Integrated Governance Monitoring Report · Number of outpatients waiting 13 weeks or more after GP...

Integrated Governance Monitoring Report

January to March 2010 (Q4)

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HOW TO READ THIS REPORT

1 Welcome to The Royal Marsden NHS Foundation Trust Integrated Governance Monitoring Report. The rationale for this report is to provide stakeholders with a detailed quarterly overview of the care, research and infrastructure provided at The Royal Marsden NHS Foundation Trust. This report sits within a portfolio of safety and quality assurance across the whole of the Trust’s provision of services. Other related documents include a monthly Board Quality Account and the Annual Quality Account.

2 The organisation of this quarterly report has been developed in response to the

Department of Health’s quality standards for all healthcare providers as published in the document Standards for Better Health, 2004. The standards are divided into seven domains as follows:

1. Safety 2. Clinical and Cost Effectiveness 3. Governance 4. Patient Focus 5. Accessible and Responsive Care 6. Care Environment and Amenities 7. Public Health

3 Chapters 3-9 in this report reflect the above domains as headings. 4 Trusts are assessed against the core standards annually by the Care Quality

Commission (previously the Healthcare Commission). 5 There are 24 Core Standards and each standard is divided into several further

elements. From 1 April 2010 these will be replaced by the 28 new Care Quality Commission outcomes.

6 The monitoring information in this report is provided for both internal and external

audiences against the Core Standards and local standards. 7 The report includes details on compliance with key performance indicators in the NHS

Trust Performance Indicator Summary. 8 Information included in the report is identified by a symbol representing internal or

external reporting requirements by type. B : Board report E : External report I : Internal report Q/q : Quarter Care Quality Commission performance indicators for the performance ratings

: Key target CQC : Care Quality Commission – Core standard, see Appendix PP : Private Patient(s) RMH : The Royal Marsden Hospital ICR : Institute of Cancer Research

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CONTENTS

Page How to read this report 3 1 Executive summary 6 2 Performance Indicator summary 8

3 SAFETY CQC 1 3.1 Accident and incident reporting 10

3.1.1 New this quarter: Serious untoward incidents (SUIs) and red incidents

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3.1.2 Investigations completed this quarter: Serious untoward incidents (SUIs) and red incidents

10

3.1.3 Executive Summary Incident Reporting 10 3.1.4 Incident reports 11

3.1.5 Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) incidents

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3.2 Claims 14 CQC 2, B 3.3 Child protection 14 CQC 4 3.4 Infection prevention and control 15 3.5 Pressure ulcer monitoring 16 3.6 Medical devices and equipment 18 CQC 4 3.7 Environmental/waste management 18 3.8 National Health Service Litigation Authority

(NHSLA) Management Standards for Trusts 20

4 CLINICAL AND COST EFFECTIVENESS 21 4.1 Clinical audit (including National Institute for Clinical

Guidance (NICE) guidance and National Service Frameworks (NSFs)

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5 GOVERNANCE 29 CQC 7, 5.1 Financial governance 29 CQC 8 5.2 Education, training and development 29 CQC 8 5.3 Human resources (governance) 31 5.4 Workforce information 32 CQC 9 5.5 Information governance 33 5.6 Access to health records 35 5.7 Freedom of information 35 CQC 12 5.8 Research governance 38 6 PATIENT FOCUS 43 CQC 14 6.1 Patient comments relating to care and service

provision 43

6.2 Letters of praise 51 6.3 Food and nutrition 52 CQC 16 6.4 Patient information 52 6.5 Interpreting services 53

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Contents (continued)

Page 7 ACCESSIBLE AND RESPONSIVE CARE 54

7.1 Access waiting times 54 7.2 Cancelled operations 54 7.3 Delayed transfers of care 54 7.4 Midnight bed status and occupancy 54 7.5 Internal targets 55 I 7.5.1 In-clinic waiting times 55 I 7.5.2 Cancelled consultant clinic sessions 56 7.6 Availability of medical notes in outpatients clinics 56 7.7 Quality systems 56 7.8 Radiotherapy 56 7.9 Chemotherapy 58 7.10 Human Tissue Authority (HTA) 61 7.11 Ethnic data capture 62 CQC 17 7.12 Patient and public involvement 63 CQC 19 7.13 Service developments 63 8 CARE ENVIRONMENT AND AMENITIES 65 8.1 Risk assessments – Trust Risk Register 65 8.2 Patient Environment Action Team (PEAT) inspection 65 9 PUBLIC HEALTH 66 9.1 Partnership working 66 Appendix Standards for Better Health 67

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EXECUTIVE SUMMARY

1 The executive summary provides brief details of the main elements in the body of the

report. 2 SAFETY: ACCIDENT AND INCIDENT REPORTING 2.1 There were 325 incidents logged in quarter four to date. This is a decrease in incidents

in this quarter compared to the other quarters of 2009/10. There were 480 in quarter one, 471 in quarter two, and 467 in quarter three (page 11).

2.2 There were no Serious Untoward Incidents (SUIs) and there were seven red incidents declared new in the quarter (page 10). This is similar to previous quarters, quarter 1: no SUIs and five red incidents; quarter two: two SUIs and nine red incidents; and quarter three: one SUI and six red incidents.

2.3 Of the 325 incidents 40 were accidents to staff and others, 38 were patient accidents, and 198 were clinical incidents and clinical near misses (page 11).

2.4 It is important to note that on investigation several incidents that are initially assessed as a red can be downgraded to an orange.

