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Council of Governors Board Room, The Royal Marsden, London

22nd March 2017, 11am – 1pm followed by lunch

1. Welcome to the Chief Nurse

(Chairman) Verbal

2. Minutes of the meeting held on 7th December 2016 (Chairman)

Enclosed

3. Chief Executive’s Report (Chief Executive)

Verbal

4. Care Quality Commission Report & Draft Action Plan (Chief Nurse)

Enclosed

5. RM Partners Update (Managing Director of RM Partners)

Enclosed

6. Financial Plan 2017-19 (Chief Financial Officer)

Enclosed

7. Membership and Communications Group 7.1. Membership Recruitment and Engagement Strategy 2017-18 7.2. Governors Report on Members’ Week (Governors Carol Joseph and Fiona Stewart)

Enclosed Enclosed

8. Nominations Committee Report - For Governors only (Chairman)

Enclosed

9. Quality and Performance 9.1. Financial Performance Report for 10 months to January 2017 (Chief Financial Officer) 9.2. Quality Account for October – December 2016 9.3. Annual Quality Account 2016/17 9.4. Governors selection of quality priorities (Chief Nurse) 9.5. Key Performance Indicators Q3 (Director of Performance and Information)

Enclosed

Enclosed Enclosed Enclosed

Enclosed

10. Any Other Business

Date of next meeting: 21st June 2017, 11am – 1pm, Boardroom, Chelsea

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Council of Governors Boardroom, The Royal Marsden Hospital, Chelsea

Wednesday 7th December 2016 11am – 1pm

Minutes

Present:- Charles Alexander (Chairman) Governors as per attached attendance list In attendance Cally Palmer (Chief Executive) Ian Farmer (Non-Executive Director) Dr. Liz Bishop (Chief Operating Officer) Marcus Thorman (Chief Financial Officer) Sarah Rushbrooke (Deputy Chief Nurse) Dr. Nick van As (Medical Director) Steven Francis (Director of Performance & Information) Antonia Newman (Head of Capital Appeals) Item 3 only Sarah Clarke (Divisional Director for Cancer Services) Item 3 only Jon Spencer (Divisional Director for Clinical Services) Item 5 only Heather Spurgeon (RMMH project manager) Item 5 only Syma Dawson (Trust Secretary) (minutes)

MEETING BUSINESS

Apologies – as noted in the attached attendance list Welcome to New Governors The Chairman introduced himself to the Governors as it was his first Council of Governor meeting as Chairman of the Trust and noted that he looks forward to working with them.

1 Minutes of meeting held on the 22nd September 2016 The minutes of the meeting held on the 22nd September were approved as an accurate record.

2

Matters Arising: 2.1. Appointment of the Chief Nurse The Chief Executive reported that Eamonn Sullivan has been appointed as Chief Nurse of the Trust and will take up post on the 23rd January 2017. A summary of Eamonn’s background and work experience was noted. 2.2. Junior Doctors The Medical Director gave an update on the Junior Doctor contractual position, noting that the new contract is currently being implemented in a phased way and will come into effect for oncology registrars from August 2017. The Trust is currently working through the cost implications of the new contract and confirmed that this will not be cost neutral. The Medical Director reported that in line with national requirements, the Trust has appointed Dr Kate Newbold, Consultant for Clinical Oncology, as the Guardian of implementation and monitoring of the new junior doctor contract to ensure a safe working environment. The Chairman asked about morale among junior doctors to which the Medical Director responded that while this has been affected nationally due to contractual negotiations and industrial strike action, he feels that the Trust has maintained a good working relationship

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with its junior doctors through effective communication and regular engagement with them on this issue. The Council of Governors noted the relevant updates with regard to the appointment of the Chief Nurse and the position regarding the implementation of the new junior doctor contract.

3.

Sutton site developments Antonia Newman, Head of Capital Appeals, and Sarah Clarke, Divisional Director for Cancer Services, delivered a presentation on the following Sutton site developments:

i) The Centre for Clinical Research and Care (CCRC): the key drivers of success for the Centre were highlighted as well as progress made-to-date on the plans and development. The invaluable support from the Duke of Cambridge for the Centre was noted as well as that from the Trustees.

ii) Maggie’s Centre: it was noted that work on the Centre is due to start in the Summer 2017 and that funding arrangements were in place. The Chief Executive reported that the Trust is facing a planning issue regarding road access to the Maggie’s Centre. The Council of Governors discussed road access and car parking on the Hospital site and noted that all major developments include a specialist review of transport arrangements.

iii) Mobile Chemotherapy Unit: careful consideration has been given with regard to the

operational policy of the unit which includes feedback from patient representatives. The unit is expected to be delivered to the Sutton site in April 2017 where it will be based for 3 months, after which it will then visit other locations. It was also noted that The Royal Marsden Cancer Charity is providing day-to-day support through the provision of a driver of the bus / administrator of the service.

The Chairman thanked Antonia Newman and Sarah Clarke for their presentation on the Sutton site developments.

4

BRC Update The Chief Executive reported that the Trust has achieved renewal of its BRC grant for five years from April 2017 however the grant has been reduced by approximately 30% from that which was requested in the Trust bid. Therefore, the Trust must carefully review what it can and cannot deliver under the new grant. The Chief Executive added that the Trust will continue to deliver research across the 8 themes submitted in the Trust BRC bid, outcomes which will be supported by a review of research productivity and transformation of the research agenda and priorities for the Trust. Following a query raised by Governor Duncan Campbell regarding digital development, the Chief Executive explained that the Trust is working with key partners to leverage capability and innovation in this area. She also noted the commitment made by the Board of Directors which approved the IT Strategy outline business case. This programme of work is being led by the Trust’s Chief Clinical Information Officer, Dr Tim Wigmore. Governor Charmaine Griffiths informed the Council of Governors that the Trust’s commitment to the IT Strategy is aligned with that of the ICR which has also recently invested in this area. The Council of Governors noted the BRC Update.

5

The Royal Marsden MacMillan Helpline The Divisional Director for Clinical Services, Jon Spencer, introduced Heather Spurgeon, who is the project manager for The Royal Marsden MacMillan Hotline (RMMH) launch. He explained that this project arose from the work of the Trust’s Transformation Programme and offers patients a 24/7 helpline to direct them to the relevant services / leads to assist them with their queries. The partnership with MacMillan is for 18 months and all staff working on the helpline are RM employed and trained. Heather Spurgeon commented on the patient benefit already being gained from the helpline which patients have welcomed.

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Following a query raised by Governor Andrew Pearson about the recording of patient information, Heather Spurgeon confirmed that there is a triage system in place which ensures information is recorded appropriately in the patient record and shared with relevant departments and other organisations involved in the patient pathway e.g. A&E departments, although excluding GPs. Following a discussion about GP involvement, it was agreed that GPs should be informed and also that this project would be noted at relevant steering groups. Governor Lesley-Ann Gooden asked when patients were made aware of the helpline service. Jon Spencer responded that the information is being fed into all relevant patient information and communications and will also be coordinated with the research teams so that patients on clinical trials also benefit from the service. Following a query raised by Governor Robert Freeman regarding the use of CNS and monitoring systems in place, the Divisional Director for Clinical Services explained that the Trust has recruited three quarters of the posts at CNS level and that CNS’s are integrated with the team. Telephone calls are also being recorded for training and monitoring purposes as well as the use of relevant metrics from the triage system combined with feedback from staff and patients. It was emphasised by the Chief Operating Officer that the helpline is not a replacement service but rather an add-on to enhance and support the existing service. The Council of Governors noted the launch of The Royal Marsden MacMillan helpline and the positive feedback received so far from patients in response to this.

6

Governance & Regulatory 6.1. NED Terms of Office The Chairman presented the enclosed report which noted the terms of office for Non-Executive Directors. He added that business would be appropriately managed via the Nominations Committee who reports back to the Council of Governors with a recommendation regarding the re/appointment. It was noted that in line with Governance requirements, a search for a new NED to replace Richard Turnor would be undertaken towards the end of 2017 as Richard has served three full terms. The Council of Governors noted the table of succession planning enclosed in the report. 6.2. Trust Constitution The Trust Secretary reported on and recommended the following three amendments to the Trust Constitution: • The 11 Paediatric and Young Adult members are distributed amongst relevant patient

Governor constituency’s, • The 122 Clinical Support Staff members are transferred to the Corporate and Support

Services constituency and; • That the indemnity clause set out in the paper is inserted into the Trust Constitution

which was noted as a standard clause amongst other NHS Constitution’s. With regard to the insertion of the indemnity clause, the Chairman queried whether Trust insurance policy includes legal cost cover for Governors and Directors to which the Chief Executive confirmed was the case. The Council of Governors approved the proposed amendments to the Trust Constitution. 6.3. Single Oversight Framework The Chief Financial Officer (CFO) informed the Council of Governors of the new regulatory framework, the Single Oversight Framework (SOF), which replaces the former Risk Assessment Framework. He noted that NHS Improvement is the new name of the Trust regulator, replacing Monitor and the Trust Development Authority. The CFO reported that RM’s position under the SOF is in segment 2 of the 4 segments, where the lowest risk Trusts are 1 and the highest risk 4, due to the exclusion of

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reallocations in the 62 day cancer wait times. This is a national issue which is being looked into so that rellocations are included in the reporting of the 62 day cancer wait performance data. The Chief Executive agreed and emphasised the need to identify individual responsibilities in the system to accurately reflect performance in this area. The CFO assured the Council of Governors that the regulator is aware of the reasons for the position and understands that this is beyond the Trust’s control. Furthermore, the Trust has been informed that because of this issue it is placed at the top of segment 2 and on the borderline of segment 1. The Council of Governors noted the RM position in Segment 2 in the new Single Oversight Framework. 6.4. CQC The Chairman informed the Council of Governors that the summary sheet provided in their pack of papers is to be withdrawn and replaced by the following verbal report from the Chief Executive. The Chief Executive reported in confidence to the Governors on the Trust position following its CQC inspection which took place in April 2016. The Trust has responded to the CQC on points of factual accuracy, which the Chief Executive noted in her verbal report as well as her concerns with regard to some inconsistencies in the initial report. The Chief Executive also noted her concern with the fact that community services was inspected 19 days after its disaggregation process and therefore she has asked the CQC to re-inspect the service to ensure a proper and fair assessment of the service. The Council of Governors discussed the inspection and appeals process as well as the importance of ensuring an effective communications plan to staff and patients following the publication of the results. The Council of Governors agreed that irrespective of the CQC ratings, relevant communications to staff and patients should highlight the Trust’s excellent results from all external surveys and other assessments. The Council of Governors noted the verbal update provided by the Chief Executive.

7 Quality and Governance 7.1. Financial Performance Report The CFO presented the enclosed Financial Performance Report highlighting that there has been an adverse variance which has impacted on expenditure however he expects that this will recover by the end of the financial year subject to activity levels. The risks and issues noted in the report were highlighted with positive results showing in the agency and temporary staffing spend. The efficiency programme position was noted as well as the cash and debt position. Following a query from Governor Simon Spevack regarding expenditure on the IT Strategy and whether this has been included in financial planning, the CFO confirmed that the business case is currently being developed which may require external financial support. The CFO noted that Private Care debt from embassies is a slow payment process as opposed to a non-payment issue. NED Ian Farmer added that the Trust has sought letters of guarantee for assurance purposes to reduce and manage any risk to the Trust. The Council of Governors noted the Financial Performance Report. 7.2. Quality Accounts The Deputy Chief Nurse Sarah Rushbrooke highlighted the following:

• A reduction in attributable patient falls with 11% reduction since September 2015 • Venous Thromboembolism – requirement of the CQUIN target of >90%

compliance with risk assessment for VT

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• Friends and Family Test – excellent response rate with >900 responses each month, in-patients -95%, Outpatients 97% and Community 100% would recommend RM to family and friends, these results are well above the national average.

• Staffing levels remain consistently good. Areas for improvement:

• Pressure Ulcers: August 2016 - one category 4 and six category 3 pressure ulcers reported from community services, zero for both categories in hospitals. September 2016 – zero category 4 and one category 3 in hospital and three category 3 in community. However the overall yearly trend shows an improving picture for all categories.

• Attributable medication incidents - the near miss reporting has increased by 82% since the same period (2015/16) this is largely due to the development of the ‘near miss’ reporting Datix form, allowing quick and easy input of near miss incidents, alongside increased awareness and education amongst the teams of the importance of near miss reporting. This has resulted in a higher number of reports, however the number of incidents reported has increased but the harm reported has not.

The Council of Governors noted the Quality Account report. 7.3. KPIs Quarter 2 The Director of Performance and Information presented the Key Performance Indicators (KPIs) for Quarter 2. He highlighted those which were reported as red and explained the reasons why, which included the following:

• There has been an improvement in the number of red indicators since the previous quarter as although the number of red ratings is the same, three of these are new indicators;

• The research accrual target is largely affected by factors beyond the Trust’s control for example, sponsors closing studies early. There is also a new research metric relating to European patients which is now being monitored;

• 62 day performance (on reallocated position) was affected in quarter 2 due to an issue with gynaecology surgical capacity however this matter has now been resolved and performance is therefore expected to improve for quarter 3;

• New metric regarding contractual sanctions whereby the Trust is penalised if it misses targets however, as previously noted in the meeting, the regulators and commissioners are aware of the issues relating to 62 day cancer waits. On this basis commissioners have agreed to reinvest in the financial penalties in the Trust.

Following a query from Governor Simon Spevack regarding mortality statistics, the Director of Performance and Information explained that on the balanced board scorecard the Trust has set itself a high target for the Hospital Standardised Mortality Ratio, but mortality data is closely monitored and clinical audited on a quarterly basis and this process has shown there to be no concerns relating to the Trust’s mortality rate. The Council of Governors noted the KPI report for quarter 2.

9 Any Other Business

9.1. Fulham Road The Chief Executive informed the Council of Governors that there is no further update on the Fulham Road Wing following NHS England’s advice to the RBKC Council that this should remain in healthcare use. She reported that The Royal Brompton is currently reviewing its estate position and strategy, particularly in light of the national review currently being led by Sir Robert Naylor who is reviewing surplus estate in the NHS and how this should be utilised. The Trust has responded to the review to explain the important reasons as to why it must remain in Chelsea. The results of the review are expected to be published at the end of the financial year. 9.2. Private Care Diagnostic It was noted that the outline business case was approved by the Board of Directors and

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therefore the Trust is currently developing the business case. 9.3. Members Week Governor Carol Joseph informed the Council of Governors that the Governors will be holding a Members Week on the week commencing 13th March 2017. Governors are currently drafting a plan to recruit and engage with as many members as possible that week and all Governors are encouraged to participate in accordance with their statutory duty.

Date of next meeting: 22nd March 2017 11am – 1pm, Boardroom, Chelsea

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Council of Governors Attendance List 7 December 2016

Elected Governors

Constituency

Signature

Maggie Harkness Kensington & Chelsea and Sutton & Merton Apologies Armine Afrikian Kensington & Chelsea and Sutton & Merton Colin Peel Kensington & Chelsea and Sutton & Merton

Fiona Stewart Elsewhere in London Dr Peter Lewins Elsewhere in London Apologies Dr Andrew Pearson Elsewhere in England Simon Spevack Elsewhere in England

Lesley-Ann Gooden Carer Duncan Campbell Carer

Public Governors Dr Carol Joseph Kensington and Chelsea Tim Howlett Sutton & Merton Ann Curtis Elsewhere in England Bernadette Knight Elsewhere in England Staff Governors Hardev Sagoo Corporate Support Services Rachel Nabawanuka Clinical Professionals Apologies Dr Jayne Wood Doctor Maureen Carruthers Nurse Nominated Governors

Dr Charmaine Griffiths Institute of Cancer Research Robert Freeman Local Authority: Borough of Kensington &

Chelsea

Anne Croudass Cancer Research UK (Charity) Cllr Stephen Alambritis Local Authority: Boroughs of Sutton & Merton Apologies Dr Chris Elliot Clinical Commissioning Group Apologies Dr Philip Mackney Clinical Commissioning Group

Council of Governors Meeting

Attendance List 7 December 2016

Elected Governors

Constituency

Signature

Maggie Harkness Kensington & Chelsea and Sutton & Merton Apologies Armine Afrikian Kensington & Chelsea and Sutton & Merton Colin Peel Kensington & Chelsea and Sutton & Merton

Fiona Stewart Elsewhere in London Dr Peter Lewins Elsewhere in London Apologies Dr Andrew Pearson Elsewhere in England Simon Spevack Elsewhere in England

Lesley-Ann Gooden Carer Duncan Campbell Carer

Public Governors Dr Carol Joseph Kensington and Chelsea Tim Howlett Sutton & Merton Ann Curtis Elsewhere in England Bernadette Knight Elsewhere in England Staff Governors Hardev Sagoo Corporate Support Services Rachel Nabawanuka Clinical Professionals Apologies Vacant Clinical Support Staff - Dr Jayne Wood Doctor Maureen Carruthers Nurse Nominated Governors

Dr Charmaine Griffiths Institute of Cancer Research Robert Freeman Local Authority: Borough of Kensington &

Chelsea

Anne Croudass Cancer Research UK (Charity) Cllr Stephen Alambritis Local Authority: Boroughs of Sutton & Merton Apologies Dr Chris Elliot Clinical Commissioning Group Apologies Dr Philip Mackney Clinical Commissioning Group

COUNCIL OF GOVERNOR PAPER SUMMARY SHEET

Date of Meeting: 22nd March 2017

Agenda item 3

Title of Document:

Chief Executive’s Report

To be presented by

Chief Executive

Executive Summary The Chief Executive will provide a verbal report to the Council of Governors with regard to relevant matters including the South West London Sustainability and Transformation Plans (STPs). Recommendations The Council of Governors is asked to note and discuss the Chief Executive’s Report. Author: Chief Executive

Contact Number or E-mail: Ext2101

Date: 9th March 2017



Agenda item 4

Title of Document:

Care Quality Commission Report & Draft Action Plan

To be presented by

Chief Nurse

Executive Summary The Royal Marsden was inspected by the Care Quality Commission between 19 and 22 April 2016 and the final reports and ratings were published on 19 January 2017. We returned extensive commentary and evidence to the CQC about the factual accuracy of their assessment and ratings, following receipt of the draft report in October 2016. The final aggregated ratings across all 5 domains of safe, caring, effective, responsive and well led for the sites are as follows: Chelsea is “outstanding”; Sutton is “good” and Community Services “requires improvement”. We have displayed the findings within the hospital and on the RM website. We have responded to the CQC consultation (closed 14 February) on the new approach to inspections and continuous monitoring. Following all CQC inspections and publication of reports, the CQC call a 'Quality Summit' to present the report to local stakeholders, commissioners and scrutiny bodies. The Chairman, Senior Independent Director, a Governor representative and Executive Directors attend the Quality Summit, and respond to the report, discussing actions with the CQC and local Commissioners. The RM Quality Summit is scheduled for the 6th of April 2017. Recommendations The Council of Governors is asked to discuss the main findings in the draft action plan. The Council is asked to nominate a Governor to attend the CQC Quality Summit on 6 April 2017.

Author: Chief Nurse



This report describes our judgement of the quality of care at this trust. It is based on a combination of what we foundwhen we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from patients, thepublic and other organisations.

Ratings

Overall rating for this trust Good –––

Are services at this trust safe? Good –––

Are services at this trust effective? Good –––

Are services at this trust caring? Outstanding –

Are services at this trust responsive? Good –––

Are services at this trust well-led? Good –––

TheThe RRoyoyalal MarMarsdensden NHSNHSFFoundationoundation TTrustrustQuality Report

Fulham RoadChelseaLondonSW3 6JJTel: 020 7808 2101Website: www.royalmarsden.nhs.uk

Date of inspection visit: 19 - 22 April 2016Date of publication: This is auto-populated when thereport is published

1The Royal Marsden NHS Foundation Trust Quality Report This is auto-populated when the report is published

Letter from the Chief Inspector of Hospitals

The Royal Marsden NHS Foundation Trust is split over twoprincipal sites, in Chelsea and Sutton, and a day-case uniton the site of Kingston Hospital. As a specialist trust, theRoyal Marsden receives referrals from beyond theimmediate areas, including national and internationalreferrals. The trust also provides community healthcareservices at a range of sites throughout the LondonBorough of Sutton, to a population of approximately196,000.

We inspected the Royal Marsden NHS Foundation Trustas part of our specialist NHS inspection programme aswell as applying our NHS community health serviceinspection methodology also. We inspected the trustbetween 19 and 22 April 2016 as well as carrying outadditional visits following the announced inspection tocollect further information and to corroborate findings.

The Royal Marsden Community Services formed Suttonand Merton Community Services (SMCS) in 2011. Variouscommunity health services were provided in the LondonBoroughs of Sutton and Merton. From 1 April 2016 TheRoyal Marsden Community Services stopped providingservices to Merton and formed Sutton CommunityServices (SCS). Our reports in to community healthservices include data from the 12 month period leadingup to our inspection which was before the disaggregationof services and therefore contains some data relating toMerton. We have included separate data where it wasavailable. Our site visits during the inspection werelimited to Sutton only.

Overall, we have rated the trust as good. We rated it goodfor providing care which was safe, effective, responsive tothe needs of the population, and well-led. We rated thetrust outstanding for the caring domain.

Additionally, we rated the radiotherapy service asoutstanding across both hospital locations. This wasbecause the radiotherapy service was patient centred;care was provided in line with national standards, withradiotherapy services participating in national andinternational research programmes.

Our key findings were as follows:

• There were robust processes for staff to follow inrelation to incident reporting and investigation. Staffunderstood the importance of being open and honest,as per the duty of candour.

• Learning outcomes, arising from incidentinvestigations, were, in the main, shared with staff andapplied in practice. Improvements were requiredwithin the adult's community service to ensure thatlearning from incidents was shared across all teams.

• Staffing arrangements supported the delivery of safediagnostics, treatment and care within the hospitalsetting. However, staffing shortages within thecommunity nursing teams meant that the delivery ofend of life care fell to more experienced staff who hadattended relevant training, this meant that there waslimited staff available to deliver end of life care.

• Specialist staff did not feel they were always beingcontacted quickly enough to support the timelycommencement and delivery of end of life care forpatients both in the hospital setting and within thecommunity.

• The environment in which people received treatmentand care was clean and organised in a manner, whichidentified and responded to potential or actualinfection control risks.

• Medicines, including controlled drugs, andchemotherapy were safely prepared, managed andoptimised.

• In the majority of cases, vulnerable individuals wereidentified and protected under safeguarding practicesand through the application of the Mental Capacity Actand associated Deprivation of Liberty Safeguards.Improvements were required within the communityadult's services to ensure capacity assessments wereroutinely recorded. Staff working within communityadults services required further support in helpingthem to understand the concepts of the MentalCapacity Act.

• Staff were enabled to perform their duties through theprovision of professional standards and guidance.However, within community services, staff were notconsistently following best practice in their approachto wound assessments. This meant that changes towound presentation were less likely to be accuratelyrecorded and deterioration may not have been

Summary of findings


addressed as readily. Additionally, community staffwere not routinely following the quality standard fornutrition support in adults which required careservices to take responsibility for the identification ofpeople at risk of malnutrition and provide nutritionsupport for everyone who needed it.

• In the majority of care settings, treatment outcomesand other departmental audits enabled staff tomonitor the effectiveness of the services provided.

• Strong multidisciplinary team work across disciplinesfacilitated the delivery of effective services to people.

• A full range of diagnostic and technological equipmentwas available, and was used by appropriately trainedstaff to monitor and deliver treatment and care.

• Staff had the right qualifications, skills, knowledge andexperience to undertake their roles andresponsibilities. They had access to developmentaltraining and were supported by senior staff through arange of approaches.

• Staff had opportunities to receive feedback on theirperformance.

• People were treated with kindness, dignity, respectand compassion whilst they received care andtreatment from staff.

• Staff took into account and respected people’spersonal, cultural, social and religious needs.

• Staff were observed to take the time to interact withpeople who used the service and those close to themin a respectful and considerate manner. They showedan encouraging, sensitive and supportive attitudetowards people receiving treatment and care, as wellas those close to them.

• People who used the services and those close to themwere involved as partners in their care. Staffcommunicated with people so they understood theircare, treatment and condition. They recognised whenpeople needed additional information and support tohelp them understand and be involved in their careand treatment and facilitated access to this.

• People received appropriate and timely support andinformation to cope emotionally with their care,treatment or condition.

We saw several areas of outstanding practice including:

• Critical care staff worked with a specialist inaromatherapy massage as part of a trial to identify ifthis type of therapy would result in better sleep

patterns amongst patients. This trial was in progress atthe time of our inspection and aimed to find if non-pharmacological intervention could be an effectivealternative to support sleep to high doses of drugs.

• The Critical Care Unit’s (CCU) research programme waswell structured and there were multiple safety nets inplace for staff conducting this. The Committee forClinical Research had oversight of every project andonly approved them after a positive peer review andethics approval. The research profile wasinternationally recognised and staff represented theunit at the NHS National Institute of Health Researchand the National Critical Care Research Group. Seniorresearch staff worked academically and clinically,which meant they could ensure critical care projectswere conducted according to established multi-professional best practice.

• Staff in CCU prescribed patients who were consideredhigh-risk for complications a pre-rehabilitationprogramme before they underwent surgery. Aphysiotherapist led this programme and providedpatients with an exercise regime and diary. This helpedthem to prepare for rehabilitation and to support theirhealth to improve their condition after surgery.

• The environmental adaptations in the Chelsea CCUdemonstrated exemplary focus on individual care andattention to detail. This included adaptedenvironments for patients with dementia, bariatricpatients and teenagers.

• Senior staff actively promoted staff welfare and hadprovided tai chi, complementary therapies andmeditation sessions to promote wellbeing andrelaxation.

• The Marsden is the only NHS hospital to have theupdated version of the da Vinci Xi surgical robot. Thisless invasive surgery allowed improved patientrecovery. The 10 year fellowship programme meantthat 30 surgeons would be trained by the trust tooperate the robot.

• There was an extensive range of information, includingfilms for patients, which provided detailed support.

• The trust had direct access to electronic informationheld by community services, including GPs. Thismeant that hospital staff could access up-to-dateinformation about patients, for example, details oftheir current medicine.

Summary of findings


• Staff demonstrated high care, arranging patienttransportation and accommodation for those that didnot live near to the hospital.

• The investment by the trust ensured that staff weredeveloped and highly trained. Many staff had studiedfor master degrees and specialist courses in cancer.

• Research, ongoing quality improvement projects andauditing were of a high level and drove the qualityimprovement agenda.

• Nursing and therapy staff had the commitment andtime to provide person-centred care that often wentthe ‘extra mile’

• The introduction of ambulatory care had managed toreduce patient bed stays and improve patientexperience.

• The end of life supportive care home team (SCHT) wasa part of a Sutton CCG (clinical commissioning group)vanguard relating to improving end of life care in careand nursing homes. Members of the SCHT wereinvolved in developing the service and had beeninvited to speak about the model and share thisdevelopment with other services. The end of lifesupportive care home team (SCHT) was a part of aSutton CCG (clinical commissioning group) vanguardrelating to improving end of life care in care andnursing homes.

However, there were also areas of practice where thetrust needs to make improvements.

Importantly, the trust must:

• Implement and embed the World Health OrganisationSafety Checklist in the outpatients department.

• When patients (aged 16 and over) are unable to giveconsent because they lack the capacity to do so, thetrust should ensure staff act in accordance with theMental Capacity Act 2005.

• Ensure that records contain accurate information inrespect of each patient and include appropriateinformation in relation to the treatment and careprovided, particularly with regard to risk assessments.

• The provider should take action to understand theshortfalls in recording of risk assessments andindividualised care plans in the integrated communityteams.

• Review the staff compliment for community adultservices to ensure there are sufficient numbers ofappropriately skilled staff to meet patient’s needs.

• The provider should strengthen the reporting on theassurance of effectiveness of governancearrangements to the trust board; this specificallyrelates to community services.

Professor Sir Mike RichardsChief Inspector of Hospitals

Summary of findings


Background to The Royal Marsden NHS Foundation Trust

Sites and locations:The trust has two principal sites: The Royal MarsdenChelsea and The Royal Marsden Sutton.

Additionally, the trust provides community servicesthroughout the London Borough of Sutton to apopulation of approximately 196,000.

In total, the trust has 212 beds; 196 beds are allocated forgeneral and acute care and 16 are dedicated to theprovision of critical care services. The trust employs 4,203staff, of which 402 are medical, 1,255 nursing, 1,203 "otherclinical" and 1,342 "other non-clinical".

ActivityDuring 2014/2015, the trust recorded 9,842 inpatientadmissions and 190,117 outpatient attendances. Withincommunity health services, the trust carried out a total of510,693 community attendances between July 2014 andDecember 2015, with community nursing accounting forthe largest share of attendances (37%).

The trust ceased providing community health serviceswithin the London Borough of Merton as of 31 March2016.

Our inspection team

Our inspection team was led by:

Chair: Robert Aitken

Head of Hospital Inspection: Nick Mulholland

The team included CQC inspectors and a variety ofspecialists with the following expertise: Consultants inClinical Oncology, Palliative medicine, Anaesthetics, and

Critical care. We also had expertise from nurses withexperience in end of life care and oncology; a ConsultantGeneral Surgeon; a Medical Director; Director of Nursingand Operations; Radiology and Radiography and aclinical Psychologist. We had one expert by experienceassisting us and analytical support.

How we carried out this inspection

To understand patients' experiences of care, we alwaysask the following questions:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people's needs?

• Is it well-led?

Our inspection was announced in advance to the trust. Aspart of the preparation and planning stage the trustprovided us with a range of information, which wasreviewed by our analytics team and inspectors.

We requested and received information from externalstakeholders including, Monitor, The General Medical

Council, The Nursing and Midwifery Council, The RoyalCollege of Nursing, and The Royal College ofAnaesthetists. We received information from NHSEngland Quality Surveillance Team, NHS EnglandSpecialised Commissioning and Health EducationEngland. Local clinical commissioning groups also sharedinformation with us.

We considered in full information submitted to the CQCfrom members of the public, including notifications ofconcern and safeguarding matters. Members of thepublic spoke with us at our open days held at the trust on11 April 2016.

We held focus group discussions with separate groups ofstaff during the week commencing 4 April 2016.Participants included; allied health professional,administration and clerical staff, band 5 and 6 nurses,

Summary of findings


senior sisters and charge nurses, matrons and clinicalnurse specialists. Focus group discussions were held withconsultants, junior doctors and members of staff atdifferent grades from black and ethnic minorities duringthe inspection week. Our announced inspection visit tookplace over the 19 -22 April 2016. We also undertook afurther announced visit on 6 May 2016 to the Sutton siteand 18 May 2016 to the critical care unit located at theChelsea site.

During our inspection we spoke with 155 patients andrelatives/friends, who provided feedback on theirexperiences of using the hospital services. We looked atover 50 patient records where it was necessary to support

information provided to us. Whilst on site we interviewedmore than 400 staff, which included senior and other staffwho had responsibilities for the front line service areaswe inspected, as well as those who supported behind thescene services, and volunteers. We requested additionaldocumentation in support of information provided whereit had not previously been submitted. Additionally, wereviewed information on the trust's intranet andinformation displayed in various areas of the hospital.

We made observations of staff interactions with eachother and with patients and other people using theservice. The environment and the provision and access toequipment was assessed.

Facts and data about this trust

The trust provides a specialist tertiary service for patientsdiagnosed with cancer. The Royal Marsden treats localpatients and patients referred from other parts ofEngland for treatment, patients participating in clinicaltrials and private patients.

The trust provides a full range of diagnostic andtreatment services, including surgery, services forchildren and young people, chemotherapy, radiotherapy,haematology and bone-marrow transplant services, endof life care and outpatients and diagnostics.

The London Borough of Sutton is in south west Londonand forms part of outer London. It has a population of191,123. The proportion of both younger people aged0-19 years and those aged 35-44 years is higher in Suttoncompared to the national profile, while the birth rate andthe population of young children (0-4 year old) is lowercompared to London or England. In 2011 79% of peopleliving in Sutton were of white ethnicity. This is lower thanEngland (85%) and higher than London (60%).Deprivation: At borough level Sutton ranks 196 out of 326boroughs (where 1 is the most deprived and 326 is theleast deprived).

The health of people in Sutton is generally better than theEngland average. It has some of the lowest avoidablemortality rates (people dying before the age of 75 years)compared to London and England. cancer remains thebiggest single cause of death in those under 75 yearolds, and the proportion of cancer deaths has increased

over the last five years. Over the same time, theproportion of deaths from circulatory disease reducedand there was a small decrease in deaths from respiratoryconditions.

According to Public Health England June 2015 figures, thehealth of people in the boroughs of Kensington andChelsea is varied, when compared with the Englandaverage. Whilst life expectancy for both men and womenis higher than the England average. In the most deprivedareas, life expectancy is 14.3 years lower for men and 4.3years lower for women. Deprivation is higher thanaverage, and there are about 21% (4,100) children livingin poverty.

Safe

• Between January 2015 and February 2016 25 seriousincidents were reported by the trust. Of these 20 wererelated to pressure ulcers. 16 cases or pressure ulcerswere attributable to community health services, ofwhich 10 were recorded as grade 3 ulcers and 6 wererecorded as grade 4. During this time period, sevenincidents occurred within Merton community healthservices; as of 31 March 2016, the trust ceasedproviding community health services within theLondon Borough of Merton.

• For the same period 3,454 incidents were reported toNRLS which was higher than the England average. Ofthese only one caused severe harm or death to thepatient.

Summary of findings


• The trust reported 795 NRLS incidents occurring in thecommunity setting between February 2014 andJanuary 2016. The majority of these incidents wereclassified as low harm. Eight incidents involved abuseor allegations of abuse.

• In 2015 25 pressure ulcers, 11 falls with harm and sixcatheter urinary tract infections were reported.

• There were 42 cases of Clostridium difficile reported inthe trust between January 2015 and January 2016.

• There were no reported cases of Meticillin ResistantStaphylococcus Aureus in the same period.

• The trust reported 11 cases of Meticillin SensitiveStaphylococcus Aureus between January 2015 andJanuary 2016.

• The trust employs proportionally more registrar staffthan England average, and a smaller share of juniordoctors.

Effective

• In the 2015 Bowel Cancer Audit the trust performedbetter than London Cancer Alliance and Englandaverage for data completeness and readmission rates,but has a higher mortality rate.

• In the 2015 Prostate Cancer Audit the trust performedbetter than England average for most screeningcompletion rates.

• The trust performed better than the England averagein eight out of ten measures on the UK RadiotherapyEquipment Survey 2013.

• No evidence of risks or mortality outliers wereidentified for any of the mortality indicators.

Caring

• Family and friends test scores for the trust were greaterthan or similar to the England average for January–December 2015. The scores ranged from 95 – 95.5%.

• In the 2013/14 cancer patient survey the trust scorewas in the top 20% of trusts for 9 of indicators (bottom20% for four indicators and in the middle 60% forremaining questions).

• The hospital scored better than the England averagefor three of the four domains in the Patient ledAssessment of the Care Environment (PLACE). It scoredjust below the England average for privacy and dignityand well-being.

• From the 2015 CQC inpatient survey the trust scoredbetter than other trusts for all of the questions.

Responsive

• The trust received 118 complaints in 2015 of which 117had since been closed. The percentage of complaintsreopened was 8%.

• The bed occupancy has been below the nationalaverage since quarter 2 2014/15.

• From February 2015 – January 2016 referral totreatment times have been above the national averagefor outpatients receiving consultant led treatment.

• Between September 2015 – December 2015 98.3% ofpatients with suspected breast cancer were seen intwo weeks by a specialist following referral by their GP.The figures for blood malignancies includingleukaemia were 100%, 93% for head and neck cancer,100% for upper gastrointestinal, 93% for sarcoma, 96%for urological cancers (not including testicular).

• There were 188 delayed transfer of care in the trust(number of delayed bed days, Jan’15 – Dec’15). Themajority of these (55) were waiting further NHS non-acute care, whilst 52 were awaiting care packages tobe provided in their own home. Patient or familychoice accounted for 48 delayed transfers of carewhilst 28 were awaiting a nursing home placement oravailability. The remaining five were awaiting referralcompletion or equipment.

Well-led

• NHS Staff Survey 2015 reported 19 positive findingsand one negative. The latter related to staff workingadditional hours over and above their expected hours.The trust score was 78.3%, with an England average of73%.

• The trust reported sickness absence rates which wereconsistently lower (better) than the England averagebetween June 2012 and September 2015.

• The trust performed worse than expected for threemeasures on the GMC Training Scheme (2015). Theywere below outlier for having a supportiveenvironment, and receiving feedback. With regard todoctors in training induction, the trust was within thelower quartile. The remainder of measures were withinexpectations.

Summary of findings


Our judgements about each of our five key questions

Rating

Are services at this trust safe?We rated the trust as good for ensuring that patients were protectedfrom the risk of harm because:

• There were systems in place for incident reporting and in themajority of cases, staff received feedback. Action was taken toreduce the risk of reoccurrence.

• The requirements of duty of candour were followed and trustprocesses were open and transparent.

• There were appropriate policies and procedures in place tosupport staff in recognising and reporting signs of abuse.

• When staffing levels fell below planned levels this wasproactively managed in the majority of cases. The trustacknowledged and was responding to an increasing nursevacancy rate within community services.

Duty of candour

• The trust was aware of its obligations in relation to the duty ofcandour requirements.

• There was a policy in place to guide and support staff infollowing the requirements of the duty of candour regulations.Staff were aware of the "Being Open and Duty of Candour"policy and were able to signpost inspectors to the relevantpolicy.

• Incident records reviewed during the inspection clearlyindicated where staff had followed the necessary guidance,including records to affirm any initial discussions with thepatient or relevant persons, any advice or support offered andconfirmation of a written apology being provided to the patient,as well as any supporting information including investigationoutcomes.

• The trust utilised the incident reporting management system torecord and monitor any notifiable safety incidents which invokethe duty of candour regulations. We observed examples of thisin practice.

• Reference to the requirements of the duty of candour wasmade in the quarterly integrated governance monitoring reportwhich was publicly available.

• The trust audited compliance with the requirements of the dutyof candour regulations and local "Being open and Duty ofCandour" policy. Between 1 July and 31 December 2015, 45incidents that resulted in moderate harm or above were

Good –––

Summary of findings


reviewed as part of the most recent audit. Results werecompared with those from the previous audit from January toJune 2015. Improvement included an increase in recording thenumber of patients being informed of an incident from 85% to93%.

• There had been an increase in the number of patients offered awritten apology from 38% between January and June 2015 to88% between July and December 2015.

Safeguarding

• The chief nurse was the executive lead for safeguarding. Allsafeguarding and vulnerable adults' activity was overseen bythe vulnerable adult working group.

• Staff were able to describe situations in which they would raisea safeguarding concern and how they would escalate anyconcerns.

• The trust had appropriate safeguarding policies andprocedures were in place for both adult and children. Thepolicies and procedures were supported by staff training.

• Oversight of trust-wide safeguarding arrangements was by wayof regular quarterly reports to the integrated governancecommittee. Section 7 of the integrated governance monitoringreport clearly set out the number of safeguarding concernsraised within the trust including summative information on thecategory of abuse. The majority of safeguarding concernsrelated to the pressure ulcers. Twice monthly pressure ulcerreview panels existed to review complex cases where pressureulcers were attributable to the trust.

• As of March 2016, 93% of staff had received training in level 1adult safeguarding and 95% in level 2 adult safeguarding.

• 89% of staff had received level 1 child safeguarding training;88% level 2 training and 83% of applicable staff had receivedlevel 3 child safeguarding training. The training compliancerates for each level of child safeguarding was marginally lowerthan the trust target of 90% for 2015/2016.

• During 2015/2016, 57% of school nurses and 75% of healthvisiting staff had received one to one supervision. The trustacknowledged a number of contributing factors in regards tothe lower than expected supervision rates including significantorganisational change due to the re-commissioning of Mertoncommunity health services to a third party; long term sick leaveof staff members and sick leave of supervisors.

Summary of findings


Incidents

• Between July 2014 and June 2015, the trust reported 3,454incidents to the national reporting and learning system (NRLS).1,962 incidents resulted in no harm; 1,365 resulted in low harm;101 resulted in moderate harm and 1 resulted in severe harm ordeath.

• The trust reported more incidents per 100 admissions whencompared nationally (11.1 incidents per 100 admissions versus8.4 nationally). This may be an indicator of a positive incidentreporting culture within the organisation, especially whenfactoring in the number of no harm incidents reported.

• The trust had reported no never events between February 2015and January 2016.

• Between January 2015 and February 2016 25 serious incidentswere reported by the trust. Of these 20 were related to pressureulcers. 16 cases or pressure ulcers were attributable tocommunity health services, of which 10 were recorded as grade3 ulcers and 6 were recorded as grade 4. During this timeperiod, seven incidents occurred within Merton communityhealth services; as of 31 March 2016, the trust ceased providingcommunity health services within the London Borough ofMerton.

• In the 2015 NHS staff survey, the trust was rated in the top 20%of all NHS trusts for:▪ Percentage of staff witnessing potentially harmful errors,

near misses or incidents in the last month▪ Percentage of staff reporting fairness and effectiveness of

procedures for reporting errors, near misses and incidents.▪ Percentage of staff reporting a high level of confidence and

security in the reporting of unsafe clinical practice.• The trust was rated about the same as other trusts in the 2015

NHS staff survey for the key question:▪ Percentage of staff reporting errors, near misses or incidents

witnessed in the last month.

Staffing

• The trust reported staff vacancy rates on a quarterly basiswithin the integrated governance monitoring report. The trusttarget for staff vacancy was set at 5%. The total trust vacancyrate for quarter 4 of 2015/2016 was 6.3%; this was an improvingtrajectory when compared to quarter 2 and quarter 3performance.

• Community services consistently flagged as a rag rating of redfor staff vacancy with quarter 4 reporting a turnover rate of16.5%. It was noted that staff vacancy within community

Summary of findings

10 The Royal Marsden NHS Foundation Trust Quality Report This is auto-populated when the report is published

services was increasing, having been 10.2% in quarter 1 of2015/2016. The executive team attributed to the high vacancyrate in part to the dis-aggregation and transfer of somecommunity services to a third party at the end of March 2016.

• The overall nurse vacancy rate as at the end of quarter 4 for2016/2017 was 11.7% with the highest vacancy rate notedwithin community nursing services at 20.6%. Nurse vacancyrates for a part of the community services risk register. Staffwere seen to be proactively prioritising community patients toensure that those with the most complex needs were seen firstand by the most experienced members of staff.

