The Royal Marsden NHS Foundation Trust

Updated 16 January 2020

The Royal Marsden was the first hospital in the world dedicated to the study and treatment of cancer. The trust has a total of 219 inpatient beds, 70 day case beds and 18 inpatient wards, as well as approximately 513 outpatient clinics across the two sites. The trust employs approximately 3978 staff.

As a specialist trust. The Royal Marsden takes referrals from all over the country and does not have a local population in the traditional sense. The four largest ethnic minority groups served are: White other, Indian, Pakistani and African.

The trust has two locations registered with the CQC:

• The Royal Marsden – London
• The Royal Marsden – Sutton

Updated 16 January 2020

Our rating of the trust stayed the same. We rated it as outstanding because:

• We rated effective, caring, responsive and well-led as outstanding and safe as good.
• The effective domain improved by one rating on both sites. At our previous inspection, the rating for effective was good on both sites. At this inspection, the rating for effective improved to outstanding on both sites.
• We rated well-led for the trust overall as outstanding.
• Our rating of the trust’s location The Royal Marsden (London) remained the same. We rated it as outstanding because we rated effective, caring, responsive and well-led as outstanding and safe as good.
• Our ratings for the core service of adult solid tumours at The Royal Marsden (London) improved. Our ratings for this core service improved from good to outstanding. We rated it as outstanding because we rated effective, caring and well-led as outstanding, and safe and responsive as good.
• Our ratings for the core service of end of life care at The Royal Marsden (London) improved. Our ratings for this core service improved from good to outstanding. We rated it as outstanding because we rated effective, caring and well-led as outstanding, and safe and responsive as good.
• Our rating of the trust’s location The Royal Marsden (Sutton) remained the same. We rated it as outstanding because we rated effective, caring, and well-led as outstanding, and safe and responsive as good.
• Our ratings for the core service of adult solid tumours at The Royal Marsden (Sutton) improved. Our ratings for this core service improved from good to outstanding. We rated it as outstanding because we rated effective and caring as outstanding, and safe, responsive and well-led as good.
• Our ratings for the core service of end of life care at The Royal Marsden (Sutton) improved. Our ratings for this core service improved from good to outstanding. We rated it as outstanding because we rated effective, caring and well-led as outstanding, and safe and responsive as good.

Updated 19 January 2017

We rated the service as requiring improvement overall because:

• There was a shortage of experienced nursing and therapy staff in the integrated community teams and insufficient time to complete holistic assessments.

• Learning from incident reporting was shared within the relevant teams however systems to share learning across teams were not embedded.

• Patient records were not completed in a consistent or thorough way. 50% of those we viewed did not have the appropriate risk assessments in place. This meant that before visiting nursing staff did not always have a clear understanding of a patient’s health status when giving treatment

• Safety information provided by the trust identified they had a high prevalence of patients with pressure ulcers. We found staff were not consistently following best practice in their approach to wound assessments. This meant that changes to wound presentation were less likely to be accurately recorded and deterioration may not have been addressed as readily.

• Baseline recordings of patient observations were not always completed.

• Deprivation of Liberty Safeguards were not always understood and mental capacity was not always appropriately assessed and recorded for patients who may lack capacity. Staff were knowledgeable about the need to act in patient’s best interest but were not clear about who could consent on the patient’s behalf and how this information should be recorded in patients’ records.

• Staff did not consistently use outcome measures to monitor patient progress. For example: key outcome measures such as the assessment of pressure ulcer risk and nutrition scoring.

• Staff were not following the quality standard for nutrition support in adults which required care services to take responsibility for the identification of people at risk of malnutrition and provide nutrition support for everyone who needed it.

• Few of the records we looked at documented people had been involved or encouraged to be partners in their care when assessing their emotional needs. However we found that in discussions with staff they gave examples and referred to practice that demonstrated they had considered the patients emotional needs although this was not always well documented.

• The arrangements for governance and quality performance did not always operate effectively. Not all risks and issues were known and those that were known were not always recorded.

• The approach to service delivery and improvement was sometimes reactive and improvements were not always identified or action taken.This meant the impact on the quality of care for patients was not always effectively monitored.

• Operational organisational processes impacted on continuity of care. We were not assured systems and processes were in place to effectively identify risks to patient care.