3 INFECTION PREVENTION AND CONTROL 3.1 There were no cases of meticillin-resistant Staphylococcus aureus (MRSA)

bacteraemia (bacterial presence in the blood) in quarter four. In 2009/10 in total there has been one case which is within the Trust’s target of fewer than four.

3.2 Eight patients were found to have Clostridium difficile deemed attributable to the Trust (page 15). During 2009/10 there were 35 attributable cases which is within the Trust annual trajectory of 39.

3.3 The Trust is currently investing in new technology to allow frequent hydrogen peroxide fogging of clinical areas in an attempt to reduce the incidence of infections.

4 THE MANAGEMENT OF RISK: NHS LITIGATION AUTHORITY (NHSLA)

RISK MANAGEMENT STANDARDS FOR TRUSTS 4.1 The Trust was assessed under the Department of Health’s NHSLA scheme and passed

its level 2 assessment in February 2010.

5 CLINICAL AND COST EFFECTIVENESS 5.1 Three reports were received by the Trust for National audits the Trust had participated

in. These were in the following clinical areas: • National Mastectomy and Breast Reconstruction (MBR) Audit, • National Head and Neck Cancer Audit, • National Care of the Dying Audit of Hospitals. The report was also received from the South West London Cancer Network following the Patient Survey 2009.

5.2 The findings have been circulated to the relevant multiprofessional teams and where relevant local action plans are in place.

5.3 Examples of local clinical audits which where completed in quarters three and four demonstrate involvement from a wide range of clinical staff across the divisions.

5.4 A patient representative continues to attend the Clinical Audit Committee meetings.

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6 STAFF TRAINING 6.1 Attendance figures at year end have shown a substantial increase in six key topic

areas. 6.2 The Safeguarding Children briefing paper initiative issued in February combined with

previous attendance at sessions through the year has significantly increased participation resulting in a year end compliance rate of 91%. NB Total attendances = 2767, includes 341 additions of staff on Honorary Contracts; ICR staff; temporary workers and volunteers.

7 RESEARCH GOVERNANCE 7.1 There were seven Suspected Unexpected Serious Adverse Drug Reactions (SUSARs)

in the quarter. Of these, three require further monitoring and one required flagging to the Research Ethics Committee (REC) (page 42).

7.2 In quarter one there were 78 SUSARs and Suspected Adverse Events (SAEs); in quarter two there were 13 and 16 in quarter three.

8 PERSONALISED CARE:

PATIENT COMMENTS RELATING TO CARE AND SERVICE PROVISION 8.1 Forty-five complaints relating to NHS patients were received in the quarter, of which

41 were acknowledged within two days of receipt, and 23 received a full response within 25 working days (page 43). The level of complaints remains stable: 52 were received in quarter one, 54 in quarter two and 41 in quarter three.

9 ACCESSIBLE AND RESPONSIVE CARE 9.1 In-clinic waiting times 9.2 Standard: At the outpatient clinic 90% of patients should be seen within 30 minutes of

appointment time. 9.3 27,509 outpatients out of 34,444 (79.9%) were seen in 30 minutes or less (page 55).

There continues to be a slight improvement from previous quarters, 76.2% in quarter one, 78.5% in quarter two and 78.9% in quarter three.

10 CARE ENVIRONMENT AND AMENITIES 10.1 The annual Patient Environment Action Team (PEAT) inspection occurred in January

2010 at both Chelsea and Sutton sites. Provisional results are excellent for both sites. An external validator joined two patient representatives and staff to complete this inspection.

11 PUBLIC HEALTH 11.1 The Trust now provides a Palliative Care service to the Royal Brompton NHS

Foundation Trust (London site). This includes a medical consultant, specialist sister and nurse consultant. From January to March 50 patients have been seen (page 66).

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2 PERFORMANCE INDICATOR SUMMARY National Access Targets Indicator Target 2009/10

Forecast** 2009/10 YTD 2008/09

% of inpatients and daycases waiting longer than 26 weeks for admission at end of each month / total number of elective booked first finished consultant episodes (FFCEs)

0.03% 0.0% 0.0% 0.0%

Number of inpatients and daycases waiting longer than 26 weeks for admission at end of each month - 0 0 0

% of last minute cancelled operations non-clinical reasons / no. of elective FFCEs 0.8% 0.6% 0.6% 0.6%

Number of last minute cancelled* operations for non-clinical reasons - 120 120 112 % of last minute cancelled operations not admitted within 28 days 5.0% 0% 0% 0.0% Number of last minute cancelled operations for non-clinical reasons not admitted within 28 days - 0 0 0

% of outpatients waiting more than 13 weeks after GP written referral at end of each month 0.03% 0.0% 0.0% 0.0%

Number of outpatients waiting 13 weeks or more after GP written referral at end of each month - 0 0 0

% of patients requiring admission who waited less than 18 weeks 90% 95.3% 95.3% 94.4% % of patients not requiring admission who waited less than 18 weeks 95% 98.4% 98.4% 98.0% * Cancellations by the hospital for non-clinical reasons on the day of surgery, on the day the patient is due to arrive, or after arrival for surgery.

National Cancer Plan Targets Indicator Target 2009/10

Forecast** 2009/10 YTD 2008/09

2 Weeks:

% of patients seen within 2 weeks of urgent GP referral 93% 98.9% 98.9% 94.5%

31 Days:

1st Treatment - % treated within 31 days of decision to treat 96% 99.7% 99.7% 99.3%

Subsequent Drugs - % treated within 31 days of decision to treat 98% 99.0% 99.8% N/A

Subsequent Surgery - % treated within 31 days of decision to treat 94% 98.9% 98.9% N/A

62 Days:

All cancers - % treated within 62 days of urgent GP referral 85% 87.6% 87.6% 95.0%

Referral from Screening - % treated within 62 days of urgent GP referral

90% 95.9% 95.9% N/A

Consultant Upgrade - % treated within 62 days of urgent GP referral tba 94.7% 94.7% N/A

Note: patients may be referred by their GP to their local hospital and from there referred onwards to the Royal Marsden for any subsequent treatment. This additional step in referral route from GP is outside the control of the Royal Marsden and is reflected in these figures.