• The GMC staff survey for 2015 identified the trust as beingwithin the middle quartile for workload.

• In the 2015 NHS staff survey the trust performed in the top 20%for the following percentage of staff feeling pressured in the last3 months to attend work when feeling unwell.

• The trust performed about the same as other trusts in the 2015NHS staff survey for the percentage of staff reporting workrelated stress in the last 12 months.

• The trust performed in the bottom 20% of trusts in relation tothe percentage of staff working extra hours. The majority of staffworking within adult community services reported that theywould rather work additional time to ensure that patients wereseen and treated within expected time frames; this wasacknowledged by the community management team.

Are services at this trust effective?Evidence based care and treatment

• Staff were aware of National Institute for Health and CareExcellence (NICE) guidance relevant to their specialty and wesaw they had access to the guidance via the trust’s intranet.

• Local protocols were in place in line with NICE guidance. Inparticular we found there were well written protocols andpathways for use in many services which were followed by staff.

• Integrated care pathways were also used to ensure adherenceto national guidance.

• Many clinical specialities were responsible for and engaged inthe development of national and international clinicalstandards.

• The trust was a founding member of the London CancerAlliance, an integrated cancer system working across South andWest London. The LCA was clinically led and was responsiblefor setting clinical standards and for establishing care pathwaysto ensure patients received evidence based care and treatment.

Good –––

Summary of findings


• Robust procedures existed for ensuring that existing guidanceand clinical protocols were updated routinely to reflect currentbest practice. For example, the Integrated Governance and RiskManagement Committee considered 40 items of guidancepublished by the National Institute for Care and HealthExcellence to determine whether they were relevant to theprovision of care at The Royal Marsden NHS Foundation Trust;12 guidance documents were considered relevant.

• Where national alerts were issued, there were procedures inplace to ensure trust policies were updated. For example, staffinvolved with intrathecal chemotherapy had to use the trustpolicy in conjunction with the national guidance HSC 2008/001and the rapid Response Report NPSA/2008/RRR004 relating tointravenous vinca-alkaloid administration.

• The trust had an established and accredited research trialsprogramme and worked in partnership with national partnersincluding the Institute of Cancer Research which was co-located at the Royal Marsden Sutton campus.

• At the time of the inspection, the trust was leading on 33 clinicaltrials to develop best practice for radiology. In addition, thetrust was leading the cancer element for 100,000 Genomesproject.

• Where care or treatment was recommended by clinical teamswhich deviated from standard care protocols, staff wererequired to complete deviation forms; this was especiallyapplicable to patients receiving care under the haematopoieticstem cell transplant unit (HSCT) which was accredited with theJoint Accreditation Committee of the International Society forCellular Therapy and the European Group for Blood andMarrow Transplantation (JACIE). The HSCT service was firstJACIE accredited in 2009, and had last undergone a re-accreditation inspection in October 2013. At the time of theinspection, the service was undertaking a document review toensure the trust was compliant with the latest JACIE qualitystandards.

• In response to the withdrawal of the Liverpool Care Pathway,the trust had piloted a new end of life care document"Principles of Care of the Dying" which was based on the "OneChance to get it Right, 2014" care standards. Subsequent to theintroduction of the new care document, the trust had reportedimprovements in regards to discussion regarding hydration,preferred place of care and preferred place of death. Thedocumentation of spiritual needs had improved from 43% to100% since the document had been introduced. There were

Summary of findings


concerns however that patients could sometimes experiencedelays in being referred for end of life care support because of acuring culture within the organisation which was appropriate inall cases.

• Many policies were based on the Royal Marsden HospitalManual of Clinical Nursing Procedures, 2015.

• The trust utilised audit processes for ensuring compliance withpolicies and procedures. It was noted that performance andcompliance against the Sepsis Six care bundle had improvedsignificantly between quarter 2 2015/2016 and quarter 4 2015/2016. The checking of lactate had increased from 41% in Q2 to78% in Q4; antibiotic delivery within an hour had also increasedfrom 41% in Q2 to 94% in Q4.

Patient outcomes

• There were no active CQC mortality outliers for the trust.• The chemotherapy service held an ISO9001:2008 quality

accreditation and was assessed by an external auditor from theBritish Standards Institute (BSI) twice a year. The ISOchemotherapy committee had monitored and discussedwaiting times.

• The radiotherapy quality management system had beenaccredited by the British Standards Institute since 1997 and wasre-accredited for a further three years in March 2015. As part ofthe radiotherapy ISO 9001:2008 certification a programme ofinternal audits needed to be completed, along with auditreports.

• Endoscopy services had attained accreditation with the JointAdvisory Group (JAG) in 2015.

• Research facilities including the Phase 1 clinical trials unit wasregistered with the Medicines and Healthcare productsRegulatory Authority (MHRA) and had last been assessed forcompliance shortly prior to this inspection.

• Children's services were Unicef friendly baby accredited to level3.

• The trust was working on attaining accreditation with theImaging Services Accreditation Scheme (ISAS) for its imagingand radiology services.

• The Stem Cell Transplant Facility was licensed by the HumanTissue Authority.

• With the Royal Marsden method of analysis, chemotherapy wasstarted by 1,281 patients in Quarter Four (January to March2016). Of these patients, 78 (5.7%) died in the 30 days afterreceiving chemotherapy. Over the eight-year monitoring periodthere has been a 2% decrease in the number of patients dyingin the 30-day period.

Summary of findings


• Fifty-three stem cell transplants took place in Quarter Three(October to December 2015). No patients died in the 100 daysfollowing transplant.

• Of the 2,564 patients who had surgery or anaesthesia in QuarterFour (January to March 2016) eight (0.4%) died in the 30 daysfollowing surgery or anaesthesia.

• An audit conducted between October and December 2015, thetrust found 43 of the 51 (84%) patients who died were referredto and seen by the specialist team before their death. However,of these 43, only 8 (16%) patients were referred to the specialistteam more than one month before death. There was a feelingamongst many staff that we spoke to that referral to the teamcould be made earlier in the patient pathway in some cases.Staff were of the opinion that this was due to the specialistnature of the hospital and the type of treatments offered, whichoften were the last line of treatment available. Patientexpectations were focused on cure and conversations aboutdying could be difficult to instigate. This had been identified asan area for improvement by the trust and an improvementwork stream was scheduled to commence shortly following theinspection.

• Patient mortality was significantly lower than the nationalaverage of 3.5%, at less than 0.5%. For patients withhaematological malignancies, the average mortality rate was34% compared with the national average of 43%.

• The critical care unit contributed to the Intensive Care NationalAudit Research Centre (ICNARC), which meant the outcomes ofcare delivered and patient mortality could be benchmarkedagainst critical care units nationwide. The latest published dataat the time of our inspection related to patients in the unit up toSeptember 2015. Between September 2014 and September2015 less than 2% of patients were readmitted within 48 hours,which was better than the national average.

• Staff contributed to the EuroQol Research Foundation EQ-5Dhealth questionnaire that measured patient outcomes aftermedical treatment. After three months and use of the follow-upclinic, 72% of patients reported an overall good quality of life.

• Within community services, staff did not consistently useoutcome measures to monitor and outcome a patient’sprogress; for example, key outcome measures such as theBraden Assessment of pressure ulcer risk and nutrition scoring.

Multi-disciplinary working

• There were excellent examples of multi-disciplinary working tosecure good outcomes. For critical care services, a dailymultidisciplinary ward round took place each morning. This

Summary of findings


was attended by critical care clinicians, physiotherapists, adietitian, a pharmacist and a speech and language therapist.The daily ward round was supplemented by a substantiveweekly meeting, which included the Sutton site by video-link.The acute oncology service, palliative care team, microbiologistand occupational therapist additionally contributed to thismeeting.

• A critical care multidisciplinary team led a weekly rehabilitationward round, including physiotherapists, occupationaltherapists, a pharmacist, a dietitian and a massage therapist. Aclinical psychologist was dedicated to critical care and couldjoin this ward round when needed.

• Members of the specialist end of life care team participated inmultidisciplinary team (MDT) meetings and worked with otherspecialists to provide good quality EoLC across clinicalspecialities. A weekly specialist MDT meeting was held at thehospital. Members of the MDT included consultants, doctors,clinical nurse specialists, discharge co-ordinator,physiotherapists, occupational therapists and a chaplain.

• There was a strong culture of multidisciplinary working withinthe chemotherapy service. Multidisciplinary teams (MDTs),based on tumour types, decided patient eligibility for systemictherapies (chemotherapy). All new patients were assessed in anMDT. Case review meetings were also held.

• There were separate MDTs for patients with cancers of unknownorigin in line with NICE guideline CG104(February 2014).

• We attended some MDTs. Attendance was monitored andrecorded to ensure meetings were quorate. Videoconferencingwas used with the trust’s Sutton hospital. Investigations weredecided and outcomes were recorded live. Although there wasgood multidisciplinary attendance (Pathologists, Clinical NurseSpecialists, Consultants and Junior Doctors), in those weobserved there was not always a clear MDT lead, and manyattendees did not actively participate in discussion.

• Clinical pharmacists were well integrated into themultidisciplinary team that facilitated effective and efficientdelivery of care and design of treatment pathways, for example:they led in design of clinical trials and treatment protocols,pharmacy research and the medicines safety agenda in theTrust.

Consent, Mental Capacity Act and Deprivation of LibertySafeguards

• Staff explained procedures for gaining consent from patientsbefore providing care and treatment.

Summary of findings


• The trust had a policy in place that detailed the procedures forobtaining consent. This included the process for obtainingconsent, recording and responsibilities.

• Clinical staff had a good understanding of mental capacityissues and were able to describe the process they followed toassess a patient's capacity to make decisions or to be involvedin decisions.

• A wide range of regimen specific consent forms clearly listedthe potential risks and their likelihood for each treatmentregimen. For example, the information explained that 10 in 100patients might experience a specific side effect but that otherside effects might only be experienced by one patient in 1000.The consent forms also listed rarer side effects and toxicities.Staff gave all patients a copy of their signed consent forms andscanned these into patient records.

• There were separate arrangements for asking patient’s consentfor storing tissue samples and for research and clinical trials, forexample of new and approved types of chemotherapy. Thesewere governed by the trust ethics committee.

• Community nursing managers told us they each had over 300allocated cases per team and some patients would have healthconditions that meant they might have fluctuating capacity orbe unable to consent. Over 50% of staff we spoke with said theyhad never completed the trusts best interest paperworkbecause there was no need. One told us it could not becompleted online and they had to print a copy and complete itmanually which all took time. Several staff did not know whereto find the form and said they never used it.

• Staff said they would consult other family members ifconcerned and do what was in the best interest for the patient.They told us they did not record them as best interest decisionson trust paperwork or record them on the electronic patientrecord.

• Discussion at the vulnerable adults working group (December2015) highlighted similar issues and confirmed what staff toldus. For example: “staff have anxiety over MCA (Mental CapacityAct) they escalate to the GP when it’s a best interest as it is verydifficult and also takes a long time to assess and theCommunity Nurses are very stretched and don’t have the time”.Whilst it had been noted in the minutes there was no actionplan in place and it was not on the community risk register.

• We looked at the patient electronic record (PER) of 13 patientsreceiving community based care. 70% did not have consent forcare recorded. Three records had identified a preference as towho information could be shared with. Staff told us consent tocare information would be written on the patients paper

Summary of findings


records in their own home. We looked at eight paper records inpatients own home. Consent had not been signed by patientsin six out of eight records. Trust policy on consent stated thatpatients must give consent to treatment and this must berecorded on their records.

Are services at this trust caring?We rated caring as outstanding because:

• Feedback from patients and their relatives was consistentlypositive about all aspects of their care. All staff consistentlycommunicated with patients in a kind and compassionate wayand treated them with dignity and respected their privacy.

• We observed and were told of many examples of staff at alllevels going the extra mile to meet patients' needs.

• We observed a commitment to providing care that was of aconsistently high standard and focused on meeting theemotional, spiritual and psychological needs of patients as wellas their physical needs.

• Staff were committed to placing the patient at the centre oftheir work; this person-centred culture was visible across thetrust.

• Staff went out of their way to ensure the atmosphere within thetrust was one which promoted calm and reassurance.

Compassionate care

• In the Cancer Patient Experience Survey 2013/14 the trust wasin the top 20% of trusts for nine out of 34 indicators, bottom20% in four questions and the middle 60% for the other 21measures.

• The trust ranked among the best for eight questions and "aboutthe same" for the remaining four areas.

• Patient-led assessments of the Care Environment (PLACE) werebetter or equal to the England average for all domains atChelsea and for three of four domains for Sutton.

• The trust’s response rate and scores to Friends and Family Test(FFT) was consistently above the England Average betweenJanuary and December 2015.

• In Q4 2015/2016, 337 letters of praise were received by the Headof Legal Services, Complaints, Patient Advice and LiaisonService (PALS) and Patient Information.

• In a 2015 LCA survey, 156 patients (100%) rated their care asexcellent or very good across both radiology departments.

Outstanding –

Summary of findings


• In the LCA experience study across both radiology departments,88% of patients questioned said their dignity and privacy wasmaintained when they were getting changed in the treatmentroom. This was the highest percentage across the fourproviders surveyed.

• Clinical staff followed the Sage and Thyme model, developed in2006. The model was designed to show staff of all grades, howto listen and respond to patients who are distressed andconcerned.

Understanding and involvement of patients and those close tothem

• Patients receiving end of life care had the opportunity todiscuss their wishes for their future in terms of resuscitation,preferred place of death at end of life and decisions to refusetreatment.

• Patients reported staff going out of their way to find outinformation for them; explaining everything clearly, listeningand answering questions. They said they were fully involved indecisions about their care and treatment and knew how toaccess advice and, if necessary, emergency care.

• Patients we spoke with told us they were given adequateinformation about the part of the radiotherapy pathway thatapplied to them. In the LCA survey, 98% of patients said theinformation given on the first day was excellent across bothdepartments.

Emotional support

• Counselling support was available for all patients and offered atpre-assessment and throughout the patient’s treatment. Staffat pre-assessment, set aside time for discussion of patientsemotional needs. Psychological care and counselling serviceswere available however this was a service, which was undersignificant pressure due to limited staff numbers. If patientsbecame upset during pre-assessment appointments, thePsychological Support Team was able to respond.

• A chaplaincy service and multi faith prayer rooms wereavailable for patients and relatives 365 days a year. Patient’spastoral needs were responded to quickly.

• Supportive therapies were available for patients. Someexamples included acupuncture, art therapy, wig and hair lossadvice, massages, reflexology and yoga. Usual referral for theseservices was through the outpatient department.

Summary of findings


• Support groups were offered and information was given topatients. Groups such as living well after surgery withoesophageal and gastric cancer, the sarcoma support groupand pre-transplant relatives coffee morning were available topatients and relatives.

Are services at this trust responsive?Service planning and delivery to meet the needs of the localpeople

• The Royal Marsden NHS Foundation Trust was a registeredVanguard provider. Vanguard providers will take a lead on thedevelopment of new care models which will act as theblueprints for the NHS. The NHS England vision for vanguardsites such as this is that they will make health services moreaccessible and more effective for patients, improving both theirexperiences and their outcomes.

• The strategic plan for the trust included the development ofnew models of care including RM@ franchise operations andthe development of hospital chains or networks, led by theRoyal Marsden. In addition, the trust reported that as part of theVanguard initiative, a system wide redesign of whole patientpathways would be considered in order that care could bemore localised where possible to ease access for patients but tocentralise services where necessary to improve quality andvalue for money.

• The executive team acknowledged the opportunities that beinga combined health provider brings. The executive team spokeof the opportunities to develop integrated models of careacross acute, community and home care provision to helpimprove both efficiency and patient experience.

• The trust acknowledged the need to increase existing capacityat the Chelsea site in order to accommodate current and futuredemand for services which was partly linked to a decision tomodernise services across the trust, resulting in a reduction ofbed stock by some 30%. The trust further acknowledged theneed to modernise both the inpatient and outpatient facilitieson the Sutton campus which had already commenced withsome £140 million of capital funding secured to improve theinfrastructure and redevelopment of the campus through the"Sutton for Life" initiative.

• The integrated community teams offered a range of servicesdedicated to treating patients needs that included preventionof admission and the Crisis intensive discharge service as part

Good –––

Summary of findings


of the “unplanned” care pathway. The services were able toprovide a range of different treatments and therapeuticinterventions including rehabilitation therapies and intensivehome support.

• The Hospitals2Home service recently expanded its reach inorder to meet needs of people outside the M25 by providingtelephone consultations to local agencies to handover caremore effectively. Face-to-face consultations were alreadyoffered to those living in the local area. Although this servicemanaged mostly patients from the outpatients department,wards were also able to refer more complex patients.

• Between October and December 2015, 51 patients died inhospital (across both sites). Of these patients, 29%(15) hadchosen the Royal Marsden as their preferred place of death(PPD). No patients died at the Royal Marsden whilst fit fortransfer and waiting for a hospice or continuing care bed.

• Clinics were organised so that patients could access servicestogether for example breast and plastic surgery clinics wereorganised on the same day. Testicular cancer and urologyclinics were run as joint clinics.

• The rapid diagnostic assessment centre (RDAC) provided arapid diagnostic service for breast, skin and urology cancers.Some patients received a diagnosis on the day, other patientswho required more tests or investigations would be contactedwith their results quickly once the results were available.

• An outpatient clinic utilisation model was being developed tomatch the level of clinical activity with staffing and clinicspaces.

Meeting peoples individual needs

• Information was available to patients to inform them about thetrust’s general services and to support them in their treatment.Translation services were available to those that required it.

• On the Chelsea campus, Arabic was the second most commonlanguage spoken by patients and their relatives. To facilitatebetter communication, publications were available in Arabicand an interpreter was available on-site Monday to Friday from9am to 5pm. This service was due to become six days per week.Translators were trained in medical terminology and were ableto attend ward rounds and handovers. Staff also had access tocommunication cards to aid them with communication.

• The Speech and Language Therapy team provided specialistassessments for patients who experienced communicationdifficulties.

• There was a dedicated dementia-friendly bed bay in theChelsea critical care unit. This bed bay had adapted lighting,

Summary of findings


dark blue curtains and flooring to reduce sensitisation andimprove orientation amongst patients with dementia. It alsohad large clocks to help patients orientate themselves to thetime of day. The clocks were an innovative addition to the unitfollowing a successful trial led by the safeguarding andvulnerable adult service improvement group (SIG).

• Staff used a blue butterfly symbol on the patient notice boardto discreetly highlight where a patient had additional needssuch as a language barrier, communication problem or thoseidentified as living with a form of dementia.

• Patients with learning disabilities received a ‘passport’ duringtheir pre-assessment visit to the critical care unit. This providedeasy-to-read information on what to expect during their stayand who would help them.

• Ward staff moved patients at the end of life to side-roomswhenever possible to provide privacy with their family andfriends. Relatives were able to stay overnight to spend time withtheir loved ones at the end of life.

• The hospital ensured the faith needs of its patients were met.The chaplaincy team provided spiritual support for differentfaiths. The team was supported by a range of pastoralvolunteers and an extensive network of connections with faithleaders from other religious traditions who visited patients ofother religions if required.

Access and flow

• In the 12 months prior to our inspection, the averageoccupancy of the Chelsea critical care unit was 64%.

• During the same period, there were no out of hours dischargesfrom the critical care unit. This was significantly better than thenational average of up to 9%. The unit performed significantlybetter than the national average for delayed dischargesbetween September 2014 and September 2015.

• The critical care team worked with theatres to plan activity oneweek in advance. As a result, there were no elective surgicalcancellations due to a lack of critical care bed capacity in the 18months prior to our inspection.

• Medical teams at the Chelsea and Sutton sites workedcollaboratively to a ‘treat and transfer’ model of care forpatients admitted at the Sutton site. A resident anaesthetistwas always available at the Sutton site and communicated withthe Chelsea team using video link to establish a timeline fortransfer if needed. A critical care consultant was always on-callfor both sites and was available within 30 minutes if needed toaccompany a transfer. The average length of stay in the Suttonunit was 15 hours.

Summary of findings


• The Hospital2Home team supported the discharge of patientsfrom active anti-cancer treatment at the hospital. Although theservice mainly took referrals from outpatients, inpatientreferrals would be considered for patients with particularlycomplex needs. The service was established as it was felt theimpact of not being offered further active treatment could leavepatients feeling isolated. After discharge, the team set ameeting as soon as practicable with the team taking overpatient care. This would generally last around an hour andcould include the patient’s GP, district nurses, the communitypalliative care provider and social services, for example.

• Rapid discharge protocols and processes were seen to beeffective in getting patients to their preferred place of care priorto dying. Rapid discharge was mostly next day and in somecases had been arranged within the same day.

• Referral data showed the Chelsea outpatient serviceconsistently met the two-week wait referral standard for breastcancer including symptomatic referrals.

• Blood test (phlebotomy) services opened at 8am ahead of themain outpatient department so that patients could have theirblood tests prior to consultations. The results were reportedback electronically to staff in the clinics so the results could bediscussed with medical staff.

• We visited the Chelsea outpatient’s department on one of thebusiest clinic days. The waiting area was very busy to the extentthat patient’s knees were touching as they sat waiting to becalled for their appointment. We noticed taller patients wereunable to sit comfortably due to a lack of space. We spoke tomanagers about this and they said they had done their best tore-organise the space they had available, and that previouslypatients and relatives sometimes had to sit on the floorbecause there were no chairs available. They had re-organisedthe waiting area in response to the feedback received frompatients. A separate waiting area had been created re-using aclinical room, as awaiting area for head and neck cancerpatients.

• A rapid access diagnostic assessment centre (RDAC) had beendeveloped to provide a rapid diagnostic service for breast, skinand urology cancers. It enabled patients to accessexaminations, diagnostic tests and a variety of healthprofessionals at one appointment. Patients we spoke withspoke with were very impressed by the one-stop clinics.Patients referred to the Rapid Diagnosis and Assessment Centrewere seen within the urgent two week wait for suspectedcancer.

Summary of findings


• Operational standards are that 95 percent of patients treated asoutpatients should start consultant-led treatment within 18weeks of referral. The latest figures available for the whole ofThe Royal Marsden NHS Foundation Trust including Sutton andChelsea for the final three months of 2015-2016 showed 96.3%of all patients started treatment within 18 weeks, achieving theoperational standard.

• 50% of patients started outpatient treatment within two weeks.Operational standards were that 95 percent of non-admittedpatients should start consultant-led treatment within 18 weeksof referral. 19 out of 20 patients commenced outpatienttreatment within nine weeks, which meant the trust weremeeting the operational standards.

• The percentage of patients with suspected breast cancer seenin two weeks by a specialist following referral by their GP duringthe three months between September 2015 and December2015 was 98%. The figures were similar for the preceding sixmonths prior to September 2015. The figures for bloodmalignancies including leukaemia were 100%, 93% for headand neck cancer, 100% for upper gastrointestinal, 93% forsarcoma, 96% for urological cancers (not including testicular).

• The percentage of patients who completed their treatmentwithin 62 days of referral during the three months fromSeptember 2015 to December was 100%for breast, 57.1% forlung, 55% for urology (not including testicular), and 100% forskin. There was wide variation in the figures for the precedingsix months from March 2015 to September 2015. For example,the percentage of patients who completed treatment for breastcancer improved from 83% to 100% and from 50% to 100% forpatients with a skin condition whilst the figure for lung cancerimproved from 28% to 80% reducing to 50% in the threemonths between September and December 2015.

• The trust had taken a number of steps to reduce the number ofbreaches in achieving the national standards for referral totreatment times. All breaches were reviewed at a breachmeeting, which was convened to identify the cause and takecorrective action.

Learning from complaints and concerns

• Information on the hospital’s Patient Advice and Liaison Servicewas readily available and the service had an office on-site thatpeople could visit for advice.

• Staff on the wards we visited were able to explain the processshould a query or concern be raised. The person would bedirected to the PALS office.

Summary of findings


• Oversight of complaints was by way of the integratedgovernance and risk committee. Themes from complaints,lessons learnt and actions plans were considered by thecomplaints team. Complaints were, in the main, divided in tofour categories; communication, clinical issues, attitude anddelays. Consideration was given to continuing or evolvingthemes or trends in order that senior managers could conductservice-level reviews as required.

• Outcomes of complaint investigations were redacted andplaced into the public domain by way of the integratedgovernance monitoring report. Summaries of complaintsincluded the nature of the complaint, any action taken and theoutcome of the complaint i.e. whether the complaint wasupheld, partly upheld, or not upheld.

• Between January 2015 and December 2015, the average lengthof time taken by the trust to process and award an outcome ofa complaint was 42 days. In the same time period, 118complaints were received by the trust, of which 39 were upheld,66 were partly upheld and 12 were not upheld. 1 complaintremained open at the time of CQC requesting the informationfrom the trust.

• As part of the inspection we reviewed 5 randomly selectedcomplaints and associated documents. We considered that ineach case, there was evidence that support had been providedto the patient; complaints were risk assessed based on thetrusts local policy; there were consistently high levels ofinvestigation carried out in each case; records were up to dateand there was evidence of a documented outcome andassociated actions.

Are services at this trust well-led?We rated the trust as good for being well-led because:

• The trust had a clear vision and strategy in place which couldbe described by both executive and non-executive directorsand by staff working throughout the trust.

• Governance and assurance frameworks were, in the main,sufficiently robust to ensure the board had oversight of qualityand risk at ward level. Some improvements were necessary toensure that there was sufficient oversight of quality withincommunity based services.

• The trust had a stable and visible leadership team whosepriority was to drive high quality, harm free care.

• The culture amongst staff across the trust was aligned to thesixteen key values of the organisation.

Good –––

Summary of findings


• The trust had considered the changing landscape andcomplexities of providing specialist cancer and communitybased care and was working towards implementing newmodels of care which were sustainable.

Vision and strategy

• The vision for the trust was clearly articulated by the majority ofstaff we spoke with during the inspection. There was howeversome ambiguity amongst staff working in the communitysetting with regards to the future and vision of communityservices hosted by the Royal Marsden, and this was likelyattributable to the recent move of community services withinthe London Borough of Merton to a third party provider.

• The Royal Marsden NHS Foundation Trust had a set of valueswhich executive staff reported as being the foundation onwhich the organisations' reputation was based and waspersonified by staff across the trust. The 16 values weredeveloped by staff from across all staff groups and departmentswithin the trust and included:

• Characteristics (What we are):▪ Pioneering▪ Knowledgeable▪ Aspirational▪ Driven

• Attitudes (how we act):▪ Determined▪ Open▪ Confident▪ Resilient

• Relationships (relating to others)▪ Collaborative▪ Trusted▪ Supportive▪ Personable

• Emotions (how we feel)▪ Compassionate▪ Calm▪ Positive▪ Proud

• Through our observation and discussions of and with staffduring the inspection, and through comments made bypatients receiving care, it was apparent that staff across thetrust were committed to the values of the Royal Marsden.

• The five year strategic plan 2014/15 - 2018/19 clearly set out thefour key strategic themes which the trust were focused on. Thetrust recognised the need to become financially sustainable

Summary of findings


whilst continuing to provide value for money; to modernise theinfrastructure from which healthcare was provided; toimplement new models of care so that care was more localisedto people however centralised where essential and to focus oninnovation and precision medicine.

• The trust acknowledged the importance of being a combinedhealth provider, and so there was a focus on enhancing theopportunities that such an arrangement offered. There was afocus on transforming existing arrangements with regards tothe early diagnosis of cancer, whilst also re-designing theexisting cancer treatment pathways across London in order thatservices could become more readily accessible to service users,and in a timely way. Through the use of General Practiceeducation days, there was a focus on enhancing the knowledgebase of primary care physicians in order that cancer could bemore easily diagnosed or recognised within the primary caresetting as compared to a diagnosis being made when a patientpresented to an emergency department.

• The trust had a robust estates strategy which included theredevelopment of some components of the Sutton site,through the "Sutton for Life" initiative. The executive team werewell appraised of the clinical and support environments whichrequired remedial works to ensure care could be provided in anappropriate setting.

• The trust had a Quality Strategy in place which had beenrefreshed in 2015 and was a five year improvement programme.The focus of the strategy was to outline the approach the trustwas taking to ensure that it became "A learning organisationcontinuously striving to improve practice, safety, outcomes andexperience across all areas of the Trust". The Quality Strategyhad five pillars on which it was based:▪ Culture of continuous quality improvement▪ External accreditation/regulation of services▪ Recruit and retain the best staff, continued professional

development▪ Harm free care - and learning from incidents▪ Data for improvement/audit

Governance, risk management and quality measurement

• A range of committees provided assurance to the boardincluding the Quality, Assurance and Risk Committee, Audit andFinance Committee and the Executive Board. With theexception of the executive board, Non-Executive Directorschaired these committees and formal reports were submittedto the trust board on a regular basis.

Summary of findings


• Each board committee was supported, and receivedinformation from a range of sub-committees including theintegrated governance and risk management committee whichin turn considered information from some 22 different steeringgroups and committees. The trust had eight corporate steeringgroups including the Equality, Diversity and Inclusion SteeringGroup, Workforce and Education, Research Executive and thePerformance Review Group.

• In addition to the clinical and operational steering committees,the trust board also received advice and guidance via some sixadvisory committees including the Medical AdvisoryCommittee, Nursing, Rehabilitation and Radiography AdvisoryCommittee and the Patient Experience and Quality AccountGroup.

• The Integrated Governance and Risk Management Committeeproduced a publically available summary of all information ithad received and considered on a quarterly basis.

• It was acknowledged through a board self-assessment,conducted by board members in February 2016 that furtherimprovements could be made to the board sub-committees toensure that there was appropriate interaction and exchange ofinformation across sub-committees. Additionally, it was notedthat chairs of board sub-committees should consider a periodicassessment to determine the effectiveness of the committee forwhich they were responsible for chairing.

• There was a Board Assurance Framework in place which hadbeen refreshed in January 2016. The BAF was linked to the fourover-arching strategic objectives of the organisation, as set outin the five year strategy of the Trust. Assurance scores wereawarded to each of the sixteen sub-objectives for 2015/2016which were linked to the umbrella strategic objective. Fiveobjectives had been rated as red (minimal assurance ofobjective being delivered); ten rated as amber (mediumassurance) and one rated as green (high assurance). Controlmeasures were in place, as well as identified gaps in bothcontrols and assurance processes. Discussion of the boardassurance framework was noted within board papers. Executiveleads had been identified as responsible directors for thedelivery of each objective.

• Corporate and operational risks were recorded on thecorporate risk register. Executive members were aware of therisks to which they were the assigned accountable officer andcould describe the actions and mitigations being taken tomanage recognised risks. The corporate risk register was

Summary of findings


considered on a quarterly basis via the Quality, Assurance andRisk Committee. Risk registers were held at a local level by eachdivision and there was a clear process for escalation of riskacross the organisation.

• The trust had a well-established governance framework whichwas used to support the delivery of harm free care and toprovide assurance from "Ward to Board". The Board andCouncil of Governor's, considered, on a quarterly basis, abalanced score-card which was set out in to six streams of data:▪ Patient safety, quality and experience▪ Finance and efficiency▪ Clinical and research strategy▪ Workforce▪ Monitor community measures▪ Staff friends and family test

• The board had conducted a board self-assessment in February2016; this was presented at the open board in March 2016. Thesummary of the self-assessment concluded that "Boardmembers demonstrated a positive response to most aspects ofBoard function and performance". A small number of boardmembers indicated a Red or Amber rating (60% amber and 20%red) against the standard "Board members feel supported intheir role through an effective training and developmentprogramme". It was noted that comments included "Nosystematic training occurs". It was acknowledged within thereport that whilst an induction was provided, a more formalisedprocess would have been welcomed. Following the self-assessment, the board had devised a five point action plan for2016/2017 to address areas of comment and concern raisedwithin the self-assessment.

• The trust had an internal audit programme and a clinical auditprogramme set for 2015 – 2016. The Integrated Governanceand Risk Committee received quarterly reports on progressagainst the audit programme.

• At the March 2016 Open Board, the board were asked toconsider the outcome of the most recent National QualityBoard Safer Staffing report. A review of staffing was carried outat the Royal Marsden in December/January 2016. The trustsourced external support to conduct a review of dependencyand acuity of patients against staffing levels using thenationally recognised Association of UK University Hospitalsdependency assessment tool. The initial report concluded that"The Royal Marsden is on the whole well-staffed; the Trust isparticularly well staffed in Band 6 RNs which may be due to thenature of the specialist and complex care that is required". Thereport considered clinical outcomes and key performance

Summary of findings


indicators as an additional source of monitoring to ensurewards were suitably staffed. Whilst the report was focused onward based care and that the board was minded to considerthe fact that the trust was also responsible for providingsufficient numbers of staff within hard-to-recruit areasincluding community, critical care and theatres. Additionally,the board were asked to consider the specialist nature of thework conducted at the Royal Marsden and the need for thetrust to adopt a proactive and timely response to changes inpatient dependency. The trust had therefore introducedmitigations including twice daily safety huddles across thetrust, pro-active reviews of staffing rotas as well as the ChiefNurse chairing a monthly Nurse recruitment group.

Leadership of the trust

• There was a well-established senior executive team; staffreported that the team were highly visible with high quality careseen as the driving motivation of the executive and the board.The Chief Executive and Chief Nurse were held in high regard byall staff we spoke with.

• There was a balance with regards to the tenures of thoseindividuals who formed the executive board with someindividuals having been in post for 18 years (CEO), whilst alsoconversely, there were new appointments including themedical director who had taken up post some three monthsprior to the inspection.

• The Chair had been in post for six years and was supported byNon-Executive Directors who had also been in post for longerterms as well as those recently appointed, within the last twoyears.

• There was a high level of clinical engagement across theorganisation; this engagement came not only from doctors, butalso from nursing staff, laboratory staff and allied healthprofessionals including pharmacists, speech and languagetherapists, physiotherapists, radiographers and dieticians.

• In the 2015 NHS Staff survey, the trust was in the top 20% of alltrusts for the percentage of staff who reported goodcommunication between senior management and staff;effective team working; recognition and value of staff bymanagers and the organisation.

• In all of the teams we visited we found that most staff felt proudof working for the trust and were positive about their work.Managers spoke openly about the challenges with recentrestructuring in community services and were positive abouttheir ability to fully support the trust to improve the quality ofservices.

Summary of findings


• Local leadership was praised by staff as visible, accessible andresponsive.

• Each clinical division had a triumvirate leadership team, whichhad the clinical Chair as the person with overall accountabilityand responsibility for their division.

• The trust had built very good working relationships with theirCouncil of Governors, with clarity about roles and purpose, sothat governors contribute significantly to the success of thetrust. The quality strategy for 2015-2019 recognised theimportance of further enhancing the role of the Council ofGovernors through the use of supported ward clinical qualityward visits as an example.

Culture within the trust

• Staff we spoke with demonstrated a commitment to thedelivery of high quality, harm free care. Staff told us they feltproud of the care they were able to give.

• The trust was rated in the top 20% of all trusts in the country in17 of the 32 questions within the NHS staff survey for 2015. Thetrust had one key question ranked in the bottom 20% of alltrusts which related to the percentage of staff workingadditional hours; this was acknowledged by the trust as an areafor improvement.

• There was good evidence of collaborative multidisciplinaryworking, which was clear in the quality improvement workwhere staff jointly demonstrated a drive to improve patientcare. The trust was rated in the top 20% of all trusts withregards to effective team working.

• Staff in all the focus groups we held were very positive aboutthe trust and the support provided and the investment made instaff to develop; again this was reflected in the NHS staff survey2015, where the trust was placed in the top 20% of all trustswith regards to the percentage considering the quality of non-mandatory training, learning and development to be good.

• There was an open and transparent culture, with a realcommitment to learn from mistakes. This is reflected in the highlevel of reporting of incidents with no harm or low harm. Thetrust performed in the top 20% of all trusts in three of the fourkey questions relating to "Errors and Incidents" in the 2015 NHSStaff survey.

• There was a strong sense of a continuous drive for innovationand improvement which was ingrained in the culture of theorganisation.

• The trust acknowledged that improvements were necessary toimprove the opportunities and experiences of medical trainees.The trust had three indicators within the 2015 GMC survey

Summary of findings


which were rated as negative outliers: Induction; supportiveenvironment and feedback. We were assured that, followingdiscussions with the medical director, significant improvementswere being made to ensure that junior doctors were sufficientlyinducted and supported during their training placements at theRoyal Marsden. The medical director was candied with regardsto the challenges faced by junior doctors, and was well sightedon the contributing factors which had led to the three outlieralerts.

Equality and diversity - including Workforce Race EqualityStandards

• Of the 4,275 staff employed by the trust, 1,160 were of a black orminority ethnicity (27%). 98% of staff self-reported theirethnicity during 2015; a 1% increase on the previous year.

• The trust had a named lead for Equality and Diversity and therewas an identified director with executive accountability.Additionally, the trust had a formal Equality, Diversity andInclusion Steering Group who were responsible for monitoringthe trusts' equality performance against the trust's equalityobjectives.

• The Royal Marsden Equality report, published in January 2016reported that there had been significant improvements in theoverall number of staff undertaking equality and diversitytraining (increase from 41% to 82% by the end of quarter 2 of2015/2016) with an expected completion rate of 90% by April2016.

• The trust had seen an increase in the number of staff declaringtheir sexual orientation (increase from 38% to 71%).

• Equality Impact Assessments had been considered in allorganisational changes. The trust reported 28 assessments hadbeen completed highlighting issues for consideration includingensuring accessible building design and supportive workingpatterns for carers.

• The trust reported a slight improvement in the percentage ofblack and minority ethnic (BME) staff reporting harassment orbullying (reduction from 35% to 27%). The trust had introducedmediation services to help support staff to resolve issuespromptly and without the need for formal escalation.

• The trust launched a BME forum to assist staff in discussing keyfindings from the NHS staff survey as well as offering a regularmeans for engaging with BME staff.

• Improvements were noted in the number of staff reportingharassment or bullying from patients, relatives or the publicwith the trust performing in the top 20% of all trusts in four ofthe key questions for 2015.

Summary of findings


• In response to a decrease in the proportion of disabled staffbelieving the trust provided equal opportunities for careerprogression and promotion and the proportion of BME staffreporting bullying or harassment by other staff marginallyincreasing, the trust conducted a recruitment masterclass forexperienced recruiters to consider the impact of unconsciousbias in decision making.

• The equality report noted that overall, the workforce findings atthe Royal Marsden were, amongst others:▪ The proportion of BME staff in Bands 1 – 4 is 31% and 66%

for White staff compared with the Trust profile of BME staff(26%) and White staff (71%)

▪ There is a slightly higher proportion of BME staff working inMedical roles (29%) compared with the Trust profile of BMEstaff (26%).

▪ There are part time staff across all staff groups▪ The largest proportion of staff are aged between 31 and 50

years old▪ The highest proportion of staff report that they are Christian,

however there is a wide spectrum of different religions andbeliefs represented.

• Shortlisting and subsequent appointment of applicants from arange of ethnic backgrounds was also considered by the trust.The findings were that:▪ 22% of applicants were from of an Asian ethnicity, of which

13% were appointed.▪ 20% of applicants were of dual heritage or mixed ethnicity,

of which 10% were appointed.▪ 22% were of black ethnicity of which 7% were appointed.▪ 30% were of "other" ethnicity of which 16% were appointed.▪ 33% were of white ethnicity of which 19% were appointed.▪ The trust reported that white staff were 1.91 times more

likely to be appointed from shortlisting than BME staff. Thiswas a decrease from the previous year where white staffwere 1.68 times more likely to be appointed fromshortlisting. Specific equality objectives were set for 2016/2017 with regards to recruitment and promotion processesto ensure that parity across the workforce.

▪ BME staff were 2.20 times more likely to enter formaldisciplinary processes than white staff. This was about thesame when compared to the previous year. In response tothis finding, the trust launched "Candid conversations"training to help support management staff in having difficultconversations regarding performance and to help improveoutcomes.

Summary of findings


Fit and proper persons

• The trust was prepared to meet the Fit and Proper PersonsRequirement (FPPR) (Regulation 5 of the Health and Social CareAct (Regulated Activities) Regulations 2014). This regulationensures that directors of NHS providers are fit and proper tocarry out this important role.

• The trust had a policy in place to support the requirements ofthe regulation: Recruitment and Selection Policy andProcedure. This was further complemented by theEmployments Checks Policy and Procedure, Employee RecordsPolicy and Procedure and the Anti-Fraud, Bribery andCorruption Policy and Procedure.

Public engagement

• There was evidence of extensive engagement with patients andthe public and the trust actively sought their views andopinions.

• As a means of seeking additional assessment of patientexperience the trust had embarked on rolling out"iWantGreatCare" across the organisation.

• The initiative allows patients to leave meaningful feedback ontheir care and enables them to make comments of their overallexperience, to suggest improvements and to makecommendations or raise concerns.

• A breakdown of iWantGreatCare was as follows:▪ The Royal Marsden (Sutton) - 5 Star rating (10,253 reviews)▪ The Royal Marsden (Chelsea) - 5 Star rating (9,914 reviews)▪ Community Services - 5 star rating (352 reviews)

• The trust proactively engaged with children, young people andfamilies and took appropriate action based upon the feedbackthey received.

Staff engagement

• The chief executive facilitated regular "Town hall" roadshows toupdate staff on major developments and provide opportunitiesto ask questions.

• The trust recognised the contribution of staff and celebratedtheir achievements and improvements to quality patient careand innovation through annual staff awards.

• Results from the 2015 NHS Staff Survey showed that the trustperformed well, with 17 positive findings, 14 findings withinexpected levels, and one negative finding.

Summary of findings


• During the inspection and focus groups, staff described thetrust as somewhere they felt they were listened to and wereengaged in the future strategy of the trust. Some improvementswere however required within the community setting wherestaff felt disconnected from the wider strategy of the trust.

Innovation, improvement and sustainability

• The trust has major research collaborations through itsacademic health sciences centre and biomedical researchcentre.

• The trust has a school dedicated to the education of nursesresponsible for the delivery of cancer care.

• Staff and divisions were actively involved in initiatives toimprove patient care, the environment and patient experience.These are detailed under each core service in the hospitallocation reports.