However we also found:

• There was a clear incident reporting system in place and staff were encouraged to report incidents.There was evidence of learning from incidents and evidence of improvements being made as a result of reporting and sharing the outcomes of incidents.

• Community staff were knowledgeable about safeguarding procedures and knew who they would report any concerns to.

• Community nursing staff had access to specialised equipment to meet patients’ needs when required.

• Staff with specialist skills and knowledge were used by community teams to provide advice or direct support in planning or implementing care. Teams worked together in a coordinated way and mad appropriate referrals on to specialised services to ensure that patients’ needs were met.

• Services were delivered in line with evidence based practice. Staff used clinical guidelines and protocols to inform their decisions about care and treatment

• The service participated in national audits and developed action plans to make improvements

• Patients were given a choice of options to manage their pain.

• Patients received a caring service from staff that were kind and respectful toward them.

• Nursing and therapy staff treated patients with dignity, involved patients and their families in their direct care and supported them during times of crisis.

• The services provided a range of specialist therapeutic interventions.

• The trust was aware of the diverse needs of the people who used the service and they provided a range of support as required.

• The trust worked closely with commissioners, local authorities, people who use services, primary care services and other local providers to ensure it understood the needs of the population it served in order to plan and deliver services.

• Staff considered the needs of people who may have difficulty accessing services and adapted their care approach to show respect for cultural factors. There was evidence of learning from the complaints received from patients and families.

• Patients reported that they were satisfied with how to make a complaint and how they were dealt with.

• Leaders encouraged and supported staff so they felt respected valued and supported.

Updated 18 September 2018

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

We rated safe, effective, caring responsive and well-led as good.

The rating for responsive improved since the last inspection. The ratings for safe, effective, caring and well-led remain the same as at the last inspection.

• The service managed patient safety incidents well.
• The service controlled infection risk well.
• Staff kept appropriate records of patients’ care and treatment.
• Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it.
• The service had enough staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and abuse and to provide the right care and treatment.
• The service provided care and treatment based on national guidance and evidence of its effectiveness.
• The service made adjustments for patients’ religious, cultural and other preferences.
• The service monitored the effectiveness of care and treatment and used the findings to improve them.
• Staff of different kinds worked together as a team to benefit patients. Health visitors, school nurses and other healthcare professionals supported each other to provide good care.
• Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005.
• Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness.
• Staff involved patients and those close to them in decisions about their care and treatment.
• Staff provided emotional support to patients to minimise their distress.
• The trust planned and provided services in a way that met the needs of local people.
• The service took account of patients’ individual needs.
• The service treated concerns and complaints seriously, investigated them and learned lessons from the results, which were shared with all staff.
• The service had managers at all levels with the right skills and abilities to run a service providing high-quality sustainable care.
• The service had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff and key groups representing the local community.
• The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected.
• The service engaged well with staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively.

Updated 18 September 2018

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

• We rated safe, effective, caring, responsive and well-led as good.
• The ratings of safe, effective, caring and responsive remained the same. The rating for well-led improved.
• Since our last inspection there had been a focus on the trust wide understanding and development of end of life care. There was now a strategy and governance programme in end of life care with a clear structure of leadership and accountability.
• There had been a focus on continuous improvement across the service since our last inspection. There are now clear audits and key performance indicators structures for delivering end of life care.
• Appropriate measures were in place to keep patients safe from avoidable harm. Incidents and safety monitoring results were collated and shared to improve the service.
• Policies, procedures and ways of working had been brought into line with local and national guidance. Advanced care planning for patients at the end of life had improved since the last inspection.
• Patients were provided with compassionate and person centred care, which took account of their individual differences and needs. Relatives and friends were involved in care planning wherever appropriate and recognised as part of the caring team.
• Staff across the service worked effectively with external agencies and attended Gold Standard Framework meetings with others in the borough to coordinate care for patients and improve pathways.

However:

• The community staff did not have rights to prescribe medication or verify patient death so were reliant on others in the community, more often than not, GPs.
• The service provided mandatory training in key skills to all staff but some completion rates were below the Trust target.
• Staff did not always have access to up-to-date, accurate and comprehensive information on patients’ care and treatment. This was particularly the case with regards to the non-transferable DNACPRs from some of the local trusts.