Other National Indicators - Data Quality Indicator Target 2009/10

Forecast** 2009/10 YTD 2008/09

% of Admitted Patient Records with valid Ethnic Category Code 85% 94.9% 94.9% 94.4%

Other National Indicators - Infection Control Indicator Target 2009/10

Forecast** 2009/10 YTD 2008/09

Number of Clostridium difficile (C.Diff) infections (CDIs)*** 39 35 35 38 Number of meticillin-resistant Staphylococcus aureus (MRSA) bacteraemia <4 1 1 1

** Forecast based on latest available information. *** Figures calculated according to the Department of Health methodology revised December 2008.

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3 SAFETY (standards for better health) 3.1 ACCIDENT AND INCIDENT REPORTING 3.1.1 Red incidents and serious untoward incidents (SUIs) declared new in this quarter Incident Number

Clinical Group/ Division

Description Action taken

RED 20 Facilities Possible delay in response to an arrest call.

Investigation Incident panel 6 April 2010

RED 21 Cancer Services Incident involving the administration of intrathecal chemotherapy.


RED 22 Clinical Services Change of patient details was not recorded in the medical records.

Investigation Incident panel 18 March 2010

RED 23 Cancer Services Patient suffered a perforated gastric ulcer.


RED 24 Facilities Waste was in the incorrect waste stream.

Investigation Incident panel 23 March 2010

RED 25 Cancer Services Incident involving a displaced feeding tube.


RED 26 Clinical Services Issues regarding chest drain insertion. Investigation Incident panel 21 April 2010

3.1.2 Red incident and SUI investigations completed in this quarter Incident Number

Clinical Group

Description Outcome Action taken following investigation

RED 16 Clinical Services

Nursing staff noticed that the patient’s face was swollen due to leakage of fluid into tissue from a central venous catheter (CVC).

The incident did not contribute to the rapid deterioration of the patient’s condition.

The CVC was returned to the manufacturer to check there was not a fault. Documentation regarding CVC insertion and monitoring to be reviewed.

3.1.3 Executive Summary Incident Reporting The total number of incidents reported shows a slight downward trend over Q1-Q3. There appears to be a further reduction in Q4 but this may be attributable to incidents that have yet to be added to the system. The data regarding the severity of incidents has been adjusted to record actual level of harm rather than potential harm. This was in response to a national change from the National Patient Safety Agency. Levels of patient falls has remained stable over Q1-Q3 with 70 incidents being reported each quarter. Although there does not appear to be an increase in falls it is an area that the Trust is targeting as part of the High Impact Actions initiative and work is being undertaken to improve patient safety in this area and reduce the number of patient falls across the organisation. Staff accidents show a slight increase in all categories.

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3.1.4 Incident Reports Incident Reports, All incidents

0

50

100

150

200

250

300

350

400

450

500

Q1 09 41 70 17 11 10 6 325 480

Q2 09 50 71 33 12 13 10 281 471

Q3 09 70 72 19 7 18 8 273 467

Q4 09 40 38 16 6 23 4 198 325

Accidents to Staff & Others

Accidents to Patients

Non Clinical Incident

Violence and Aggression

Fire Incident/Risk

Security Incident/Risk

Clinical Incident / Risk Totals:

Clinical Incidents

0

20

40

60

80

100

120

140

Q1 09 2 8 13 4 5 31 1 26 138 34 12 9 18

Q2 09 2 4 5 2 6 29 0 45 117 14 9 13 15

Q3 09 0 2 26 2 0 39 6 22 130 24 8 4 11

Q4 09 0 2 15 1 1 20 8 15 79 19 6 6 17

Anaesthetics Consent

Blood Transfus

ion

Stem Cell

Infection Control Logistics

Diagnostic

Radiolog

Equipment

Medication

Record Keeping

Radiotherapy

Specimen

Handling

Theatre/Post

surgical

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Clinical Incident Severity

0

50

100

150

200

250

300

350

High 7 5 1 1

Moderate 29 20 18 12

Low 136 117 117 56

Very low 155 139 137 129

Totals: 327 281 273 198

Q1 09 Q2 09 Q3 09 Q4 09

Medication Incidents Severity

0

20

40

60

80

100

120

140

High 2 1

Moderate 10 8 4 3

Low 60 54 56 24

Very low 67 55 59 52

Totals: 138 117 119 79

Q1 09 Q2 09 Q3 09 Q4 09

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Patient Falls

0

10

20

30

40

50

60

70

80

Q1 09 36 29 6 71

Q2 09 25 42 14 72

Q3 09 25 32 15 72

Q4 09 11 15 12 38

Fall from height Slip, trip or fall (same level) Other Totals:

Staff Incidents

0

10

20

30

40

50

60

Slip, trip or fall 7 11 15 8

Manual Handling 2 3 4 0

Needlestick/ sharps 9 12 12 9

Other 18 15 27 14

Totals staff incidents 36 41 58 31

Q1 09 Q2 09 Q3 09 Q4 09

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Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) incidents There have been four RIDDOR reportable incidents this quarter: Three where staff have been off work for more than three days as a result of an incident, however severe: • Eye injury as a result of knocking of glasses and catching the eye with a finger.