Summary of findings


Our ratings for The Royal Marsden - Chelsea

Safe Effective Caring Responsive Well-led Overall

Critical care Good GoodOutstanding Outstanding Outstanding Outstanding

End of life care Good RequiresimprovementOutstanding Good Good Good

Outpatients anddiagnostic imaging Good Not rated Good Good Good Good

Chemotherapy Good GoodOutstanding Good Good Good

Radiotherapy GoodOutstanding Outstanding Outstanding Outstanding Outstanding

Adult solid tumours Good GoodOutstanding Good Good Good

Overall Good GoodOutstanding Outstanding Outstanding Outstanding

Overview of ratings


Our ratings for The Royal Marsden - Sutton


Services for childrenand young people Good GoodOutstanding Good Good Good

End of life care Good Requiresimprovement Good Good Good Good

Outpatients anddiagnostic imaging

Requiresimprovement Not rated Good Good Requires

improvementRequires

improvement

Chemotherapy Good GoodOutstanding GoodOutstanding Outstanding

Radiotherapy GoodOutstanding Outstanding Outstanding Outstanding Outstanding

Adult solid tumours Good GoodOutstanding Good Good Good

Haematology Good GoodOutstanding Good Good Good

Overall Good GoodOutstanding Good Good Good

Our ratings for The Royal Marsden NHS Foundation Trust


Overall Good GoodOutstanding Good Good Good

Overview of ratings


Our ratings for Community Services


Community healthservices for adults

Requiresimprovement

Requiresimprovement Good Good Requires

improvementRequires

improvement

Community healthservices for children,young people andfamilies

Good Good Good Requiresimprovement Good Good

Community End of LifeCare services Good Good Good Good Requires

improvement Good

Overall Community Requiresimprovement

Requiresimprovement Good Requires

improvementRequires

improvementRequires

improvement

NotesIn considering the overall ratings for the Royal MarsdenNHS Foundation Trust, we have deviated from thestandard aggregations rules. We considered that due tothe size and activity of community services, whencompared to the wider activity of specialist cancerservices provided by the trust, it would have beendisproportionate to have rated the trust as requiringimprovement in the domains of safe, effective, responsiveand well-led.

When considering the ratings, we have carefullyconsidered all of the evidence available to us and haveused our professional judgment to aggregate the finaltrust ratings. We have carefully considered thecharacteristics for ratings as set out in our guidance, andwhere we have identified that improvements arerequired, these have been identified within the individualcore service reports; within the "must" and "should"section of reports and within the requirement noticesections of reports.

Overview of ratings


Outstanding practice

• Critical care staff worked with a specialist inaromatherapy massage as part of a trial to identify ifthis type of therapy would result in better sleeppatterns amongst patients. This trial was in progress atthe time of our inspection and aimed to find if non-pharmacological intervention could be an effectivealternative to support sleep to high doses of drugs.

• The Critical Care Unit’s (CCU) research programme waswell structured and there were multiple safety nets inplace for staff conducting this. The Committee forClinical Research had oversight of every project andonly approved them after a positive peer review andethics approval. The research profile wasinternationally recognised and staff represented theunit at the NHS National Institute of Health Researchand the National Critical Care Research Group. Seniorresearch staff worked academically and clinically,which meant they could ensure critical care projectswere conducted according to established multi-professional best practice.

• Staff in CCU prescribed patients who were consideredhigh-risk for complications a pre-rehabilitationprogramme before they underwent surgery. Aphysiotherapist led this programme and providedpatients with an exercise regime and diary. This helpedthem to prepare for rehabilitation and to support theirhealth to improve their condition after surgery.

• The environmental adaptations in the Chelsea CCUdemonstrated exemplary focus on individual care andattention to detail. This included adaptedenvironments for patients with dementia, bariatricpatients and teenagers.

• Senior staff actively promoted staff welfare and hadprovided tai chi, complementary therapies andmeditation sessions to promote wellbeing andrelaxation.

• The Royal Marsden is the only NHS hospital to have theupdated version of the da Vinci Xi surgical robot. This

less invasive surgery allowed improved patientrecovery. The 10 year fellowship programme meantthat 30 surgeons would be trained by the trust tooperate the robot.

• There was an extensive range of information, includingfilms for patients, which provided detailed support.

• The trust had direct access to electronic informationheld by community services, including GPs. Thismeant that hospital staff could access up-to-dateinformation about patients, for example, details oftheir current medicine.

• Staff demonstrated high care, arranging patienttransportation and accommodation for those that didnot live near to the hospital.

• The investment by the trust ensured that staff weredeveloped and highly trained. Many staff had studiedfor master degrees and specialist courses in cancer.

• Research, ongoing quality improvement projects andauditing were of a high level and drove the qualityimprovement agenda.

• Nursing and therapy staff had the commitment andtime to provide person-centred care that often wentthe ‘extra mile’

• The introduction of ambulatory care had managed toreduce patient bed stays and improve patientexperience.

• The end of life supportive care home team (SCHT) wasa part of a Sutton CCG (clinical commissioning group)vanguard relating to improving end of life care in careand nursing homes. Members of the SCHT wereinvolved in developing the service and had beeninvited to speak about the model and share thisdevelopment with other services. The end of lifesupportive care home team (SCHT) was a part of aSutton CCG (clinical commissioning group) vanguardrelating to improving end of life care in care andnursing homes.

Outstanding practice and areas for improvement


Areas for improvement

Action the trust MUST take to improve

• Implement and embed the World Health OrganisationSafety Checklist in the outpatients department.

• When patients (aged 16 and over) are unable to giveconsent because they lack the capacity to do so, thetrust should ensure staff act in accordance with theMental Capacity Act 2005.

• Ensure that records contain accurate information inrespect of each patient and include appropriateinformation in relation to the treatment and careprovided, particularly with regard to risk assessments.

• The provider should take action to understand theshortfalls in recording of risk assessments andindividualised care plans in the integrated communityteams.

• Review the staff compliment for community adultservices to ensure there are sufficient numbersof appropriately skilled staff to meet patient’s needs.

• The provider should strengthen the reporting on theassurance of effectiveness of governancearrangements to the trust board; this specificallyrelates to community services.

Outstanding practice and areas for improvement


DRAFT

1

Report on actions you plan to take Please see the covering letter for the date by which you must send your report to us and where to send it. Failure to send a report may lead to enforcement action.

Account number RPY

Our reference SPL1- 2430502431

Location ID RPY02

Location name The Royal Marsden - Sutton

(Note For regulations requiring actions: Require one page per regulation)

Regulated activity(ies)

Regulation

Surgical procedures

Regulation 12 HSCA (RA) Regulations 2014: Safe care and treatment. 12 (1) (2) (a) (b) How the regulation was not being met: 12 (1) (2) (a) (b) The world health organisation (WHO) five steps to safer surgery checklist was not being used in the outpatients department even though a range of procedures were being carried out for which it should have been used. The five steps to safer surgery checklist was not used in the outpatients departments. The hospital must take action to: • Ensure the safer surgery checklist is consistently implemented for all surgical procedures in the outpatients department including the five steps of team brief, sign in, time out, sign out, and debriefing. Reg 12 (1) (2) (a) (b) • Ensure adequate audit and monitoring systems are in place to monitor performance and compliance of the safer surgery checklist to guide improvement. Reg 12 (1) (2) (a) (b)

DRAFT

2

Please describe clearly the action you are going to take to meet the regulation and what you intend to achieve

1) Develop a Trust policy on National Safety Standards for Invasive Procedures (NatSSIPs), which will contain information about Local Safety Standards for Invasive Procedures (LocSSIPs). As well as outlining the definitions and scope of LocSSIPs this will outline the roles and responsibilities for each department in conducting regular compliance audits and feeding back the results to the Quality Assurance Department.

2) Develop an appropriate WHO Surgical Safety Checklist (along with a Team Brief and Debrief document) to allow the 5 Steps to Safer Surgery to be completed in the Outpatients Department for minor surgical procedures.

3) Develop (LocSSIPs) documents for the following procedures. • OPD Minor Plastics • OPD Nasoendoscopes • CAU Ascitic Drain Insertion • Chest Drain Insertion Clinic

Who is responsible for the action? Dr Rohit Juneja, Consultant Anaesthetist

How are you going to ensure that the improvements have been made and are sustainable? What measures are going to put in place to check this? Policy compliance will be monitored by the established Trust ‘Clinical Product Review Committee’, chaired by a Divisional Nurse Director. The Trust will conduct monthly audits into the 5 Steps to Safer Surgery Checklist in Outpatients with the data presented at the monthly Theatre Quality and Safety (TQS) Meeting. Results to be reported every six months to the Integrated Governance and Risk Management committee. Results to be presented at the Surgical Audit Group each quarter and forwarded to the Clinical Audit Committee each quarter.

Who is responsible? Laura Dopson, Matron for Theatres, Day surgery, Endoscopy and the pain management team

DRAFT

3

What resources (if any) are needed to implement the change(s) and are these resources available? No new resources will be required, this work will be integrated into the established Theatre WHO checklist procedures. Dr Rohit Juneja, Consultant Anaesthetist, is the designated Clinical Lead for the Trust’s NatSSIPs. He is supported in this work by the Trust with the appropriate resources and support from Matron for Theatres, Day surgery, Endoscopy and the pain management team

Date actions will be completed: 1) Policy written and ratified by April 2017.

2) WHO Surgical Safety Checklist (s) for Outpatients to be approved by April 2017, and implemented by June 2017.

3) The four primary relevant OPD LocSSIPs will be completed by May 2017.

4) Monthly monitoring to be

implemented by June 2017.

How will people who use the service(s) be affected by you not meeting this regulation until this date? No evidence that people are currently being affected. The Trust through the risk management processes monitor incidents and near misses on a daily basis, including any that may be submitted that may relate to this area (as of March 2017, no near misses or incidents have been reported).

Completed by: (please print name(s) in full)

Eamonn Sullivan

Position(s): Chief Nurse

Date: March 2017

DRAFT

4

Account number RPY


Location ID RPYX1

Location name The Royal Marsden – Community Services


Regulation

Accommodation for persons who require nursing or personal care. Diagnostic and screening procedures. Nursing care. Personal care. Treatment of disease, disorder or injury.

Regulation 11 HSCA (RA) Regulations 2014 Need for Consent How the regulation was not being met: The provider had failed to ensure care and treatment was provided with the consent of the relevant person. Staff were not clear about who could consent on the patient’s behalf and how this information should be recorded in patient’s records. Deprivation of Liberty Safeguards were not always understood and mental capacity was not consistently appropriately assessed and recorded for patients who may lack capacity.


1) To establish a new Safeguarding Operational Group.

2) Review specialist safeguarding staffing levels in the Community.

3) Conduct baseline case record audit of compliance with the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DOLS) across Community Services.

4) Write Community specific adult safeguarding action plan, including a review of staff training in MCA and DOLs.

Who is responsible for the action? Sarah Rushbrooke, Interim Director Community Service, Edwina Curtis, Associate Safeguarding Adults Lead.

How are you going to ensure that the improvements have been made and are sustainable? What measures are going to put in place to check this?

DRAFT

5

The new Safeguarding Operational Group reports to the Safeguarding Board (monthly) which reports directly to the Board designated Quality Committee (Quality, Assurance & Risk Committee). The results of the Community Services Case-record audit will be reported to the Trust Integrated Governance and Risk Management Committee (IGRM) bi-annually. The Chief Nurse will review Adult Safeguarding (specialist) staffing levels in the Community. Staff mandatory training compliance will be monitored via established Divisional Performance Review Monitoring (PRM) structures.

Who is responsible? Sarah Rushbrooke, Interim Director Community Services and Deputy Chief Nurse, Edwina Curtis, Associate Safeguarding Adults Lead.

What resources (if any) are needed to implement the change(s) and are these resources available? Deployment of a senior Adult Safeguarding specialist to Community Services, with immediate effect. Following the review, it is anticipated that some additional staffing resources will be required.

Date actions will be completed: 1) To establish a new Safeguarding Operational Group. April 2017

2) Review specialist safeguarding staffing levels in the Community. April 2017.

3) Conduct baseline case record audit of compliance with the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DOLS) across Community Services. April 2017.

4) Write Community specific adult safeguarding action plan, including a review of staff training in MCA and DOLs. May 2017, conclude priority actions by September 2017 (end of Q2).

DRAFT

6

How will people who use the service(s) be affected by you not meeting this regulation until this date? No evidence that people are currently being affected. The Trust through the risk management processes monitor incidents and near misses on a daily basis, including any that may be submitted that may relate to this area (as of March 2017, no near misses or incidents have been reported). The Trust will monitor complaints that are submitted that may relate to this area. The Trust will monitor the Friends and Family Test comments that are received each month that may relate to this area.


Eamonn Sullivan


Date: March 2017

DRAFT

7

Account number RPY


Location ID RPYX1

Location name The Royal Marsden – Community Services


Regulation

Accommodation for persons who require nursing or personal care. Diagnostic and screening procedures. Nursing care. Personal care. Treatment of disease, disorder or injury.

Regulation 17 HSAC (RA) Regulations 2014 Good governance How the regulation was not being met: The provider had failed to assess, monitor and improve the quality and safety of services provided in the carrying on of regulated activity (including the quality of the experience of service users in receiving those services). The provider had failed to ensure that their audit and governance systems were effective in relation to community services for adults.


1) Review and strengthening of Community Services leadership, including Governance Structures across Community Services.

2) Establish new weekly team meetings, chaired by a Clinical Director. The agenda will

include key governance issues, such as reviewing of serious incidents, risk register, complaints and safeguarding issues (adult and child).

3) Establish weekly, Director-led, Recruitment and Retention meetings, including

developing a Community Services Recruitment Plan.

4) To review and strengthen the Community Services Clinical Audit Programme, including increasing the sample size and frequency of the case-record and risk assessment audits.

5) The Community Services Division to report to the Trust Integrated Governance & Risk Management Committee (IGRM) on a (minimum) quarterly basis.

Who is responsible for the action? Sarah Rushbrooke, Interim Director Community Services and Deputy Chief Nurse,

DRAFT

8

How are you going to ensure that the improvements have been made and are sustainable? What measures are going to put in place to check this? Records documentation audit will be performed six monthly by community staff in addition to the annual audit independently conducted by the Risk Management team. Trust’s annual Consent audit to perform six monthly audit of a sample from community services consent procedures. Community services audit lead to review the Clinical Audit Plan to be presented at the Clinical Audit Committee each quarter. The Community Services Division to report to the Trust Integrated Governance & Risk Management Committee (IGRM) on a (minimum) quarterly basis.

Who is responsible? Sarah Rushbrooke, Interim Director Community Services and Deputy Chief Nurse,

What resources (if any) are needed to implement the change(s) and are these resources available? Immediate action (completed) – appointment of an experienced interim Clinical Director. Conduct review of leadership structure and resources required to deliver plan.

Date actions will be completed: 1) Review and strengthening of Community Services leadership, including Governance Structures across Community Services – April 2017.

2) Establish new weekly team

meetings, chaired by a Clinical Director. The agenda will include key governance issues, such as reviewing of serious incidents, risk register, complaints and safeguarding issues (adult and child). March 2017.

3) Establish weekly, Director-led,

Recruitment and Retention meetings, including developing a Community Services Recruitment Plan - March 2017.

DRAFT

9

4) To review and strengthen the

Community Services Clinical Audit Programme, including increasing the sample size and frequency of the case-record and risk assessment audits – June 2017

5) The Community Services Division to report to the Trust Integrated Governance & Risk Management Committee (IGRM) on a (minimum) quarterly basis. End of Quarter 1 (to July 2017 IGRM)

How will people who use the service(s) be affected by you not meeting this regulation until this date? No evidence that people are currently being affected. The Trust through the risk management processes monitor incidents and near misses on a daily basis, including any that may be submitted that may relate to this area (as of March 2017, no near misses or incidents have been reported). Will monitor the number of complaints that are submitted that may relate to this area. Will monitor the FFT monthly comments that are submitted that may relate to this area.


Eamonn Sullivan


Date: March 2107



Agenda item 5

Title of Document:

RM Partners Update

To be presented by

Nicola Hunt, Managing Director, RM Partners

Executive Summary

In 2015, the Independent Cancer Taskforce set out an ambitious vision for improving services, care and outcomes for everyone affected by cancer. One of its recommendations was the establishment of cancer alliances, bringing together key partners at a sub-regional level, including commissioners, providers and patients, to drive and support improvement and integrate care pathways.

RM Partners has made good progress in establishing itself as the cancer alliance for north west and south west London, and in agreeing and aligning clinical priorities for cancer across partners within this geographic area. There has been some considerable success in our initial projects which will result in tangible benefits to patients and the health economy. RM Partners is also actively exploring different models of organising services across multiple partners, and is developing plans to test a lead provider model over the next year.

The injection of transformation funding for the financial year 2017/18 will enable RM Partners to make a step change towards improving outcomes for its population, focusing on diagnosing cancer earlier. This is a really exciting opportunity to lead a major transformation programme at pace across partner organisations in west London. Detailed plans for delivery of individual projects are being developed currently.

The paper sets out in more detail the vision and values of RM Partners, its vanguard projects (including the exciting opportunity afforded in 2017/18 further to the allocation of transformation funding), and its next steps.

Recommendations The Council of Governors is asked to note:

• Progress on development of RM Partners, including transformation proposals; • Progress on development of the RM Partners delivery plan; and • The next steps as set out in the Report.

Author: Nicola Hunt



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RM Partners update

1. Background to RM Partners

In 2015, the Independent Cancer Taskforce set out an ambitious vision for improving services, care and

outcomes for everyone affected by cancer. One of its recommendations was the establishment of cancer

alliances, bringing together key partners at a sub-regional level, including commissioners, providers and

patients, to drive and support improvement and integrate care pathways.

RM Partners is one of 19 cancer alliances being established across England, and will be driving the change

needed to achieve the Taskforce’s vision across north west and south west London. We are one of three

alliances – the others being Greater Manchester Cancer Vanguard Innovation and UCLH Cancer

Collaborative – that were formed earlier, so that we could work together as the national Cancer Vanguard

to pilot and test new models of care that can be replicated nationally. The RM Partners Executive Board

consists of all acute Trust providers in north west and south west London, the Chair of the RM Partners

Clinical Oversight Group (Dr Nick van As, Medical Director at RMH), and primary care and

commissioner representation in the form of Sustainability and Transformation Plan leads for both of

these health economies.

2. Vision and values

Our vision is to work in partnership and achieve world class cancer outcomes for the

population we serve. This includes improving outcomes and survival through earlier diagnosis and

detection; reducing unwanted variation through the development and implementation of evidence based

best practice pathways; improving and enhancing experience and quality of life for everyone affected by

cancer; and improving access to expert palliative and end of life care.

We will bring together organisations and build strong relationships across the health

community to support local delivery of new models of care. Working closely with public health

and screening, primary and community care, secondary and tertiary care and hospice care, will enable us

to create a strong collaborative voice and provide high quality evidence based care across the whole

patient pathway and deliver better outcomes.

We will use the world class expertise in our cancer services to deliver across

organisational boundaries. This allows us to share knowledge and best practice while making the

most efficient use of NHS resources, moving towards individualised outcome based cancer care rather

than current process based care.

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Our clinical leaders are at the front and centre of our work. Strong clinical leadership,

collaboration and coordination across the whole system will enable us to make the step change

towards significantly improving survival and quality of life for our patients.

We will focus on explicit clinical priorities to maximise impact for our patients. Initially this

includes the development and implementation of timed pathways for lung, upper GI, lower GI and

prostate cancer as well as improving early diagnosis, moving towards stratified follow up and

implementing the recovery package.

Strong investment in and focus on primary care is key to improving early diagnosis and

patient experience. Our transformational work will focus heavily on GP and primary care service

development required to embed and sustain new models of care.

Patients, their families and carers are at the heart of our cancer service planning, delivery

and on-going improvement. We will be focusing on understanding, co-designing and improving the

experience of cancer services for both patients and staff, and working at local level to introduce a

systematic, real time feedback tool to measure improvement that will enable services to better understand

the experience of their cancer patients.

3. Key priorities

Through critical review of our data and understanding the priorities of both STPs, we have collectively

agreed to focus our energies and attention on the lung, GI and prostate pathways. Our data shows that by

improving these pathways – and giving our population parity of access to the most innovative

technologies – we will make the biggest impact on diagnosing cancer earlier (Figure 1 – overleaf).

of 7

We are also focused on developing and testing a lead provider model, where RM Partners would act as a

system integrator holding a single contract with commissioners and subcontracts with co-providers.

Further work and engagement with partners is needed to define the detail of any model, and we are

looking to begin shadowing components in 2017/18.

Other key projects we are developing include:

• Patient experience tool: a single tool to collect, compare and report cancer patient experience

and subsequently outcomes across all providers in West London, in order to identify areas of

variation for improvement;

• Best practice pathways: agreeing a single set of timed pathways for lung, colorectal and

prostate across the three Vanguard delivery systems to reduce variation in outcomes, cost and

experience for patients;

• Digital infrastructure: we are developing a number of proof of concepts around sharing of

information across the system to reduce duplication and provide clinicians with more timely

access to reports and scans;

• Informatics: we have established a pan-Vanguard informatics function to provide analysis and

benchmarking to highlight where there is variation of provision or outcomes, and where we need

to make improvements;

• Pharma challenge: a series of projects funded by the pharma industry across the Vanguard

footprint such as developing models for chemo closer to home, roll-out of biosimilars and a

number of others. These will not only benefit patients (eg by providing care closer to home) but

will also provide significant cost savings for the NHS; and

• Additional challenges: following the success of the pharma challenge we are launching a

similar challenge on early diagnosis and digital infrastructutre to engage industry partners and

ensure that we are at the cutting edge of innovation and improvement.

We have agreement and alignment with our STPs on these clear priorities that will make the most

difference, and we understand which interventions will be truly transformational and impactful in

delivering the world class cancer outcomes our whole population needs and deserves.

4. Cancer Transformation Fund

We have applied for additional funding through the Cancer Transformation Fund, which would be a

unique opportunity to expand and accelerate the transformational changes we are looking to make. The

funding will support us in developing programmes to improve earlier diagnosis, increase access to

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stratified follow up and to implement the recovery package to improve the lives of those affected by

cancer. A summary of the key elements of our early diagnosis bid is below. Bids for the stratified follow up

and recovery elements have been developed pan-London (of a total value of £4.3m for 2017/18), to

ensure that we develop a consistent methodology but have the flexibility to deliver locally to address local

variation and needs.

5. Next steps

Confirmation of transformation funding is expected during the week commencing 13 March 2017. RM

Partners is working with all its stakeholders to develop a delivery plan which will set out project plans,

trajectories and milestones to deliver all of the relevant National Cancer Taskforce recommendations over

the next four years. This will have particular emphasis on diagnosing more cancers at stage 1 and 2,

rolling out the recovery package. and implementing risk stratified follow up pathways for breast, prostate

and colorectal patients in years 1 and 2. This delivery plan will be agreed by partners early in the financial

year 2017/18.

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The Council of Governors can expect to see more detail of the projects contained in the delivery plan [in

early 2017/18], and regular updates on progress to improve outcomes for the population of north west

and south west London thereafter. This will include more detailed proposals to develop a shadow lead

provider model across partners as these plans are developed.

6. Summary

RM Partners has made good progress in establishing itself as the cancer alliance for north west and south

west London, and in agreeing and aligning clinical priorities for cancer across partners within this

geographic area. There has been some considerable success in our initial projects which will result in

tangible benefits to patients and the health economy. We are also actively exploring different models of

organising services across multiple partners, and are developing plans to test a lead provider model over

the next year.

The injection of transformation funding for the financial year 2017/18 will enable us to make a step

change towards improving outcomes for our population, focusing on diagnosing cancer earlier. This is a

really exciting opportunity for RM Partners to lead a major transformation programme at pace across

partner organisations in west London. We are developing detailed plans for delivery of individual projects

and will report back to the Council of Governors on these plans our progress.

The Council of Governors is asked to note:

• Progress on development of RM Partners, including transformation proposals;

• Progress on development of the RM Partners delivery plan; and

• The next steps as set out in this report.

Nicola Hunt

Managing Director

RM Partners

March 2017



Agenda item 6

Title of Document:

Financial Plan 2017-19

To be presented by

Chief Financial Officer

Executive Summary The Chief Financial Officer will deliver a presentation on the Financial Plan 2017-19 which is due for submission at the end of March 2017.

Recommendations The Council of Governors is requested to note and discuss the Financial Plan 2017-19.

Author: Chief Financial Officer


Date: 13th February 2017

The Royal Marsden

Financial Plan 2017 – 2019 Council of Governors

March 2017

The Royal Marsden

Overview

Planning context

Financial plan

Conclusion and Recommendations

The Royal Marsden

Overview 3

The Board has reviewed the summary financial plan for 2017/18 at the February meeting and will approve the final plan at the end of March. The plan highlights a range of risks and these are acknowledged by the Board ahead of the final submission to NHS Improvement.

This paper provides the Council of Governors an overview of the plan presented to the Board reflecting the work of the Trust’s internal business planning process and external factors. It details the key planning assumptions and provides an analysis of the main financial risks and mitigating actions in relation to those risks.

There are two sections:

1. Planning context: this includes a recap of the requirements from the regulatory bodies (content and timeline) and our internal processes for planning;

2. Financial plan: this section covers an overview of the financial position with capital plan, movements from the draft plan alongside the underlying assumptions and risks.

The Royal Marsden

Overview

Planning context

NHS Improvement requirements

Internal process

Timeline

Financial plan


The Royal Marsden

NHS Improvements requirements 5

NHS Trusts are required to submit a two-year Operational Plan for 2017/18 to 2018/19, organisation-based but consistent with the five-year Sustainability and Transformation Plan (STP).

The five-year STP is place based and driving delivery of the Five Year Forward View. The initial five-year plan was submitted in June 2016 and has formed the basis for the two-year operational plan. Two-year contracts will reflect two-year activity, workforce and performance assumptions that are agreed and affordable within each local STP.

For this financial year the planning process was brought forward with guidance disseminated in September 2016 and draft operational plans submitted by end of December 2016. This was aligned with contracts being signed with Commissioners too. A final plan will be submitted to NHSI at the end of March following approval by the Board.

Continuing on from 2016/17 a sustainability and transformation fund (STF) is in place again for 2017/18. This has been allocated to providers based on their proportion of emergency care. After negotiation with NHS Improvement (NHSI) the Trust agreed the control total for 2016/17 and will receive a maximum of £1.5m based on financial and operational performance. There is an additional fund available for those organisations that can improve upon their control total.

For 2017/18, RMH has been allocated £1.8m, however this is contingent on a surplus (control total) of £3.3m. Based on the financial projections this is achievable so the Board decided to accept NHSI’s offer. In year achievement will be assessed quarterly by NHSI and will include financial and operational performance metrics as it has in 2016/17.

The Royal Marsden

Internal process 6

Guidance was issued in September 2016 on the two-year Operational Plan so the following process has been undertaken to deliver against the requirement set out in the guidance.

• Quarterly Performance Review Group (PRG) meetings currently occur for the clinical divisions throughout the year and at the half year for the non-clinical divisions. They are an opportunity to review each division’s financial position in more detail and share this with the executive team. These meetings form the basis of a rolling 12-month business planning process:

• underlying (normalised) run rate of expenditure and income are reviewed with a high level view of efficiency opportunities. The forecast for the following four quarters are reviewed, not just the period until the year end

• At the Q3 PRGs we reviewed plans for the following year including cost pressures and efficiency schemes.

• These PRGs acted as the Business Planning Panel, leading the process and reviewing plans developed by Directors for final approval.

• The Medical Director and Chief Nurse have been consulted on all efficiency schemes and proposed changes to service.

• Outside of the quarterly meetings there should be no changes to budgets unless a business case is approved. All business cases valued >£100k revenue and/or capital investment are now reviewed by Financial Strategy Group (FSG).

• The timetable of the process followed is set out on the following page.

The Royal Marsden

Timetable 7

Date Milestone October/November Q2 PRG meetings

November/December

CIP scheme development, ensuring liaison with support services effected. Underlying growth in NHS activity forecast by CBUs and provided to support services impacted.

End December Draft “top-down” plan submitted to NHSI.

January/February Q3 PRG meetings. Proposed “bottom-up” 2017/18 plans presented.

Late February Follow up Q3 PRG meetings to agree divisional plans.

9th March FSG review Financial Plan.

22nd March CoG review the draft financial plan. AFC review detailed financial plan for onward approval of the Board.

29th March Board presented with 2017/18 plan for approval.

End March Final plan submitted to NHSI.

The Royal Marsden

Overview

Planning context

Financial plan

I&E Summary

Assumptions

Capital expenditure

Balance Sheet

Risks


The Royal Marsden

Financial plan: I&E Summary 9

Plan Forecast Draft Plan Draft Plan

16/17 16/17 17/18 18/19NHS acute activity income 177,845 174,135 189,400 188,470 Community services income 17,145 16,048 21,915 21,315 Private patient income 89,534 92,282 96,800 105,000 Total income from patient care activities 284,524 282,465 308,115 314,785

Research and development 26,526 29,130 23,688 25,639 Education and training 6,961 6,491 5,939 6,784 Donations / grants for the purchase of capital assets 7,000 7,000 6,600 6,600 Charitable contributions to expenditure 10,890 8,813 15,289 11,096 Sustainability and Transformation Fund (STF) 1,500 4,025 1,847 1,847 Other 28,010 28,848 22,953 22,492 Total other operating income 80,888 84,307 76,316 74,458

Total Operating Income 365,411 366,772 384,431 389,243

Employee expenses 202,570 201,811 211,989 215,441 Drugs costs 70,704 65,788 71,397 74,620 Clinical and non-clinical supplies and services 31,396 42,809 35,351 35,292 Other 39,029 31,004 40,790 36,982 Total Operating Expenditure 343,698 341,412 359,527 362,335

Operating Surplus 21,713 25,360 24,904 26,908

Depreciation/Amortisation 13,984 13,600 14,910 14,363 Net Finance expense 199 215 197 163 PDC dividends payable 5,115 4,500 3,900 5,133

SURPLUS FOR THE YEAR 2,415 7,045 5,897 7,249

Remove capital donations/grants I&E impact 3,384- 3,000- 2,490- 2,165- Adjusted financial performance surplus/(deficit) 969- 4,045 3,407 5,084 Control totals for planning years 969- 969- 3,336 5,067 Performance against control total - 5,014 71 17 Underlying financial performance less STF 2,469- 20 1,560 3,237

The Royal Marsden 10

Income & Expenditure Summary RMH has set a small surplus for 2017/18, which would deliver a £14m “development reserve for investment” to help fund the Trust’s capital programme.

The key changes from the 2016/17 forecast outturn to the 2017/18 plan are as follows: 1) An increase in NHS Clinical Income due to the following main areas; national tariff pricing

including specialist top-ups; local prices recognised within contracts; growth in some key areas e.g. chemo attendances.

2) Additional Private Care Income as per the agreed growth strategy approved by Governors. 3) A reduction in R&D Income due to the loss of £4m BRC, partly mitigated through increased

commercial trial income and alternative grant income. 4) An increase in Provider-to-Provider Income through maximisation of commercial

opportunities. 5) Additional Employee expenses as a result of investments and inflation as well as the new

apprenticeship levy. 6) An increase in non-pay expenses relating to drugs, which in the main is due to growth in

both NHS and Private activity. Further inflationary increases are also budgeted in all non-pay areas.

CIPs schemes over £100k are identified and tracked separately. Their delivery will be monitored monthly through PRG.

The Royal Marsden

Financial plan: I&E Assumptions 11

The table below sets out the main assumptions underpinning the financial plan:

Area Assumption

NHS income 0.1% Tariff Inflator (2.1% cost inflation less 2% efficiency)

Pay costs 2.1% inflation plus changes in pension costs

Drug Costs 2.8% inflation in both income and spend

Other Non-Pay Costs 1.8% inflation

Donated asset income Initial assessment, dependent on timing of key schemes

Depreciation Increase due to the revaluation of the estate impacting asset lives

Dividends Reduction due to revaluation of the estate

BRC allocation Reduction in funding of £4m

CIPs (Revenue & Cost) 3% for clinical areas and 5% for non-clinical areas

The Royal Marsden

Financial plan: Capital expenditure 12

The capital plan for the next three years was reviewed at the February Board prioritising the investment in IT in the main to replace the EPR.

The table below sets out the capital plan for 2017/18 to 2018/19.

2016/17

Plan

2016/17 Forecast Outturn

2017/18 Plan

2018/19 Plan

Internally Financed £'000 £'000 £'000 £’000

IT Schemes 4,059 3,330 3,000 3,000

Backlog & Minor Works 1,250 1,216 1,200 1,200

Private Patients 3,803 3,265 0 0

Estates 5,196 5,195 1,300 1,750

Medical Equipment 500 798 500 500

Other schemes/Contingency 25 138 1,800 800

14,833 13,942 7,800 7,250 Donated Income Financed

Medical Equipment 4,950 4,916 3,500 3,500

Estates (inc. CCRC) 2,050 2,084 3,100 3,100

7,000 7,000 6,600 6,600

ITFF Loan Financed Schemes 301 301 600 5,800

Total Capex 22,134 21,243 15,000 19,650

The Royal Marsden

Financial plan: Risks 13

The table below sets out the main financial risks and mitigating actions in the financial plan:

Risk Mitigation

Risk £m

2017/19 NHS Commissioner Contracts

Risk in local price income increase in plan as not yet fully agreed

Significant progress made in a number of areas with a 2016/17 positive settlement secured and a contract value and principles agreed with NHSE. CCGs are yet to agree and sign the contract for 2017/19.

<£5m

Private Care Strategy

Risk that growth is not delivered

Risk to cash flow as growth expected through shift from UK sponsored to embassy activity

Strategic plan developed and marketing plan agreed.

International Patient Manager in place to develop relationships with Embassies to improve payment.

Monthly review of debt in Performance Review Group.

<£5m

BRC reduced award

Significant reduction in BRC funding from 2016/17.

Plans to mitigate this through increased funding from alternative sources as well as cost efficiencies so volume of research does not significantly decline.

<£2.5m


Risk Mitigation Risk £m

Junior Doctor position

Deanery discussions to reduce workload of Junior Doctors and remove Private Care caseload.

Unknown cost impact of all new Junior Doctor contracts.

Junior Medical Workforce Plan in development with a contingency set aside to fund this.

Workforce reviewing all communications on new contracts so an impact assessment can be performed as soon as an agreement is reached. No significant cost pressure identified thus far.

<£0.5m

Temporary Staffing Costs

CIPS have been identified to reduce usage and rate reduction. Pressure to maintain this position esp. if other London Trusts do not adhere to the NHSI price caps.

Controls on agency usage continue with close monitoring in both Performance Review Group and the Temporary Staffing Board.

Adherence to price caps being enforced with agencies, internally and liaison with London Trusts and NHSI to maintain the wider position.

<£0.5m

Undeveloped CIP schemes

Not all CIP schemes have been fully developed.

Regular meetings with all divisional heads are occurring to drive the development of these plans.

<£2.5m

Financial plan: Risks Continued

The Royal Marsden

Financial plan: Medium Term Risks 15

Medium Term Risks Mitigation

Capital Prioritisation Internally financed capital is insufficient to fund all capital requirements.

Capital requests are collated and measured against a prioritisation matrix to assess selection for funding. Charitable funds are being sought for specific items of Medical Equipment as well as the funding from National Programmes particularly for IT.

Vanguard As host of RM Partners, RMH will receive a number of transformation and other monies for the delivery of initiatives across the patch. The risks are that costs may exceed funding and RMH may be responsible for the shortfall.

Initiative budgets to be reviewed by Finance and performance monitored on a monthly basis. Contingency to be built into budgets to support overruns. Initiatives to be agreed on a fixed cost basis so RMH will not accept activity risk.

The Royal Marsden

Overview

Planning context

Financial plan




There is a great deal of financial pressure currently in the sector which has caused uncertainty and resulted in a not insignificant level of risk in the proposed financial plan. These risks have been identified and are being managed, but none the less remain within this financial plan.

The Council of Governors are asked to note the following:

The draft financial plan for 2017/18 was submitted to NHSI in December. The final plan subject to Board approval will be submitted to NHSI at the end of March. The key elements of the plan are as follows:

• Delivering the control total of £3.3m surplus;

• Capital Investment of £15m;

• A number of risks as outlined in the plan.



Agenda item 7.1

Title of Document:

Membership Recruitment and Engagement Strategy 2017-2018

To be presented by

Governors Carol Joseph and Fiona Stewart

Executive Summary The purpose of Membership Recruitment and Engagement Strategy is to outline the ways in which The Royal Marsden will recruit and engage with its members for 2017-18. The Membership & Communications Group, a working group of the Council of Governors, is responsible for the implementation of the Membership Recruitment and Engagement Strategy and who regularly review and monitor the progress of this. Recommendations The Council of Governors is asked to approve the Membership Recruitment and Engagement Strategy.

Author: Trust Secretary / Membership & Communicati0ns Group



1

Membership Recruitment and Engagement Strategy

1. Purpose The purpose of this Strategy is to outline the ways in which The Royal Marsden will recruit and engage with its members for 2017/18.

2. Becoming a Member 2.1 Who can become a member of The Royal Marsden?

Anyone aged 16 years old or over and lives in England can become a member of The Royal Marsden. The Trust has defined England as the geographical boundary for its membership constituencies for public, patient and carer, thus reflecting the patient profile of the Trust. The membership is split into the following three constituencies:

• Patient and carer membership The Patient constituency is subdivided into three geographical areas: Kensington & Chelsea and Sutton & Merton, Elsewhere in London, and Elsewhere in England. Anyone living in these areas, who has been a patient at the Trust within the last five years can become a member of the relevant patient sub-constituency. In addition, there is a carer sub-constituency which is open to individuals who class themselves as carers of a current or former patient within the last five years.

• Public membership The Public constituency comprises individuals who live within the three geographical areas of the Kensington and Chelsea, London Boroughs of Sutton and Merton, and Elsewhere in England.

• Staff membership The Staff constituency comprises individuals who are employed by the Trust, hold an honorary contract with the Trust or hold an honorary contract with the Trust and the Institute of Cancer Research. Upon joining the Trust, staff will become members of the Trust automatically unless they choose to opt-out. The constituency is divided into five staff groups: Corporate and Support Services, Clinical Professionals, Doctor, and Nurse.

3. Membership Recruitment 3.1 Membership numbers

As of 2nd February 2017, the Trust has 8,080 members, comprising the following constituencies:

• 1,554 Patient/Carer members • 3,228 Public members • 3,298 Staff members

3.2 Current recruitment initiatives

It’s important to provide a simple and seamless process in becoming a member. The Trust currently promotes membership through:

• The Trust website : dedicated FT Membership Pages including an online application form • Membership application forms on display across both sites • RM magazine - advertising membership in every edition

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• Trust information screens across both sites • Promoting Trust membership in official Trust literature and patient information • Volunteers - The Friends of The Royal Marsden to ensure these are recruited as members • Governors visiting local schools to promote the work of the Trust amongst young adults while

encouraging them to become members • Holding an annual Members’ Week led by the Governors • Member get member: encouraging existing members through communications and events to

invite anyone they know who is interested in RM to become a member • Welcome letters being sent from the Chief Executive to new patients at the point of

registration and at different stages of the patient pathway inviting them to become a member • Membership application forms being handed to patients when collecting their prescriptions

onsite at the hospital.

3.3 Recruitment options to be considered

• Automatically opting in new patients at registration who are residents in England • Approaching the volunteers of The Royal Marsden Friends to be membership champions • Promoting membership to Cancer related organisations • Promoting to students of The Royal Marsden School.

3.4 Representative membership

Our overall aim is to not only increase our membership but ensure it is representative of the various communities served by The Royal Marsden, spread across different age groups, ethnicities and socio-economic categories, for example, encouraging young adults to become members (under the age of 21). The Trust Equality and Diversity Lead will be invited to attend relevant Membership and Communications Group meetings to provide advice and expertise to the Group on how to ensure representative membership base. 4. Engagement 4.1 Level of involvement

The Trust recognises that not all members can be or want to be active members; the Trust has two levels of membership to help determine each member’s level of involvement and allows the Trust to manage resources more effectively.

Level 1

Level 2

Invited to stand in elections

Vote in elections

Receive RM magazine

(excluding Staff Members)

Personal invites to events

Notified of annual review

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Invited to participate in surveys and consultations

Invited to focus groups

Invited to AGM

(Staff Members invited)

4.2 Current membership engagement initiatives

• Membership mailings - All patient/carer and public members receive a minimum of 4 mailings a year which includes a covering letter from their relevant governor(s), a copy of RM magazine and details of forthcoming events (e.g. Members’ Events, Annual General Meeting etc.) and other ad hoc engagement opportunities.

• E-bulletins - Members who have given their email addresses receive an e-copy of RM

magazine and ad hoc information e.g. Surveys as well as information about forthcoming events and engagement opportunities for members.

• The Trusts website - The Membership & Communications Group is reviewing the

membership and Council of Governors pages with the digital team to see if they can make them look more appealing.

• Welcome Pack - All new registered members receive a welcome pack which includes; a copy

of the latest RM Magazine, letter from the Chairman re: Governors, info re: membership and the two levels of membership, key contacts and My Trust Benefits.

• Members’ Events – Level two members are invited to attend members event which are held 3 times a year and range from clinical presentations to behind-the scenes tours of the hospital.

• Elections - When a vacancy arises on the Council of Governors all members within the

constituency are written to advising them an election will be held and inviting them to stand and/or vote.

4.3 Proposed membership engagement initiatives

To explore ways to encourage more involvement and engagement with members:

• Identifying more initiatives where members can be used as a source of feedback and for

members to engage in Trust work.

• To encourage staff Governors to establish methods of communicating with their members using a variety of formats, such as: bulletins, holding staff governor meetings whereby updating staff on information following Council of Governors meetings, including information within staff Trust induction packs re. membership and Governor information.

5. Strategy review and evaluation The Membership and Communications Group will regularly review their action plan to monitor progress of the implementation of this Strategy. A summary report will be presented to the Council of Governors on an annual basis by the Governor co-chair of this Group.



Agenda item 7.2

Title of Document:

Governors Report on Members’ Week

To be presented by

Governors Carol Joseph and Fiona Stewart

Executive Summary As part of the drive to increase membership and engagement at the Trust, and as outlined in the Membership Recruitment and Engagement Strategy, the Membership and Communications Group agreed to hold a Members’ Week in March this year at both the Sutton and Chelsea sites which was a Governor led activity. This paper provides a summary and outline of activities for the week and a verbal update on the outcome of Members’ Week will be given at the Council of Governors meeting. Recommendations The Council of Governors is asked to note and discuss the outcome of Members’ Week. Author: Governors Fiona Stewart and Carol Joseph

Contact Number or E-mail:


Members’ Week: 13th to 19th March 2017

As part of the drive to increase membership and engagement at the Trust, and as outlined in the Membership Recruitment and Engagement Strategy, the Membership and Communications Group agreed to hold a Members’ Week in March this year at both the Sutton and Chelsea sites. All Governors were invited to attend two open meetings of the Membership & Communications Group to discuss plans for the week. The arrangements put in place are as follows:

• A centrally placed Membership stall will be at both the Sutton and Chelsea sites, manned by Governors and displaying membership application forms, posters, noticeboards and merchandise

• Governors also agreed to visit various outpatient areas (e.g. Radiotherapy, Chemotherapy, Outpatients, Transport and Pharmacy Departments) to explain to people the advantages of membership and help those interested complete the application form

• On Friday 17th March in the Chelsea Boardroom, Governors are due to hold a drop-in session to meet existing and potential members. The screens in the Boardroom will display video clips and photographs about the hospital’s work

• Posters advertising Members’ Week and the benefits of membership (including MyTrustBenefits) will be on show at the main entrances of the Hospital and also on noticeboards across both sites.

