient-led assessments of the care environment (PLACE) audit the trust scored 99.8% for cleanliness compared to a national average of 97.6% and patients commented positively about cleanliness.

Staffing

• Medical, nursing and radiographer staffing was good and in line with the expectations at a specialist trust. Staff told us that they felt well-staffed and they felt that they had enough time to care for patients and medical response was timely when required.

• Nurse staffing levels were based on an acuity tool. Staff sickness and turnover rates were as expected. Staff told us that they felt well-staffed and they felt that they had enough time to care for patients. Staff vacancies were noted on the risk registers and actions had been identified to mitigate these risks. There was a reliance on temporary staffing on some of the wards but there was a buddy system in place to make sure they were well supported.

Mortality rates/ Patient outcomes

• As a specialist cancer trust, it is inevitable that many patients with advanced cancer spend their final weeks as patients of The Clatterbridge Cancer Centre, and whilst acknowledging the desire of the most terminally ill patient to die at home, for some, symptom control issues or social difficulties mean that their end-of-life care is delivered within a hospital.

• Between April 2014 and March 2015 there were 50 deaths at the centre.

• Accordingly a significant number of deaths occurring within the trust were "expected”. The Trust Management Group reviewed the 99 inpatient deaths occurring between April 2014 and January 2016, only 5 were deemed to be unexpected. The palliative care team had significant input into the management of in-patients with advanced disease, and often patients had been on the amber care or an end-of-life pathway in the days or weeks prior to their death.

• The service participated in the National Chemotherapy Multi-Disciplinary Team (MDT) Peer Review (2014) being compliant with 35 out of 36 standards and scoring 97.6% overall. The service scored 100% overall compliance with the 19 standards for intrathecal chemotherapy in the National Chemotherapy MDT Peer Review (2014).

• Data contributions to the National Care of the Dying audit showed that the service had performed better than others nationally in the ten key clinical performance indicators.

Nutrition and hydration

• Patient records included assessments of patients’ nutritional requirements. Where patients were identified as at risk, there were fluid and food charts in place and these were reviewed and updated by the staff.

• Patient records also showed that there was regular dietician involvement with patients who were identified as being at risk.

• Patients told us they were offered a choice of food and drink and spoke positively about the quality of the food offered.

We saw several areas of outstanding practice including:

In the End of Life Service;

• The service had developed a simulation based training programme to develop the skills and knowledge of staff throughout the hospital. This involved simulating difficult situations so that staff developed their confidence when dealing with patients and relatives at the end of life.

• All staff were committed to facilitating the requests of patients at the end of life. For example, there had been a number of weddings organised within a short period of time at the request of patients. Several staff were involved in facilitating these.

• The service had responded to NICE guidance by developing a day after death service which met the needs of the bereaved in that a number of risk assessments were undertaken to ensure their welfare.

• The SPC consultant was involved in a number of projects. For example, the serious illness programme UK was being piloted alongside a number of organisations from the United States of America and had been designed in response to services recognising the challenging situations that clinicians faced when dealing with patients and relatives at the end of life.

In the Outpatients and Diagnostics service;

• Individual needs of patients were identified through completion of a Holistic Needs Assessment at varying times during treatment and surveillance. Following completion a care plan was formulated to summarise any concerns and identify actions to address them.

In the Radiotherapy service;

• The development of the advanced practice radiographer posts that enabled consultants and registrars to do the more complex work.

• The uses of skill mix across the department for staff at all levels including health care assistants

• The continuing development of the Papillon service as an alternative to radical surgery.

• The proton beam service for the treatment of eye cancers and its continuing development and training of staff from other centres.

• Radiographers able to prescribe medicines for head and neck cancer patients to alleviate their pain.

• The development and use of the vac bags to help to immobilise patients during treatment and the making of individual head rests to make patients more comfortable.

In the Chemotherapy service;

• The innovative introduction of the rapid chair initiative in the Delamere unit had improved the experience and waiting times for patients receiving shorter treatments.

• The introduction of the Adjuvant Zoledronatec service was innovative and market leading. The introduction of this service meant that patients with breast cancer were receiving the very latest evidence based treatment to reduce their risk of death and reoccurrence.

• The Chemotherapy at Home project was outstanding and provided patients with treatment in their own homes. This service embodied the overall trust and service vision of providing the best cancer care to their patients.

• The positivity and compassion shown by staff and reflected in the feedback from patients was outstanding. It was clear that all levels of staff continuously strived to provide outstanding care to their patients.

• The interaction and utilisation of the Maggie’s Merseyside charity was excellent. It meant that patients could access all the advice, support and treatment in one place at one time.

• The support offered to patients throughout their treatment was outstanding. This included the implementation of the end of treatment bell, the PAT therapy dog and handler, massages and relaxation techniques for patients and the program of activities provided in the Maggie’s centre. All of which contributed to patients receiving an excellent level of emotional and practical support.

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

Importantly, the trust must:

• Ensure that staff are up to date with all mandatory training especially in infection control and life support.

• Improve the staffing within the diagnostic imaging service.

• Ensure that the protection documentation (as required by the Ionising Radiation Regulations 1999 (IRR) and Ionising Radiation (Medical Exposure) Regulations 2000 (IR(ME)R)) which was overdue for review or did not reflect current clinical practise such as a risk assessment from 2013, and local rules from 2014 are addressed.

Professor Sir Mike Richards

Chief Inspector of Hospitals