Appropriate personal protective equipment safety eye wear was being used at the time. The incident occurred in a non-clinical environment part of the Estates team. The member of staff returned to work after a period of absence.

• Footing was lost as a result of an uneven surface and the staff member suffered a fracture to their foot. Remedial action was taken to level the surface of the outside car park in Sutton.

• Steam burn to arm when removing hot food from an oven. Staff have been reminded regarding safe use of the equipment.

The fourth incident occurred when a visitor tripped over a table and fell and required transfer to Accident and Emergency. Assessment of the area has resulted in a reorganisation of the furniture layout. The outcome is not known as visitors are not obliged to keep the Trust informed. 3.2 CLAIMS 3.2.1. The Trust has received no formal letters of claim relating to alleged clinical negligence

in this quarter. 3.2.2. There were no public liability/personal injury claims.

3.3 CHILD PROTECTION [Board] 3.3.1 Training

To reach the Trust target of 100% compliance with staff attending Safeguarding Children level 1 training, a briefing paper was developed jointly by the named professionals and the Learning and Development team. This was circulated to all Trust employees and compliance is now 91%.

There were two cases of concern that had been reported to the Trust named nurse:

• In the first case ward staff had followed the Trust procedures and had referred the child to local social services where the child was already known. Local social services are now managing this.

• The second case is ongoing with involvement from the Trust and local social services.

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3.4 INFECTION PREVENTION AND CONTROL

3.4.1 Incidence of Health Care Associated Infections

No. Organism RMH

Jan 10

RMH

Feb 10

RMH

Mar 10

RMH

YTD

Attributable to RMH YTD*

RMH Annual Trajectory

London SHA

1. Meticillin-resistant Staphylococcus aureus (MRSA) bacteraemia

0 0 0 1 1 4 33

2. Clostridium difficile infection (CDI)

4 (3) 4 (4) 7 (1) 63 35 39 350

3. Vancomycin Resistant Enterococcus (VRE)

8 7 12 106 n/a n/a unknown

4. Respiratory Syncitial Virus (RSV)

3 3 0 27 n/a n/a unknown

* The Department of Health (DH) and Health Protection Agency (HPA) do not attribute cases of Clostridium difficile infection (CDI) to the Trust if the patient is found to have the infection within 48 hours of admission. Of the 15 cases of CDI from January to March, eight are deemed attributable to the Trust (shown in brackets in the CDI row).

3.4.2 Meticillin-resistant Staphylococcus aureus (MRSA) There were no MRSA bacteraemias this quarter.

3.4.3 Clostridium difficile infection (CDI) The Trust is within its allocated trajectory for Clostridium difficile infections in 2009/10. The trajectory for next year is lower (35) so there must be a continuing effort to reduce the risk of this infection.

3.4.4 Multi-Resistant Organisms 13 patients were identified as carrying multi-resistant organisms during this period.

3.4.5 Hand Hygiene Improvement Weekly hand hygiene audits continue to be undertaken in all clinical areas; compliance is still variable but improving overall, with definite evidence of improvement since the audits were introduced.

3.4.6 Compliance with the “Hygiene Code” Compliance with the Health and Social Care Act 2008 Code of Practice for the Prevention and Control of Healthcare-associated Infection (the “Hygiene Code”) is monitored by the Trust’s Hospital Infection Prevention and Control Committee using an assurance framework mapped against the Code. All objectives for this year have been achieved. Ongoing compliance with the Code in inpatient areas is monitored by a programme of visits to clinical areas by a matron or designated deputy from a different area, similar to those carried out by the Care Quality Commission (CQC).

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3.5 PRESSURE ULCER MONITORING

The total number of pressure ulcers within the Trust, and the number of pressure ulcers that develop within the Trust, are included in the Quality Account presented to the Trust Board each month. The pressure ulcers are graded using the Sterling pressure ulcer classification system (see the table on page 17).

Month January 2010 February 2010 March 2010

Total number of pressure sores for the month 33 21 26

Total number RMH acquired pressure sores 13 7 12

Sores graded below 1.2 8 5 6

Sores graded 2.0 to 2.4 25 15 20

Sores graded 3.0 to 3.4 0 1 0

Sores graded above 4.0 0 0 0

The tables below show how many patients acquired pressure ulcers at the Trust and which wards they were on. Please note some patients may develop more than one pressure ulcer.

Sores graded below 1.2

Wards January (nos of patients)

February (nos of patients)

March (nos of patients)

Burdett Coutts 1 0 0 Chevallier 0 2 0 Critical Care unit 1 0 1 Smithers 0 0 1 Bud Flanagan West 0 0 1 Wiltshaw 1 0 0 Total 3 2 3

Sores graded 2.0 to 2.4




Wiltshaw 1 1 1 Critical Care unit 2 1 2 Kennaway 1 1 1 Chevallier 0 1 1 Burdett Coutts 1 0 0 Smithers 1 0 0 Total 6 4 5

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Chevallier 0 1 0 Total 0 1 0





Total 0 0 0 Description of Sterling pressure ulcers grades

Sterling Description of Stage

0 No clinical evidence of a pressure sore 0.1 Healed with scarring 0.2 Tissue damage not assessed as pressure sore 1.1 Non-blanching hyperaemia 1.2 Blue / purple / black discolouration 2.0 Partial thickness skin loss – epidermis & or dermis 2.1 Blister 2.2 Abrasion 2.3 Shallow ulcer, no undermining of adjacent tissue 2.4 Any of these with underlying blue / purple / black 3.0 Full thickness skin loss 3.1 Crater, without undermining of adjacent tissue 3.2 Crater with undermining of adjacent tissue 3.3 Sinus, the full extent of which is uncertain 3.4 Necrotic tissue masking full extent of damage 4.0 Full thickness skin loss extensive destruction 4.1 Visible exposure of bone, tendon or joint capsule 4.2 Sinus associated as extending to bone, tendon / joint capsule