• Details of Members’ Events will be available together with a selection of RM magazines

• Governors will wear a ‘Governor’ sash as they tour the Hospital • Promotional merchandise will be available to hand out to for those who sign

up as members – pens and post-it notes. All applications to become a member during Members’ Week are eligible for a prize draw to win John Lewis vouchers

• The Trust’s Twitter account and the staff intranet will give updates about Members’ Week

• In addition, several Governors are taking part in the Marsden March on Sunday 19th March and will continue their recruitment drive during the walk. A Membership stall will be set up at the finish in Sutton.

The current membership recruitment drive, and the organisation and planning of Members’ Week, has been Governor-led, but we are very grateful to the support provided by the Member & Governor Lead, Rebecca Hudson and the Trust’s Marketing & Communications team. A further update on the outcome of Members’ Week will be given at the Council of Governors meeting.



Agenda item 8

Title of Document:

Nominations Committee Report

To be presented by

Chairman

Executive Summary The Council of Governors will receive separate reports regarding the business of the Nominations Committee. Recommendations The Council of Governors is asked to approve the recommendations of the Nominations Committee with regard to the reappointment of NEDs Ian Farmer and Professor Dame Janet Husband and to approve the recruitment process and documentation for a new Clinical NED to replace Dame Nancy Hallett.

Author: Trust Secretary





Agenda item 9.1

Title of Document:

Financial Performance Report

To be presented by

Chief Financial Officer

Executive Summary The Trust had a favourable variance in its financial performance for the month when removing the fixed assets impairment. There are a number of risks still to be managed through to year end in order to deliver upon the revised control total. Recommendations To note the performance to the end of month 10.

Author: Chief Financial Officer



Summary Financial Performance Report for 10 Months to January 2017

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1. Introduction

The paper provides a summary of the financial position to date for the financial year 2016/17. The reporting format within this paper provides consistent reporting to all Trust Committees. The Trust Board is requested to note the contents of this report and the risks highlighted.

2. Summary Financial Position

Key headlines

Month 10: o Operating surplus of £2,762k, a favourable variance of £1,346k o Retained deficit of £27.8m, an adverse variance of £27.6m o Agency expenditure of £515k, a favourable variance against the cap of £241k o CIP delivered of £1,332k, a favourable variance of £187k

Year-to-date: o Operating surplus of £12.3m, a favourable variance of £1.5m o Retained deficit of £27.1m, an adverse variance of £28.6m o Agency expenditure of £6.3m, a favourable variance against the cap of £1.2m o CIP delivered of £8.7m, a favourable variance of £0.1m o Capital expenditure of £14.8m, a favourable variance of £5.2m o Cash in bank of £11.8m, an adverse variance of £5.6m

In the month of January the Trust had a deficit of £27.8m, an adverse variance against the plan of £27.6m. This was entirely due to an impairment of £29.3m on fixed assets in the month due to the revaluation of the Trust’s estate using the modern equivalent asset valuation methodology. In month, excluding Private Care income, there were minor variances on income and expenditure which net to a small favourable variance on the operating surplus.

Private Care income was a favourable variance in month of £1.1m and is £8m year on year favourable variance to the same point as last year, as well as £2.9m favourable to plan. The main variance in Other Operating Income was on Commercial Trials, which was £0.5m adverse in month. Overall income was £0.6m favourable in the month and is now £0.8m favourable year-to-date. On expenditure, agency usage was £0.5m in month, broadly flat compared with the previous month. YTD the Trust is now £1.2m under the spend cap and only 183 shifts breached the rate cap in month, which is low when benchmarked against other London Trusts and down from the figure in December. These shifts were all Medical and Nursing and only framework agencies continue to be used. Overall pay expenditure was £0.3m favourable to plan in month. The Single Oversight Framework was implemented by NHSI on 1st October 2016. In this the Financial Risk Rating has been replaced with a Use of Resources Rating. The segments have been reversed, with 1 representing providers afforded maximum autonomy to 4 representing providers in special measures. The Trust delivered a Use of Resources rating of 1, against a plan of 2. The details are in appendix 1.

The Key Financial Risks and Issues have been highlighted during the year and relate to the 2016/17 plan, which was discussed at the Board in March 2016. These are updated as follows:

NHS Commissioner Contracts – the Trust requested that local prices are re-based as per the Monitor (NHSI) framework so that the income covers the cost of the services provided. In addition, the Trust runs 25 MDTs a week for which it receives only a small contribution towards four of them. The final report was received in October 2016 and there has been an agreed outcome for 2016/17 plus good discussions on their implementation for 2017/18.

Private Care Strategy – there has been significant growth in the past few years on income, however the embassy work does fluctuate and other areas are being pursued to continue the growth alongside the additional capacity that opened in September. The main issue with embassy growth is the slowness of payment increasing the debt levels again this year.


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Junior doctors’ contract – the Trust has taken the national guidance that the contract is cost neutral for providers. The rotas have now been reviewed with some initial impact upon the Trust which will impact in the new financial year when the main rotas are changed.

Temporary staffing – controls are in place and have been for several months. This is ensuring the cap imposed upon the Trust is being met. The cap will be achieved this financial year due to the continued controls in place and this will need to continue into 2017/18 as the cap will be in place next year too.

3. Income and Expenditure

The Income and Expenditure position for the Trust, in month, year-to-date and the forecast is set out in Appendix 1.

Income – The income position in month 10 was £0.7m favourable variance. NHS Clinical Income was favourable to plan in month due to overperformance in inpatient admissions, BMTs and critical care. The continued underspend in the Cancer Drug Fund is partially offset by High Cost Drugs pass-through income.

Private Care was above plan in month with a favourable variance of £1.1m. The year on year increase is now at £8m and with the investment in new facilities Private Care income is expected to continue its growth. At month 10 it is £2.9m favourable variance year-to-date. Additional resources and processes improvements have reduced the billing lag but this has not impacted debt levels. The total private debt is now at £27.1m an increase of £3.0m since the beginning of the year. The trend chart below shows actual income compared to the 2016/17 plan, alongside 2015/16 and 2014/15 income levels.

£8.0

£9.0

£10.0

£11.0

£12.0

£13.0

£14.0

£15.0

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

NHS Acute Income for 2016/17

Acutal 14/15 Actual 15/16 Actual 16/17 Plan 16/17 Forecast 16/17


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The remaining key variance on income in month is £0.5m adverse on Commercial Trials which despite this adverse variance in month is still favourable for the year. Pay expenditure – was a favourable variance of £0.3m in month compared to the plan and is now £1.3m underspent year-to-date. The two charts below provide pay and temporary staffing data for 2016/17. Costs were under plan for January, with the amount spent on agency continuing to be under the cap imposed before the start of the year by NHSI. Agency usage was low again in January and the year on year reduction in agency spend is £3m. There are a few areas that have been consistent in their usage of agency across the year as recruitment remains a national issue; junior doctors, theatres and CCU staff, community nurses and AHPs. Other areas of usage have been managed down all year with any usage in the corporate divisions requiring COO approval. The first chart shows total pay costs against the budget by month. The second chart reflects the bank and agency usage. The focus on agency staffing spend continues with NHSI requiring weekly reporting and the Trust has a spend cap that it is required to work towards as well as caps on agency rates for suppliers. The Trust is expected to utilise only agencies that apply the caps in rates. There were 183 cap shift breaches recorded in January. The Trust is working with individuals and encouraging them to convert to the internal staff bank where feasible. In month the expenditure was 3%, below the NHSI cap by £241k (Appendix 2, chart 2.2). The controls, initiatives and monitoring tools are continuing to keep this spend under control as the Trust is now £1.2m under the cap.

£-

£1.0

£2.0

£3.0

£4.0

£5.0

£6.0

£7.0

£8.0

£9.0

£10.0


Private Care Income for 2016/17

Acutal 14/15 Actual 15/16 Actual 16/17 Plan 16/17 Forecast 16/17


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Non-pay expenditure – was a favourable variance of £0.4m to plan in month and is now £0.6m adverse variance YTD. The position in January was driven by an underspend in drugs due to a reduction in the cancer drug fund activity, with the year-to-date underspend being £2.7m. Additional Private Care activity and drugs spend only partially offset this position. Other expenditure in month was a favourable variance of £0.1m, which relates to unspent inflation reserves and small variances, both favourable and adverse, in the timing of spend versus budget.

In January, the estate was re-valued by the new Trust valuers, Montagu Evans. Valuation techniques and the assumptions therein evolve over time, so a fresh review has been conducted. Using the modern equivalent asset valuation methodology, the carrying value of the estate was reduced by £52m, with £29m being taken to the I&E as non-operating expenditure and £23m to the Revaluation Reserve. This lowered valuation impacts the Public Dividend Capital (PDC) calculation with a full year effect of a £1.2m saving, half of which will be realised in 2016/17.

£13.0

£14.0

£15.0

£16.0

£17.0

£18.0

£19.0

Pay Cost Trend

Substantive Bank Agency Pay Budget


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4. Efficiency Programme

The Trust was favourable to plan in month for the efficiency programme and is now £120k ahead of the targeted CIP programme year-to-date and is expected to deliver the overall programme for the financial year. Overall the Trust has delivered £8.7m of savings year-to-date and continues to focus on efficient delivery of services. The CIP position is presented in Appendix 2, chart 2.1.

5. Capital Expenditure

Capital expenditure totals £14.8m as at the end of January which is a favourable variance of £5.2m YTD. There is no clinical risk impact with the slippage of any schemes, with timing differences in spend on the large Estates projects driving the main YTD variance with IT schemes being the remaining variance.

6. Cash and Debt

Cash – The Trust ended January with £11.8m cash in the bank, an adverse variance of £5.6m against the plan. Chart 2.3 in Appendix 2 shows the trend of cash balances in the last four months and the forecast and plan for the next 12 months. There were a number of delayed payments in January that were paid in early February, so the January position is artificially low. Debt – Invoices raised but not yet paid have increased in month by £7.1m to £60.8m at the end of January. This was driven in the main by an increase in NHS debt and a lack of payment from organisations in January, which has been recovered in February. There have been particular issues with NHSE paying a number of invoices that are direct pass-through payments, which was resolved in February. Private Care debt increased in month as an expected payment from one of the embassies was not made. Chart 2.4 in Appendix 2 provides a trend of debtor balances for the last twelve months by age of debt, which shows the increase in debt over 90 days, the majority of which is with embassies.

7. Conclusion and Recommendation

Month 10 performance overall was favourable to plan when removing the variance due to the impairment. This performance needs to continue through the remaining months of the year and the Trust will deliver the control total set by NHSI. The Trust Board is requested to note

The financial performance as at month 10;

The continued risks highlighted in section 2.

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Budget Actual Var Budget Actual Var Actual Var Budget Var 1516 Q4 1617 Q1 1617 Q2 1617 Q3

£'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000

Income Actual Actual Actual Actual

NHS Clinical Income (16,291) (16,342) (51) (161,938) (159,324) 2,614 (172,312) 12,988 (195,406) 1,198 (18,537) (16,080) (15,849) (15,731)

Non NHS Clinical Income (7,800) (8,868) (1,069) (73,655) (76,586) (2,930) (68,564) (8,022) (89,570) (2,712) (7,282) (7,446) (7,321) (7,806)

Non Clinical Income (6,222) (5,755) 468 (61,083) (61,578) (495) (57,571) (4,007) (73,589) 307 (7,047) (6,003) (6,198) (6,407)

(30,313) (30,965) (652) (296,677) (297,488) (811) (298,447) 959 (358,565) (1,206) (32,866) (29,529) (29,368) (29,944)

Expenditure

Pay 17,083 16,775 (309) 168,719 167,411 (1,308) 170,823 (3,412) 202,838 (1,027) 17,672 16,724 16,643 16,846

Non Pay 11,814 11,428 (386) 117,119 117,753 634 116,407 1,346 141,015 (1,414) 13,634 11,591 11,702 12,148

28,897 28,203 (695) 285,838 285,164 (674) 287,230 (2,066) 343,853 (2,440) 31,305 28,315 28,345 28,994

Operating Surplus (1,416) (2,762) (1,346) (10,838) (12,324) (1,485) (11,217) (1,107) (14,712) (3,647) (1,561) (1,214) (1,023) (950)

PDC, Interest, JV 449 69 (380) 4,417 4,361 (56) 4,072 288 5,313 (598) 343 433 507 491

Development Reserve for Inv (967) (2,693) (1,726) (6,421) (7,963) (1,541) (7,144) (819) (9,399) (4,245) (1,218) (781) (516) (459) -

Donated Asset Income (82) (77) 5 (6,774) (5,289) 1,485 (4,419) (870) (7,000) - (565) (408) (1,298) (31)

Depreciation 1,217 1,290 73 11,668 11,085 (583) 10,858 227 13,984 (384) 1,142 1,067 1,097 1,101

Loss Disposal Fixed Assets - - - - (2) (2) 98 (100) - (2) - - - (1)

Impairment - 29,260 29,260 - 29,260 29,260 1,487 27,773 - - 653 - - -

Retained Surplus 168 27,779 27,611 (1,527) 27,091 28,619 879 26,212 (2,415) (4,631) 12 (123) (717) 610

Use of Resources Rating Plan Y TD Actual Y TD

Liquidity 2 1 (1) - Liquidity = Cash for l iquidity purposes (net current assets excluding inventories) divided by operating expenditure expressed in days

Capital Debt Cover Ratio 2 2

I&E Margin 3 2

Variance From Plan 2 1 (3) - I&E Margin - degree to which the Trust is operating at a surplus / deficit

Agency Spend 1 1 (4) - Variance between the Trust's planned I&E Margin and its actual I&E Margin year to date

Use of Resources Rating 2 1 (5) - Distance from the Trust's agency spend cap

The Trust delivered a £28m deficit in January due to an estates revaluation resulting in an asset impairment. Before the impact of the impairment, the Trust delivered a £1.5m surplus, £1.6m favourable to plan. This was driven by

strong PP income, cost control and lower PDC costs as a result of the impairment.

This brought the YTD variance (pre-impairment) to £0.6m favourable to plan which is forecast to improve to £4.6m favourable to plan by year-end (exceeding the NHSI Control Total by £5m). Trust overpeformance of £2.5m

against the Control Total has been forecast (due to the drivers mentioned above) and matched by £2.5m of additional STF monies.

Agency usage was 3%, similar to previous months, with 183 shifts exceeding the NHSI cap in month (Medical only). This is low when benchmarked against other London Trusts (5th lowest agency % in London out of 36 Trusts).

Only framework agencies continue to be used and the Trust is £1.2m below the NHSI agency spend cap.

This delivers a YTD Use of Resources Rating of 1, compared to a plan of 2.

Appendix 1: Income and Expenditure

In Month Year to Date Year - 2016/17 Average Monthly Run RatesPrior Year to Date

N.B. In Budget and Actual Columns, Income is shown in brackets, Costs are without brackets. In Variance Columns, Red is an Adverse

Variance and Black a Favourable Variance.

(2) - Capital Debt Cover Ratio = revenue available for debt servicing (EBITDA plus interest receivable) divided by annual debt (PDC

Dividends, Loan repayments, Loan interest)

-20

-15

-10

-5

0

5

10

15

20


1.1 Liquidity Ratio 2015/16 (1)

-1

0

1

2

3

4


1.2 Capital Debt Cover 2015/16 (2)

-2%

-1%

0%

1%

2%


1.3 I&E Margin 2015/16 (3)

-3%

-2%

-1%

0%

1%

2%


1.4 Variance from plan (4)

-20%

0%

20%

40%

60%

1.5 Agency Spend Variance to cap 2016/17 (5)

4

3

2

1

Actual

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Appendix 2: CIPs, Capital, Debt and Cash

Efficiency programme - The Trust reported that it is ahead of plan in month and year to date January 2017. Private Care Schemes to increase prices have delivered additional income

which has offset slippage on their Business Case schemes. Increased savings in Estates and Cancer Services, is offsetting the pay and procurement CIPs in Clinical Services that are

slipping. The Q3 Forecast is that the Trust will exceed the CIP programme by year end.

Agency - the £756k NHSI monthly cap was met in month showing a steady reduction since the start of the year. The Trust is now £1.2m under the cap YTD. High but reducing spend

continues in Community and Clinical Services, so biweekly meetings are being conducted with management to control and monitor this position, which is bringing spend down.

Cash - the cash balance decreased to £11.8m in January, £5.6m behind plan. The lower opening position and increasing debt was only partially offset by slower capital spend.

Debt - invoices raised to customers not yet paid has increased by £7.1m in January to £60.9m. All debt increased in month as commissioner contracts were finalised so overperformance

was billed and increased activity in Private Care drove more billing. Significant sums have subsequently been paid in February to reduce this debt position.

£-

£2.0

£4.0 £6.0 £8.0

£10.0

£12.0

£14.0

£16.0 £18.0 £20.0

2.3 Cash Balance

Actual Forecast Plan

£1

4.2

£1

3.5

£1

4.1

£1

8.4

£1

8.6

£1

5.3

£1

5.6

£1

6.2

£1

7.6

£1

9.1

£2

0.4

£1

9.3

£1

4.5

£1

5.3

£1

4.3

£1

1.7

£1

6.2

£1

3.9

£1

2.5

£1

4.3

£9

.3

£1

3.0

£1

3.9

£1

9.9

£-

£10.0

£20.0

£30.0

£40.0

£50.0

£60.0

£70.02.4 Debtors - Aging over time

>365 90-365 30-90 0-30



Agenda item 9.2

Title of Document:

Quality Account for October – December 2016

To be presented by

Chief Nurse

Executive Summary The monthly Quality Account reports the current Trust performance against the targets for 2016/17 described in the Annual Quality Account (2015/16) under the following three nationally agreed categories:

• Safe care; • Effective Care; and • Patient Experience

The report highlights good performance in many of the key areas:

• Pressure Ulcers: August 2016 - no category 4 pressure ulcers reported for this period. • Continued reducing trend in attributable patient falls. • Friends and Family Test – excellent response rate with for this reporting period, in-

patients -96%, Outpatients 93% and Community 95% would recommend RM to family and friends all, above the national average.

Area of note:

• A new easier to use ‘medicine near-miss’ reporting system has been launched, this new process has yielded a 147% increase in ‘near miss medication incidents’ reported in this period. It is important to note that despite the increase in overall reporting – the incidence of harm events has not increased.

Recommendations The Council of Governors is invited to note the performance of the Trust against the agreed national and local quality targets for October-December 2016 and the actions being taken.

Author: Chief Nurse



1

The Royal Marsden NHS Foundation Trust Quality Account for October, November and December 2016

1.0. Introduction

The monthly Quality Account reports the current Trust performance against the targets for 2016/17 described in the Annual Quality Account (2016/7) under the following three nationally agreed categories:

• Safe care • Effective care • Improved Patient experience.

1.1. Data Quality Information and data at the Royal Marsden is produced by a centralised expert team separate from the clinical and operational teams. This separation and expertise is critical to ensure that the data is accurate and is not affected by the operational teams who are trying to comply with local and national improvement targets. All healthcare associated incidents, falls, medication incidents and pressure ulcers are reported locally onto the central Datix incident reporting system. The Datix analyst from the risk management team who is separate to the clinical care team compiles the reports for the quality account. All falls and medication incidents are also reviewed by subject matter experts to ensure accuracy and learning from themes. Every month a report is generated for each clinical area and if there is a reduction in reporting there is a central and local alert with action taken.

2.0. Safe Care

2.1. Reduction in Healthcare Associated Infections (MRSA bactereamia and C Difficile infections)

Target: <31 C Difficile infections and <1 MRSA bactereamia

The NHSE guidelines on reporting of C.Dificile infection (CDI) allows commissioners to use discretion as to whether a case is considered against the trajectory. Only cases deemed as a ‘lapse in care’ are attributed against the objective number (for the RM in 16/17 =31 cases). Where a Trust can demonstrate that the case is a single isolated case, or there are sound clinical reasons which may lead to CDI (such as chemotherapy or gut surgery) and that procedures have been correctly followed including antibiotic prescribing, hand hygiene, device care and environmental cleaning, then the commissioners are able to exclude the case from trajectory numbers. The C. difficile toxin objective for 2016/17 has been set at 31 again this year. In 15/16 there were two cases that were categorised as “lapse in care” by the commissioners and therefore counted against the trajectory of 31.

2

Table 2.1

Organism RM attributable October 2016

RM attributable November 2016

RM attributable December 2016

YTD Trajectory

MRSA

bactereamia

0 0 1 0*

C.Difficile

3 4 5 41 31

2.2. Rate of patient safety incidents and percentage resulting in severe harm or death

To include: • Reduction of severe/moderate risk medication errors • Reduction of harm from falls

Target: Reduction in the rate of patient safety incidents per 100 admissions and the proportion that have resulted in severe harm or death

2.3. Reduction in Falls Target: < 0.7 moderate and above (resulting in harm) falls per 1000 bed days Year to date - to the end December 2016 the Trust has met the target.

5

Severity of Patient Fall incidents: 3 - Severity - Current Period

2016 01 2016 02 2016 03 2016 04 2016 05 2016 06 2016 07 2016 08 2016 09 2016 10 2016 11 2016 12 TotalNo Harm 18 18 24 10 18 12 13 13 11 15 17 7 176Low / Minor (Minimal harm) 5 8 13 9 7 5 6 3 4 8 6 7 81Moderate (Short term harm) 1 1 0 0 0 0 1 0 0 1 0 0 4Severe / Major (Permanent or long term harm) 0 0 0 0 0 0 0 0 0 0 0 0 0Death / Catastrophic (Caused by the incident) 0 0 0 0 0 0 0 0 0 0 0 0 0Totals: 24 27 37 19 25 17 20 16 15 24 23 14 261% Harm Patient Fall 25% 33% 35% 47% 28% 29% 35% 19% 27% 38% 26% 50% 33% 2.4. Reduction in medication errors Target: To increase the reporting of near misses and decrease the incidents that cause actual harm (low<2 per 1000 bed days and moderate <0.17 per 1000 bed days). N.B. To place medication errors in perspective, annually 0.09% of all medicines administered result in a medication error. For December 2016, the figure is 0.09%. There has been an increase of 147% in medication incidents categorised as near miss in comparison to the same period in 2015/2016. A streamlined near miss reporting method utilising the current IT system has now been imbedded. The Pharmacy department has been raising awareness on reporting near misses and a plan has been agreed at the Executive Medication Safety Group to increase identification and reporting to ensure the organisation has meaningful data to help improve the management of systems thus, reducing risk and increasing safety. In the current period, 1365 attributable medication incidents have been reported using the IT system Datix, of which 74% caused no harm. 395 incidents have been categorised as low severity and 8 incidents as moderate severity (resulting in harm), this represents 6.6 and 0.13 medication incidents per 1000 bed days respectively. As such, the Trust has missed the target relating to low severity medication incidents, however the target relating to moderate severity incidents has been met.

8

Severity of medication incidents:

3 - Severity - Current Period2016 01 2016 02 2016 03 2016 04 2015 05 2016 06 2016 07 2016 08 2016 09 2016 10 2016 11 2016 12 Total

No Harm 77 105 90 89 71 77 74 71 71 85 81 71 962Low / Minor (Minimal harm) 30 28 46 27 33 39 33 27 25 28 46 33 395Moderate (Short term harm) 1 1 1 0 0 0 2 0 0 2 0 1 8Severe / Major (Permanent or long term harm) 0 0 0 0 0 0 0 0 0 0 0 0 0Death / Catastrophic (Caused by the incident) 0 0 0 0 0 0 0 0 0 0 0 0 0Totals: 108 134 137 116 104 116 109 98 96 115 127 105 1365% Harm Medication Incidents 29% 22% 34% 23% 32% 34% 32% 28% 26% 26% 36% 32% 30%

2.5. Percentage of admitted patients risk assessed for Venous Thrombo-embolism (VTE) Target: 95% have completed VTE risk assessments Performance: The Trust consistently achieves >90% compliance with risk assessment (CQUIN target is 90%). All patients with confirmed VTE as reported by radiology undergo a Root Cause Analysis (RCAs). The VTE steering board monitor all confirmed VTE and scrutinise the RCAs.

9

3.0 Effective Care

Incidence of Trust acquired pressure ulcers

3.1 The number and severity of healthcare acquired pressure ulcers are used internationally as a proxy for the effectiveness of care provision. Many people with cancer and or co-morbidity are more vulnerable to tissue damage for the following reasons; multiple hospital admissions, frailty, multiple drugs including high dose steroids (decreases skin elasticity), immobility, malnutrition or susceptibility to infection.

3.2 Data for this report was taken on 1st December (hospital) and on 12th December (SCHS) 2016 from DATIX. Data may have been updated since. From 1

April 2016 community services data only contains pressure ulcers reported from Sutton Community Health Services. Total number of patients with the Trust (hospital/community services) attributable pressure ulcers for the month of

December 2016: 29 [Hospital=15, Community services=14] 3.3 For serious incident reporting to Steis [Strategic Executive Information System] as Hospital/Community Services. Only category 4 pressure ulcers are

reportable.

10

Number of patients with Trust attributable pressure ulcers at category 4 for the month of October 2016: 0 [Hospital=0, Community services=0] Number of patients with Trust attributable pressure ulcers at category 3 for the month of October 2016:2 [Hospital=0, Community services=2] Number of patients with Trust attributable pressure ulcers at category 4 for the month of November 2016: 0 [Hospital=0, Community services=0] Number of patients with Trust attributable pressure ulcers at category 3 for the month of November 2016:3 [Hospital=1, Community services=2] Number of patients with Trust attributable pressure ulcers at category 4 for the month of December 2016: 0 [Hospital=0, Community services=0]

Number of patients with Trust attributable pressure ulcers at category 3 for the month of December 2016: 8 [Hospital=1, Community services=7]

Number of patients with Trust attributable category 4 pressure ulcers

11

Number of patients with Trust attributable pressure ulcers, all categories monthly totals

12

3.3.1 Number of patients with all categories of Trust attributable pressure ulcers with monthly and cumulative totals

Description of European Pressure Ulcer Advisory Panel (EPUAP) pressure ulcer classification system.

EPUAP Description of Stage 1 Non blanching redness of intact skin 2 Partial thickness skin loss or blister 3 Full thickness skin loss (fat visible) 4 Full thickness tissue loss (muscle/bone visible)

13

3.4 Emergency re-admissions to hospital within 28 days of discharge Target: Reduction in the number of avoidable re-admissions to hospital within 28 days of discharge Some emergency re-admissions following discharge from hospital are an unavoidable consequence of the original treatment, however some can be potentially avoided through ensuring the delivery of optimal treatment according to each patient’s needs, careful planning and support for self care. It is important to note that some readmissions will inevitably include patients who are admitted with side effects of treatment therefore it may be difficult to explain any differences between RMH with other acute Trusts. Performance: Within 28 days of original admission there were the following emergency admissions:

0.00%

0.20%

0.40%

0.60%

0.80%

1.00%

Apr-1

3M

ay-1

3Ju

n-13

Jul-1

3Au

g-13

Sep-

13O

ct-1

3N

ov-1

3D

ec-1

3Ja

n-14

Feb-

14M

ar-1

4Ap

r-14

May

-14

Jun-

14Ju

l-14

Aug-

14Se

p-14

Oct

-14

Nov

-14

Dec

-14

Jan-

15Fe

b-15

Mar

-15

Apr-1

5M

ay-1

5Ju

n-15

Jul-1

5Au

g-15

Sep-

15O

ct-1

5N

ov-1

5D

ec-1

5Ja

n-16

Feb-

16M

ar-1

6Ap

r-16

May

-16

Jun-

16Ju

l-16

Aug-

16Se

p-16

Oct

-16

Nov

-16

Dec

-16%

of e

ligib

le a

dmis

sion

s re

sulti

ng in

an

elig

ible

re-

adm

issi

on

Month

Reported % of Emergency Readmissions

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4.0 Patient Experience 4.1. Reduction in Chemotherapy Waiting times

Background:

A review group has been set up to identify reasons for delays in patients receiving their parenteral systemic anti-cancer treatment (SACT) and how these can be improved. The table below shows the chemotherapy waiting times for 2015/16, broken down by site.

Current Performance

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4.1.1. Service improvement initiatives

Much has been done to improve the prescribing, screening, ordering and making of chemotherapy. These are summarised below

1) E-CHEMO E-chemo was introduced in October 2014 as a pilot in the Lung unit, and subsequently rolled out to all adult clinical units throughout 2015-16. E-chemo has facilitated a more streamlined patient pathway through reduction in prescription transit time, real time updates to the system, remote access. In addition, the system is able to be interrogated to provide significant audit data and enable quality improvement / route cause analysis of quality exceptions. As of April 2016, all adult clinical units are live on the e-chemo system and the paediatric rollout has commenced.

16

Pre-prescribing of chemotherapy

Pre-prescribing of chemotherapy >5days in advance of patients’ appointments is well established within the Trust in recognition of the significant benefits related to chemotherapy ordering and availability for patients.

Although improvements have been made in areas, the overall pre-prescribing rates >5 days remains at above 70%. Discussions have taken place with clinical units where the rates can be improved and this needs further focus and ownership by the CBUs.

17

4.1.2. Pre-screening of chemotherapy In addition to pre-prescribing efficiency, it was evident from early e-chemo performance data that there was significant improvement to be made in the efficiency in the pharmacy team screening the prescriptions prior to passing to the aseptic unit for ordering. This was particularly evident on the Sutton site where capacity was significantly constrained. A quality improvement exercise was undertaken to better understand where improvements could be made with the aim to improve process efficiency. Process mapping and staff engagement resulted in the following actions being undertaken:

a) Regular sharing of performance data with the team b) Early escalation to the pharmacy management team when c) Additional e-chemo system development (Ward / Date functionality) to reduce the time required by clinical pharmacy staff to move patient

appointments. d) Cross site coordination of clinical pharmacy services e) Introduction of proscriptive daily task lists to improve consistency of service f) Skill mix review and better utilisation of admin grade staff.

The result of this work has been to improve pre-screening rates on the Sutton site from approximately 80% in Q1 2015/16 to 97% in Q4. This has enabled a larger proportion of prescribed treatments to be processed and ordered on time.

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4.1.3. Patient pathway and opportunities for improvement

Whilst there are notable areas of improvement, there remain areas where the waiting times can be improved but this now requires a whole system review. There are a number of contributing factors that can cause delays in patients receiving their chemotherapy and these are listed in the table below. These primarily centre around the patient and fitness for treatment (Late attendees, require repeat bloods or additional investigations etc), Facilities and infrastructure (IT / sophisticated scheduling capability, adequate waiting areas, available treatment chairs etc), workforce (trained medical, nursing and pharmacy workforce), availability of chemotherapy treatment (Prescribing in advance, timely clinical pharmacy screening, preparation and supply of chemotherapy).

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Issues that contribute to delays Part of pathway Possible solutions identified by MDT

Drugs / IV can arrive late due to delays in that team or due to late orders Patient preparation • Education of Drs about the impact of late ordering and (if taken forward) segmented ordering

• Collect data on ‘late ordering’ and target repeat offenders

• Regular feedback to CBUs who consistently fail to meet minimum service standards

Delays in supplying SACT from pharmacy.

This is due to late orders and dose reductions, staffing constraints, aging software & facilities, multiple entries required on to three different software systems.

Patient preparation • Regular meetings now being held between Aseptic unit and MDU / wards and Clinical trial areas to improve scheduling.

• A drive on ordering well in advance from external partner (Hospira).

• Dose banding and purchasing in batches to dispense ‘off the shelf’ will speed up dispensing times.

‘Difficult’ cannulations (taking longer than 30mins); either one off or ‘repeated’ difficulties (with limited feedback about booking these patients with ‘extra’ time)

Patient preparation • Enhanced cannulation training • Re-deployment of Trust IV team for difficult

cannulations • More warm water facilities (promote

vasodilation) • Additional time built into schedule for patients

with regular challenges in venous access Bloods done >24 hrs in advance of treatment in order to facilitate 2-stop pathway – number of patients subsequently require repeat blood tests on day of treatment.

Patient preparation • Quicker blood test mechanisms for this cohort of patients (potentially ‘point of care’ testing)

Delays in getting samples to labs (possibly due to bundling of samples or delays in being transported around the hospital)

Patient preparation • Need data regarding source of delays – i.e. time taken on whole pathway, not simply turnaround within labs

Chairs are not always available (e.g. due to overrunning) Infrastructure / Space • Creation of additional space in Mobile Chemo Unit

• Build in flexibility into schedule for ‘some’ appointments

Patients arrive late (e.g. due to delays for getting a car park spot) Infrastructure / Space • Update patient information / patient education about blood requirements and ‘space issues’

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Overruns / Limited flexibility of seats (due to high utilisation) / inflexible schedule

Infrastructure / Space • Build in flexibility into schedule for ‘some’ appointments

Short staffed / nursing availability Schedule / management of service

• Availability of MDU ‘supporter’ (floating / supernumerary role to support MDU nursing team)

Length of appointment is unrealistic / incorrect for regimen Schedule / management of service

• Measure ‘compliance’ with type of appointment

4.1.4. Aseptic preparation and supply

Significant work and review has taken place within the aseptic unit to improve the processing, ordering and manufacturing of SACT.

Improvements have been made in the ordering from the external partnership with Hospira and a new contract is about to be signed with Hospira to allow batch production of SACT for common doses used. This will significantly improve the turnaround time for supply of SACT as doses will be available ‘off the shelf’.

There is a remaining concern on the aging manufacturing facilities on both sites and these will form part of the capital works programme in the coming 2-3 years. The current manufacturing IT system that is used to order SACT needs replacing as this does not facilitate an efficient way of working. The replacement of the manufacturing system will be reviewed as part of the Trust EPR replacement programme.

4.1.5. Next steps for 2016/17

1) Identify a lead / group to identify and improve the contributing factors to efficient prescribing, supply and administration of SACT across the Trust and target improvements in all of these.

2) Complete actions from the qualitative audit to establish route cause for all patients on MDUs waiting >30mins for their chemotherapy administration. Sep 2016. Associate Chief Pharmacist, Clinical Services.

3) Introduce batched production of dose banded SACT from Hospira. Nov 2016. Chief Pharmacist / Associate Chief Pharmacist. 4) Consider introduction of electronic scheduling to manage the scheduling of chemotherapy administration on MDUs.

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4.2. FFT areas for improvement

December 958 responses overall: Inpatients 232, Day Care 304, Outpatients (OPD) 262 Inpatients 28 patients made suggestions for improvement.

Some examples follow:-

“the only reason for ticking likely rather than extremely likely is that several things let you down weekends sometimes felt like the wild west. I have been here 8 weeks and have often felt I cannot get the full support I need because staffing is poor. It’s even worse when staff are not regulars so you are faced with strangers caring for you”

“the most likely factor in a recommendation would be the consultant rather than the hospital”

“Staff were all great. Spent too long waiting around without any idea of how long on discharge day. At 9am I asked specifically to get away by 1pm, I’m still waiting at 2.3pm and nobody has any idea how much longer I’ll be here. In consequence my husband has missed a medical appointment”

“the night attendant, however (29-30th Nov) fell a little short of the normal standard these attributes and she was difficult to understand. I would like to have stayed in hospital a little longer – I felt pushed out”

“Patient transport was a letdown. The crew complained about my late arrival to the ward nurses. She rushed discussing my meds with my wife and left my cannula in as she pressurized by them.”

“would be useful to have been sent home with a “what happens next” sheet (discharged from CCU). Listing medication to be taken at home, follow up apt. i.e. with hospital or GP, emergency number of help number, brief summary of operation/procedure in case of need to go to A and E and describe what happened. If stitches will dissolve or go to GP etc., other FAQ’s should reduce follow up calls to hospital.”

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We also asked all inpatients on discharge the following questions about their care.

Day care (304) comments Alongside positive comments from inpatients 26 made made suggestions for improvement. Some examples follow

“poor heating and television didn’t work until I got a room change.”

“lack of information in the crowded waiting area makes every body tense”

“there is a bottle neck with bloods. It is slow for taking bloods and then you miss Doctor and treatment time slots long day”

“consultants and nursing staff very good but sometimes the communication between departments is not efficient”

“mostly the care has been excellent, not very that when I ended up in hospital nobody bothered to check on me”.

“recording the dosi-fuser flouroucil dosage delivered doesn’t seem to be part of the procedure for this treatment regime. Perhaps it should be?”

Score (out of 5) Jan 2016

Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Were you treated with dignity and respect? 4.94 4.91 4.86 4.98 4.87 4.85 4.95 4.89 4.95 4.90 4.92 4.96

Did you feel involved enough in decisions made about you?

4.79 4.79 4.80 4.84 4.75 4.75 4.86 4.84 4.90 4.75 4.83 4.80

Did you receive timely information about your care and treatment?

4.76 4.78 4.70 4.89 4.74 4.76 4.87 4.82 4.90 4.76 4.81 4.80

Was the location clean? 4.88 4.87 4.82 4.88 4.78 4.78 4.89 4.81 4.92 4.77 4.88 4.89

Were you treated well by the staff looking after you?

4.94 4.91 4.88 4.98 4.88 4.88 4.94 4.96 4.95 4.91 4.91 4.98

23

We also asked all day case patients on discharge the following questions about their care. Score (out of 5)



Were you treated with dignity and respect? 4.95 4.91 4.92 4.95 4.90 4.98 4.97 4.96 4.93 4.94

4.95 4.91


4.86 4.81 4.82 4.87 4.82

4.87 4.91 4.86 4.88 4.85 4.90 4.84


4.84 4.77 4.77 4.88 4.82 4.84 4.88 4.84 4.82 4.84 4.90 4.80

Was the location clean? 4.91 4.88 4.88 4.90 4.88 4.94 4.95 4.94 4.92 4.91 4.94 4.94 Were you treated well by the staff looking

after you? 4.97 4.92 4.94 4.98 4.91 4.96 4.97 4.97 4.95 4.96 4.96 4.94

Outpatient (262) comments Alongside positive comments from OPD 11 made suggestions for improvement. These were around the following:-

“my personal experience has been excellent, that of my husband was incredibly poor. It depends on the team you are assigned to.”

“for once my treatment was on time! That’s incredibly unusual in the Marsden. I’ve waited over 2 hours for a five min injection before now. I get very frustrated by the amount of time I spend waiting for appointment”

“the gowns could be better. No ties on mine.”

“it’s trivial but there was no paper in the toilet”

“room when waiting on bed for 1 hour could have been warmer”

“the only negative nothing to do with the team of course was on 2 occasion the changing room had not been swept clean, soon rectified however.”

24

We also asked all outpatients on discharge the following questions about their care. Score (out of 5)



Were you treated with dignity and respect?

4.85 4.94 4.91 4.92 4.96 4.91 4.96 4.95 4.98 4.93 4.88 4.96


4.77 4.87 4.80 4.85 4.85 4.81 4.87 4.85 4.86 4.81 4.80 4.88


4.75 4.82

4.79 4.89 4.89 4.83 4.84 4.89 4.89 4.85 4.80 4.91

Was the location clean? 4.85 4.93 4.90 4.93 4.93 4.91 4.94 4.97 4.95 4.91 4.87 4.96

Were you treated well by the staff looking after you?

4.86 4.96 4.90 4.93 4.96 4.93 4.95 4.99 4.98 4.94 4.88 4.98

Sutton Community Health Services (160) Comments

Alongside positive comments 6 people made suggestions for improvement. These were around the following:-

“Directions could be better” Letter did not mention east of west buildings”

“however, the admin sent me a letter to start the class on the wrong day. There was no class and no one answered the phone and it was only when I wrote a letter that I got a most apologetic response.”

“Because 2my care2 in intermediate catheterization I do need visits at regular intervals mostly the nurses can manage to do this but occasionally they simply cannot achieve this. Twice recently I have been left off the list but this is an ‘administrative’ fault.”

25

We also asked all people who use community services the following questions about their care.

4.2.4. National FFT inpatient results reporting:

From November 2014 NHS England report a percentage of those who would recommend the Trust to friends and family.

Inpatient data was collected for 177 Acute NHS trusts and independent sector providers. Nationally, the overall average percentage for those who would recommend the service to friends and family was 95% in November. The Trust is above this with an average of 98%.

Outpatient data was collected for 238 Acute NHS trusts and independent sector providers. Nationally the overall average percentage for those who would recommend outpatients to friends and family was 93% in November. The trust was above this with an average of 98%.

Community health services data was collected from 144 NHS organisations and independent sector providers who provide community health services. Nationally the overall average percentage for those who would recommend community services to friends and family was 95% in November. The trust was above this with an average of 98%.

The tables below show the results for the Trust each quarter or month to date. At the time of reporting (20 January 2017) national figures were available up to November 2016.

Score (out of 5) Apr May Jun Jul Aug Sep Oct Nov Dec

Were you treated with dignity and respect? 4.68 4.95 4.94 4.96 4.98 4.97 4.91 4.95 4.96

Did you feel involved enough in decisions made about you? 4.57 4.88 4.87 4.84 4.86 4.89 4.85 4.89 4.88


4.59 4.84 4.91 4.88 4.90 4.84 4.79 4.89 4.86

Were you treated well by the staff looking after you? 4.71 4.83 4.83 5.00 5.00 4.71 4.53 4.96

4.96

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INPATIENTS Q4 2014-2015

Q2 2015-2016

Q3 2015-2016

Q4 2015-2016

Q1 2016-2017

Q2 2016-2017

Oct 2016

Nov 2016

The Royal Marsden percentage of inpatients who would recommend

99% 96.7% 96.7% 97% 98% 98% 98% 98%

National average 95% 95.7% 96% 96% 96% 96% 95% 96% Response number 601 1986 1986 1691 1473 1437 375 521 OUTPATIENTS Q2

2015- 2016

Q3 2015- 2016

Q4 2015-2016

Q1 2016-2017

Q2 2016-2017

Oct 2016

Nov 2016

The Royal Marsden percentage of outpatients who would recommend

97% 98% 96% 98% 98% 99% 98%

National average 92% 92% 93% 93% 93% 93% 93% Response number 451 1084 918 1157 964 313 301 Community health services (overall)

Q4 2015-2016

Q1 2016-2017

Q2 2016-2017

Oct 2016

Nov 2016

The Royal Marsden percentage of those in community services who would recommend

98% 98 % 100% 96% 98%

National average 95% 95% 95% 95% 95% Response number 733 264 322 224 457

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5.0. Nurse Safer staffing From June 2014 all Trusts are required by the Department of Health, Monitor and the Care Quality Commission to be able to assure their Boards around the provision of nursing care on its wards and units. This requirement followed the national failings in care at Mid Staffordshire NHS Foundation Trust and other Trusts since placed on “special measures”. The final Francis report recommended that Boards regularly check that levels of nurse staffing are appropriate for good quality care. Overall the percentages are as follows: October 2016

Average fill rate for night staff 101.1% Average fill rate for day staff 96.8% Average fill rate for Registered staff 97.8% Average fill rate for Care staff 101.4% Average Trust wide fill rate (All staff, night and day) 98.5%

November 2016


December 2016


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5.1 Nursing Leavers and Starters Report

Band 5-7 Nurses (2015/16) Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Total

Starters (wte) 6 12 16 13.6 13.8 22.49 21.27 21.45 12.8 17.59 21.08 10.57 188.65

Leavers (wte) 15 15 14 11.5 10.66 7.18 8.75 10.61 11.61 13.18 15.18 9.33 142

Variance -9 -3 2 2.1 3.4 15.31 12.52 10.84 1.19 4.41 5.9 1.24 46.62

Band 5-7 Nurses (2015/16)

Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Total Starters

(wte) 21.52 13.00 9.88 11.60 14.50 29.5 33.50 11 7.4 151.9 Leavers

(wte) 10.74 14.11 7.29 15.21 13.55 10.12 12.60 10.79 10.71 106.12 Variance 10.78 -1.11 2.59 -3.61 0.95 19.38 21.19 0.21 -3.31 45.78

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Nurse leavers October 2016

Area Job Title Leaving date LOS Band WTE Reason for leaving

Bud Flanagan East Staff Nurse 23-Oct-2016 1 y 0 m Band 5 1.00 Voluntary Resig. - RelocationChildren's Unit (S) Late effects - Clinical Nurse Specialist 30-Oct-2016 0 y 11 m Band 7 0.49 Voluntary Resig. - Relocation

G I Tract Unit (L) Clinical Nurse Specialist 07-Oct-2016 15 y 3 m Band 7 0.60 Voluntary Resig. - RelocationKennaway Ward Staff Nurse 02-Oct-2016 11 y 4 m Band 6 0.31 Voluntary Resign. - To undertake further Education or Training

Wilson Ward Senior Staff Nurse 26-Oct-2016 4 y 1 m Band 6 1.00 Voluntary Resig. - Promotion

Admissions, Sutton Clinical Site Practitioner 31-Oct-2016 6 y 3 m Band 7 0.46 Volun. Early Retirement Day Surgery Unit (L) Senior Staff Nurse - Day Surgery 07-Oct-2016 5 y 11 m Band 6 1.00 Voluntary Resig. - Relocation

Hospital2Home Programme pecialist Sister for Hospital2Home Programm 24-Oct-2016 0 y 3 m Band 7 0.60 Retirement - AgeOutpatients (S) Sister/Charge Nurse 31-Oct-2016 6 y 3 m Band 7 0.85 Retirement - Age

Theatres (L) Staff Nurse 02-Oct-2016 3 y 4 m Band 5 0.64 Voluntary Resig. - Child DependantsTheatres (L) Staff Nurse 26-Oct-2016 4 y 6 m Band 6 0.51 Voluntary Resig. - Relocation

Oak Ward Staff Nurse 26-Oct-2016 1 y 3 m Band 6 0.60 Voluntary Resign. – Work Life Balance - Cost of Living (Travel, Accomodation)

Childrens Safeguarding Team Specialist Safeguarding Nurse 02-Oct-2016 1 y 2 m Band 7 1.00 Voluntary Resig. - RelocationWallington Community Nurse 30-Oct-2016 1 y 6 m Band 5 1.00 Voluntary Resign. – Work Life Balance - Cost of Living (Travel, Accomodation)

GH Day Services Senior Staff Nurse 27-Oct-2016 0 y 6 m Band 6 1.00 Voluntary Resig. - PromotionWiltshaw (PP) Staff Nurse 25-Oct-2016 1 y 5 m Band 6 1.00 Voluntary Resign. – Work Life Balance - Cost of Living (Travel, Accomodation)

Total Leavers -12.06 WTE

Nursing Leavers Bands 5-7 October 2016

Cancer Services Division- 3.40 WTE

Clinical Services Division- 4.06 WTE

Clinical Research Division - 0.60 WTE

Community Services- 2.00 WTE

Private Care - 2.00 WTE

30

Nurse leavers in November 2016


Bud Flanagan East Staff Nurse 06-Nov-2016 4 y 4 m Band 6 1.00 Voluntary Resig. - RelocationEll is Ward Staff Nurse 04-Nov-2016 1 y 0 m Band 6 1.00 Voluntary Resig. - Relocation

Minor Procedure Suite (S) Senior Staff Nurse 30-Nov-2016 23 y 0 m Band 6 0.75 Retirement - Age

Critical Care Unit (L) Senior Staff Nurse 12-Nov-2016 2 y 8 m Band 6 0.54 Voluntary Resign. - To undertake further Education or TrainingOutpatients (L) Staff Nurse 30-Nov-2016 6 y 4 m Band 6 1.00 Retirement - Age

Haemato-Oncology & Myeloma Research Research Nurse 02-Nov-2016 11 y 5 m Band 7 1.00 Voluntary Resig. - Better Reward Package

Carshalton Team Sister 25-Nov-2016 5 y 1 m Band 6 1.00 Voluntary Resign. – Work Life Balance - Cost of Living (Travel, Accomodation)Childrens Safeguarding Team Specialist Safeguarding Nurse 21-Nov-2016 5 y 1 m Band 7 1.00 Voluntary Resig. - Promotion

Sutton & Cheam Community Nurse 08-Nov-2016 1 y 1 m Band 5 1.00 Voluntary Resignation - Work Life BalanceWallington Team Sister 18-Nov-2016 5 y 1 m Band 6 1.00 Voluntary Resignation - Work Life Balance

GH Day Services Staff Nurse 20-Nov-2016 4 y 2 m Band 6 1.00 Voluntary Resig. - RelocationPrivate Care Clinical Nurse Specialists Clinical Nurse Specialist Plastics & Reconstructive Surgery 04-Nov-2016 1 y 2 m Band 7 0.50 Voluntary Resign. – Work Life Balance - Cost of Living (Travel, Accomodation)

Nursing Leavers Bands 5-7 Novembr 2016

Total Leavers - 10.79 WTE



Clinical Research Division - 1.00 WTE



31

Nurse leavers in December 2016


G I Tract Unit (S) Clinical Nurse Specialist 25-Dec-2016 28 y 8 m Band 7 1.00 Retirement Age

Outpatients (L) Staff Nurse 06-Dec-2016 4 y 2 m Band 5 0.20 Voluntary Resignation - Work Life Balance

HV Sutton Health Visitor 25-Dec-2016 2 y 11 m Band 6 0.60 Voluntary Resignation - Child DependantsSutton & Cheam Community Nurse 15-Dec-2016 5 y 2 m Band 5 1.00 Voluntary Resignation - RelocationSutton & Cheam Community Nurse 21-Dec-2016 2 y 4 m Band 5 1.00 Voluntary Resignation - Relocation

Sutton SN School Nurse 04-Dec-2016 2 y 2 m Band 5 0.70 Voluntary Resignation - Child DependantsSutton SN School Nurse 21-Dec-2016 0 y 11 m Band 5 0.72 Voluntary Resignation - Child Dependants

Wallington Community Nurse 09-Dec-2016 5 y 2 m Band 5 0.80 Retirement Age

Private Care Division Staff Nurse 16-Dec-2016 2 y 8 m Band 6 1.00 Voluntary Resignation - Work Life BalancePrivate Care Division Staff Nurse 23-Dec-2016 1 y 5 m Band 6 1.00 Voluntary Resignation - Work Life BalancePrivate Care Division Senior Staff Nurse 28-Dec-2016 5 y 1 m Band 6 1.00 Voluntary Resignation - Child DependantsPrivate Care Division Staff Nurse 31-Dec-2016 3 y 2 m Band 6 1.00 Voluntary Resignation - Work Life BalancePrivate Care Division Staff Nurse 16-Dec-2016 2 y 3 m Band 6 0.69 Voluntary Resignation - Child Dependants


Total Leavers -10.71 WTE

Nursing Leavers Bands 5-7 December 2016




6.0. The Council of Governors is invited to note the performance of the Trust against the agreed national and local quality targets for October, November and December 2016 and the actions being taken.



Agenda item 9.3

Title of Document: Annual Quality Account 2016/17

To be presented by Chief Nurse

Background For the last seven years NHS Trusts have been required by government to produce an Annual Quality Account. This year NHS England and NHS Improvement, the regulatory body for Foundation Trusts, issued specific guidance as to its content. Executive Summary The Council of Governors should have received a copy of the Annual Quality Account 2016/17 with their meeting papers. The quality account shows that at the time of reporting where relevant data has been received all the quality priorities have been achieved up to the end of December 2016 (p7-9). Recommendations The Council of Governors is asked to review the Annual Quality Account and provide any feedback to the Corporate Governance Team by the 31st March 2017.

Author: Chief Nurse


Date: 1st March 2017

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Quality account 2016/2017 Contents Part 1 What is a Quality Account? Statement on Quality from the Chief Executive Part 2 Performance against priorities for Quality improvement 2016/2017 Statements of assurance from the Board Priority 1- Reduction in Healthcare Associated Infections (MRSA bacteraemia and Clostridium difficile infections): applies to Hospital and Community Services Priority 2- Reduction in the rate of incidents resulting in severe harm or death: applies to Hospital and Community Services Priority 3- Percentage of admitted patients risk assessed for venous thromboembolism: applies to Hospital Priority 4- Avoidance of emergency re-admissions to hospital within 28 days of discharge: applies to Hospital Priority 5- Reduction in attributable community acquired category 3 and 4 pressure ulcers: applies to Community Services Priority 6- For patients to be given information about the side effects of medicines to take after being discharged Priority 7a- Ensuring that we are responding to inpatients’ personal needs: applies to Hospital Priority 7b- Use the ‘Friends and Family test’ question for clients receiving community care: applies to Community Services Priority 8- Percentage of staff who would recommend The Royal Marsden to friends or family needing care: applies to Hospital and Community Services Priority 9a- Reduction in chemotherapy waiting times and improvement in patient experience related to waiting times: applies to Hospital Priority 9b- Reduction in waiting times in outpatient clinics and improve patient experiences related to waiting: applies to Hospital Priority 10a- Increase the number of relevant community services patients who have a falls risk assessment completed: applies to Community Services Priority 10b- Reduction in the number of medication incidents causing moderate of low harm to patients under the care of community services to less than four for the year: applies to Community Services Part 3 Outline of Quality Improvements in 2016/2017 The quality priorities for 2017/2018 The quality objectives and priorities of the Trust for the last seven years Statements of assurance from the Board Part 4 Review of quality performance previous year’s performance Appendices Appendix 1: Quality indicators where national data is available from the Health and Social Care Information Centre Appendix 2: Our values Appendix 3: Sign Up to Safety: Patient Safety Improvement Plans Appendix 4: Statements from key stakeholders Appendix 5: Statement of Trust Director’s responsibilities for the Quality Account Appendix 6: Independent Auditor’s Assurance Report Appendix 7: Glossary

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What is a quality account? All NHS hospitals or trusts have to publish their annual financial accounts. Since 2009, as part of the drive across the NHS to be open and honest about the quality of services provided to the public, all NHS hospitals have had to publish a quality account. You can also find information on the quality of services across NHS organisations by viewing the quality accounts on the NHS Choices website at www.nhs.uk. The purpose of this quality account is to: • summarise our performance and improvements against the quality priorities and objectives we set

ourselves for 2016/2017; and • set out our quality priorities and objectives for 2017/2018.

To begin with, we have given details of how we performed in 2016/2017 against the quality priorities and objectives we set ourselves under the categories of:

• safe care; • effective care; and • patient experience.

Where we have not met the priorities and objectives we set ourselves, we have explained why, and set out the plans we have to make sure improvements are made in the future. Secondly, we have set out our quality priorities and objectives for 2017/2018 under the same categories. We have explained how we decided upon the priorities and objectives, and how we will achieve these and measure our performance. Quality accounts are useful for our board, who are responsible for the quality of our services, and they can use it in their role of assessing and leading the trust. We encourage frontline staff to use quality accounts to compare their performance with other trusts and to help improve their service. For patients, carers and the public, this quality account should be easy to read and understand, and highlight important areas of safety and effective care provided in a caring and compassionate way. It should also show how we are concentrating on any improvements we can make to care or experience. It is important to remember that some parts of this quality account are compulsory. They are about important areas, and are generally presented as numbers in a table. If there are any areas of the quality account that are difficult to read or understand, or you have any questions, contact us through the Patient Advice and Liaison Service (PALS) by phoning 0800 783 7176, or visit our website at www.royalmarsden.nhs.uk.

Quality Information

Look Back

Set out priorities Quality Improvement 2017/2018 Look Forward

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This quality account is divided into four sections. Part 1 Introduction to The Royal Marsden NHS Foundation Trust and a statement on quality from

the Chief Executive (CE) Part 2 Performance against 2016/2017 quality priorities for improving quality and statements of

assurance Part 3 Outline of improvements made in 2016/2017 Part 4 Review of quality performance

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Part one Introduction to The Royal Marsden NHS Foundation Trust and a statement on quality from the Chief Executive The quality of care patients and their families receive, and their experiences, are central to all that we do. The Royal Marsden is the largest cancer centre in Europe and, with the Institute of Cancer Research, is responsible for the largest cancer research programme in the UK. This year has been another outstanding year for us as we have continued to achieve high ratings from our two major regulators – NHS Improvement and the Care Quality Commission (CQC). We look forward to welcoming the CQC in April so they can inspect our services and see the excellent standards we deliver to our patients. Our commitment to meeting the challenges of continuing to provide quality care and experience within a cost-effective framework underpins the following four corporate objectives for 2016/2017.

1. ‘Improve patient safety and clinical effectiveness’ 2. ‘Improve patient experience’ 3. ‘Deliver excellence in teaching and research’ 4. ‘Ensure financial and environmental sustainability’

Our commitment to improving quality is demonstrated by the following achievements in the year from 1 April 2016 to 31 March 2017. o Care Quality Commission inspection

During the year 2016/2017, we had a routine inspection by the CQC in April 2016. The final report was published in January 2017. The CQC currently aggregates ratings across all service areas, and for cancer and community services overall the Trust has been rated “Good”. The Royal Marsden’s services have been rated “Outstanding” for the Chelsea site, for Radiotherapy, Critical Care, and Chemotherapy (Sutton site). The Trust has also been rated “Outstanding” for the quality of its caring environment. In addition, The Royal Marsden has been rated “Good” for services for Children and Young People, Haematology, the treatment of Adult Solid Tumours and Outpatients (Chelsea site).

In 2011 The Royal Marsden accepted responsibility for Community Services in Sutton to trial new integrated pathways of care for local people. Sutton Community Services was inspected by the CQC and rated “Good” for Children and Young People, and End of Life Care, with Adult Community Services requiring improvement, principally in documentation and staffing levels. o Customer Service Excellence Standard (to be updated after assessment on 10 March

2017)

In March we will be assessed against the Customer Service Excellence Standard. The standard recognises public services that are ‘efficient, effective, excellent, equitable and empowering – with the citizen always and everywhere at the heart of public services provision’. We have held the standard for seven years, and are one of only a few hospitals to do so. o Equality and Diversity

The Royal Marsden is committed to ensuring equality, diversity, inclusion and human rights are central to the way we deliver healthcare services to our patients and how we support our staff. We want to be known as an organisation that promotes equality, values and celebrates diversity and has created an inclusive environment for receiving care and for employment. The Care Quality Commission (CQC) report, received in January 2017, rated our caring as Outstanding and made significant reference to the work to progress equality and inclusion for our patients and staff. Specifically they noted the improvements made in our Workforce Race Equality Standard findings, workforce demographics and equality governance. The report also highlighted that staff demonstrated awareness and understanding of equality issues in a patient context and that

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people were “treated with kindness, dignity, respect and compassion whilst they received care and treatment from staff.” This is a tremendous achievement.

During this reporting period, we were highly commended at the 2016 BMA Patient Information Awards for our resource on supporting children with cancer in school, trained 253 staff as dementia friends, supported an event for people with diabetes from different faiths who fast as part of their religion and attained 89% compliance for equality and diversity training

o The Royal Marsden School

The Royal Marsden School continues to add value and spread excellence. Student numbers have held up well, despite the cuts in education funding. The academic partnership with the University of East Anglia (UEA) is in its second year and progressing successfully. UEA continues to monitor the School’s quality and hold it to high standards of academic performance. For the sixth year in succession, the School met 100% of its quality performance and contract monitoring measures as assessed by Health Education England North West London (HENWL). In summarising the assessment of the School’s performance against these quality indicators, the Senior Commissioning Manager at HENWL wrote:

I would like to take this opportunity to reiterate how impressed I am with the quality of the information and supporting evidence submitted to HEE from The Royal Marsden School. It is clear that you and your team approach the Workforce Development Contract and Quality requirements with a real dedication to ensuring robust internal processes, strong relationship management and collaboration with commissioning partners from NHS Trusts and smaller providers alike and to developing innovative programmes to meet the changing needs of the NHS workforce.

A total of 52 modules ran in 2016-17 attended by 929 students, 30% of whom were staff at RM. In October 2016 we held a Graduation Ceremony to bestow academic awards from St George’s University of London to the largest number of students ever – 80 – after they had successfully completed their education in the School.

Commissions for School staff to travel to provide education and training for other organisations and NHS Trusts have increased significantly this year. Communication skills training, end of life care, acute oncology and chemotherapy courses are in great demand by Trusts in London and across the UK.

o Improving Patient Experience – Always Events In January 2016 we became one of 10 trusts delivering the Always Events programme supported by NHS England. Our Always Event focusses around improving patient experience on Bud Flannigan Ambulatory Care at Sutton. The Always Event that ’Patients will always be informed about key information for their out patients visit’ was co designed by the staff and patients on the unit. The patients and carers have produced a video explaining their experience of care and what improvements could be made to enhance their experience. The ward sisters were also invited to speak at a national conference in November 2016 to share their experience of co designing an Always Event. The programme will continue to be delivered on the unit and once embedded will be rolled out across the trust. o Research excellence The Applied Health Research programme at The Royal Marsden is designed to provide support throughout treatment, living with, and beyond cancer. We have a portfolio of over 50 studies and service evaluations that address ongoing rehabilitation needs and support for cancer patients. Some of the highlights of our current studies include: People's ability to maintain their physical activity levels during chemotherapy treatment for soft tissue sarcoma. Presence and impact of swallow difficulties for people with advanced lung cancer. Art Therapy for Chronic Pain. Aromatherapy massage to enhance Sleep in critical care (CCR 4308);

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A CBT training intervention for women with psychosexual difficulties post-gynaecological cancer treatment. Developing an on-line emotional support resource for men affected by prostate cancer Sing with Us London, Tenovus Cancer Choir study to explore the benefits of singing for those affected by cancer. PREDICT: Predicting patients at risk of developing gastrointestinal symptoms after treatment with pelvic radiotherapy. The impact of targeted therapies on the cognitive function for patients in Phase I trials and those undergoing (chemo)radiation with intensity modulated radiotherapy (IMRT) for Head and Neck Cancer (HNC). o Sign up to Safety In June 2016 we celebrated the first year of the Sign up to Safety campaign. Over 60 delegates attended the event including patient and carer representatives, student nurses, governors and clinical and managerial staff. We showcased the significant work achieved in year 1 in reducing harm to patients in our 3 work streams; reducing harm from sepsis, reducing medication incidents and reducing harm from pressure ulcers. We will continue to focus on these 3 harms over the next 2 years of delivering the safety improvement plan for the trust. We and our board have tried to take all reasonable steps to make sure the information in this quality account is accurate. On behalf of the Board of The Royal Marsden NHS Foundation Trust I can confirm that, as far as I know and believe, the information in this quality account is accurate.

Cally Palmer CBE Chief Executive xx May 2017

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Part two Performance against 2016/2017 quality priorities for improving quality Introduction The quality priorities and targets for 2016/2017 are shown in the table below. The priorities and targets in blue were mandatory in 2016/2017 (that is, we had to include them) and the priorities and targets in red are the ones we have set ourselves. Table 1: Quality priorities and targets for 2016/2017 Category Quality priority Target Achieved to

date (April – December 2016)

Safe care 1 To reduce the number of cases of healthcare related infections (MRSA and clostridium difficile infections). Applies to hospital inpatient beds at The Royal Marsden and patients of Sutton Community Healthcare Services.

For there to be less than one case of MRSA infection per year. For there to be fewer than 31 cases of clostridium difficile infection per 100,000 bed days. (A bed day is when a patient is in hospital overnight. It is measured in a large number to spot trends.)

Achieved Achieved

Safe care 2 To maintain or increase the number of patient safety incidents and near misses that are reported, reducing the percentage of incidents that have resulted in severe harm or death (A patient-safety incident is an incident which could have harmed or did harm a patient.) Applies to hospital inpatient beds at The Royal Marsden and Sutton Community Healthcare Services.

For the rate of reported patient-safety incidents that have caused severe harm or death to be below 0.089 per 1000 bed days. (In 2015/2016 the rate of severe harm or death from incidents per 1000 bed days was 0.033 for hospital and 0.0 for community.)

Achieved

Safe care 3 To maintain the percentage of admitted patients assessed for the risk of venous thromboembolism (getting a blood clot in a vein).

For the percentage of patients who have been assessed to stay above 95%. Of those patients assessed as high risk, appropriate treatment is started. Reassess 70% of patients within 24 hours.

Achieved Awaiting data

Effective care

4 To reduce the incidence of emergency readmissions to

For the number of avoidable readmissions to be below 0.2%.

Achieved

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hospital within 28 days of patients being discharged.

Effective care

5 To reduce the incidence of category-3 pressure sores (full-thickness skin loss) and category-4 pressure sores (full-thickness tissue loss) developing in patients while they are receiving community care. Applies to Sutton Community Healthcare Services.

For the percentage of category-3 and category-4 pressure sores arising in patients receiving community care to be less than 0.2%. For 90% of category-3 and category-4 pressure sores, both already existing and developing while receiving community care, to have healed or improved to category 1 (redness of intact skin, which does not fade when pressed) or category 2 (partial thickness skin loss or blister) within three months.

Achieved Achieved

Effective care

6 For patients to be given information about the side effects of medicines to take after being discharged.

For 75% of patients to receive information about side effects of medicines before they are discharged home.

Achieved Q1. Not measured Q3.

Patient experience

7 a To make sure that we are responding to inpatients’ personal needs. b To continue using the ‘friends and family test’ question for patients receiving community care. (The friends and family test question asks people who use NHS services whether they would recommend the services to others.)

a) For our results in the friends and family test for hospital inpatients to still be higher than the national average. b) For the friends and family test results to be above 90% and to increase patient satisfaction, using the CARE Measure tool, to over 90% for community services.

a) Achieved b) Achieved

Patient experience

8 To increase the percentage of staff who would recommend The Royal Marsden to friends or family needing care.

For more than 95.5% of surveyed staff to say that they would recommend The Royal Marsden.

Awaiting national results to be published in March 2017.

Patient experience

9 a To reduce waiting times at chemotherapy appointments and improve patients’ experiences relating to waiting times. b To reduce waiting times in outpatient clinics and improve patient experiences

a For 80% of patients to be satisfied with the length of time they had to wait to start their treatment. b For no more than 8% of patients to have to wait more than one hour.

Not measured Q3. Achieved

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relating to waiting times

Adult services (community services)

10a a) To increase the number of relevant community services patients who have a falls risk assessment completed.

a) For the adult services team to develop and integrated falls risk assessment. Ensure that 65% of patients who are identified as being at risk of falls have a falls risk assessment undertaken.

Achieved


10b b). To reduce the number of medication incidents causing moderate of low harm to patients under the care of community services to less than four for the year.

b) To ensure a medicine review (reconciliation) takes place during the first assessment of a patient post hospital discharge or secondary care consultation

Achieved

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Priority 1: To reduce the number of cases of healthcare related infections (MRSA infection and clostridium difficile infection). (updated Q3) Applies to patients at The Royal Marsden and patients of Sutton Community Healthcare Services. Targets: For there to be less than one case of meticillin-resistant staphylococcus aureus (MRSA) infection per year. For there to be fewer than 31 cases of clostridium difficile infection caused by a failure in care per 100,000 bed days. (A bed day is when a patient is in hospital overnight. It is measured in a large number to spot trends.) ‘‘Ensuring patients come to no harm is one of the pillars of care at the Marsden. Infection prevention and control is a fundamental aspect of caring for patients with cancer” Sarah Whitney, Matron Infection Prevention and Control Because of their reduced immunity, patients with cancer are more vulnerable to infection, even from germs that would normally be harmless. This makes preventing infection an important priority for patient safety. Target: For there to be less than one case of meticillin-resistant staphylococcus aureus (MRSA) infection per year. What we did in 2016/2017 • There has been one MRSA bacteraemia which occurred in Q2. • Clostridium difficile (C.difficile) remains within trajectory. • We have raised the focus on hand hygiene to maintain good compliance. • We have refocused the matrons audits and ward checklist to ensure quality on the ward. • We have focussed on antimicrobial stewardship including the weekly ward round and use

of review stickers. • Following the MRSA bacteraemia, there has been renewed emphasis on the collection of

blood cultures in Trust mandatory training. Target: For there to be fewer than 31 cases of clostridium difficile infection caused by a failure in care per 100,000 bed days. (A bed day is when a patient is in hospital overnight. It is measured in a large number to spot trends.) What we did in 2016/2017 • Q3 C.difficile Toxin: there have been 32 cases of C.difficile to date this year which have

occurred more than 3 days after admission. Cases up to July have been reviewed by the commissioner for any ‘lapse in care’ and a meeting is scheduled for February to review the remaining cases. Three cases thus far have been assigned against the trajectory (reported in Q2).

• In Q2 there was one MRSA bacteraemia which was a contaminated specimen. The West Kent Clinical Commissioning Group determined that it this is attributable to the trust due to a poor technique in taking the blood culture.

How we performed in 2016/2017 • The Trust is on target to meet the allocated objective for C.difficile infection (CDI) which

is to have no more than 31 hospital attributed cases. • The Trust recorded one Meticillin resistant Staphylococcus aureus (MRSA) bacteraemia.

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Actions to improve our performance • Antimicrobial stewardship has been promoted through weekly antibiotic ward rounds,

regular audits, education sessions and promotion of European Antimicrobial Awareness Week. A red review sticker has been rolled out across the Trust.

• A protocol for ‘universal decolonisation’ of patients undergoing surgery has been implemented to minimise harm to patients from the risk of surgical site infection and post-operative pneumonia

• The Infection Prevention and Control Team and housekeeping teams have carried out weekly operational audits of the patient environment in conjunction with the matrons to monitor standards and identify any areas for improvement.

• High level disinfection with hydrogen Peroxide Vapour (Bioquell) continues to be used after discharge of patients with infection to minimise the risk to subsequent patients occupying these rooms.

• A novel ultra-violet technology for room disinfection is being successfully used in Sutton as a quick but effective method for room disinfection where Bioquell is not possible.

• E-learning was introduced to cover basics of infection Prevention, allowing annual face to face education for clinical staff to focus on key areas of concern and ‘hot topics’.

How improvements will be measured and monitored • The Trust is registered without conditions with the Care Quality Commission. • The Infection Prevention and Control Team (IPCT) has an audit plan for the year

including audits of premises used by Sutton Community Services. • Audits for hand hygiene and hygiene codes are undertaken by ward staff and have

demonstrated good compliance levels. • Further work will be undertaken to review and improve the way we monitor hand

hygiene compliance. • Clinical departmental audits focussing on isolation practice, invasive device care and

environment are undertaken with feedback to the department to improve practice. • Audits of MRSA and CPE screening are undertaken monthly to monitor and improve

compliance. • Clinical review of all post 72 hour C.difficile isolates is undertaken and reviewed with the

clinical team an then with the local commissioner. • Root cause analysis is undertaken for MRSA bacteraemia or any infections where there is

concern.

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Priority 2: To maintain or increase the number of reported patient safety incidents and near misses whilst reducing the rate and percentage of patient-safety incidents resulting in severe harm or death. (A patient-safety incident is an incident which could have harmed or did harm a patient.) (Q3 update) Applies to patients at The Royal Marsden and patients of Sutton Community Healthcare Services. Target: For the rate of reported patient-safety incidents that have caused severe harm or death to be below 0.089 per 1000 bed days. (In 2015/2016 the rate of severe harm or death from incidents per 1000 bed days was 0.033 for hospital and 0.0 for community.) ‘Incident reporting continues to be a patient-safety priority, we strive to increase the number of near-miss and no-harm incidents reported by increasing the feedback that individual staff receive when they report an incident and also the trust-wide dissemination of learning from investigations.’ Chris Lafferty Risk management

What we did in 2016/2017

• All staff that reported an incident received individual feedback.

• Incident reports on significant events were submitted to the Integrated Governance and Risk Management Committee and then disseminated widely across the Trust to facilitate learning.

• Examples of incidents were used at mandatory training.

• We reported all attributable patient-safety incidents to the National Reporting and Learning Service (NRLS). Before NRLS produced their six-monthly reports, we re-submitted all changes made as a result of investigations. (These changes may not be reported by the NRLS so the information we hold may not be the same as that reported by the NRLS.).

How we performed in 2016/2017 • We reported all attributable patient-safety incidents to the National Reporting and Learning

Service (NRLS). Before NRLS produced their six-monthly reports, we re-submitted all changes made as a result of investigations. (These changes may not be reported by the NRLS so the information we hold may not be the same as that reported by the NRLS.).

• The tables below separate out the information for the acute hospital sites of Chelsea and Sutton and for Sutton and Merton Community Services. Should the reporting trend continue into Q4, 2016/2017 we will see an increase in reported incidents. This is due to an increased awareness of incident reporting.

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Table 2 shows that, at the Chelsea and Sutton sites, the rate of reported incidents that caused severe harm or death in the third quarter of 2016/2017 was 0. Table 2: Chelsea and Sutton patient-safety incidents

Measure

2014/ 2015

2015/ 2016

1st quarter of 2016/2017

2nd quarter of 2016/2017

3rd quarter of 2016/2017

4th quarter of 2016/2017

Overall for 2016/2017

Number of Inpatient bed days

63598

60443 14853 14779 15246

Rate of reported patient-safety incidents (severe harm or death) per 1000 bed days

0.031 0.033 0.135 0 0

Number of patient-safety incidents (severe harm or death)

2 2 2 0 0

Total patient-safety incidents

2780 3233 932 838 875

Patient-safety incidents (severe harm or death) as a percentage of all patient-safety incidents

0.07% 0.06% 0.22% 0% 0%

Table 3 shows that in community services there have been no patient-safety incidents resulting in severe harm or death to date in quarters 1 to 3, 2016/2017. Table 3: Sutton Community Healthcare Services patient-safety incidents

Measure

2014/2015

2015/2016 1st

quarter of 2016/2017




Overall for

2016/2017 Number of contacts (appointments attended) 513,707 677,293 91,107 77,992 76,342

Rate of reported patient-safety incidents (severe harm or death), per number of contacts

0 0 0 0 0

Number of patient-safety incidents (severe harm or death)

0 0 0 0 0

Total patient-safety incidents 1034 768 110 109 94

Patient-safety incidents (severe harm or death) as a percentage of all patient-safety incidents

0% 0% 0% 0% 0%

Note: the figures for the first and second quarters have been updated to reflect the most recent available data.

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Comparison with national figures The National Reporting and Learning System (NRLS) reports that for the period from October 2015 to March 2016, the proportion of incidents resulting in severe harm or death was less than 1% of all incidents reported, which is consistent with national figures. At the time of reporting this is the latest national data available. Recognising and reporting an incident resulting in severe harm or death is an indicator of an organisation’s culture of accurately reporting incidents. The NRLS’s reports show that The Royal Marsden is within the highest 25% of reporting organisations. Actions to improve our performance • Keeping to regulation 20 – the duty of candour.

This is a regulation to make sure that we are open and honest about care and treatment. Under regulation 20, if there is a patient-safety incident that is graded moderate harm or above, we must follow a set process. You can find full details at www.cqc.org.uk/content/regulation-20-duty-candour

Our Being Open and Duty of Candour Policy incorporates the requirements of the Duty of Candour. To make sure that we are open and honest about incidents that fall under regulation 20, the Risk Management Team review every reported incident that is graded moderate harm and above. The review commences on the day the incident is reported or the next working day. If the incident is confirmed as being correctly graded as moderate harm or above, the Risk Management team works with the appropriate clinical staff to make sure the patient is told about the incident and that an appropriate apology is given within 10 days of the incident being reported on the incident reporting system. The patient is kept informed of our investigation. If a report is being produced, the patient is asked if they would like a copy of it. The Risk Management Team follow up to make sure that the report is sent to the patient with an offer to meet to go through the findings.

The Duty of Candour process is monitored every six months by an audit and the results are given to the Integrated Governance and Risk Management Committee, Quality, Assurance and Risk committee and the Trust Board committee.

http://www.cqc.org.uk/content/regulation-20-duty-candour

http://www.cqc.org.uk/content/regulation-20-duty-candour

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Priority 3: To maintain the percentage of admitted patients assessed for the risk of venous thromboembolism (getting a blood clot in a vein). (Q3 partial update) Targets: For the percentage of patients who have been assessed to stay above 95%. Of those patients assessed as high risk, appropriate treatment is started. It is vital that we maintain the focus on VTE within the Trust, our patients are at a higher risk and we have a duty to inform them. Ann Duncan Matron, Cancer Services Venous thromboembolism (VTE) is a single term for both deep-vein thrombosis and pulmonary embolism. A deep-vein thrombosis is a blood clot that forms in a deep vein (usually in the leg). If a clot breaks off and travels to the arteries of the lung, it causes a pulmonary embolism, which can be life-threatening. VTE can be avoided by giving preventative treatment (prophylaxis) to patients at risk. Patients with cancer are at greater risk of developing VTE, so this continues to be a safety priority for us. The VTE Steering Board is now well established and VTE risk assessments are carried out for all appropriate patients. All planned inpatients are sent information leaflets before their appointment to tell them what they can do to help prevent clots forming, how to recognise the signs and symptoms of clots and what to do if they have any of these signs and symptoms. There are also posters and information leaflets throughout the hospital and available from Patient Advice and Liaison Service (PALS). The VTE risk assessment may be carried out using either the patient’s drug chart or by using the electronic clinical documentation system. What we did in 2016/2017 • We ensured patient representation on the VTE steering board. • We completed an audit ‘Snap-shot survey of verbal and written information on blood clot

prevention’. • We have altered the size of the ‘Blood clot Alert- Recognise the signs and reduce the risks in

response to the feedback from the snapshot audit to be wallet size. • We converted to below knee anti-embolic stockings (AES) based on an up to date literature

review. • We trialled a new AES product. • We developed a new VTE Care Plan which requires patient sign off.

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How we performed in 2016/2017 We achieved the target of 95% success in making sure all of our patients are appropriately assessed for the risk of developing VTE. Table 4: Percentage of patients who have had a risk assessment completed Percentage of

patients who have had a risk assessment completed

Those identified as high risk (% or number)

Appropriate treatment started (% or number)

Number of patients reassessed within 24 hours

2012/2013 96.5% - - - 2013/2014 96.75% - - - 2014/2015 97.1% - - - 2015/2016 96.1% - - - 2016/2017 1st quarter of 2016/2017

96.9%


96.7%


96.7%


Actions to improve our performance

• Ensure there are VTE Posters in all clinical areas. • Develop the use of handheld tablets in the MDU with the integrated patient safety VTE film

‘Blood Clots and you’. • Audit the delivery and understanding of information surrounding VTE Check and monitor

compliance with the use of VTE care plan on all wards/ integrate the care plan into the admission booklet.

• Ensure training of Harm Free Care Champions and staff on MT. • Celebrate World Thrombosis day 13th October 2017. • Repeat audit July 2017. • Work with leading VTE Charities to ensure that VTE risks are clear consistent and available

for people with cancer. • Ensure VTE risk is part of the Chemotherapy Care Bundle.

How improvement will be measured and monitored The VTE Steering Board will continue to monitor VTE incidents, assessments and prevention procedures. Performance will also be monitored at the trust’s Steering Board and through the monthly board scorecard. The scorecard is reviewed at each trust board meeting and contains, among other items, the number of patients assessed for risks associated with VTE. We have reached our targets, but this will continue to be included as a priority for 2017/2018 as this remains an important indicator of our improvement in protecting patients from avoidable harm. We will continue to monitor our performance with regards to raising awareness of VTE/VTE care plan compliance- by further snap shot audit.

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Priority 4: To reduce the incidence of emergency readmissions to hospital within 28 days of patients being discharged. (partial update Q3) Target: For the number of avoidable readmissions to be below 0.2%. ‘staff quote’ Lorraine Hyde Since 2012/2013, Quality Accounts should show the percentage of patients of all ages and sexes who were readmitted within 28 days of being discharged, and the national average. It is important to note that some readmissions will include patients who are admitted because of the side effects of treatment, so it may be difficult to explain any differences between us and other NHS trusts. What we did in 2016/2017

How we performed in 2016/2017 (updated Q3) Graph 1 shows the percentage of patients who were readmitted within 28 days from April 2013 to March 2017. Readmissions have stayed below 0.4% of all admissions since April 2012. Some emergency readmissions are an unavoidable consequence of the original treatment. However, some could be avoided by making sure that patients receive: • the best possible treatment according to their needs; and • careful planning and support for caring for themselves when they leave hospital. Table 5: Number of patients who were readmitted within 28 days from 1 April 2016 to 31 March 2017.

Month Number of patients readmitted within 28 days April 2016 8 May 2016 7 June 2016 8 July 2016 5 August 2016 7 September 2016 6 October 2016 10 November 2016 4 December 2016 9 January 2017 February 2017 March 2017 Total

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Graph 1: Percentage of emergency readmissions within 28 days (updated Q3)

Actions to improve our performance • Continuously reviewing and evaluating medical care using the Enhanced Recovery Programme

(ERP).

• Developing an Enhanced Recovery Programme for after liver surgery.

• Developing closer links with community services.

• Developing short-stay surgical procedures.

• 10% of readmissions being reviewed and common themes explored.

• Introducing the acute oncology out-of-hours admission prioritisation guide and updating the access policy. This guide has a specific ‘triage’ sheet to help staff prioritise care. This is then recorded on the patient’s electronic record.

• Putting telephone triage into practice to reduce patient anxiety.

• Communicating better with the Acute Oncology Service (AOS) at other hospitals. • Reviewing non-elective patients and the Acute Oncology Service team.

• The Acute Oncology Service team discussing, at monthly meetings, patients who have been

readmitted within 28 days.

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Priority 5: To reduce the incidence of category-3 pressure sores (full-thickness skin loss) and category-4 pressure sores (full-thickness tissue loss) developing in patients while they are receiving community care. (Q3 update) Applies to Sutton Community Healthcare Services. Targets: • For the percentage of category-3 and category-4 pressure sores arising in

patients receiving community care to be less than 0.2%.

• For 90% of category-3 and category-4 pressure sores, both already existing and developing while receiving community care, to have healed or improved to category 1 (redness of intact skin, which does not fade when pressed) or category 2 (partial-thickness skin loss or blister) within three months.

‘It remains a high priority area for our service to focus on prevention, early identification and management of patients with pressure ulcers and patients at risk of developing pressure ulcers to enable the appropriate care delivery to be implemented in a timely manner.’ Nanette Garner- Senior Sister- Sutton and Cheam Integrated Locality Team Sutton Community Healthcare Services This remains a challenging but important priority for community services and we have continued to focus upon the prevention and management of pressure ulcers for the benefit of patients. What we did in 2016/2017 • Community nursing staff have continued to embed into practice the requirement to carry out a

pressure ulcer risk assessment during the first face to face contact with the patient. • Improvement has been achieved regarding the reporting of patients being admitted to the

community services caseload. • A working group was set up to develop a pressure ulcer care bundle based upon best practice. This

will ensure a standardised approach to the management of pressure ulcers across community services.

How we performed in 2016/2017 • From 1 April 2016 to 30 September 2016, we met our first target of having less than 0.2% of

patients developing category-3 and category-4 pressure sores while under the care of community services. See table 6 over the page for more details.

• From 1 April 2016 to 31 December 2016, 0.12% of patients developed category-3 and category-4

pressure sores while under the care of community services.

• From 1 April 2016 to 31 December 2016, 92% of patients referred to community nursing received

a pressure-sore risk assessment at their first appointment. • From 1 April 2016 to 30 December 2016, 100% of category-3 and category-4 pressure sores

improved to at least category 2 within three months of being diagnosed.

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Table 6: Number of category-3 and category-4 pressure sores developed while receiving care from community services. Number of patients

with a category-3 or category-4 pressure sore developing while under the care of Sutton and Merton Community Services

Percentage each month

Percentage over quarter

April 2016 Category 3 = 4 Category 4 = 0

0.2% Quarter 1 (1 April to 30 June): 0.17%

May 2016 Category 3 = 6 Category 4 = 0

0.3%

June 2016 Category 3= 1 Category 4 = 0

0.04%

July 2016 Category 3 = 3 Category 4 = 0

0.12% Quarter 2 (1 July to 30 September): 0.10%

August 2016 Category 3 = 3 Category 4 = 1

0.15%

September 2016 Category 3 = 0 Category 4 = 1

0.04%

October 2016 Category 3 = 1 Category 4 = 0

0.04% Quarter 3 (1 October to 31 December): 0.09%

November 2016 Category 3 = 2 Category 4 = 0

0.09%

December 2016 Category 3 = 3 Category 4 = 0

0.14%

January 2017 Category 3 = Category 4 =

% Quarter 4 (1 January to 31 March): %

February 2017 Category 3 = Category 4 =

%

March 2017 Category 3 = Category 4 =

%

Actions to improve our performance • Community services are continuing with the agreed programme of service improvement to deploy

strategies for prevention, early detection and management of pressure ulcers both acquired whilst under our care or as patients who are admitted into our community services.