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3.6 MEDICAL EQUIPMENT AND DEVICES

3.6.1 As part of the recent NHS Litigation Authority (NHSLA) visit, medical device training and maintenance came under scrutiny. The maintenance performed on medical devices by the equipment library was highly rated. They found the medical device inventory to be very detailed but wanted consumables to be separated from other equipment for clarity. The equipment folders on the wards were seen as good practice. Overall the training records for medical devices were comprehensive but some improvements need to be made related to the record keeping of when and who was trained particularly in relation to the training of doctors.

3.6.2 The evaluation of ambulatory devices for administration of infusional chemotherapy has been ongoing since last year. A number of devices had to be evaluated. due to some devices causing infusions to be administered too fast or too slow, which resulted in side effects or issues for disconnection in the community. The Baxter Infusor seems to have been well evaluated with no flow rate problems and will now be the device of choice.

3.7 ENVIRONMENTAL/WASTE MANAGEMENT 3.7.1. Environment

3.7.2. The Carbon Reduction Commitment scheme begins in full from April 2010 with the First Compliance Year and Footprint Year for the Introductory Phase.

3.7.3. It is a mandatory energy efficiency scheme that affects both the private and public sector. It involves annual emissions reporting, emissions allowance trading and a published performance league table. Within this project the Trust will be expected to review and develop existing policies related to sustainability. The implementation of this will require day-to-day control by a senior manager who has significant knowledge of the Trust.

3.7.4. The Assistant Director of Projects will therefore be taking the lead on Sustainability and Carbon Credits, and will be based at the Sutton site, reporting to the Interim Director of Estates.

3.7.5. The first exercise in the scheme was to determine if the Trust qualified for participation in the scheme. The criteria for qualification was based on the electrical consumption of the Trust in calendar year 2008. It has now been established that the Trust does qualify for the scheme and will now have to register for the scheme. The registration period is April to September 2010. The Trust will also have to obtain a comprehensive record of all its carbon dioxide emissions for the period April 2010 to March 2011. This year will be the footprint year during which the Trust will purchase carbon credits for forthcoming years.

3.7.6. Waste

3.7.7. Initiatives

• Mixed recycling introduced at the Sutton site. Plastic, paper, tins, glass and card is being collected in clear sackholders, which are then placed in several 1100

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litre wheeled waste carts. The material is then transported to a “clean” Materials Recovery Facility (MRF) in Greenwich. As the scheme progresses and more areas are included, the potential to “swap” storage medium will be examined (potential to use the waste compactor for the recyclate). Plans are being made to extend the scheme to all administration and patient areas of the Sutton site. Audit of areas, supply of internal collection containers, staff training, posters and leaflets aiming to increase recycling of domestic waste to 50%. Meetings have been held with the contractor to develop joint initiatives to increase the waste going to recycling.

3.7.8. Activities

• Environment Agency (EA) Audit: During August 2009 the Sutton site was visited by a team of EA auditors examining all aspects of waste collection, storage, disposal and transfer as well as other environmental issues including oil storage and pollution prevention. A similar exercise was also carried out at the Chelsea site on 22 October. The EA has issued a report and an action plan has been developed to address the requirements and recommendations.

3.7.9. Upcoming

• Producer Audits: Both the Sutton and Chelsea sites are required to audit all of their clinical waste production areas if we are to continue to have the waste accepted by the contractor. The Interim Waste Manager has completed the audits of both sites. Staff to be aware of the need to accurately describe the material and the process which has produced the clinical waste.

• A review of the confidential waste system, including paper documents, electronic, film and glass media. To include examination of on site storage and collection frequencies.

• Genetically modified (GM) waste disposal: following cessation of autoclave operations all movement, storage and disposal currently being examined for safety, practicality and legal compliance. An autoclave plant refurbishment scheme has been designed and agreed.

• The Trust Waste Policy is currently being revised to include recent statutory requirements such as the Producer Audits. The Environment Agency has been provided with a copy of the draft revised policy and has provided input. The policy will be completed and submitted for authorisation in April 2010.

• Waste Training Programme: examination of Trust requirements to include training to comply with updated Waste Policy. Selection from formal seminars, hands on training, workshops, internet and electronic training (e-training). Domestic Services staff are commencing training regarding handling, loading and storage of all Trust wastes as per revised Waste Policy.

• Interviews were held on 5th February 2010 for the permanent Waste Manager Post. The successful candidate will take up the post from 10 May 2010.

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3.8 NHS LITIGATION AUTHORITY (NHSLA) RISK MANAGEMENT STANDARDS FOR TRUSTS

3.8.1 The Secretary of State’s overall aim for the Authority in administering the schemes is to promote the highest possible standards of patient care and to minimise the suffering resulting from any adverse incidents which do nevertheless occur.

3.8.2 The risk management standards and assessment process are designed to provide a structured framework within which to focus effective risk management activities in order to deliver quality improvements in organisational governance, patient care and the safety of patients, staff contractors, volunteers and visitors. The process provides assurance to the organisation, other inspecting bodies and stakeholders, including patients.