• Developed pressure ulcer care bundle to be introduced throughout March 2017 to ensure a standardised approach to the management of pressure ulcers across community services.

How improvement will be measured and monitored All diagnoses of category-3 and category-4 pressure ulcers will be investigated through a root cause analysis approach and the findings presented at planned 2 weekly pressure ulcer panel meetings. This will identify root causes and learning from incidents to inform improvements required in clinical practice in the care delivery to patients. Once the pressure ulcer care bundle is fully implemented an audit will be undertaken to review the compliance regarding completion and accuracy of recordings. The audit will take place before the end of July 2017.

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Priority 6: For patients to be given information about the side effects of medicines to take after being discharged. (updated Q3) Target: For 75% of patients to receive information about side effects of medicines before they are discharged home. ‘staff quote’ Pharmacist Quality healthcare outcome depends on patient’s adherence to recommended treatment regimes. The Trust aims to support patients with understanding the purpose of their medication as well as the potential side effects that they may encounter, as it is recognised that this will enhance adherence to the recommended treatments. Medication information is communicated at various stages of the patients’ treatment; prescribing, medication review and discharge. Comparison with National Figures The Care Quality Commissions Patient Survey conducted, between August 2015 to January 2016, found that in comparison to other organisations The Royal Marsden rated ‘better’ scoring 7.8/10 when asked if patients were told about medication side effects to watch out for. The pharmacy department are working to increase the number of patients that will be counselled on their medications by a member of the pharmacy team on discharge. What we did in 2016/2017

• A review and change to pharmacy workflow enabling pharmacy Medicines Management

technicians to counsel patients at the point of discharge. • An audit to identify the increase in patient counselling undertaken by pharmacy

medicines management technicians. • A audit to identify whether the level of information received by patients on the Medical

Day unit is perceived as satisfactory, and what the preferred methods for delivery of information are. This audit will compare departments whereby pharmacy medicines management technicians are deployed to counsel patients versus areas that do not currently have technician support.

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How we performed in 2016/2017 Table 7: Number of patients counselled by an MDU Pharmacy Technician

Month Number of MDU patients requiring eChemo TTO’s

Average percentage of patients counselled by MDU

Pharmacy March 2016 (prior to work

flow change) 290 14%

April 2016 299 75% May 2016 (until 20/05/16) 295 84%

Q4 data to follow Table 7 shows a significant increase in the number of patients receiving counselling from a pharmacy technician on their medications at the point of discharge. All patients are currently seen by a pharmacist while on the Medical Day Unit. Following on from the above audit the work flow change is now embedded in practise and pharmacy technicians are substantive staff on the medical day units and counsel all patients at the point of discharge on their medications. Actions to improve our performance • To collect audit data on the patient perceived level of information on medicines and their

side effects after being discharged. This data collection will provide insight into the level of satisfaction patients have regarding the information they receive and the preferred method of delivery of information e.g. verbally or via information leaflets.

• A staffing plan has been proposed to increase the availability of technicians to all patients at the point of discharge from all day units, to counsel patients on their medications including side effects.

How improvement will be measured and monitored Monthly review of progress monitored through pharmacy department scorecards to cover all day unit areas. To regularly monitor patient satisfaction with the levels of information they receive on medication (including side effects).

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Priority 7a: To make sure that we are responding to inpatients’ personal needs. (updated Q3) Target: For our results in the friends and family test for hospital inpatients to still be higher than the national average. ‘staff quote’ Matron The ‘friends and family test’ was announced by the Prime Minister on 25 May 2012. Under this test, all NHS patients are asked whether they would recommend a particular A&E department or ward to their friends and family. The results of the test will be used to improve the experience of patients and highlight priority areas for action. The question asked is: ‘How likely are you to recommend our ward to friends and family if they need similar care or treatment?’ The patients then choose their answer from the following.

• Extremely likely • Likely • Neither likely nor unlikely • Unlikely • Extremely unlikely • Don’t know

We then ask a second question: ‘What was good about your care and what could be improved?’ Patients answer this question freely. Comments are reviewed by the matrons and ward and, where appropriate, action is taken. What we did in 2016/2017 • We have a poster about the friends and family test, and a collection box for responses, outside all

wards and in outpatient and day-care areas. • We ask all patients to fill in the friends and family test form and put it into a collection box. Once a

week the forms are collected and an external company processes the feedback and gives us details. • As well as the friends and family question, we have introduced extra questions to allow patients to

rate our services in terms of dignity, involvement, information, cleanliness and staff. • A new Patient Experience Steering Group chaired by the Deputy Chief Nurse was established to

review the FFT responses alongside results from national patient experience surveys.

http://www.dh.gov.uk/health/2012/05/friends-test/

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How we performed in 2016/2017 To date we have achieved our target with an average across the year of 98% of inpatients saying that they would recommend us. This is higher than the national average of 96%. Graph 2 below shows the percentage of inpatients who would recommend the trust.

NHS England displays the information that has been collected each month for 170 providers of NHS-funded services for inpatients and independent-sector providers for inpatients, outpatients, community services, dental, ambulance, accident and emergency (A&E), maternity, mental-health and GP services. The information is on the website at www.england.nhs.uk/statistics/statistical-work-areas/friends-and-family-test/friends-and-family-test-data/.

To date we have achieved our target with an average across the year of 98% of outpatients saying that they would recommend us. This is higher than the national average of 93%. Graph 3 below shows the percentage of outpatients who would recommend the trust.

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Actions to improve our performance • Continuing to use the friends and family test question to encourage all patients to let us know how

we can improve our services. • Continuing to work with staff who are in contact with patients to increase the response rate for the

friends and family test. • Continuing to communicate results – to trust staff, patients, relatives and carers – by discussing

them at meetings and publicly displaying results on wards’ notice boards and our website. • Analysing the comments received to identify key areas for improvement. • Developing local and trust-wide improvement plans for identified areas of concern. How improvement will be measured and monitored Results will continue to be passed to the ward sisters and matrons each month and we will take action following any comments for improvements. The results will continue to be included in our monthly quality account to the board. The results will be included as part of the terms of reference for a new Patient Experience Strategy group.

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Priority 7b: To continue using the ‘friends and family test’ question for patients receiving community care. (The friends and family test question asks people who use NHS services whether they would recommend the services to others.) (Updated Q3) Target: For the friends and family test results to be above 90% and to increase patient satisfaction. ‘The information we receive from patient feedback can help us tailor our services to the need of our patients & can offer useful suggestions. It can be difficult for a service to demonstrate the need for services through quantitative data alone. Patient feedback can help us to justify current services & explain the need for changes or new services in the patient’s words, which is so valuable.’

Anna Lovegrove Occupational Therapy Lead Community Neuro Therapy Team Sutton Community Healthcare Services What we did in 2016/2017 • We continued to routinely ask our patients receiving community services the friends and family

test question as part of our patient experience surveys. • From 1 April 2016 we started using the same service provider as the rest of the Royal Marsden use

for gathering feedback. This has streamlined the process of gathering, reviewing and acting on feedback.

• We gather survey data from patients, carers and children accessing our services through paper surveys (written and picture/easy read forms), web links and via an App on our mobile devices.

How we performed in 2016/2017 Friends and family test During Quarter 2 (1/7/16-30/9/16) 322 patients responded to our survey request. Their responses to the question ‘How likely are you to recommend this service to friends and family if they needed similar care or treatment?’ are shown below. During Quarter 3 (1/10/16-31/12/16) 843 patients responded to our survey request. Their responses to the question ‘How likely are you to recommend this service to friends and family if they needed similar care or treatment?’ are shown below.

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In Q2, 99.69% of patients responded that they were likely or extremely likely to recommend the service, with 0.31% being unlikely or extremely unlikely to recommend the service.

81%

19%

0%

0%

0%

0%

Q2 FFT responses1 - Extremely Likely

2 - Likely

3 - Neither likely norunlikely

4 - Unlikely

5 - Extremely unlikely

6 - Don't Know

In Q 3, 97.03% of patients responded that they were likely or extremely likely to recommend the service, with 0.36%being unlikely or extremely unlikely to recommend the service.

80%

17%

2% 0%0% 1%

Q3 - FFT Responses 1 - Extremely Likely

2 - Likely

3 - Neither likely norunlikely

4 - Unlikely

5 - Extremely unlikely

6 - Don't Know

Comments from patients included: Community Neurotherapy Professional and caring. Exercises were realistic , achievable and practical. Children’s Physiotherapy Excellent help, this service was fantastic. Outpatient physiotherapy I think your physio has been of real benefit to me. School Nursing I feel like I am not alone and that someone understands.

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Respiratory Service Staff were helpful, considerate and a good grasp of the condition. Community Nursing Nurses always helpful, always willing to help you, always pleasant and cheerful. Couldn’t ask for better care. Community Nursing My husband could not have had better treatment over the last 13 years. Even when I have had to call out night visits when he had problems with his catheter. All I can say is that the staff in our district are angels Musculoskeletal Service I have a right shoulder injury. Got to be seen by MSk team and my physio has been marvellous. I was worried and frightened. Just few words of comfort and help had given me a lot of confidence. He sent me for an ultrasound and after the result he explained about my injury, after concerns and results most of my pain is almost gone and got so much relief and I am so thankful. Health Visiting Great nurse, listened and answered all my worries. Caring and polite. Early Supported Discharge I have been given regular repetitive exercises to aid movement in my hand/arm. I have been given so much encouragement to inspire me. Looked After Children Nurse was very friendly. She explained what she was doing. Very caring OPARS It was very good as it is helping me once again walk with confidence. Actions to improve our performance • Routinely asking patients to give feedback through surveys or by using paper surveys in clinical

areas. • Using Apps and web links to invite patients to provide feedback when they are seen in other

settings • Including feedback from patients in the weekly newsletter that the Divisional Director produces

and sends to staff. • Service managers and patient champions in each team monitoring patient feedback each month

and reporting back to their clinical area at team meetings. • Making sure that survey forms which mention specific members of staff are given to those staff to

be included in their development records. • Teams discussing feedback comments which highlight possible improvements and taking

appropriate action. In Quarter 2 these included: Outpatient Physio First appointment earlier than 4 weeks after surgery would have been better Longer sessions with the physio would help Community Nursing Shorter time period when nurses could visit e.g. between 9 and 12 instead of 9 and 3. Prefer female nurses to visit Children’s Occupational therapy Maybe you could allow parents to view the group sessions as well as explaining the sessions to us at the end

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OPARS Waiting for transport was a drawback Children’s Speech and Language Therapy A sooner follow up appointment could improve the service Cedar Lodge Do more lifestyle type activities

• Teams discussing feedback comments which highlight possible improvements and taking appropriate action. In Quarter 3 these included:

Musculo Skeletal service I waited too long for this appointment. If the GP had referred me for a scan it would have saved time. Team feedback-Musculo Skeletal service has now instigated a ‘triage and treat’ service which includes additional investigations including scanning and will allow patients to access the service directly following referral. Family Nurse Partnership If I was to recommend the FNP I would not know where to tell them to go Team feedback-Work has begun to update website information on services and also on the Community Services Service Directory. How improvement will be measured and monitored Team specific reports will allow services to monitor and tackle issues throughout the year. Survey results will be reported back to the Clinical Commissioning Group (via the Clinical Quality Review Group) every three months. Feedback is also provided to all services through divisional and service-led team meetings. Service managers are to report on ‘You said we did’ actions at monthly internal performance meetings.

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Priority 8: To increase the percentage of staff who would recommend The Royal Marsden to friends or family needing care. (Partial update Q3) Target: For more than 95.5% of surveyed staff to say that they would recommend The Royal Marsden. The quotes below are samples from the anonymous comments staff provided in quarter 1 (1 April 2016 to 30 June 2016) on why they would recommend The Royal Marsden to friends or family needing care. “A junior doctor recently summed up care/staff in the Breast Unit as 'brilliant brains and kind hearts' - I think this stands across the hospital and I would not hesitate to recommend RMH should friends or family need treatment.”

The quotes below are samples from the anonymous comments staff provided in quarter 1 (1 April 2016 to 30 June 2016) on why they would recommend The Royal Marsden to friends or family as a place to work “Over the past year I have been made to feel welcome and part of the team and organisation. From lead management to the front reception. The culture is one of friendliness and openness.” Each year we carry out a staff survey (the annual staff survey) and ask staff how strongly they agree with the statement: ‘If a friend or relative needed treatment, I would be happy with the standard of care provided by this trust.’ In 2016/2017, XX% of staff agreed or strongly agreed with the statement, so we achieved our target. (Will be published nationally in March 2017).

Three times a year we also ask staff to respond to the friends and family test question: ‘How likely are you to recommend this organisation to friends and family if they needed care and treatment’. In quarter 1 (1 April 2016 to 30 June 2016), 95.5% of staff said that they would recommend us.

What we did in 2016/2017 • We ran the staff friends and family test to get feedback on how likely staff would be to recommend

us for care or treatment.

• We continued to share the responses to this and the findings of patient surveys with staff.

How we performed in 2016/2017

Friends and family test

The results of the friends and family test are shown in table 8.

Table 8: staff response to the question ‘How likely are you to recommend this organisation to friends and family if they needed care and treatment’


1st quarter of 2016/2017




Would recommend 96% 95.5% 100% NA

Would not recommend 1.8% 0.9% 0% NA

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The number of staff responding to the friends and family test in quarter 1 (561) is significantly higher to the numbers responding in Quarter 4 2015/16(163). The Q2 survey was only circulated to the Leadership Team to identify ways to retain and develop our leaders. Response rate was good. The survey is not carried out in quarter three as we run the national NHS staff survey then. Workforce Race Equality Standard (to be updated end of February 2017) The Workforce Race Equality Standard requires all NHS organisations to demonstrate how they are dealing with race-equality issues in staffing areas such as recruiting and promoting staff. There has been a marked reduction in the percentage of staff experiencing bullying, harassment or abuse from other staff members. There has also been an increase in the number of staff from black and ethnic-minority backgrounds (BME staff) who believe that there are equal opportunities. Table 9 provides a breakdown. Table 9: Royal

Marsden 2014/2015

Royal Marsden 2015/2016

Average (median) for acute specialist trusts 2015/2016

Royal Marsden 2016/2017

Percentage of staff experiencing bullying harassment or abuse from staff in last 12 months

White 23% 21% 23% BME

27% 24% 24%

White White 90% 90% 91% BME BME 72% 76% 78% Over the last 12 months, we have taken a number of steps to support our Equality and Diversity Strategy, including developing a Black and Minority Ethnic Network to share the experiences and views of BME staff and consider appropriate action to take. We have also launched a mediation service to reduce the number of grievances that reach a formal level. Actions to improve our performance • Promoting the surveys to all staff to encourage a greater response. • Reviewing the comments given in response to the friends and family test question to identify areas

where improvements can be made. • Promoting greater accountability for taking action on the findings from local and national survey

results. • Raising awareness of the Workforce Race Equality Standard and actions being taken to deal with

issues that come to light. How improvement will be measured and monitored The Trust will continue to run the Staff Friends and Family Test and the Annual Staff Survey to ensure feedback is gathered from staff throughout the year. The results will be analysed and reviewed through the Workforce and Education Committee and a set of targeted actions will be agreed to support continuous improvement and ensure excellent staff engagement levels. All action plans will be regularly reviewed through the Workforce and Education Committee to chart progress.

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Priority 9a: To reduce waiting times at chemotherapy appointments and improve patients’ experiences relating to waiting times. (Updated Q3)

Target: For 80% of patients to be satisfied with the length of time they had to wait to start their treatment.

‘staff quote’ To understand and improve chemotherapy waiting times, analysis of the reasons that lead to delayed treatment times is key. By reducing the waiting times for patients we aim to improve patient satisfaction with the process.

What we did in 2016/2017 • A multidisciplinary group has been set up to lead on improving waiting times at chemotherapy

appointments.

• A focus group has been held to discuss the causative factors leading to delays in chemotherapy treatment.

The following identifiers contributing to delays were made:

• Drugs / IV can arrive late due to delays in that team or due to late orders

• ‘Difficult’ cannulations (taking longer than 30mins); either one off or ‘repeated’ difficulties (with limited feedback about booking these patients with ‘extra’ time)

• Bloods not done within 24 hours of treatment

• Consent missing

• Delays in getting samples to labs (possibly due to bundling of samples or delays in being transported around the hospital)

• Chairs are not always available (e.g. due to overrunning)

• Patients arrive late (e.g. due to delays for getting a car park spot)

• Overruns / Limited flexibility of seats (due to high utilisation) / inflexible schedule

• No waiting space for early arrivals

• Short staffed / nursing availability (e.g. unavailability due to sickness)

• Patients overbooked due to breach waits

• Reluctance for patients to be seen ‘late’ in the day

• Need to finish “new” treatments by 5pm`

• Length of appointment is unrealistic / incorrect for regimen

• Data is wrong or incorrectly entered

• Over-testing of bloods – not all markers need to be tested for, for certain regimens

• An audit of (n=132) patients has taken place on the Sutton Medical Day Unit to evaluate the times taken to receive chemotherapy and to evaluate any reasons for any delays to treatment.

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• Reasons for late commencement of chemotherapy A total of 132 patients were recorded as being late in the audit period, and 147 contributory factors identified in 21 categories.

The top 6 categories accounted for approximately 70% of all late starting chemotherapy. These categories are:

Table 10: top 6 reasons of chemotherapy starting late.

Issue Frequency Route Cause Difficulty in Cannulation 17% Additional Clinical Care Availability of Nursing Staff 16% Staffing Chemotherapy not available 12% Multi-factorial Late patient arrival 10% Patient / Transport Repeat bloods required 10% Additional Clinical Care Further medical review required 6% Additional Clinical Care

Looking at the top 6 reasons for SACT delay, these can subdivided into those resulting in increased patient waiting time or those where patients are requiring additional tests or intervention prior to commencement of administration. The two highlighted Issues are those which resulted in a ‘True wait’ whereby the patient was fit and ready for treatment but did not start on time for service related issues.

Figure 2. Reasons for late commencement: split by magnitude of lateness

Analysis of the data showed that whilst common themes persisted regardless of how late the start of the chemotherapy, there were subtle differences. Cannulation issue which were the most prevalent issue in the audit seemed to be addressed within the hour in the majority of cases. Where chemotherapy was not available, repeat bloods were required or there were nursing shortages the issue was not always as easily resolved with a significant impact to those in the category waiting over 90 minutes.

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• Following the results from the audit cycle in Sutton the group repeated the audit at the Chelsea site

Figure 2: Results representing initial responses to audit on reasons identified for delays in waiting times in Chelsea The data shows variation in causes for delay between each site with most frequent documented reason at the Sutton site, being sighted as delays associated with cannulation in comparison to the Chelsea site, where the most common reason for delay was a lack of nursing staff. The data allows for a closer inspection and targeted action plan to reduce delays caused by each of these contributing factors. The variation in data between sites is possibile representative of different processes, staffing and environments within the two hospitals. It also allows us to share learning across the Trust of good practise at one site which may contribute to lower numbers of a contributing facor to delays. I.e. practise surrounding delays in cannulation.

Actions to improve our performance • This analysis provides a baseline to target actions to improve overall waiting times; however the

data does not evaluate the patient experience of these waiting times. • The next steps within this project is to gather this information.

How improvement will be measured and monitored Audit of patient experience regarding chemotherapy waiting times to be embedded into regular audit cycles looking at waiting times. Targeted interventions to improve overall waiting times to be evaluated by measuring the full waiting time and identification of delays, and reasons for delays to be re-visited.

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Priority 9b: To reduce waiting times in outpatient clinics and improve patients’ experiences relating to waiting times. (updated Q3) Target: For no more than 8% of patients to have to wait more than one hour. "The Outpatients Department is often the first impression people have of The Royal Marsden Hospital so we always strive to make it a warm, welcoming and efficient place for our patients to visit." Senior Staff Nurse Out Patients Department Within our outpatient departments we aim to communicate well with our patients to make sure that they have a good experience, particularly at their first appointment. What we did in 2016/2017

• Carried out a full skill mix review of all nursing and administrative staff at both sites to ensure appropriately skilled staff are in each clinic

• Met with each clinical unit to determine their specific needs in clinic in terms of skills and admin support- Skill mix review as part of the of the outpatient transformational work stream

• As part of our planning for a new Outpatient building project, we held process-mapping sessions at the Sutton site to determine each step in the patient journey in order to highlighted bottlenecks and find solutions.

• Commenced working on Create 2 more clinic rooms in Sutton by re-locating offices and the ECG room

• Working on increase number of phlebotomy chairs in Sutton to reduce blockages in patient flow and enable quicker turnaround of blood results for review in clinics

• Continue to audit all information relating to causes of clinic delays by the use of exception reporting by the nurses in every clinic and utilise this information to feedback to the cancer services business units to make appropriate changes

• Introduce new Clinical Assessment Unit in Sutton to enable timely transfer of acutely ill patients away from Outpatients to reduce blockages in clinics

• Develop nurse and multi-professional-led clinics to run concurrently with medical clinics to reduce waiting times, This includes chemo toxicity clinics, dressings clinics and acupuncture clinics

• Created a pathway to refer unwell patients to CAU

How we performed in 2016/2017 This year in response to a request from the council of governors we monitored the number of people in the main Chelsea and Sutton outpatient departments who waited less than 15 minutes. The table below shows an improvement from April when 63% of people were seen within 15 minutes to December where 69% of people were seen within 15 minutes. Table 11 below shows that we achieved our target of less than 8% of patients waited more than one hour for treatment. Table 11: Chelsea and Sutton waiting times 2016/2017 Waiting time

Less than 15 minutes

Less than 30 minutes

30 to 60 minutes

More than one hour

April 2016 63% 19% 13.6% 4.7% May 2016 66% 18% 11.9% 4.2% June 2016 68% 18% 11.2% 3.1% July 2016 66% 18% 11.9% 4.1% August 2016 65% 18% 11.8% 4.6%

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September 2016 68% 18% 11.1% 3.0% October 2016 67% 18% 11.8% 3.6% November 2016 66% 19% 11.8% 3.3% December 2016 69% 18% 10.5% 2.2% January 2017 February 2017 March 2017 Actions to improve our performance Through the Outpatient Transformation Project we will:

• observe clinics and the waiting areas; • speak to patients through their ‘patient journey’ on one visit and hold focus groups to listen to

their views on what works well and what needs improving; • As part of our planning for a new Outpatient building project, we will hold process-mapping

sessions at the Sutton site to determine each step in the patient journey in order to highlighted bottlenecks and find solutions.

• Continue with the development of a clinic utilisation model in RDAC at both sites to determine capacity and roll this out to Outpatients

• Repeat a patient survey on satisfaction with the new waiting zones in Sutton • Reception staff will continue to update the visual display screen and make regular

announcements to tell patients about clinics that are running late. • Create 2 more clinic rooms in Sutton by re-locating offices and the ECG room • Increase the number of clinic co-ordinators in clinics • Increase number of phlebotomy chairs in Sutton to reduce blockages in patient flow and

enable quicker turnaround of blood results for review in clinics • Continue progress with a full skill mix review of all nursing and administrative staff at both

sites to ensure appropriately skilled staff are in each clinic • Meet with each clinical unit to determine their specific needs in clinic in terms of skills and

admin support • Continue to audit all information relating to causes of clinic delays by the use of exception

reporting by the nurses in every clinic and utilise this information to feedback to the cancer services business units to make appropriate changes

• Introduce new Clinical Assessment Unit in Sutton to enable timely transfer of acutely ill patients away from Outpatients to reduce blockages in clinics

• Develop nurse and multi-professional-led clinics to run concurrently with medical clinics to reduce waiting times, This includes chemo toxicity clinics, dressings clinics and acupuncture clinics

• Develop increased number of telephone clinics including some that are nurse-led • Continue to undertake review of clinic templates following NHS elect work on this • Review check in and registration process and all paperwork sent to patients prior to

appointment to ensure clarity and to reduce repetition • Review and enhance pre-assessment interaction with clinics to reduce waiting times and

improve patient experience

How improvement will be measured and monitored We will measure and monitor any improvement by: • Audit the number of patients transferred to CAU from OPD to prevent clinic delays • Monthly OPD operational meetings to monitor scorecards of patient safety, incidents, staff

training and FFT and develop action plans

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Priority 10a: To increase the number of relevant community services patients who have a falls risk assessment completed. (Q3 updated) Target: For the adult services team to develop and integrated falls risk assessment.

Ensure that 65% of patients who are identified as being at risk of falls have a falls risk assessment undertaken.

“Staff awareness has increased regarding the importance of identifying patients at risk of falling and the strategies that can be put into place to reduce this risk.” Chris Dyson- Clinical Service Manager for Unplanned Care Services. Sutton Community Healthcare Services What we did in 2016/2017

• Members of the falls team worked closely with the community nursing teams to develop a falls risk assessment that was then incorporated into the service holistic assessment document. The holistic assessment document ensures the practitioners identifies patient centred health and social care needs based upon the activity of daily living that incorporates, physical, emotional, social, spiritual and cultural requirements. This enables care planning and delivery that is individualised and supports informative partnership working to reduce duplication and supports timely responses.

• Service improvement was achieved regarding the management of urgent falls referrals into the service. To ensure a prompt review was undertaken by appropriate community team member.

• New patient pathway for urgent falls referrals from London Ambulance service was implemented to support avoidable hospital attendances.

• Community nursing service has embedded falls risk assessment into their holistic assessment of patients.

• Community prevention of admission team triage all urgent falls referrals and assess patients at most risk urgently implementing strategies to reduce risk of further falls and making onwards referrals into falls prevention service as required.

How we performed in 2016/2017

• From 1 April 2016 to 30 June 2016, we met our first target by achieving 71.5% of patients who were identified as being at risk of falls have a falls risk assessment undertaken during the first assessment visit by community services. See table 10 for more details.

• From 1 July 2016 to 30 September 2016, we achieved 87.6% of patients who were identified as being at risk of falls have a falls risk assessment undertaken during the first assessment visit by community services.

• From 1 October 2016 to 31 December 2016, we achieved 83.3% of patients who were

identified as being at risk of falls have a falls risk assessment undertaken during the first assessment visit by community services.

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Table 12: Number of falls risk assessment completed at first assessment visit Number of

falls risk assessments undertaken at first assessment


Percentage over quarter Target achieved or not (Target -65%)

April 2016 121 63% Quarter 1 (1 April to 30 June): 71.5%

Achieved May 2016 161 78.9% June 2016 151 71.9% July 2016 301 87.7% Quarter 2 (1 July to 30

September): 87.6% Achieved

August 2016 275 85.7% September 2016 290 89.2% October 2016 224 77.2% Quarter 3 (1 October to 31

December): 83.3% Achieved

November 2016 264 84.6% December 2016 268 87.6% January 2017 % Quarter 4 (1 January to 31

March): %

February 2017 % March 2017 % Actions to improve our performance

• The community services team are continuing to undertake falls risk assessments during the first visit to the patient. The team will ensure all strategies for preventing falls are in place.

• Developing closer links with social care providers and Sutton Age UK.

• Review the current ‘falls prevention service’ to establish areas where improvements could be made to reduce waiting times for patient reviews from point of referral.

• Investigate potential training providers for “Extend Training” to increase group

capacity for falls prevention classes. ‘Extend training’ is a credited well recognised national exercise programme that supports improvement and maintenance to movement, balance and coordination.

How improvement will be measured and monitored Reporting will continue to be monitored via Quality Accounts reporting and through community services monthly key performance reporting process to the Clinical Commissioning Group. This quality priority will continue to be included as a priority for 2017/2018 as this remains an important indicator of our improvement in protecting patients from avoidable possible harm associated related to falls. We will continue to monitor our performance with regards to the timely assessment of patients identified at risk of experiencing falls and falls prevention classes attended.

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Priority 10b: To reduce the number of medication incidents causing moderate of low harm to patients under the care of community services to less than four for the year. (Q3 updated) Target: To ensure a medicine review (reconciliation) takes place during the first assessment of a patient post hospital discharge or secondary care consultation “Staff can see clear evidence of improvement in practice and safer care delivery to patients by undertaking medicine reviews during first assessment.”

Liz O’Brien –Clinical Integrated Locality Manager. Sutton & Cheam Locality. Sutton Community Healthcare Services What we did in 2016/2017

• The community nursing service has embedded medicine reviews into their holistic assessment of patients.

• Improvements have been achieved regarding the identification of medicine prescribing errors from both primary and secondary care settings.

• An escalation process has been put in to place for staff to raise concerns if they are not able to read the doctors handwriting on the form that enables them to give medicines to patients. In community services the doctors complete a document called ‘authorisation to administer medicines document’. This allows staff to give medicines safely to patients.

• Improvement in incident reporting regarding both near misses and unsafe discharge information relating to medicines.

How we performed in 2016/2017 We agreed the target of 90% medicine review (reconciliation) during the first assessment of a patient following discharge from hospital or a secondary care consultation.

• From 1 April 2016 to 30 June 2016, we met our first target by achieving 90.9% of patients having had a medicines review (reconciliation) during the first assessment visit by community services. See table 6 over the page for more details.

• From 1 July 2016 to 30 September 2016, we achieved 90.6% of patients having had a medicines review (reconciliation) during the first assessment visit by community services.

• From 1 October 2016 to 31 December 2016, we achieved 91.8% of patients having had

a medicines review (reconciliation) of during the first assessment visit by community services.

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Table13: Number of patients who had a medicine review at the first assessment visit Number of

patients who had a medicine review undertaken at the first assessment visit


Percentage over quarter Target achieved or not (Target -90%)

April 2016 171 89.1% Quarter 1 (1 April to 30 June): 90.9%

Achieved May 2016 189 92.6% June 2016 191 90.9% July 2016 311 90.6% Quarter 2 (1 July to 30

September): 90.6% Achieved

August 2016 295 91.9% September 2016 290 89.2% October 2016 269 91.03% Quarter 3 (1 October to 31

December): 91.8% Achieved

November 2016 284 87.8% December 2016 281 87.6% January 2017 % Quarter 4 (1 January to 31

March): %

February 2017 % March 2017 % Actions to improve our performance

• Community services will continue to undertake a review of patients on their caseload. The review will include administration or prompting of medicines, to ensure all strategies for preventing medication incidents and self-management are in place.

• To review current authorisation to administer processes with the clinical lead for the Clinical Commissioning Group to establish if process requires redefining to reduce current variations across the system.

• To undertake a snapshot audit of our transcribing of medicines documentation within patients care records.

How improvement will be measured and monitored The Executive Medicines management committee will continue to monitor reported near misses and all other medication incidents and outcomes at the monthly meetings. Performance will also be monitored as part of the monthly Clinical Commissioning Group’s Clinical Quality Review Group meetings through the monthly scorecard. The scorecard is also reviewed at each Trust board meeting. This priority will continue to be included as a priority for 2017/2018 as this remains an important indicator of our improvement in protecting patients from avoidable possible harm associated to medication errors. We will continue to monitor our performance with regards to reducing the number of medication incidents causing moderate or low harm to patients under the care of community services to less than four each year. We will evidence progress made by including data collected through incident reporting and a six monthly audit of our transcribing of medicines document against patients available prescribe medicines. First audit to be carried out during March 2017 and findings will be included in Q4 reporting period.

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Part 3 Outline of quality improvements in 2016/2017 In January 2017, NHS England published the quality accounts: reporting arrangements for 2016/2017. We chose to include the mandatory (must do) set of quality indicators for requirements for 2016/2017. Some of the indicators are not relevant to us (for example, ambulance response times), so we have not included them. In February 2017, NHS Improvement issued ‘Detailed requirements for quality reports for foundation trusts 2016/2017’. In addition they issued ‘Detailed requirements for external assurance for quality reports for foundation trusts 2016/17’ as from 2011/2012 all acute trusts must have their Quality Accounts checked by external auditors. However, we also felt it was important to consult with our members and council of governors to incorporate their views about ‘quality’ into the quality account. The process for agreeing the quality priorities for 2017/2018 was as follows. October 2016 Held a Patient Experience and Quality Account meeting to review progress in quarter 1 (1 April 2016 to 30 June 2016) against our priorities for 2016/2017. October 2016 Sent out a survey to foundation trust members to choose quality priorities for 2017/2018. November 2016 Held an event for foundation trust members on 29 November 2016 to carry out a survey and vote on quality priorities for 2017/2018. February 2017 Held a Patient Experience and Quality Account meeting to review progress during quarter 3 (1 October 2016 to 31 December 2016) against our priorities for 2016/2017. March 2017 Hold a Council of Governors meeting to review results of previous surveys and voting on quality priorities for 2017/2018. Council of Governors to then select a quality priority for 2017/2018. Draft the final version of the quality accounts. Draft reviewed by external stakeholders for 30 days. April 2017 Plain English campaign to review draft. Draft reviewed by the Trust Board committee and stakeholders returned comments and statements to be included in appendix 4. May 2017 Approved at the Finance and Audit committee as delegated by the Board. Final annual quality account included as part of the trust’s annual report sent to NHS Improvement.

June 2017 Final annual quality account published with Plain English Campaign's Crystal Mark. Annual quality account published on the NHS Choices website and the Trust’s website.

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The quality priorities for 2017/2018 (draft) The quality priorities and targets for 2017/2018 are shown in the table below. The priorities and targets in blue were mandatory in 2017/2018 (that is, we had to include them) and the priorities and targets in red are the ones we have set ourselves. Table 14: Quality priorities and targets for 2017/2018 Category Quality priority Target Safe care 1 To reduce the number of cases

of healthcare related infections (MRSA and clostridium difficile infections). Applies to hospital inpatient beds at The Royal Marsden and patients of Sutton Community Healthcare Services.


Safe care 2 To maintain or increase the number of reported patient safety incidents and near misses whilst reducing the rate and percentage of patient-safety incidents resulting in severe harm or death. (A patient-safety incident is an incident which could have harmed or did harm a patient.) (In 2015/2016 the rate of severe harm or death from incidents per 1000 bed days was 0.033 for hospital and 0.0 for community.) Applies to hospital inpatient beds at The Royal Marsden and Sutton Community Healthcare Services.

For the rate of reported patient-safety incidents that have caused severe harm or death to be below 0.089 per 1000 bed days.



Effective care 4 To reduce the incidence of emergency readmissions to hospital within 28 days of patients being discharged.


Effective care 5 To reduce the incidence of category-3 pressure sores (full-thickness skin loss) and category-4 pressure sores (full-thickness tissue loss) developing in patients while they are receiving community care.

For the percentage of category-3 and category-4 pressure sores arising in patients receiving community care to be less than 0.2%. For 90% of category-3 and category-4 pressure sores, both

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Applies to Sutton Community Healthcare Services.

already existing and developing while receiving community care, to have healed or improved to category 1 (redness of intact skin, which does not fade when pressed) or category 2 (partial thickness skin loss or blister) within three months.

Effective care 6 For patients to be given information about the side effects of medicines to take after being discharged.


Patient experience


a) For our results in the friends and family test for hospital inpatients to still be higher than the national average. b) For the friends and family test results to be above 90% and to increase patient satisfaction.

Patient experience



Patient experience

9 a To reduce waiting times at chemotherapy appointments and improve patients’ experiences relating to waiting times. b To reduce waiting times in outpatient clinics and improve patient experiences relating to waiting times








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Table 15 below summarises our quality priorities for the last seven years. Priorities for community services are provided from 2010/2011 onwards.

Safe care 2010/2011 2011/2012 2012/2013 2013/2014 2014/2015 2015/2016 2016/2017 Reduce the incidence of healthcare-associated infections

Reduce the incidence of healthcare-associated infections

Reduce the incidence of healthcare-associated infections (mandatory priority)



Reduce the number of cases of healthcare-related infections (mandatory priority)

To reduce the number of cases of healthcare related infections (MRSA and clostridium difficile infections). Mandatory

Reduce the number of medication incidents

Reduce the number of medication incidents

Reduce the rate of patient-safety incidents and the percentage resulting in severe harm or death (mandatory priority)




To maintain or increase the number of patient safety incidents and near misses that are reported, reducing the percentage of incidents that have resulted in severe harm or death

Reduce the number of falls

Reduce the number of falls in hospital Increase by 15% the number of falls screens (applies to Sutton and Merton Community Services)

--------------- --------------- --------------- --------- ---------

Assess, monitor and treat venous thromboembolism (a blood clot in a vein)

Reduce the incidence of venous thromboembolism (blood clots)

Maintain the percentage of admitted patients assessed for the risk of venous thrombo-embolism (mandatory priority)



Maintain the percentage of admitted patients assessed for the risk of getting a venous thrombo embolism – a blood clot in the vein (mandatory priority)

To maintain the percentage of admitted patients assessed for the risk of venous thromboembolism (getting a blood clot in a vein).

Meet national health-visit

Meet national health-visit

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targets – new birth visits (applies to Sutton and Merton Community Services)

targets – new birth visits (applies to Sutton and Merton Community Services)

--------------- ------------- ----------- ---------

Meet national guidance and training – safeguarding children (applies to Sutton and Merton Community Services)

----------

---------------

---------------

-------------

-------------

Reduce the hospital standardised mortality ratio (HSMR)



--------------

---------------

------------

------------

Effective care 2010/2011 2011/2012 2012/2013 2013/2014 2014/2015 2015/2016 2016/2017 Reduce the incidence of pressure sores arising in hospital

Reduce the incidence of pressure sores arising in hospital Reduce the incidence of pressure sores, especially categories 3 and 4, developing in patients receiving community services (applies to Sutton and Merton Community Services)

Reduce the incidence of category-3 and category-4 pressure sores developing in patients receiving community services

Reduce the incidence of category-3 pressure sores (full-thickness skin loss) and category-4 pressure sores (full-thickness tissue loss) developing in patients while they are receiving community care (applies to Sutton and Merton Community Services)

Reduce the incidence of category-3 pressure sores (full-thickness skin loss) and category-4 pressure sores (full-thickness tissue loss) developing in patients while they are receiving community care (applies to Sutton and Merton Community Services)

Reduce the incidence of category 3 pressure sores (full thickness skin loss) and category 4 pressure sores (full thickness tissue loss) developing in patients while they are receiving community care

To reduce the incidence of category-3 pressure sores (full-thickness skin loss) and category-4 pressure sores (full-thickness tissue loss) developing in patients while they are receiving community care.

--------------

---------------

More than 42% of patients to die where they have chosen to die

Increase the number of patients who die where they have chosen to die

------------

-----------

-----------

Reduce the length of stay

Reduce the length of stay

------------

------------

------------

-----------

-----------

---------------

-------------

Increase the number of patients offered a holistic needs

Increase the number of patients who have a holistic needs

Increase the number of patients who have a holistic needs

-----------

-----------

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assessment assessment (an assessment that considers all aspects of a person’s needs, such as emotional, social and cultural needs, not just their medical needs)

assessment (an assessment that considers all aspects of a person’s needs, such as emotional, social and cultural needs, not just their medical needs)

---------------

-------------

Reduce the number of emergency readmissions to hospital within 28 days of discharge (mandatory priority)



Reduce the number of emergency admissions to hospital within 28 days of patients being discharged (mandatory priority)

To reduce the incidence of emergency readmissions to hospital within 28 days of patients being discharged.

Patient experience 2010/2011 2011/2012 2012/2013 2013/2014 2014/2015 2015/2016 2016/2017 Be in the top 20% of trusts for key areas in the national inpatient survey

Be in the top 20% of trusts for key areas in the national inpatient survey

Improve or maintain a high score in relation to responding to inpatients’ personal needs in the national survey (mandatory priority)

Make sure that we are responding to inpatients’ personal needs (mandatory priority) Introduce a patient survey for Sutton and Merton Community Services (mandatory priority)

Make sure that we are responding to inpatients’ personal needs (mandatory priority) Introduce a patient survey for Sutton and Merton Community Services (mandatory priority)

Make sure that we are responding to inpatients’ personal needs (mandatory priority) To continue using the ‘friends and family test’ question for patients receiving community care (mandatory priority)

a To make sure that we are responding to inpatients’ personal needs. b To continue using the ‘friends and family test’ question for patients receiving community care. (mandatory)

Be in the top 20% of trusts for key areas in the national outpatient survey

Be in the top 20% of trusts for key areas in the national outpatient survey

--------

Improve communication, particularly at first appointments

Improve communication, particularly at first appointments

-----------

Immediately gather patient feedback throughout the trust

Immediately gather patient feedback throughout the trust

------------

------------

------------

-----------

Reduce chemotherapy

Reduce waiting times




a To reduce waiting times

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waiting times Improve patients’ experiences of hospital transport Improve communication at every part of the patient’s experience

at chemotherapy appointments and improve patients’ experiences relating to waiting times



at chemotherapy appointments and improve patients’ experiences relating to waiting times. Reduce waiting times in outpatient clinics and improve patients' experiences relating to waiting times

at chemotherapy appointments and improve patients’ experiences relating to waiting times. b To reduce waiting times in outpatient clinics and improve patient experiences relating to waiting times

-------------

-------------

Increase the percentage of staff who would recommend The Royal Marsden to friends or family needing care (mandatory priority)




To increase the percentage of staff who would recommend The Royal Marsden to friends or family needing care. (mandatory priority)

------------

-------------

Reduce the length of time a patient waits for medicines or equipment when they are discharged

Reduce the length of time a patient waits for medicines or equipment at the point when they are discharged

Reduce the length of time a patient waits for medicines when they are discharged.

For patients to be given information about the side effects of medicines to take after being discharged.

------------

-------------

Increase the uptake of immunisation, working in partnership with primary care

Improve health outcomes for children in reception class, in line with the ‘Healthy Child Programme 5-19. (This programme sets out a framework of services for children and young people to promote good health and well-being.)

Make sure that children in Sutton and Merton have high levels of protection against disease within the local communities. Measure the number of girls who receive the HPV (human papilloma virus) immunisation, and the number of school-leavers

Adult community services. a) To increase the number of relevant community services patients who have a falls risk assessment completed. b). To reduce the number of medication incidents causing moderate of

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receiving the booster for diphtheria, polio and tetanus, and report findings across Merton and Sutton boroughs.

low harm to patients under the care of community services to less than four for the year.

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Statements of assurance from the Board

Review of services

During 2016/2017, we provided or subcontracted comprehensive cancer services and community services. We have reviewed all the information they have on the quality of care provided by all their relevant health services. The income generated by the health services reviewed in 2016/2017 is equal to the total income generated from the relevant health services in 2016/2017. The information provided in part three of this quality account covers the three aspects of quality – patient safety, clinical effectiveness and patient experience. Taking part in clinical audits (updated Q3)

At The Royal Marsden we undertake many clinical audits for quality improvement. We participate in all the national cancer audits which are applicable to the organisation. This allows us to benchmark against other hospitals in England and sometimes across the world. We also have a comprehensive programme of local clinical audits which clinical staff including consultants, junior doctors, nurses and allied health professionals conduct regularly to improve local areas of care.