3.8.3 The assessment process is undertaken at three levels: • Level 1 Policy. The process for managing risk has been described and

documented • Level 2 Practice. The process for managing risk as described in the policies at

Level 1 is in use. • Level 3 Performance. The process for managing risk is working across the

whole organisation. Where deficiencies have been identified, action plans must have been drawn up and changes made to reduce the risk.

3.8.4 There are five standards and within each standard are ten criteria. The pass mark at

each level is 40 out of 50 criteria with no fewer than seven criteria passed in each standard.

3.8.5 Level 2 Assessment February 2010 The Trust was assessed at Level 2 for the first time in February 2010 with a positive result in 47 out of the 50 criteria. The assessors found that sufficient evidence was provided to assure them that the risk management processes described in the policies were in use in the 47 areas. The assessors noted that the evidence provided for some criteria indicated that there were relatively new processes that required further embedding and work in order to ensure that safe systems are in place across the Trust.

3.8.6 The Trust is committed to effective risk management processes, delivering quality improvements in organisational governance, patient care and the safety of patients, staff, contractors, volunteers and visitors. Over the next 18 months work will need to be undertaken Trust wide to embed the risk management processes currently in place and monitor and develop action plans to address any deficiencies.

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4 CLINICAL AND COST EFFECTIVENESS (standards for better health)

4.1 CLINICAL AUDIT (INCLUDING NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE (NICE) GUIDANCE AND NATIONAL SERVICE FRAMEWORKS (NSF)

4.1.1 National audits

Title Standards/criteria Outcomes Healthcare Quality Improvement National Clinical Audit Patient Outcomes Programme (NCAPOP)

Second annual report of the National Mastectomy and Breast Reconstruction (MBR) Audit. This is a national audit of provision and outcomes for women in England and Wales. It includes all women treated between 1 January 2008 and 31 March 2009. Report published in December 2009

National standards of care. Results discussed at the Surgical Audit Group, Breast Audit and Research Meeting and Clinical Audit Committee Third annual report of the National Mastectomy and Breast Reconstruction audit expected in June 2010. Local action plan in place.

National Head and Neck Cancer Audit, fourth annual report for audit period October 2007 to November 2008. Report published in 2009

National standards of care Report disseminated to Surgical Audit Group.

National audits not part of NCAPOP

The Second National Care of the Dying Audit of Hospitals (NCDAH) Second Round report A prospective audit design was used to gather Liverpool Care Pathway for the Dying Patient (LCP) data from up to 30 consecutive deaths in each of the participating hospitals between 1 October 2008 and 31 December 2008. Report published in September 2009.

National standards of care within LCP, best practice in the last hours and days of life in UK National policy (DH 2006, 2008) and more recently in the National End of Life Care Strategy: Quality Markers and Measures for End of Life Care (2009).

LCP Facilitator presented audit findings at Senior Nurse Meeting and encouraged ward sisters to inform staff of need for greater attention to completion of LCP. LCP Facilitator presented audit findings to Palliative Care Unit Audit meeting and discussed how some of these gaps in end of life care might be addressed. The new version of the LCP (version 12) was launched nationally in December 2009. Its new layout is intended to improve compliance and completion of the tool. Local action plan in place.

South West London Cancer Network (SWLCN) clinical audits

SWLCN – Patient Survey 2009, The Royal Marsden NHS Foundation Trust, Picker Institute Europe, December 2009 report

Patient Experience Survey Report disseminated. Local action-planning in place.

4.1.2 Local clinical audits

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This is a selection of the audits that have been completed in the last six months and whose results and action plans have been presented to the Clinical Audit Committee.

Title Standards/criteria Outcomes Breast Prospective comparison of complications following mastectomy with and without reconstruction.

National standards of care; Benchmarking. Post-operative morbidity reflects decision making, planning and technical expertise. The National mastectomy and breast reconstruction audit measured in-patient events only. Complications were evaluated and compared at 7, 30, 90 and 180 days for mastectomy alone or with reconstruction.

A 30-day minimum is required to reflect the true extent of surgical morbidity. A benchmark for future performance monitoring has been established. Presentation at British Association of Surgical Oncology (BASO) San Antonio and international meeting of Oncoplastic and Reconstructive Breast Surgery (ORBS).

Does having primary breast reconstruction influence chest-wall radiotherapy rates?

National standards of care; Local guidelines. Immediate breast reconstruction should be discussed with all patients who require mastectomy. The immediate reconstruction may interfere with postmactectomy chest wall radiotherapy (RT). The adverse impact of chest-wall RT on the reconstructed breast is widely reported. Predicting who will require chest-wall RT prior to surgery can be difficult, limited to the knowledge of full pathological staging and often only known after mastectomy. Does having primary reconstruction influence in chest-wall RT decision making? Are women who opt for primary reconstruction less likely to receive Radiotherapy than those who choose no reconstruction?

Chest wall RT rates are broadly comparable across the three risk groups for mastectomy immediate reconstruction (MIR) and mastectomy only (MO), suggesting MIR doesn’t influence decision making regarding RT. The number of high risk MIR was small (14%) suggesting successful preoperative selection. Slightly higher radiotherapy rate for implant based reconstruction may be explained by staged reconstruction. Presentation at British Association of Surgical Oncology (BASO) San Antonio and the international meeting of Oncoplastic and Reconstructive Breast Surgery (ORBS).

Snap shot audit of timeliness of diagnosis notification to General Practitioners (GPs), Sutton site

National Cancer Peer Review Programme; Manual for Cancer Services 2008: Breast measure topic 08-2B-110

Compliance to measure 100%: Breast multi-disciplinary team (MDT) has a system in place for timely communication with GPs. No change in operational policy.