During Q3 2016/17 19 national clinical audits and 6 national confidential enquiries covered relevant health services that The Royal Marsden provides. National clinical audit and confidential enquiries

National confidential enquiries are “inspections” that are carried out nationally to investigate areas of care where there may have been problems or where the patients may be particularly vulnerable. All hospitals are asked to take part in them so that all care across England can be monitored. During Q3 2016/17 The Royal Marsden registered and/or participated in 19 of the national clinical audits and all national confidential enquiries in which it was eligible to participate in (Table 16). Many of the national audits undertaken by other hospitals cannot be undertaken at The Royal Marsden because we only have patients with cancer. The national clinical audits and national confidential enquiries that The Royal Marsden participated in, and for which data collection was completed for the period 2016/17, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry (Table 16 and 18). Table 16: National clinical audits we took part in during 2016/2017

No National Clinical Audits Participated Cases submitted (%)

1 National Oesophago-Gastric cancer audit (OG) Audit

Yes Data collection stage

2 National Bowel Cancer Audit (NBOCAP)


3 National Lung Cancer Audit (NCLA) Yes Data collection stage

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4 National Emergency Laparotomy Patient Audit Year 3

Yes 100%

5 National Prostate Cancer (NPCA) Yes 100%

6 Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme (CMP)

Yes 100%

7 Sentinel Stroke National Audit Programme (SSNAP)

Yes 100%

8 National Head and Neck Cancer Audit (DAHNO/HANA)


Other National Audits

9 National Health Service Cancer Screening Programme (NHSCSP) Audit of Invasive Cervical Cancer


10

The British Association of Urological Surgeons (BAUS) Nephrectomy audit 2016

Yes 100%

11 BAUS Total Cystectomy audit 2016 Yes 100%

12 BAUS Radical Prostatectomy audit 2016

Yes 100%

13 BAUS Retroperitoneal Lymph Node Dissection (RPLND) 2016


14 The iBRA2 (implant breast reconstruction evaluation) Study: a national audit of practice and outcomes of implant breast reconstruction


15 National reaudit of Adjuvant Breast Radiotherapy Technique and Tumour Bed Boost Practice in Early Breast Cancer after Breast-Conserving Surgery 2014


16 The Association of Breast Surgery (ABS) & NHS Screening Audit


17 The Breast Cancer Clinical Outcome Measures (BCCOM) Project


18 National Mastectomy Decisions Audit Yes Data collection stage

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(MASDA)

19 Re-audit of National Comparative Audit of Patient Blood Management in adults undergoing elective, scheduled surgery

Yes 100%

The reports of 8 national clinical audits were reviewed by The Royal Marsden in Q3 2016/17. The Royal Marsden will take the following actions (awaiting confirmation of actions) to improve the quality of healthcare provided, where appropriate. In 2016/2017 we reviewed the reports of 13 national clinical audits. Where appropriate, we will take the following actions to improve the quality of healthcare we provide. Table 17: National clinical audit reports published and actions taken

No National Clinical Audit reports published in 2016/17

Description of actions

1 National Bowel Cancer Audit (NBOCAP) Report reviewed

2 National Oesophago-Gastric cancer audit (OG) Audit

Report disseminated

3 Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme (CMP)

Report reviewed at Surgical Audit Group

4 National Comparative Audit of Lower Gastrointestinal bleeding and the Use of blood

Report reviewed

5 National Emergency Laparotomy Patient Audit Year 2

Report reviewed at Surgical Audit Group

6 The British Association of Urological Surgeons (BAUS) Nephrectomy audit 2015

Report reviewed.

7 BAUS Total Cystectomy audit 2015 Report reviewed

8 BAUS Radical Prostatectomy audit 2015 Report reviewed

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Table 18: National confidential enquiries we were eligible to take part in during 2016/2017

National Confidential Enquiry into Patient Outcome and Death (NCEPOD) studies

Took part? Percentage of cases used

1 Acute Pancreatitis Not applicable Not applicable

2 Mental Health in General Hospitals Yes Organisational questionnaire completed

3 Chronic Neurodisability ( focusing on cerebral palsy study)

Yes Organisational questionnaire completed

4 Young People’s Mental Health Study Yes Data collection

5 Non Invasive Ventilation Yes Data collection

6 Cancer in Children, Teens and Adults Yes Data collection

The report of 1 national confidential enquiries report was reviewed by The Royal Marsden in 2016/17. The Royal Marsden intends to take the following actions to continue to improve the quality of healthcare provided. Table 19: National Confidential Enquiries reports published and actions

No National Confidential Enquiry into Patient Outcome and Death (NCEPOD) studies

Description of actions (local)

1 Acute Pancreatitis Study Report disseminated for information only

The reports of 18 local clinical audits and local action plans to improve the quality and outcomes of patient care were reviewed by the Clinical Audit Committee of The Royal Marsden in Q3 2016/17. The following actions are examples of some of the actions taken. Should you require more information about the local audits please contact the Quality Assurance department on 020 7808 2702 or email [email protected].

mailto:[email protected]

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Table 20: Local audits reviewed and examples of some of the actions we plan to take

Name of local audit Actions and learning arising from the audit

Acute pain management documentation re-audit

Results presented at matrons and sisters meetings and at Fulham Road pain collaborative meeting. Pain roadshow to raise further awareness of acute pain management. All missed observations entered on Datix. Patient controlled analgesia (PCA) observations chart updated to include respiratory rate recording space.

Audit of hospital handovers Findings distributed to outreach leads and admissions teams. Action plan sent to registrars, junior doctors and anaesthetists. All missing attendees are now telephoned prior to the start of each hospital handover meeting. Specialist registrar (SpR) now liaises with consultant in charge of each patient for whom a clear escalation plan was not communicated. Night senior house officer (SHO) now telephones relevant SpR to gain clarity with regard to their patient’s escalation strategy if the SpR is not sufficiently familiar with the patient. Re-audit in January 2017.

A retrospective audit to establish the current practice of advance care planning and referral to specialist palliative care services within the lung oncology outpatient setting

Introduce the advanced care plan framework within the lung oncology department and to assess whether this has any effect on the timely referral to specialist palliative care services and also on early advanced care planning discussions.

Concerns and complaints management audit 2015/16

Results of the audit presented to the Patient Advice and Liaison Service (PALS) team and the Complaints department. PALS team reminded that all concerns must be followed up to ensure they have been resolved. New escalation process implemented when responses from staff confirming resolution are not forthcoming. All lead investigators emailed and reminded that all statements and supporting documentation must be returned with the final draft in accordance with criteria 6 and 7 of the standards. Failure to return draft response on due date now escalated to the Complaints Manager to address with lead investigator and Divisional Director. Complaints department will consider appropriateness of agreeing extension of time for return of draft responses in exceptional circumstances.

A prospective clinical audit comparing radiographer and clinician based localisation for metastatic spinal cord compression (MSCC) to assess the feasibility of a radiographer led service

Report published in British Institute of Radiology journal. Radiographer-led service for patients with MSCC and vertebral metastasis implemented.

Pharmacy interventions audit (including cytotoxic prescribing)

Prescribers to be contacted and intervention discussed in real time to act as an educational tool and reduce risk of recurrence.

Antimicrobial stop and review stickers implementation audit

Antimicrobial review stickers implemented.

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Re-audit of opioid prescribing Pharmacy Inpatient Endorsing Guidelines updated. Controlled drug policies at The Royal Marsden Hospital reviewed. Inpatient drug chart amended to include all Royal Marsden controlled drug requirements. All prescribers and pharmacy staff made aware of the opioid prescribing guidance, with more emphasis on the Trust requirements. All pharmacy staff informed of the different endorsements that are required.

Audit of antimicrobial point prevalence In accordance with the trust antimicrobial stewardship programme, training and enforcement to focus on allergy status documentation for safety documentation of indication on the drug chart for good communication switching intravenous antimicrobials where appropriate ensuring relevant microbiology samples are sent and antimicrobial therapy changed in accordance to the susceptibility profile

Audit of thalidomide prescribing requirements

Best practice confirmed.

Pharmacy inpatient experience survey Improvement in awareness in the Medicine Information Service. Hello My name is… campaign introduced to the pharmacy service to assist in ensuring patients are aware they are speaking to a member of the pharmacy team. Standards for this survey to be used for future audits about inpatient experience. Re-audit in March 2017 planned.

Pharmaceutical waste reduction: an audit to assess the extent of unused high cost oral anti-cancer medication dispensed for patients at The Royal Marsden

Best practice confirmed.

Falls risk assessment process audit Further training provided to both nursing and pharmacy staff. Discussion with respect to the individual patient can take place on completion of the Patient Handling Assessment and the At Risk of Falls Assessment and Prevention Care Plan by the nurse on admission, and the medicines reconciliation by the pharmacist. Patient Handling Assessment Review Chart revised. Falls Prevention and Management policy amended to include the responsibility of attaching red Falls stickers to the corner of patients’ drug charts.

Self-Administration of Medications Programme (SAMP) staff patient survey

SAMP implemented at The Royal Marsden Hospital.

Use of intravenous immunoglobulinin haematology patients

Pharmacy and clinical teams to be made aware of dose rounding down instead of up, in line with Royal Marsden policy and the Department of Health national guidelines.

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Tissues for Research Consent 2015/16 Further awareness raised with Royal Marsden staff of the importance of patients agreeing and signing the Tissues for Research consent form. Consent form will be added into the welcome leaflet that is given to all new patients and this will be raised with the patient education team. Re-audit in March 2017.

Deprivation of Liberty Safeguards (DoLS): an audit into current local practice of a 16-bed specialist cancer critical care unit (CCU)

Steps required in pre-consent for surgical patients simplified. Continue education regarding DoLS, including further work at induction. DoLS policy changed for CCU.

CCU care created on Anaesthetic Medical Sheet on ICIP.

Critical care unit documentation audit

Improvement in the documenting of the feeding plan/status and generating the final discharge form.

Improve CCU booklets. Sepsis admissions to critical care unit

Improvement in compliance with anti-microbial guidelines. Sepsis awareness raised with CCU staff. Programme of sepsis roadshows at The Royal Marsden. Sign up to Safety campaign started. Improve in lactate measurement.

Re-audit in March 2017 planned. End of life care on the critical care unit Improvement in multidisciplinary team decisions.

Improvement in communication between doctors and nurses. Provide more advance decisions regarding ceilings of care prior to critical care unit admission. Provide more training and education. Introduce early involvement from the palliative care team to make the transition between active treatment and withdrawal easier. Regular debriefing provided. Teaching programme for end of life care for the critical care team introduced.

Taking part in clinical research (updated Q3) The Royal Marsden and The Institute of Cancer Research form the largest centre for cancer research in Europe. This is important because it means that our patients and our staff are always aware of the latest research in treatments, medicines and therapies that make such a big difference to outcomes and patients’ experiences of care. If you would like to find out more about our research work, visit our website at www.royalmarsden.nhs.uk. From April 2016 to March 2017, we recruited 3296 patients as part of 288 different clinical studies in research approved by a research ethics committee.

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Revalidation of doctors (Updated Q3)

In quarter 3 (October –December 16), 4 doctors were due for revalidation (the process of making sure that doctors, except trainees, can stay registered). RMH made 4 positive recommendations for revalidation to the GMC. This is 100% of all doctors due for revalidation in this quarter. We did not have to recommend any deferrals to the GMC. At the end of December 2016, 95% (total no of doctors) of eligible doctors were recorded as having completed an appraisal in the last 12 months. An annual report on appraisal and revalidation was presented in May 2016, with a clear action plan to increase the number of doctors with a valid appraisal and reduce the number of GMC deferrals. We also have processes in place to support and improve our compliance and governance arrangements. We will complete an internal audit this financial year, and we report our appraisal rates to NHS England each quarter. Commissioning for Quality and Innovation (CQUIN) (updated Q3)

Commissioning for quality and innovation is a mechanism for commissioners to reward quality by linking a proportion of the Trust’s income (2-2.5% in 2016/17) to the achievement of quality improvement goals.

• In 2014/15, CQUINs were not available to the Trust however local quality incentive schemes (LQIS) were agreed in their place. The Trust’s cancer specialist services achieved 100% of its acute LQIS goals which equated to approximately £47,000. Community Services Division achieved 100% of its LQIS goals until Q3. At the time of publication, achievement of Q4 milestones was still to be confirmed however it is expected that Community Services will meet 100% of its LQIS goals which will equate to £800,000 in total.

• CQUIN goals for 2016/17 have been agreed with commissioners in the following subject areas for cancer specialist services and for community services:

Cancer specialist services

1) NHS England CQUIN Schemes

− Clinical Utilisation Review (CUR) − Enhanced supportive care access for advanced cancer patients − Nationally standardised dose banding for adult intravenous systemic anti-

cancer treatment − Adult critical care − Development of risk stratified pathways − The Royal Marsden Macmillan Hotline.

2) CCG CQUIN Schemes − NHS Staff Health and Wellbeing − Enhanced supportive care access for advanced cancer patients − Development of risk stratified pathways − The Royal Marsden Macmillan Hotline

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− Living with and Beyond cancer

Community Services

− Falls prevention − Venous leg ulcers − Wellness and promotion of self-care. − Reducing inequalities in health screening – the over 75s check.

Acute CQUIN goals 2016/17

The table shows the Trust’s position against Q3 milestones, which was submitted to NHS England on 31st January 2017.

Table 21: NHS England CQUIN milestones

NHSE

CQUIN scheme Milestone

Quarter 3 2016/17

Clinical Utilisation Review (CUR)

Provider and commissioner have an agreed and documented operational / mobilisation plan. Appropriate information flows are being established, datasets and a schedule of regular reports are being agreed with commissioners.

Evidence of a signed contract with a recognised UR software provider stating “Go live” dates.

Software and interfaces are installed and live; training completed by the agreed “Go live” date.

Achieved

Enhanced support care

Roll out in pilot tumour sites. Success in line with trajectory

Achieved

Dose banding Performance in line with trajectory.

Achieved

Adult critical care

Performance in line with trajectory. Achieved

Development of risk stratified pathways

Planning and development of comprehensive action plan to roll out into the other identified tumour sites. Agree a reduction in follow-ups for eligible cohorts within selected tumour sites.

Achieved

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NHSE


Quarter 3 2016/17

The Marsden Macmillan Hotline

Evaluation of pilot rollout in Q2 Audit and baseline response time of answering the call Audit and baseline completion of proforma Develop action plan in light of findings Progress against success metrics

Achieved

Submission against Q4 milestones is due on 30 April 2017.

The table shows the Trust’s position against Q3 milestones, which was submitted to Sutton CCG on 31st January 2017.

Table 22: CCG CQUIN milestones

CCG


Quarter 3 2016/17

NHS Staff Health and Wellbeing

Introduction of health and wellbeing initiatives : Providers should have developed an action plan to introduce and actively promote the three initiatives that is peer reviewed and signed off. Healthy food for NHS staff and visitors : The collection of the 11 national data points and the submission via unify Improving the uptake of flu vaccinations for frontline clinical staff : Evidence total number of front line healthcare workers who have confirmed they have received their flu vaccine, and staff who have been offered the vaccine and declined.

Achieved Achieved t.b.c. Data validation is ongoing. The final position will be submitted on 13/2/2017

Enhanced support care

Roll out in pilot tumour sites. Success in line with trajectory

Achieved

Development of risk stratified pathways

Planning and development of comprehensive action plan to roll out into the other identified tumour sites. Agree a reduction in follow-ups for eligible cohorts within selected tumour sites

Achieved

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CCG


Quarter 3 2016/17

The Marsden Macmillan Hotline

Evaluation of pilot rollout in Q2. Audit and baseline response time of answering the call. Audit and baseline completion of proforma. Develop action plan in light of findings. Progress against success metrics.

Achieved

Living With and Beyond Cancer

Investigate why care plans are not being generated at the time of HNA. Ascertain what templates are in use and determine ways to capture this data.

Achieved

Submission against Q4 milestones is due on 30 April 2017.

Community Services CQUIN goals 2016/17

An extension has been granted by commissioners to allow the submission of evidence to support achievement of Quarter Three milestones schemes by 28 February 2017.

Submission against Quarter Four milestones is due on 30 April 2017.

The Royal Marsden is waiting for confirmation of the Quarter One and Quarter Two CQUIN goals from both cancer specialist and community services commissioners.

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What others say about The Royal Marsden

Registration with the Care Quality Commission (CQC) (updated Q3) The Royal Marsden NHS Foundation Trust (the Trust) must be registered with the Care Quality Commission. Their current registration status is ‘registered with no conditions’. To date, the Care Quality Commission has not taken enforcement action against the Trust during 2016/2017. To date, The Royal Marsden is not having to have regular reviews carried out by the Care Quality Commission. To date, The Royal Marsden has not been involved in any of our special reviews or investigations during 2016/2017. Care Quality Commission ratings During the year 2016/2017, we had a routine inspection by the CQC in April 2016. The final report was published in January 2017. The CQC currently aggregates ratings across all service areas, and for cancer and community services overall the Trust has been rated “Good”. The Royal Marsden’s services have been rated “Outstanding” for the Chelsea site, for Radiotherapy, Critical Care, and Chemotherapy (Sutton site). The Trust has also been rated “Outstanding” for the quality of its caring environment. In addition, The Royal Marsden has been rated “Good” for services for Children and Young People, Haematology, the treatment of Adult Solid Tumours and Outpatients (Chelsea site). In 2011 The Royal Marsden accepted responsibility for Community Services in Sutton to trial new integrated pathways of care for local people. Sutton Community Services was inspected by the CQC and rated “Good” for Children and Young People, and End of Life Care, with Adult Community Services requiring improvement, principally in documentation and staffing levels. Table 23: CQC overall Trust ratings January 2017 Overall rating Good

Are services at this trust safe?

Good

Are services at this trust effective?

Good

Are services at this trust caring?

Outstanding

Are services at this trust responsive?

Good

Are services at this trust well-led?

Good

Areas requiring improvement At the time of the report the Trust is waiting to have the Quality Summit (where CQC inspectors meet with the Trust and commissioners to agree the actions that are required). After that meeting an action plan will be developed and submitted to CQC within one month. The areas that require improvement are detailed in the tables below.

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Table 24. The Royal Marsden- Sutton Regulated activity(ies)

Regulation

Surgical procedures Regulation 12 HSCA (RA) Regulations 2014: Safe care and treatment. 12 (1) (2) (a) (b) How the regulation was not being met: 12 (1) (2) (a) (b) The world health organisation (WHO) five steps to safer surgery checklist was not being used in the outpatients department even though a range of procedures were being carried out for which it should have been used. The five steps to safer surgery checklist was not used in the outpatients departments. The hospital must take action to: • Ensure the safer surgery checklist is consistently implemented for all surgical procedures in the outpatients department including the five steps of team brief, sign in, time out, sign out, and debriefing. Reg 12 (1) (2) (a) (b) • Ensure adequate audit and monitoring systems are in place to monitor performance and compliance of the safer surgery checklist to guide improvement. Reg 12 (1) (2) (a) (b)

Table 25. The Royal Marsden- Sutton Community Healthcare Services


Regulation

Accommodation for persons who require nursing or personal care.

Diagnostic and screening procedures.

Nursing care.

Personal care.

Treatment of disease, disorder or injury.

Regulation 11 HSCA (RA) Regulations 2014

Need for Consent

How the regulation was not being met: The provider had failed to ensure care and treatment was provided with the consent of the relevant person.

Staff were not clear about who could consent on the patient’s behalf and how this information should be recorded in patient’s records.

Deprivation of Liberty Safeguards were not always understood and mental capacity was not consistently appropriately assessed and recorded for patients who may lack capacity.

Table 26. The Royal Marsden- Sutton Community Healthcare Services


Regulation

Accommodation for persons who require nursing or personal care.

Diagnostic and screening procedures.

Nursing care.

Personal care.

Treatment of disease, disorder or injury.

Regulation 17 HSAC (RA) Regulations 2014

Good governance

How the regulation was not being met: The provider had failed to assess, monitor and improve the quality and safety of services provided in the carrying on of regulated activity (including the quality of the experience of service users in receiving those services).

The provider had failed to ensure that their audit and governance systems were effective in relation to community services for adults.

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Quality of information (updated Q3) Good-quality information is very important for effectively providing the best patient care. During 2016/2017 the Trust sent the Secondary Uses Service records to be included in the Hospital Episode Statistics (a database containing details of all admissions, outpatient appointments and Accident & Emergency care at NHS hospitals in England). The percentage of the Trust’s records published in the statistics, and which included the patient’s valid NHS number, was 99.96% for admissions, 99.91% for outpatient appointments, and none for A&E care (The Royal Marsden does not have an A&E). The percentage of records that included the valid General Medical Practice Code for the patient’s GP practice was 99.8% for admissions and 99.7% for outpatient appointments. See table 25 for further information. Table 27: Percentage of complete records provided Details included Admissions –

inpatient and day case

Outpatient appointments

Patient’s NHS number

2013/2014 99.9% (see note below)

99.8% (see note below)

2014/2015 99.9% 99.9% 2015/2016 99.9% 99.9% 2016/2017 – first quarter 99.96% 99.91% 2016/2017 – second quarter 99.92% 99.88% 2016/2017 – third quarter 99.93% 99.91% 2016/2017 – fourth quarter

Patient’s GP practice

2013/2014 99.8 % 99.8% 2014/2015 99.5% 99.6% 2015/2016 99.8% 99.8% 2016/2017 – first quarter 99.8% 99.7% 2016/2017 – second quarter 99.7% 99.7% 2016/2017 – third quarter 99.7% 99.8% 2016/2017 – fourth quarter

Although the quality of information is very good, the Trust aims for continual improvement. The Trust performs the following actions to improve the quality of information. • A dedicated data-quality team is responsible for running routine checks and reports to identify

mistakes and inconsistencies. • Monthly communications throughout the Trust promote the importance of accurate information

and data collection for all trust staff. • Trust-wide audits of the quality of key information points are conducted once a year. Information Governance Toolkit attainment levels (Updated Q3) The Information Governance Toolkit is an online system which allows NHS organisations to assess themselves against Department of Health policies and standards. On 31 March 2016, our Information Governance Toolkit assessment provided a final score of 89% for version 13. This was equal to our previous year’s score of 89% for version 12. The Trust continues to work towards this year’s Toolkit submission which is due by the 31st March 2017. The Information Governance Toolkit is available on the Health and Social Care Information Centre (HSCIC) website (www.nww.igt.hscic.gov.uk/).

http://www.nww.igt.hscic.gov.uk/

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Payment by Results clinical coding error rate In 2015/2016, the 'Payment by Results (PbR) data assurance framework' provides assurance over the quality of the information that payments in the NHS are based on. Clinical coding is translating the medical terminology written by clinicians into a coded format for statistical, clinical and financial purposes. Clinical coding describes a patient’s complaint, diagnosis, treatment and reason for getting medical attention. The accuracy of clinical coding was audited at 50 acute trusts. 40 of those trusts were chosen because of the high number of cases where there was a change in payments in previous audits. We were not chosen to take part in this audit. Table 28. Clinical coding

Coding Accuracy 2013/2014 (figures taken from the Information Governance Clinical Coding Audit in December 2013)

2014/2015 (figures taken from the Information Governance Clinical Coding Audit in January 2015)

2015/2016 (figures taken from the Information Governance Clinical Coding Audit in January 2016)

2016/2017 (figures taken from the Information Governance Clinical Coding Audit signed off in February 2017)

Primary diagnosis correct 94.0% 94.0% 95.0% 90.5%

Primary procedure-code correct 94.9% 93.0% 95.5% 95.5%

Secondary diagnosis correct 97.5% 92.3% 96.4% 93.25%

Secondary procedure-code correct 95.8% 90.3% 90.4% 92.25%

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Part 4 Review of quality performance (previous year’s performance)

Table 29: National targets (updated Q3)

Cancer waiting times targets

National target – 2016/2017

Performance – quarter 1 2016/2017




Overall performance 2016/2017

All urgent GP referrals seen within 14 days

93% 93.91% 97.38% 98.67%

All referrals for breast symptoms seen within 14 days

93% 93.22% 95.99% 96.70%

Treatment within 31 days of decision to go ahead for first treatment

96% 99.27% 98.09% 98.34%

Subsequent surgical treatment started within 31 days of decision to go ahead with surgery

94% 95.24% 94.42% 94.06%

Subsequent drug treatment started within 31 days of decision to go ahead with drug treatment

98% 99.83% 99.65% 99.44%

Subsequent radiotherapy treatment started within 31 days of decision to go ahead with radiotherapy treatment

94% 98.34% 97.21% 98.08%

Treatment started within 62 days of urgent GP referrals

85% 85.43% 80.61% 77.89%

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Treatment started within 62 days of recall date for urgent screening-centre referrals

90% 78.26% 88.89% 93.33%

Time from referral to start of treatment – patients should start treatment within 18 weeks of referral. Complex rules and guidance apply to how performance against these targets is measured and reported. However, the complexity and range of the services we provide mean that we need to apply local policies and interpretations, including those set out in our Access Policy. As a specialist provider, receiving referrals from other trusts, a key issue is reporting progression for patients who were first referred to other providers. The ‘incomplete pathways’ measure in the table below represents the proportion of patients at the end of the reporting period who are still waiting for treatment and have waited for less than 18 weeks since their initial referral. Table 30: referral time to treatment

Overall 2014/ 2015

Overall 2015/ 2016

Quarter 1 2016/ 2017

Quarter 2 2016/ 2017

Quarter 3 2016/ 2017

Quarter 4 2016/ 2017

Overall 2016/ 2017

National target 2016/ 2017

Referral time to treatment (RTT), incomplete pathways 95.8%

95.2% 94.3% 95.9% 96.5% 92% From 2015-2016 (to be updated for 2016/2017) This is the only NHS waiting-time standard which is reported while the patient is still waiting. For this reason, it creates unique challenges in making sure the most up-to-date information is reported accurately each month, especially we rely on receiving information rapidly from external sources to assess whether the patient is on an 18-week pathway (18 weeks of treatment) and to determine the start date of the pathway. Last year our 18-week reporting received limited assurance from our external auditors for the first time, and we became aware of some process issues which affected the precision of our reported performance. These issues were addressed immediately and similar problems have not been seen since. This year’s limited assurance did, however, identify further issues that affect our reported figures. The most notable issue was that we received late or incorrect pathway information from trusts referring patients to us and, although the limited assurance noted this was outside our control, it does affect the accuracy of our reported performance. The limited assurance also found internal process issues which should be improved to strengthen our 18-week reporting, as well as two human errors (mistakes) which, if corrected, would actually improve our performance against the 92% target.

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Our auditors have found that most trusts struggle with reporting against this target due to its unique challenges and the lack of sophisticated technology to track pathways across the NHS. The manual nature of this reporting brings with it some risk of human error. We will continue to introduce further procedures to minimise the risk of human errors happening. The issues above relate only to the technical counting of the reported position and they have no effect whatsoever on how patient pathways are managed. Despite the accuracy issues noted above, we continue to report about 3% above the target. We also continue to monitor 18-week pathways that were stopped (which does not suffer from some of the complexities of the incomplete pathway reporting), and we are confident that it meets the 18-week standard. Table 31: Access targets Percentage of operations

cancelled by the Trust at the last minute

Percentage of cancelled operations not subsequently performed within one month

2012/2013 0.5% 0% 2014/2015 0.7% 0% 2015/2016 0.5% 0.04% Quarter 1 of 2016/2017 0.4% 0% Quarter 2 of 2016/2017 0.4% 0 Quarter 3 of 2016/2017 0.3% 0% Quarter 4 of 2016/2017 Overall for 2016/2017

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Outpatient waiting times

The number of outpatients attending appointments has increased by between 3% and 5% a year over the past five years. See the table below for the numbers for the year from 1 April 2014 to 31 March 2017. Despite more patients attending, the length of time patients wait has been maintained.

Table 32: Outpatient waiting times: Number of patients seen and time waited.

Financial quarter

Patients seen within 30 minutes

Patients seen after 30 minutes but within one hour

Patients seen after one hour Grand total

Total 2014/2015 129369 20702 992 159993 Total 2015/2016 133995 18744 9788 162527 Quarter 1 2016/17 34329 4709 2433 41471 Quarter 2 2016/17 34252 4515 2581 41348 Quarter 3 2016/17 34145 4214 2280 40639 Quarter 4 2016/17 Total 2016/2017 Table 33: Outpatient waiting times: Percentage of patients seen and time waited

Financial quarter

Patients seen within 30 minutes

Patients seen after 30 minutes but within one hour

Patients seen after one hour Grand total

Total 2014/2015 80.9% 12.9% 6.2% 100.0% Total 2015/2016 82.4% 11.5% 6.0% 100.0% Quarter 1 2016/17 82.8% 11.4% 5.9% 100.0% Quarter 2 2016/17 82.8% 10.9% 6.2% 100.0% Quarter 3 2016/17 84.0% 10.4% 5.6% 100.0% Quarter 4 2016/17 Total 2016/2017

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Plain English Campaign’s Crystal Mark does not apply to this appendix 1. Appendix 1: Quality Indicators where national data is available from the Health and Social Care Information Centre (NHS Digital will refresh the links to this and make this available nationally in March 2017) Since 2012/2013 NHS foundation trusts have been required to report performance against a core set of indicators using data made available to the Trust by the Health and Social Care Information Centre. The Royal Marsden NHS Foundation Trust considers that this data is as described as taken from the Health and Social Care Information Centre. The Trust has taken actions to improve the percentage and so the quality of its services (see priorities for each indicator in Part 2 for further information). Not all of the core indicators are relevant to The Royal Marsden NHS Foundation Trust for example those relating to the ambulance response times. The tables below show those core indicators which are relevant and how the Trust compares against other trusts. The tables show the highest and lowest national scores. Trust quality priority 1 Core indicator 24) The data made available to The Royal Marsden NHS Foundation Trust by the Health and Social Care Information centre with regard to the attributable cases of C. difficile infection reported within the trust amongst patients aged 2 or over during the reporting period. Indicator 24: Rate of C. difficile infection. March 2015 to February 2016: Number of apportioned C-difficile infections.

February 2015 to January 2016 Number of apportioned C-difficile infections.

National Average apportioned C-difficile infections per provider.(March 2015 to February 2016)

Comparator Group

Comparator - Highest apportioned C.difficile infection rate (March 15 to February 16)

Comparator - Lowest apportioned C.difficile infection rate (March 15 to February 16)

42 37 34.2 All Acute Trusts

142 0

Trust quality priority 2 Core indicator 25) The data made available to The Royal Marsden NHS Foundation Trust by the Health and Social Care Information Centre with regard to the number, and where available, the rate of patient safety incidents reported within the trust during the reporting period, and the number and percentage of such patient safety incidents that resulted in severe harm or death. Indicator 25a: Patient Safety incidents that resulted in severe harm or death 25b: Patient Safety percentage that resulted in severe harm or death Indicator April 2015

to September 2015

October 2014 to March 2015

National Average (April 2015 to September 2015)

Comparator Group

Comparator - Highest (April 2014 to September 2014)

Comparator - Lowest (April 2014 to September 2014)

25a 1 1 2 Acute Specialist

9 0

25b 0.1% 0.1% 0.2% Acute Specialist

1.8% 0.0%

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Trust quality priority 3 Core indicator 23) The data made available to The Royal Marsden NHS Foundation Trust by the Health and Social Care Information Centre with regard to the percentage of patients who were admitted to hospital and who were risk assessed for venous thromboembolism during the reporting period. Indicator 23: Patients admitted to hospital who were risk assessed for venous thromboembolism Quarter 3 2015/ 2016

Quarter 2 2015/16

National Average (Q3 2015/ 2016)

Comparator Group

Comparator - Highest (Quarter 3 2015/2016)

Comparator - Lowest (Quarter 3 2015/ 2016)

96% 96% 95.4% Acute Trusts 100% 62%

Trust quality priority 4 Core indicator 19) The data made available to The Royal Marsden NHS Foundation Trust by the Health and Social Care Information Centre with regard to the percentage of patients aged – i) 0-15; and ii) 16 or over, readmitted to a hospital which forms part of the trust within 28 days of being discharged from a hospital which forms part of the trust during the reporting period. Indicator 19a: Patients readmitted to a hospital within 28 days of being discharged (Aged 0 to 15 years old) 19b: Patients readmitted to a hospital within 28 days of being discharged (Aged 16 or over) Indicator Description

April 2011 to March 2012

April 2010 to March 2011

National Average April 2011 to March 2012

Comparator Group

Comparator - Highest April 2011 to March 2012

Comparator - Lowest April 2011 to March 2012

19a Data not published nationally as small numbers may allow identification of an individual

19b 9.47% 7.94% 11.45% Acute Specialist

14.09% 0%

Trust quality priority 6a Core indicator 20) The data made available to The Royal Marsden NHS Foundation Trust by the Health and Social Care Information Centre with regards to the trust’s responsiveness to the personal needs of its patients during the reporting period. Indicator 20: Responsiveness to the experience of care. Adult Inpatient Survey April 2014 to March 2015

Adult Inpatient Survey April 2013 to March 2014

National Average April 2014 to March 2015

Comparator Group

Comparator - Highest April 2014 to March 2015

Comparator - Lowest April 2014 to March 2015

87.4 87.0 76.6 All trusts 88.2 66.8

Trust quality priority 6b Core indicator 21.1) Friends and family test- Patient. The data made available to The Royal Marsden NHS Foundation Trust by the Health and Social Care Information Centre for all acute providers of adult NHS funded care, covering services for inpatients and patients discharged from Accident and Emergency (types 1 and 2). The trust’s score from a single question survey which asks patients

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whether they would recommend the NHS service they have received to friends and family who need similar treatment or care. Indicator 21.1: Patient Friends and Family test: Inpatient February 2016

January 2016

National Average (Feb 2016)

Comparator Group

Comparator - Highest (Feb 2016)

Comparator - Lowest (Feb 2016)

97% 97% 95.7% All Trusts 100% 74%

Trust quality priority 7 Core indicator 21 ) The data made available to The Royal Marsden NHS Foundation Trust by the Health and Social Care Information Centre with regard to the percentage of staff employed by, or under contract to, the trust during the reporting period who would recommend the trust as a provider of care to their family or friends. Indicator 21: Staff who would recommend the Trust to their family or friends. NHS Staff Survey 2015

NHS Staff Survey 2015

National Average (2015)

Comparator Group

Comparator - Highest (2015)

Comparator - Lowest (2015)

87% 89% 84% Acute Specialist Trusts

89% 72%

Indicator code 12a: The Value of the Summary Hospital-Level mortality Indicator ("SHMI") The banding of the Summary Hospital-Level mortality Indicator ("SHMI") October 2014 to September 2015

July 2014 to June 2015

National Average

Comparator Group

Comparator - Highest

Comparator - Lowest

Trust data not published nationally for this indicator. Not applicable Not applicable

Trust data not published nationally for this indicator. Not applicable Not applicable

Indicator 12b: The percentage of patient deaths with palliative care coded at either diagnosis or specialty level. October 2014 to September 2015

July 2014 to June 2015

National Average

Comparator Group

Comparator - Highest

Comparator - Lowest

Trust data not published nationally for this indicator.

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Appendix 2: Our values We, The Royal Marsden, are guided by 16 values that define our: • characteristics (what we are); • attitudes (how we act); • relationships (how we relate to others); and • emotions (how we feel). Characteristics Attitudes Relationships Emotions Pioneering Determined Collaborative Compassionate Aspirational Confident Supportive Positive Knowledgeable Open Trusted Calm Driven Resilient Personable Proud Over the last year we have continued to focus on a different value each month and explored how our staff adopt these values in their daily work. Below we have some quotations from staff on the relationship ‘trusted’ and the characteristic ‘driven’. Personable Being personable is a relationship attribute we value as we believe being pleasant and friendly helps build trusting relationships and puts patients and their families at ease during a difficult time in their lives. Claire Riddell, Play Specialist in The Oak Centre for Children and Young People, said: “It’s paramount that we are personable because we are dealing with children and their family’s lives that have just been shattered, and we are one of the first few people they see in hospital. Listening, getting down to the children’s level and spending time with the family gives them reassurance.” Aspirational Our staff aspire to excellence, and we believe this determination to always improve and develop ourselves and the quality of the services we offer is the key to a success. Ehsan Sattar, Energy Manager, is leading The Royal Marsden’s Carbon Management Plan, which aims to reduce the Trust’s carbon emissions by 20% by 2020. Ehsan said: “One hundred per cent of the money saved by the Trust in reducing energy consumption will be reinvested back into clinical services and patient amenities. It’s very important for us all to aspire to achieve this target as it’s something that all staff can contribute towards.” He added: “We have already started to make changes, such as using super energy efficient LED lighting, upgrading heating, cooling and ventilation plants, implementing energy efficiency measures in new capital projects, and introducing low-carbon on site generation of heat and power at the Sutton site. The hospital is known as a centre of excellence for cancer treatment, but we also want to be champions of sustainability.”

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Appendix 3: Sign Up to Safety We joined the national Sign Up to Safety campaign in the summer of 2015. The aim was to reduce avoidable harm in three distinct areas – sepsis, medication errors and pressure ulcers. In each area, a safety group has been established. The following tables show the aims and proposed actions relating to sepsis, medication errors and pressure ulcers.

Patient-safety improvement plans – increasing awareness, identification and

treatment of sepsis and reducing death from it (Updated Q3) Aims: • to increase awareness of sepsis; • to prevent sepsis; • to recognise and manage, as early as possible, patients with sepsis; • to reduce emergency admissions through early intervention strategies; and • to have no avoidable deaths from septic shock from 1 June 2018.

Primary goals

Necessary actions

Prevent and control infection

• Effective handwashing. • Training in vascular access devices (for example, cannulas). • Central venous catheter bundles. These are a set of measures that,

when carried out together, reduce the risk of infections from having tubes inserted into large veins.

• Urinary catheter bundles. These are a set of measures that, when carried out together, reduce the risk of infections from having tubes inserted into the bladder.

• Effective management of the use of antibiotics. • Sepsis screening - increase the numbers identified in the ‘Golden

Hour’. This is the time period in which early recognition and treatment can reduce the risk of sepsis progressing and so improve outcomes.

• Educate patients and volunteers. • Management of neutropaenic sepsis. This happens when there is an

infection related to a reduction in the number of white blood cells (neutrophils), which fight infections.

• Patients with a NEWS points score of more than four are referred to the Critical Care Outreach Team (CCOT). The National Early Warning Score (NEWS) allocates points for changes to patient parameters such as heart rate, temperature, blood pressure and respiratory rate. The greater the abnormality, the higher the number of points. The points are added and if they are above four, this prompts a review by the Critical Care Outreach Team to decide if the patient needs to go to the critical care unit.

• Lactate measurement available 24/7 in hospitals. A raised lactate level in the blood of patients may be a sign of a severe infection. Measurement should be possible in patients all day, every day.

• SBAR training. To help healthcare professionals get appropriate

Identify and treat patients with sepsis as early as possible

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advice and action in good time, the SBAR tool has been introduced to provide a structure for communication between colleagues. The four letters of SBAR indicate the Situation (problem being discussed), Background (the medical history of the patient and treatment to date), Assessment (of the patient) and Recommendation (of the person initiating the discussion).

• Trigger tools for patients calling in from home. Patients, for instance those receiving chemotherapy, are given information on when to get medical advice (for example, if they have a temperature). Collectively, trigger tools are the parameters that should lead to patients phoning for medical advice.

• Early referrals to the Critical Care Outreach Team are available in the hospitals at Fulham Road and Sutton, all day and every day. The Critical Care Outreach Team is made up of nurses trained in identifying, stabilising and increasing the level of care for patients who are critically ill for any reason. They work with the teams on the wards and in the critical care unit.

• Reliable communication at handover about patients who are at risk.

• Clinical Site Practitioner to tell CCOT about after-hours emergency admissions.

• Reporting to senior team, critical care and CCOT.

Deliver the sepsis-six care bundle

• Delivery of sepsis-six (02, Blood cultures, Antibiotics, Fluids, Lactate measurement and urine output monitoring). The ‘sepsis-six’ are a group of interventions that may help treat patients with sepsis. The interventions are providing oxygen, taking blood cultures (a sample of blood sent to the microbiology laboratory to identify organisms making the patient unwell), giving antibiotics early on to fight the infection, measuring lactate (as high levels in the blood may indicate a severe infection), and measuring urine production (which generally falls as the patient becomes more unwell and increases when the patient improves).

• Escalation of patients with severe sepsis or septic shock for critical-care review and admission. Patients who are severely unwell may need a higher level of care and be ‘escalated’ to get the Critical Care Team’s opinion on whether a patient needs to be moved to the critical care unit.

• Giving antibiotics within an hour of suspected sepsis. • Early control of the source of the sepsis. • Increase the number of nurses for administering antibiotics to the

Patient Group Direction (PGD). Normally, medications are given on prescription by a doctor. Patient Group Directions (PGDs) are a mechanism by which authorised professionals can administer medications to groups of patients without there being a prescription from a doctor. In this case, if a patient is suspected of having a severe infection, a trained nurse could give an antibiotic to reduce the delay of getting a prescription.

• Increase the number of nurses who can insert cannulas and have access to portacath devices. Portacaths are devices (ports) placed under the skin, attached to a tube tunnelled under the skin to enter

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a large vein. A needle can be inserted through the skin into the port to allow blood to be taken or medication to be given. The skin over the port reduces the risk of infection from the device staying in the body for a long period of time.

• For sepsis patients admitted, gather information relating to IT Coding, morbidity and mortality rates, root-cause analysis. Identifying patients with sepsis allows us to gather valuable information on the number of patients with sepsis and their outcomes (morbidity – how unwell they become and how long they stay in hospital as well as mortality – whether the patient dies due to the severe infection). Reviewing the notes of patients with sepsis can uncover ways to improve care for future patients. This is called root-cause-analysis and is based on the idea that several factors (roots) can contribute to a problem (sepsis) developing. One way of identifying patients is by using information technology (IT) coding. This is where each episode of a patient’s care is summarised into a variety of codes by dedicated professionals (clinical coders). This allows a large database to be searched to find information (for example, those patients with severe sepsis or septic shock).

Raise awareness and education for staff, patients and carers

• RM School of Nursing formal teaching programmes. • Nurses new to cancer care module and Acute Cancer Care Module.

We have a teaching school for nurses. It is planned to educate nurses in identifying sepsis, getting early help and starting treatment promptly. There are two modules – ‘Nurses new to cancer care’ and ‘Acute cancer care’ – which sepsis training can be part of.

• Mandatory refresher training for staff on the six signs of sepsis and managing the condition.

• Hold a Sepsis Roadshow twice a year, both on-site and in the community.

• Standardise the approach to managing sepsis across all sites. • Simulation training. • Ward-based and

community-based teaching sessions. • Embedding training for serious incidents. If there was a serious

incident related to sepsis (where there is significant harm to the patient), then learning from investigations will be incorporated into training in order to reduce the risk of the event happening again.

Escalation and review. Escalation involves getting help from more senior members of the team as well as increasing the amount of care for the patient (such as transferring them from the

• Senior review of the patient (by a registrar or a consultant). • Review critical care and CCOT. • Review unplanned emergency admissions.

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ward to the critical care unit)

Produce clear management plans

• Clear criteria for emergency admission. • Clear management plans for those with ward-based ceilings of care.

For some patients, transferring them to the critical care unit is not appropriate. They have a ‘ceiling of care’ in place, where medical treatment is offered up to a limit (the ‘ceiling’) on the ward. Treatment options only available in the critical care unit include breathing support from a mechanical ventilator, support to increase blood pressure and some artificial kidney support (dialysis). Patients staying on the ward will not receive these treatments.

• Reporting on the ‘Datix’ incident form when patients meet the criteria for emergency admission but no bed is available. If a patient is severely unwell with an infection at home, they should be admitted to hospital as an emergency. Very occasionally it may be that the patient cannot be admitted due to a lack of beds. This would be reported as an incident on the Datix form, which is a summary of what happened and whether the patient came to any harm. These incidents are analysed by the risk management department to determine the risk of the situation arising again, and how severe the harm was, before making recommendations to reduce the risk of it happening again.

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Patient-safety improvement plans – reducing harm from medication errors

(Updated Q3)

Aims:

• To improve the pharmacy-led medicines reconciliation rates on admission to 100% by 2018;

• To reduce chemotherapy-prescribing errors by 20% by 2018; and • To make sure allergies are recorded accurately for 100% of patients when they are

admitted.

Primary goals Necessary actions Update Q3 2016/2017

Prevention: • Reduce harm related to

hypersensitivity and allergy reactions through consistent assessment and recording of patients’ allergies when they are admitted

• Introduce and use

chemotherapy e-prescribing technology to reduce the opportunity for harm from prescribing errors

• Reduce harm from the

incorrect medicines being prescribed, or necessary medication not being prescribed, by improving pharmacy-led medicines reconciliation at admission and discharge

• Introduce electronic prescribing for chemotherapy, and give prescribers feedback on common errors.

• Undertake regular

chemotherapy audits to monitor error rates.

Use the medicines-safety thermometer. (The medicines-safety thermometer is a national tool to reduce the number of medication mistakes causing serious harm. The information is collected from wards. Each month, the results are fed back to all nursing and pharmacy staff. The results are also published on the monthly dashboards displayed in all ward areas. This raises awareness and empowers the nursing teams to make improvements locally.) • Have the medicines-safety

thermometer tailored to the medicines-safety drivers for RM.

• Have visible information

• Current medicines reconciliation rate 99% (Medication Safety Thermometer Jan 2017)

• A re-audit to

asses Chemotherapy prescribing errors at The Royal Marsden Hospital (NHS Foundation Trust) post e-chemo implementation.Over 42% drop in of errors detected from the 2011 audit cycle to the 2016 audit cycle.

• Current

documentation of allergies 100% (Medication

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• Implementation of the Medication Safety Thermometer

Education and raising awareness: • Produce a monthly

dashboard showing progress with qualitative and quantitative metrics

• Improve feedback

given to doctors and NMPs about medication and prescribing errors

about the medication safety thermometer on all wards.

• Learning from RCAs:

o MDT huddles for every high-risk medication error detected when collecting information for the medicines-safety thermometer.

o Improved recording of near-miss prescribing errors.

• Regularly send out a

medication incidents summary to nursing, medical and pharmacy staff.

Safety Thermometer Jan 2017)

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Patient-safety improvement plans – reducing harm from pressure ulcers (Updated Q3)

Aims: To reduce avoidable pressure ulcers: • by 100% within hospitals; and • by 50% within the community; by June 2018 Primary goals

Interventions

Identify patients with pressure sores, or at risk of pressure sores, as early as possible

• Accurate assessment of risks and related conditions • Complete the Pressure Ulcer Assessment and the Prevention &

Management booklet when patients are admitted • Have visible data – ward dashboards, safety thermometer and

so on • Patient stories • Hold Pressure Ulcer Panel meetings

Prevent pressure sores

• Use suitable devices – Aderma, prophylactic meplix border, heel lift boots, mattresses and cushions

• Get patients moving around out of bed as early as possible • Provide patient-education video and leaflets • Follow the recommendations of the ‘Stop the Pressure’

campaign • Intentional rounding

Raise awareness • Raise awareness of the extent of incidents and the effect on patients through ward meetings, nurse meetings, matron’s meetings and so on. • Take part in the Sign up to Safety Pressure Ulcer Strategy group • Learning from RCAs: • Risk Management feedback • Develop a pressure-ulcer prevention strategy for in hospital and in the community. • Include ‘Harm Free Care’ as part of mandatory training • Correct identification of pressure ulcers and moist lesions

Reporting / review

• Community TVN’s to confirm if a pressure ulcer is attributable and the category with 72hours of reporting.

• RCA’s to be completed within two weeks from allocation followed by one week with the manager for review prior to panel.

• Panel reports to be completed by Divisional Nurse Directors within 48 hours.

• Quarterly audits to be presented to the quarterly strategy group by Community Divisional Clinical nurse Director.

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Plain English Campaign’s Crystal Mark does not apply to this appendix 4 Appendix 4: Statements from key stakeholders (these statements will be added once the draft quality account has been reviewed during the 30 day period). Council of Governors Healthwatch Sutton Healthwatch Kensington & Chelsea Director of Quality Sutton Clinical Commissioning Group NHS England (Specialised Commissioning (London) Overview and Scrutiny Committee Chair, Patient Carer and Advisory Group

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Plain English Campaign’s Crystal Mark does not apply to this appendix 5. Appendix 5 Statement of Trust Directors’ responsibilities for the quality account The directors are required under the Health Act 2009 and the National Health Service (Quality

Accounts) Regulations to prepare Quality Accounts for each financial year.

NHS Improvement has issued guidance to NHS foundation trust boards on the form and content of annual quality reports (which incorporate the above legal requirements) and on the arrangements that NHS foundation trust boards should put in place to support the data quality for the preparation of the quality report.

In preparing the Quality Report, directors are required to take steps to satisfy themselves that:

• the content of the Quality Report meets the requirements set out in the NHS foundation trust annual reporting manual 2016/17 and supporting guidance

• the content of the Quality Report is not inconsistent with internal and external sources of information including:

- board minutes and papers for the period April 2016 to March 2017 - papers relating to quality reported to the board over the period April 2016 to March 2017 - feedback from commissioners dated XX/XX/2017 - feedback from governors dated XX/XX/2017 - feedback from local Healthwatch organisations dated XX/XX/2017 - feedback from Overview and Scrutiny Committee dated XX/XX/2017 - the trust’s complaints report published under regulation 18 of the Local Authority Social

Services and NHS Complaints Regulations 2009, dated 07/06/2016 - the [latest] national patient survey XX/XX/2017 - the [latest] national staff survey XX/XX/2017 - the Head of Internal Audit’s annual opinion of the trust’s control environment dated

XX/XX/2017

- CQC inspection report dated 19/01/2017

• the Quality Report presents a balanced picture of the NHS foundation trust’s performance over the period covered

• the performance information reported in the Quality Report is reliable and accurate • there are proper internal controls over the collection and reporting of the measures of

performance included in the Quality Report, and these controls are subject to review to confirm that they are working effectively in practice

• the data underpinning the measures of performance reported in the Quality Report is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review and

• the Quality Report has been prepared in accordance with NHS Improvement’s annual reporting manual and supporting guidance (which incorporates the Quality Accounts regulations) as well as the standards to support data quality for the preparation of the Quality Report.

The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Report.

By order of the board

XX May 2017.....Date.................................Charles Alexander Chairman XX May 2017.....Date.................................Cally Palmer CBE Chief Executive

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Plain English Campaign’s Crystal Mark does not apply to this appendix 6. Appendix 6: Independent assurance report Independent auditor’s report to the Council of Governors of The Royal Marsden NHS Foundation Trust We have been engaged by the Council of Governors of The Royal Marsden NHS Foundation Trust to perform an independent assurance engagement in respect of The Royal Marsden NHS Foundation Trust’s Quality Report for the year ended 31 March 2017 (the “Quality Report”) and certain performance indicators contained therein. Deloitte LLP Chartered Accountants St Albans May 2017

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Appendix 7: Glossary Bacteraemia Having bacteria in the blood. Care Quality Commission (CQC)

The independent regulator of health and adult social care services in England, including those provided by the NHS, local authorities, private companies or voluntary organisations. They also protect the interests of people detained under the Mental Health Act.

Chemotherapy Treatment with anti-cancer drugs to destroy or control cancer cells.

Clinical coding Clinical coding is the process whereby information written in the patient notes is translated into codes and entered onto hospital information systems. This usually happens after the patient has been discharged from hospital, and must be completed within strict deadlines so hospitals can receive payments for their services.

Clinical commissioning groups (CCGs)

NHS organisations set up by the Health and Social Care Act 2012 to organise the delivery of NHS services in England. They took over many of the functions of primary care trusts.

Clostridium difficile (C. diff) Bacteria that are a significant cause of infections arising in hospital.

CNS Clinical nurse specialist. Commissioning for Quality and Innovation (CQUIN)

A payment framework that lets commissioners link a proportion of a healthcare providers’ income to the achievement of local quality-improvement goals.

Customer Service Excellence (CSE) Standard

The Government's standard for customer service. This scheme replaced the Charter Mark.

Enhanced Recovery Programme

A national scheme that places the patient at the centre of a multi-professional team to plan for greater partnership in care, improved quality of care and shorter lengths of stay in hospital.

EPR Electronic patient record. Escherichia coli (E. coli) Bacteria that live in the intestines of humans

and animals. Although most types are harmless, some cause sickness.

http://en.wikipedia.org/wiki/Health_and_Social_Care_Act_2012

http://en.wikipedia.org/wiki/Health_and_Social_Care_Act_2012

http://en.wikipedia.org/wiki/National_Health_Service_(England)

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Foundation trust Foundation trusts have a significant amount of managerial and financial freedom when compared to NHS hospital trusts. They are considered to be like co-operatives, where local people, patients and staff can become members and governors and hold the trust to account.

Friends and family test (FFT) A simple questionnaire to get feedback about services. Patients are asked if they would recommend the services they have used and staff are asked if they would recommend the services offered at their workplace or if they would recommend it as a place to work.

Healthcare-associated infection

An infection arising in a patient during the course of their treatment and care.

Healthwatch The new independent consumer champion to gather and represent the views of the public at a national and local level. Healthwatch England will work with local Healthwatches and has the power to recommend that the Care Quality Commission take action where there are concerns about health and social-care services.

Holistic needs assessment (HNA)

A process of gathering information from the patient or carer in order to lead discussion and develop a deeper understanding of what the patient knows, understands and needs.

Standardised mortality ratio An indicator of healthcare quality that measures whether the death rate at a hospital is higher or lower than expected.

Information governance A process that makes sure that organisations achieve good practice relating to data protection and confidentiality.

Key performance indicators Organisations use key performance indicators to evaluate their success or the success of a particular activity.

Multidisciplinary team A team made up of healthcare professionals from different fields who work together.

Meticillin-resistant staphylococcus aureus (MRSA)

Bacteria that are a significant cause of infections arising in hospital.

Meticillin-sensitive staphylococcus aureus (MSSA)

Bacteria that are a significant cause of infections arising in hospital.

NHS Improvement The independent regulator of NHS foundation trusts.

National Institute for Health and Care Excellence (NICE)

NICE reviews medicines, treatments and tests. It makes clinical guidelines and public-health recommendations.

http://en.wikipedia.org/wiki/NHS_hospital_trust

http://en.wikipedia.org/wiki/Co-operative

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PALS The Patient Advice and Liaison Service (PALS) provides information, advice and support to help patients, families and their carers. Each NHS trust has a PALS service.

Patient and Carer Advisory Group (PCAG)

The Patient and Carer Advisory Group works to improve the experience of patients at The Royal Marsden. It is a self-managed group of patients, carers and members of the public who play a vital part in continually improving the care and services we provide.

Pressure ulcers Bed sores or pressure sores. Prophylaxis A measure taken to prevent a disease or

condition. Radiotherapy The use of high-energy rays to destroy

cancer cells. It may be used to cure some cancers, to reduce the chance of cancer returning, or to control symptoms.

TTAs Discharge prescriptions – medicine ‘to take away’

Vancomycin-resistant enterococci (VRE)

Bacteria that are resistant to the antibiotic vancomycin and can cause infections arising in hospitals.

Venous thromboembolism (VTE)

A blood clot, typically occurring in the leg but which can form in any blood vessel.

http://en.wikipedia.org/wiki/Bacterium

http://en.wikipedia.org/wiki/Antibiotic_resistance

http://en.wikipedia.org/wiki/Antibiotic

http://en.wikipedia.org/wiki/Vancomycin



Agenda item 9.4

Title of Document: Governors selection of quality priorities

To be presented by Chief Nurse

Background For the last seven years NHS Trusts have been required by government to produce an Annual Quality Account. This year NHS England and NHS Improvement, the regulatory body for Foundation Trusts, issued specific guidance as to its content. Executive Summary Consider the proposed quality priorities that will become part of the draft Annual Quality Account 2017/18.

Recommendations The Council of Governors is asked to provide comments to the Corporate Governance Team by the 31st March 2017 on the aspects of the proposed quality priorities and indicate which should be carried over to 2017/18, which should be replaced, and suggest new topics for monitoring as a quality priority. Author: Chief Nurse


Date: 1st March 2017

1

Annual Quality Accounts: Council of Governors Selection of Quality Priorities

1.0. Introduction For the last seven years NHS Trusts have been required to produce an Annual Quality Account (QA). Each year NHS England and NHS Improvement for Foundation Trusts issues specific QA guidance. 2.0. Consultation One of the most important principles in the authorship of the QA is the consultation and engagement with the Public, Patients, Families, Governors, Frontline staff, external bodies. To ensure that the Trust is able to meet the timelines imposed by NHS England the Chief Nurse, Deputy Chief Nurse and Quality Assurance Team have met regularly with several engagement groups since June 2016:

• Patient experience and quality account group – Jointly chaired by Deputy Chief Nurse and Governor Member. Represented by Patients, Carers, Governors, Healthwatch, Health and Wellbeing Board members and Matrons.

• Members’ Event in November- Patients, Carers, Governors, Healthwatch,

staff members.

• Patient and Carers Advisory Group.

• Staff- It is planned to take a paper to the March Nursing, Radiography and Rehabilitation Advisory committee and the Trust Consultative Committee.

All of the people represented in the above groups have commented and contributed to the QA. 3.0. The role of the Council Of Governors The Governors have several roles, their authorship role is detailed above. In 2016/17 the current draft guidance from NHS Improvement indicates that the quality report should describe areas for improvement in the quality of relevant health services that the NHS foundation trust intends to provide or sub-contract. The quality priorities should be selected by the board in consultation with stakeholders, with an explanation of the underlying reason(s) for selection. The indicator set selected must include:

• at least three indicators for patient safety; • at least three indicators for clinical effectiveness; and • at least three indicators for patient experience.

3.1 Methodology In order to assist the Governors in selecting a quality indicator the Patient Experience and Quality Account meeting in September it was agreed that a questionnaire would be sent via post and online for all members to complete. The questionnaire was based

2

on previous targets and data. The members’ event in November also included the opportunity for all members to ‘vote’ for which quality priority should be selected. 3.2 Response rate 320 hard copies were sent out and 43 received in the post with a further 5 responding online. There were 31 at the member’s event who took part in the voting.

1. Patient Safety Indicators

Reducing harm to patients from patient safety incidents has always been a trust quality improvement priority. All patient safety issues are a priority but we would like to know which ones cause you the most concern. The table and graph below shows how many people selected each indicator as their priority. Patient Safety indicator Postal and online Vote Total Reducing harm from pressure ulcers 2 1 3 Reducing harm from sepsis (severe infections) 21 17 38 Reducing harm from medication mistakes 9 7 16 Reducing harm from venous thrombotic events (blood clots) 1

0

1

Reducing the number of falls 2 1 3 Reducing the numbers of infections such as MRSA & C. Difficile 7

5

12

2. Effective Care Indicators

Delivering effective quality care to our patients is vital. Being effective demonstrates our ability to respond to patient need. The table below indicates how many people selected each indicator as their priority.

3

Effective Care indicator Postal and online Reducing the length of stay in hospital 5 Reducing the waiting times in outpatient clinics 2 Reducing the amount of time waiting for chemotherapy appointments 6 Ensure every patient has a holistic needs assessment completed 1 Reducing the numbers of patients re-admitted as an emergency within 28 days after discharge form hospital 7 Improve the way we discharge patients from hospital to the community 2 Reduce the amount of time patients wait for medication or equipment on discharge 3 Ensure every patient had an end of treatment summary sent to their GP 1 Ensure patients are involved in decision making about their care 10 Ensure patient privacy and dignity are maintained at all times 3

3. Patient Experience Indicators

Gathering information about patients’ experience of care is very important and ensures we strive to improve on areas of concern and also share. There are many different ways that the trust collects this information and we wanted to identify which way was useful to members. The table and graph below shows how many people selected each indicator as their priority. Patient Experience Indicator Postal and online Vote Total Friends and Family test 4 2 6 National cancer Patient Experience Survey 6 1 7 National Inpatient and Outpatient Surveys 15 9 24 Learning from complaints and compliments 10 9 19 Listening Post 2 1 3 Healthwatch information 2 1 3

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3.3. Additional free text comments The questionnaire allowed for members to write additional free text comments in response to the questions as well as prioritising the questions. Below are some examples of these comments. Patient Safety

• these are all extremely important areas therefore they are all priority I am sure this is already ensured at the Royal Marsden ensuring that at all times patients are given fluids when they request them that they are helped when required at meal times. That their calls are responded to quickly and that by being given the correct medication at the right times they do not suffer pain.

• patients are well supervised at meal times they are able to eat unaided • all are important of course in the broader sense: interactions whilst in

hospital • good control of diet & assistance & eating where necessary, security on wards

re possible unwanted visitors? • but really they are all important • language issues - vital to have medical staff with good English speaking &

understanding • once a patient is in a bed in hospital all the above statements must apply

Effective care

• talking about the after hospital needs potential difficulties as you stated • a higher standard of bathrooms on ward and often in toilets a higher standard

of floor cleaning on wards

Patient Experience

• finding a very public way to communicate what action has been taken following complaints and suggestions

5

• talking to the children those most affected by the patients diagnosis. All affected as an experience of cancer reference an individual including all staff of course employers of patients could be included.

• I would like to mention that having been an inpatient there is nothing I can complain the nurses were very good even the food was NHS was very good and well served.

• reduce stress to outpatients by improving enlarging parking and reducing cost.

• I think that as the Royal Madsen is an excellent hospital, the staff are in a better position than members to decide on the priorities. All aspects of patient safety and effective care are of the greatest importance to patients.

• some patients are reluctant to speak to staff of their concerns & worries regarding their condition because they don't (wish to be a nuisance) our oncology staff are great at putting some at ease keep u the good work

4. Results

It can be seen from the tables and graphs above what the most popular choices were from postal and voting responses. At the member’s event after the historical data was shown to members many changed their mind about the priorities. For example results from the postal questionnaire showed that ‘Sepsis’ was the most popular choice, however in the voting only 1 person out of 25 voted for this. The voting showed that pressure ulcers, medication and reducing the number of infections were equal first choice with five votes each. The overall most popular choices are set out below and Governors are asked to agree which quality priority from below should be selected for the Trust to achieve during 2017/2018. Patient Safety- ‘Reducing harm from sepsis’ and ‘reducing harm from medication mistakes’. Effective care- Ensuring patients are involved in decision making about their care. Patient Experience- Obtaining feedback from the results of the national inpatient survey and outpatient surveys. Members who attended the event fed back how pleased they were to be given the opportunity to take part in the voting, particularly after being shown the historical data about how the trust performed in certain areas. 5. Council of Governors action Appendix A lists what the current quality priorities are for the year 2016/2017 with the progress at time of reporting up to quarter three. Governors are asked to agree which quality priority should be selected for the Trust to achieve during 2017/2018. Appendix A: Current quality priorities in 2016/2017. The quality priorities and targets for 2016/2017 are shown in the table below. The priorities and targets in blue were mandatory in 2016/2017 (that is, we had to include them) and the priorities and targets in red are the ones we have set ourselves.

6

Table 1: Quality priorities and targets for 2016/2017 Category Quality priority Target Achieved to date

(April – December 2016)

Safe care 1 To reduce the number of cases of healthcare related infections (MRSA and clostridium difficile infections). Applies to hospital inpatient beds at The Royal Marsden and patients of Sutton Community Healthcare Services.


Achieved Achieved

Safe care 2 To maintain or increase the number of patient safety incidents and near misses that are reported, reducing the percentage of incidents that have resulted in severe harm or death (A patient-safety incident is an incident which could have harmed or did harm a patient.) Applies to hospital inpatient beds at The Royal Marsden and Sutton Community Healthcare Services.

For the rate of reported patient-safety incidents that have caused severe harm or death to be below 0.089 per 1000 bed days. (In 2015/2016 the rate of severe harm or death from incidents per 1000 bed days was 0.033 for hospital and 0.0 for community.)

Achieved



Achieved Awaiting data

Effective care

4 To reduce the incidence of emergency readmissions to hospital within 28 days of patients being discharged.


Achieved

Effective care

5 To reduce the incidence of category-3 pressure sores (full-thickness skin loss) and category-4 pressure sores (full-thickness tissue loss) developing in patients while they are receiving community care.

For the percentage of category-3 and category-4 pressure sores arising in patients receiving community care to be less than 0.2%. For 90% of category-3 and category-4 pressure

Achieved

7

Applies to Sutton Community Healthcare Services.

sores, both already existing and developing while receiving community care, to have healed or improved to category 1 (redness of intact skin, which does not fade when pressed) or category 2 (partial thickness skin loss or blister) within three months.

Achieved

Effective care

6 For patients to be given information about the side effects of medicines to take after being discharged.


Achieved Q1. Not measured Q3.

Patient experience


a) For our results in the friends and family test for hospital inpatients to still be higher than the national average. b) For the friends and family test results to be above 90% and to increase patient satisfaction, using the CARE Measure tool, to over 90% for community services.

a) Achieved b) Achieved

Patient experience



Awaiting national results to be published in March 2017.

Patient experience

9 a To reduce waiting times at chemotherapy appointments and improve patients’ experiences relating to waiting times. b To reduce waiting times in outpatient clinics and improve patient experiences relating to waiting times.


Not measured Q3. Achieved




Achieved

8




Achieved



Agenda item 9.5

Title of Document:

Key Performance Indicators Q3

To be presented by

Director of Performance and Information

Executive Summary This paper provides a report on the Trust’s performance for quarter 3 2016/17 including the balanced scorecard for the Trust and a commentary on the red rated indicators and actions underway to improve performance. Recommendations The Council of Governors is asked to discuss and note the Trust’s performance against the balanced scorecard indicators for quarter 3 2016-17.

Author: Director of Performance and Information



1

KEY PERFORMANCE INDICATORS

QUARTER 3 2016/17

1. PURPOSE This paper is intended to provide the Council of Governors with an update on the Trust’s performance for quarter 3 2016/17. The scorecard and narrative is also submitted to the Board. The report includes the balanced scorecard for the Trust and a commentary on the red-rated indicators in the quarter 3 report including actions underway to improve performance. 2. KPI REVIEW A full review of the scorecard metrics, definitions and thresholds has been completed as previously reported. There has been an overall reduction in the number of measures to ensure continued focus in line with the Trust’s strategy and statutory requirements. 3. PERFORMANCE FOR QUARTER 3 Appendix A shows the balanced scorecard report for quarter 3 for 2016/17. A commentary is only provided for indicators where performance is ‘red’ rated. 3.1 Patient Safety, Quality and Experience The Governance Risk Rating metric has been replaced by the Single Oversight Framework (SOF) metric this quarter. NHS Improvement has segmented trusts according to the level of support each trust needs across the five themes of quality of care, finance and use of resource, operational performance, strategic change and leadership and improvement capability. Each Trust is segmented into one of the following four categories: Single Oversight Framework metric Segment rating

Segment description

1 Providers with maximum autonomy: no potential support needs identified.

2 Providers offered targeted support: there are concerns in relation to one or more of the themes. We've identified targeted support that the provider can access to address these concerns, but which they are not obliged to take up.

3 Providers receiving mandated support for significant concerns: there is actual or suspected breach of license and a Regional Support Group has agreed to seek formal undertakings from the provider.

4 Providers in special measures: there is actual or suspected breach of license with very serious and/or complex issues. The Provider Regulation Committee has agreed it meets the criteria to go into special measure

2

Q3 16/17

Single Oversight Framework: level of support segment

Actual: 2 Target: 1 Forecast: 2

In Q3, the Trust had a segment rating of 2.

Q3 16/17

62 day wait for first treatment – GP referral to treatment (before reallocation)

Actual: 77.90% Target: 85% Forecast: Meet target using national reallocation methodology

RMH did not meet the 62 day urgent GP referral standard (before reallocations) with performance at 77.90%. During Q3 there were 43 accountable breaches prior to reallocation. Of those, 27.5 accountable breaches were received late in the pathway (defined as after day 38). The remaining 15.5 breaches are categorised as follows :- Out of the Trust’s control (12.5 breaches)

• Complex diagnostic pathway (4.5) • Patient compliance with pathway (2.0) • Patient Fitness (2.0) • Inappropriately early referral (1.0) • Other medical condition prioritized (1.0) • Patient choice (1.0) • Entry into clinical trial (0.5) • Late referral – day 55 (0.5)

Within the Trust’s control (3.0 breaches)

• Admin delays (2.5) • Surgical capacity (0.5)

RMH did meet the 62 day urgent GP referral standard following reallocation, based on the national reallocation policy. RMH continues to receive a high number of late referrals, as shown in the graph at Appendix B. A full action plan is in place and has been shared with commissioners and covers internal improvements and work with referring Trusts. In addition, the Trust continues to work closely with its referrer trusts through the System Leadership Forum and the South West London Providers’ Group. The Trust expects to continue to meet the standard post-reallocation. The full breakdown of performance by tumour site prior to reallocation can be found in the table at Appendix C.

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3.2 Finance, Productivity and Efficiency

Q3 16/17

PP Debtors over 90 days (% of total PP-debtors) Actual: 49% Target: <25% Forecast: Amber Private Care Debt over 90 days has increased to 49% and remains above target. The growth of Embassy work has driven the aged debt and staffing shortages has hampered the efforts to improve the metric. A revised billing methodology has been requested and implemented in Q4 with the largest Embassy debtor, which targets faster invoice payment. Additionally, a newly appointed Head of Private Care Commercial Finance will be reviewing the end-to-end billing and debt collection process to deliver further improvements.

Q3 16/17

Non-PP Debtors over 90 days (% of total PP-debtors) Actual: 51% Target: <25% Forecast: Amber Non-Private Care Debt over 90 days has remained stable at around 50% all year. This is driven by a number of key invoices in discussion with commissioners that are being resolved at FD level and targeted for resolution before year-end. 3.3 Productivity and Asset Utilisation

Q3 16/17

Bed Occupancy - Sutton Actual: 79.26% Target: 85% Forecast: Amber Reduced bed occupancy is often seen in quarter 3 due to fewer elective operations and patients choosing to wait until after Christmas for their treatment. Despite this, bed occupancy at the Sutton site was below the target performance at 79.26% in Q3. This drop was caused by the combination of reduced elective admissions as well as an on-going trend of reducing non-elective admissions throughout the year. Of note, in Q3 there were 250 fewer non-elective occupied bed-days than in the same quarter the previous year. In quarter 4, bed occupancy is expected to increase driven by a return to normal levels of elective admissions. This target may need to be reviewed for next year as the introduction of the Acute Oncology Service in Sutton may further affect bed occupancy.

Q3 16/17

Theatre Utilisation - Sutton Actual: 69.81% Target: >80% Forecast: Amber Service performance against this metric represents theatre utilisation of scheduled sessions between Monday to Friday 8am-6pm. The utilisation rate in Q3 for the two theatre suites in Sutton is below target performance at 69.81%. Timetabled sessions allocated to paediatric and plastic surgery contributed to the majority of unutilised sessions. Paediatric Consultant Surgeon cover has been reduced since July 2016 following 1 of the Consultants leaving. This post has not been recruited to and the surgical session is planned to be used as a Nurse-led session for PICC insertions under general anesthetic. In the interim, these sessions will be utilised for private plastic patients which started in February 2017.

4

In addition, 8 surgical sessions were not used on 2 bank holidays and a further 13 sessions were not used between 23 – 30 December 2016 due to surgical teams not planning surgeries during this period. It is expected that this indicator will improve next quarter. 3.4 Clinical and Research Strategy

Q3 16/17

Total NHS referrals Actual: 4710 Target: 4900-5250 Forecast: Amber NHS Referrals have decreased in what appears to be a steady decline since Q1. The quarterly aggregated figures however, mask a large amount of monthly fluctuation. At the end of December the total NHS referrals for the year is still slightly above the number of referrals expected based on last year’s figures. This is the cumulative result of a very high number of referrals throughout quarter 1 but a very low number in December 2016. GP referrals for diagnosis dropped more in Q3 than hospital referrals for patients with a cancer diagnosis. Traditionally GP referrals decline in December and volumes increase in January. Early sight of the January data shows a substantial increase in referrals again, in-line with this seasonal pattern. It is therefore expected that this indicator will improve significantly next quarter.

Q2 16/17

Accrual to target, % of closed commercial trials meeting contracted recruitment target (1 quarter in arrears)

Actual: 42.6% Target: 85% Forecast: Red The NIHR has made changes to its Delivery metric (from quarter 4 2015/16), which now focuses on recruitment to target, by target date recorded in each trial’s contract. The recruitment target is set following discussion between the Principal Investigator and the Sponsor and is a best estimate of recruitment at the site – recruitment to time and target. Recruitment to target is affected by many factors. Recruitment may be more challenging than anticipated; the Sponsor can often chooses to close the trial earlier than anticipated; the trial is sometimes withdrawn by the Sponsor. In some instances, the recruitment window may be extended in agreement with the Sponsor, with no change to the date held within the trial Contract (and hence the metric does not reflect the agreed extension). The NIHR collects reasons for recruitment targets not having been met but, unlike the NIHR Initiation metric, no adjustment is made to account for these reasons. In order to improve our performance against the NIHR metric, our researchers are negotiating recruitment ranges, rather than a single definitive number of patients, and will request amendments to contracts where recruitment is not happening at the anticipated rate. Recruitment data are reviewed regularly at Clinical Research Team meetings, and are reported at quarterly performance meetings held with the teams.

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3.5 Workforce

Q3 16/17

Staff turnover rate Actual: 15.1% Target: <12.0% Forecast: Amber The overall staff turnover rate for the Trust is 15.1% in Q3. When split by Acute and Community Services, the staff turnover rate is 14.3% and 21.o% respectively. However, the overall staff turnover over for the Trust is average for a London Acute Trust. A new online exit questionnaire and new joiner survey has been rolled out and the results from this will support and direct efforts to improve retention rates. In addition, there is significant on-going recruitment activity with 218wte waiting to start positions. The turnover rate is expected to return to below 15% in Q4. 4.0 Conclusion The Council of Governors is asked to note the Trust balanced scorecard and commentary for Q3 2016/17 and is invited to discuss the position.

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The Royal Marsden NHS Foundation Trust APPENDIX ABalanced Scorecard 2016/17

NHSi denotes NHS Improvement standard

Patient Safety, Quality & ExperienceQ3

(Oct-Dec 16/17)

Q2(Jul-Sep 16/17)

Q1(Apr-Jun 16/17)

Q4(Jan-Mar

15/16)

Q3(Oct-Dec

15/16)

NHSi 2 New in Q3

Quality Account indicators G G G G G

NHSi G G G G G

Serious incidents (excl pressure sores) 0 0 3 0 2Complaints - % upheld 24.00% 21.00% 29.00% 18.00% 25.00%

MortalityHospital Standardised Mortality Ratio (rolling 12 month - qtr in arrears - NHS patients only) 68.68 81.95 76.90 74.70 77.20Mortality audit (based on qtr data in arrears) A A A G G30 day mortality post surgery 0.36% 0.58% 0.59% 0.59% 0.37%30 day mortality post chemotherapy 2.27% 1.99% 2.18% 2.22% 1.87%100 day HSCT mortality in previous 6 months (Deaths related to SCT) 5.40% 1.90% 4.30% 0.00% 3.17%100 day HSCT mortality in previous 6 months (All deaths) 5.40% 1.90% 5.80% 0.00% 3.17%

Medicines Management% Medicines reconciliation on admission 98% 99% 96% 90% 86%Unintended omitted critical medicines 2.5 1.6 1.6 New in Q1

Cancer stagingStaging data completeness sent to Thames Cancer Registry (1 qtr in arrears) 72.62% 68% 72% 73% 72%

Patient satisfaction Friends and Family Test (inpatient and day care) 97.90% 97.60% 98.40% 97.10% 97.00%Friends and Family Test (outpatients) 98.20% 97.50% 97.90% 96.95% 98.00%Waiting times for day chemotherapy (over 3 hrs) 12.69% 12.54% 13.15% 11.87% 12.34%Mixed sex accommodation breaches 0 0 0 0 0PP access to single rooms - Chelsea % 100.00% 99.92% 100.00% 100.00% 99.89%PP access to single rooms - Sutton % 100.00% 100.00% 95.03% 98.80% 99.75%

National waiting times targetsNHSi 2 wk wait from referral to date first seen: all cancers 98.70% 97.40% 93.90% 95.30% 96.90%NHSi symptomatic breast patients 96.70% 95.50% 93.30% 96.10% 95.40%NHSi 31 day wait from diagnosis to first treatment 98.30% 98.10% 99.30% 99.00% 98.80%NHSi 31 day wait for subsequent treatment: surgery 94.00% 94.50% 95.20% 97.60% 96.40%NHSi drug treatment 99.40% 99.70% 99.80% 100.00% 100.00%NHSi radiotherapy 98.10% 97.10% 98.30% 98.30% 98.50%NHSi 62 day wait for first treatment: GP referral to treatment (reallocated) 87.00% 82.40% 85.40% 85.30% 88.40%NHSi GP referral to treatment (pre-reallocations) 77.90% 75.20% 77.10% 78.60% 79.30%NHSi Screening referral (reallocated) 93.30% 90.00% 78.30% 94.00% 93.70%NHSi Screening referral (pre-reallocations) 92.60% 90.50% 84.30% 95.90% 90.80%NHSi 18 wks from Referral to Treatment still waiting (incomplete) 94.70% 95.90% 94.30% 95.90% 94.80%NHSi 18 wks pathways - patients waiting > 52 wks. (distinct patients across the quarter) 3 4 6 5 6

Staff Friends and Family Test Q3(Oct-Dec

16/17)

Q2(Jul-Sep 16/17)

Q1(Apr-Jun 16/17)

Q4(Jan-Mar

15/16)

Q3(Oct-Dec

15/16)Recommend – Care N/A 100.00% 95.50% 96.30% N/ANot recommend – Care N/A 0.00% 0.90% 1.80% N/A

NHSi Community Measures Q3(Oct - Dec

16/17)

Q2(Jul-Sep 16/17)

Q1(Apr-Jun 16/17)

Q4(Jan-Mar

15/16)

Q3(Oct-Dec

15/16)NHSi Community care data completeness referral to treatment information 75.00% 75.00% 75.00% 75.00% 75.00%NHSi referral information 75.00% 75.00% 75.00% 75.00% 75.00%NHSi activity information 76.20% 76.20% 76.20% 76.20% 76.20%

Certification against compliance : access to health care for people with a learning disability

3. NHSi Community Measures

2. Staff Friends and Family Test - How likely are you to recommend this organisation to friends and family… as a place to receive care or treatment

1. To achieve the highest possible quality standards for our patients, exceeding their expectations, in terms of outcome, safety and experience

Single Oversight Framework: level of support segment

of 2

The Royal Marsden NHS Foundation Trust APPENDIX ABalanced Scorecard 2016/17

NHSi denotes NHS Improvement standard

Finance, Productivity & Efficiency Q3(Oct-Dec

16/17)

Q2(Jul-Sep 16/17)

Q1(Apr-Jun 16/17)

Q4(Jan-Mar

15/16)

Q3(Oct-Dec

15/16)NHSi NHSi financial sustainability risk rating N/A 4 4 3 3NHSi NHSi Use of Resources risk rating 2 New in Q3

%age variance from Agency Spend Cap -13% -7% 9.30% New in Q1NHSi %age variance from Agency Spend Cap -13% -7% 9.3% New in Q1

Cash (£m) 13.6 11.7 10.9 24.1 34.7NHS activity Income Variance YTD (£000) 904 826 680 -4,487 -3,257PP activity Income Variance YTD (£000) 1,862 1,498 1,349 -537 -568PP Debtors over 90 days (% of total PP debtors) 49% 41% 47% 46% 49%Non-PP Debtors over 90 days (% of total non PP-debtors) 51% 51% 52% 35% 36%Achievement of Efficiency Programme YTD (%) 99% 98% 66% 87% 89%Capital Expenditure Variance YTD (£000) -5,072 -2,494 -1,781 -12,007 -5,684Quarter in arrears Q2

(Jul-Sep 16/17)

Q1(Apr-Jun 16/17)

Q4(Jan-Mar

15/16)

Q3(Oct-Dec

15/16)

Q2(Jul-Sep 15/16)

Contractual Sanctions incurred (£000) 0 77.95 New in Q1CQUIN %age achievement Acute NHSE 87.5% 100% (TBC) New in Q1CQUIN %age achievement Acute CCG 100% (TBC) 100% (TBC) New in Q1CQUIN %age achievement Sutton Community Services 100% 100% New in Q1

Productivity & Asset UtilisationBed occupancy - Chelsea 82.47% 81.92% 83.12% 81.99% 81.15%Bed occupancy - Sutton 79.26% 80.16% 82.95% 83.04% 80.01%Care Hours per Patient Day 92.35% 96.44% 96.71% 92.99% 93.16%Theatre utilisation - Chelsea 92.35% 96.44% 96.71% 92.99% 93.16%Theatre utilisation - Sutton 69.81% 77.57% 76.35% 72.24% 75.15%MDU Patients per Chair 3 3 3 New in Q1

Clinical and Research Strategy Q3(Oct-Dec

16/17)

Q2(Jul-Sep 16/17)

Q1(Apr-Jun 16/17)

Q4(Jan-Mar

15/16)

Q3(Oct-Dec

15/16)Total NHS referrals 4710 4824 5146 New in Q1Total PP referrals 1033 996 1095 1026 1024RMH Patients recruited to 100K Genome Project 184 127 74 New in Q1

Efficient clinical modelsNHS Average (mean) Elective LoS 5.24 5.22 5.05 New in Q1NHS Non-Elective Admissions as %age of all NHS Admissions 25.01% 25.08% 23.72% New in Q1

Research (1 QUARTER IN ARREARS)

Q2(Jul-Sep 16/17)

Q1(Apr-Jun 16/17)

Q4(Jan-Mar

15/16)

Q3(Oct-Dec

15/16)

Q2(Jul-Sep 15/16)

70 day target (for externally sponsored trials) NIHR Adjusted figure (excl delays attributed to sponsor/neither sponsor or trust) 94.30% 97.90% 96.40% 98.0% 90.9%

Accrual to target (1Q arrears) - National definition % of closed commercial interventional trials meeting contracted recruitment target (excluding trials that had no set target)

42.60% 43.60% New in Q1

No. of 1st European patients in previous 12 months 1 0 New in Q1Patients on interventional trials as %age of first treatments 9% 10% New in Q1Trials lead by RMH as %age of all trials with RMH involvement 54.00% 42.60% New in Q1

Workforce Q3(Oct-Dec

16/17)

Q2(Jul-Sep 16/17)

Q1(Apr-Jun 16/17)

Q4(Jan-Mar

15/16)

Q3(Oct-Dec

15/16)Workforce productivityVacancy rate 8.60% 9.30% 6.60% 6.3% 6.4%Staff turnover rate 15.10% 14.60% 15.10% 14.6% 14.3%Sickness rate 2.80% 2.60% 2.90% 3.1% 3.2%

Quality & developmentConsultant appraisal (number with current appraisal) 94.00% 92.00% 91.70% 90.00% 72.90%Appraisal & PDP rate 83.00% 80.50% 82.40% 85.40% 84.81%Completed induction (new measure) 72.00% 76.00% 84.50% 78.60% 73.40%Statutory and Mandatory Staff Training 86.40% 91.20% 90.40% 89.50% 86.77%

6. To recruit, retain and develop a high performing workforce to deliver high quality care and the wider strategy of the Trust

4. To improve the productivity and efficiency of the Trust in a financially sustainable manner, within an effective governance framework

5. To deliver the Trust's clinical and research strategy; to better meet the needs of patients and commissioners

6

APPENDIX B 62 Day GP Urgent Referrals by Category

7

APPENDIX C 62 Day Wait for First Treatment (GP Urgent). Performance by Tumour Type (prior to reallocation). Tumour site Q316/17 Q2 16/17 Q1 16/17 Q4 15/16 Q3 15/16 Breast 98.3% 89.6% 96.7% 95.7% 96.5% Children's N/A 100.0% N/A N/A 100.0% Gynaecological 66.67% 51.7% 57.1% 66.7% 85.7% Haematological (excl. Acute Leukaemia) 75% 55.6% 85.7% 77.3% 100.0% Head & Neck 67.9% 45.0% 50.0% 81.3% 47.6% Lower GI 70.8% 83.3% 75.7% 62.96% 75.0% Lung 71.4% 85.3% 71.1% 58.3% 83.3% Referred elsewhere for treatment N/A N/A N/A N/A 100.0% Other/Unknown 50% 66.7% 71.4% 100.0% 71.4% Sarcoma 72.2% 66.7% 57.6% 65.7% 58.3% Skin 88% 83.3% 71.4% 91.3% 72.7% Testicular 100% 100.0% N/A N/A 50.0% Upper GI 54.5% 64.3% 76.5% 72.7% 70.0% Urological 67.7% 60.4% 45.8% 64.9% 40.5%

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