Operational policy for named key worker and a permanent record of their consultation spot check of The Royal Marsden’s patient checklist in Electronic Patient Record (EPR), Sutton site

National Cancer Peer Review Programme; Manual for Cancer Services 2008: Breast measures: topic 08-2B-111 and 08-2B-120.

Compliance to both to measure 100%. Breast multi-disciplinary team (MDT) has a system in place for timely communication with GPs. Operational policy to be updated to reflect current practice: a copy of the checklist is now held on the EPR.

Recording of treatment planning on multi-disciplinary team (MDT) proforma: agree and record individual patient treatment plans on Electronic Patient Record – Sutton site

National Cancer Peer Review Programme; Manual for Cancer Services 2008: Breast measure topic 08-2B-124.

Compliance to measure 100%: recording of treatment planning on MDT proforma and on Electronic Patient Record. Operational policy to be updated to reflect current practice.

Breast and Drug Development Unit

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Title Standards/criteria Outcomes Metastatic Breast Cancer patients referred to the Drug Development Unit, Royal Marsden Hospital

Local guidelines The audit has helped to understand the characteristics of those patients with metastatic breast cancer who are referred to Phase I clinical trials in the Drug Development Unit. With the better characterization of these patients we are able to plan treatment resources in accordance and to use this data to guide future trial recruitment numbers and trial selection. Results fed back to local team.

Diagnostic imaging Audit of infiltration of IV contrast in CT, RA 056

RMH policy 67 and extravasation rates from literature (0.7%, Wang 2007; 0.08% Grinstead 2007; 0.6% Jacobs 1998; 0.9% Federle 1998).

Radiology Infiltration Management Forms have been re-written to improve data collection for future audits.

Gastro-intestinal Unit Irintotecan and docetaxel as second line chemotherapy for advanced oesophago-gastric cancer, GI 124

A Phase II study of irinotecan and docetaxel combination chemotherapy for patients with previously treated metastatic or recurrent advanced gastric cancer, Sym et al. (2008) Cancer Chemother Pharmacol. 2008 Dec;63(1):1-8. Response rate 20.4% (95% CI 9.1-31.7%) Median time to progression 2.7 months (95% CI, 1.7-3.8 months) Median overall survival 8.9 months (95% CI, 6.6-11.3 months).

Performance status is now recorded on the electronic patient record (EPR) annotation after every patient attendance.

Haemato-Oncology Audit of ‘Serum free light chain’ testing in myeloma and amyloidosis

The Trust guidelines produced in July 2006 in the original business case state that tests should be carried out on the following: 1) all myeloma/amyloidosis patients

with each new chemotherapy regime at first presentation or relapse

2) patients with “oligosecretory” myeloma (i.e. non-secretory or urine Bence Jones protein only) or with amyloidosis.

As follows: • with each new chemotherapy regime

at presentation or relapse • before treatment (cycle 1 day 1 or

within 14 days prior to treatment) • cycle 1 day 8 • day 1 of each cycle of chemotherapy • before high dose melphalan • three months after high dose

melphalan • every one to three months thereafter.

Clarification required in the current guidelines. Results circulated to staff involved with initiating tests. Information and Communication Technology to address issue of pending results. Re-audit with new guidelines.

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Title Standards/criteria Outcomes Head and Neck/Thyroid Correct administration of thyroxine

Local standard Thyroid clinic staff (Doctors and Clinical Nurse Specialist) to check correct administration each visit. Results fed back to the Radiotherapy Audit Group Meeting.

Comparison of prescribed radioiodine activity with administered activity for benign thyroid disease

Local guidelines In routine practice the activity of I-131 for out-patient treatment will be restricted to a maximum activity of 740MBq. If there is clinical need to give higher activities than 740MBq than an individual risk assessment must be completed before the administration is confirmed or the patient is admitted for treatment To continue to monitor the variation in measured I-131capsule activities against nominal activity purchased

Are we following National Institute for Health and Clinical Excellence (NICE) guidelines on Laboratory monitoring of Head and Neck Cancer patients at risk of refeeding syndrome?

NICE guidelines Local form designed and introduced. Re-audit planned.

Lung Unit Audit of Chronic Obstructive Pulmonary Disease (COPD) in the lung oncology clinic, LUN 071

NICE and British Thoracic Society Guidelines on the management of COPD. Thorax 1997. 52: (Suppl V).

Spirometry Is encouraged for all new lung cancer patient referrals. A scoring method for dyspneoa has been adopted. Criteria for patients requiring COPD screening have been agreed. The scoring tool for COPD is re-presented to patients after 6 weeks’ treatment.

Use of Zometa in non-small cell lung cancer (NSCLC), LUN 086

Bone metastases in lung cancer Tsuya A, Fukuoka M. Clin Calcium. 2008 Apr;18(4):455-9.

The Lung Unit guidelines have been updated to recommend that every newly-referred lung cancer patient requires a bone scan (or PET scan) assessment.

Cockcroft-Gault calculation and ethylenediaminetetraacetic acid (EDTA) clearance for estimation of glomerular filtration rate in lung cancer patients receiving platinum- based chemotherapy, LUN 082

EDTA clearance was used as the gold-standard for measurement of GFR

For lung cancer patients receiving platinum–based chemotherapy, EDTA testing will be limited to patients where the CG estimation is under 50 or over 120.

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Title Standards/criteria Outcomes Nursing and Rehabilitation

Review of documented care of patients dying in the Critical Care Unit (CCU) following introduction of the Intensive Care Unit Liverpool Care of the Dying Patient Pathway (ITULCP)

National standards of care within the LCP

The ITULCP seems to have helped to improve the documentation of some aspects of end of life care although in other areas documentation has deteriorated and there is a considerable amount of missing data. This and the infrequent use of the ITULCP might imply that the current document is too long to be used completely and appropriately when patients’ end of life care lasts for a period of a few short hours. Results of audit have been forwarded to senior CCU nursing and medical staff Small working party of CCU staff to consider ways of modifying current ITULCP to make it more succinct and practical for use in the short timeframes in which end of life care is delivered in CCU

Annual Medical Device Training records

NHS Litigation Authority (NHSLA) standards; Local guidelines

Highlight to all staff that although some of the training is recorded centrally by attendance at mandatory training it is still required that a training log is kept at ward level in the medical device folder. Training programmes reviewed for oral syringes and microclaveage. Where possible incorporate into current sessions within mandatory training/induction. Discussed with Consultant Dietitian re training for pH indicator strips and training records. Representatives to visit wards to update training where required. Action plan monitored by the Medical Devices Strategy Group.

Snap-shot audit of the documentation of patients’ preferred name

Local policy

No change in policy. Re-audit planned to ensure improvement in documentation.

Re-audit of Nutrition Screening and Weight

Local guidelines; Patient Environment Action Team (PEAT); NHS Litigation Authority (NHSLA) standards

Repeat results confirmed improvement.

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Title Standards/criteria Outcomes Patient survey of wig provision at The Sir William Rous Unit

Annual National Patient Survey High standard of service provided by hairdresser. Future plan: The service will continue to use the existing supplier and range of wigs as this appears to meet the needs and requirements of patients. The Procurement department carried out an extensive benchmarking exercise and advertised for bids to be sent in and we believe that we offer the best price and quality available.

“What you can expect from the Royal Marsden” – patient survey

Patient experience survey While the scores are generally very good there are specific areas which can be improved. Quality Officer working with different committees to ensure unmet needs identified addressed.

Snap-shot audit on documentation of care of patients with religious, spiritual and cultural beliefs

Local guidelines Significant beliefs to be consistently recorded. Development of self report form for booked patients so they can indicate specific needs to nursing staff Spirituality care plan to be revised and relaunched

Snap-shot survey of chaplaincy service one week in October 2009

Local guidelines Use of self assessment tool so patients in these areas can indicate they want to see chaplain Referral information to be available on Hospital intranet Leaflet for all patients particularly those in side-rooms giving information about the chaplaincy service Leaflet on Multi-Faith Chaplaincy Service

Views of staff from ward and clinical areas with chaplaincy service

Staff views Review out-of-hours and weekend cover for Roman Catholic priest Review contact for other religion/spiritual beliefs e.g. Jewish, Hindu or Sikh, Buddhist, No specified faith Produce poster for each ward indicating services of full chaplaincy team and how to contact them at all times Intranet site for directory of spiritual/religious/faith resources including documented protocol for referral to the chaplaincy service

Paediatrics Opiate use on the Paediatric ward, PAE 074

British National Formulary for children 2008, p24. Pain management, Chapter 8, Handbook of Palliative Care, 2nd edition. Faul, Carter and Daniels, 2005.

Opiates can contribute to nausea and vomiting and may require further anti-emetics especially in the first three days of opiate use. Local guidelines have been updated.

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Title Standards/criteria Outcomes Palliative Care Use of Methylnaltrexone Local guideline development Inappropriate use investigated.

Trust guidelines for the use of methylnaltrexone established.

Pharmacy/Anaethetics Prescribing Errors Before & After the Introduction of a New Pre-Printed Drug Chart on Critical Care Unit (CCU)

Results fed back to surgical audit group, 15 May 2009.

Radiotherapy and Physics

Reducing systematic and random errors for cranial radiotherapy using ExacTrac

Local guidelines The audit shows that using the ExacTrac system setup accuracy within 1mm can be achieved for patients undergoing fractionated stereotactic radiotherapy in a shell. If patient position remains stable during treatment (intrafraction), the accuracy achieved using the ExacTrac system may allow margin reduction. Further analysis is underway to assess this. Standard guidelines have been met. Further research to be undertaken into intrafraction motion

Surgery and Anaesthetics

Surgical Antibiotic Prophylaxis in Critical Care CCU

Local guidelines RMH antibiotic guidelines for surgical prophylaxis reviewed. Data relating to our implants and infection rates and a month’s data of breast/plastic surgery antibiotic usage across the Trust biweekly oncoplastic Multi-Disciplinary Team Meeting.

Computerized tomography (CT) angiogram imaging in Deep Inferior Epigastric Perforator (DIEP) flap breast reconstruction

Standard preoperative tool for assessment of DIEP flaps, April 2008.

To continue to develop abdominal free flap techniques.

Urology Inter-operator variety in length of total prostate biopsy cores in the active surveillance programme

There should be no clinically significant difference in the individual biopsy core length between operators compared to average of all second core biopsies within the active surveillance programme. Clinically significant difference is defined as less than 1mm, this is a local standard.

No clinically significant difference in lengths of individual core biopsies sampled by different operators within the active surveillance programme.

A baseline audit has been provided background and data. This is to be re-audited again in 2011.

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5 GOVERNANCE (standards for better health) 5.1 FINANCIAL GOVERNANCE

Financial governance is reported separately to the Trust Board and via MONITOR. 5.2 EDUCATION, TRAINING and DEVELOPMENT 5.2.1 Mandatory Training

In the period 1 January 2010 to 31 March 2010 the following number of participants completed the mandatory training listed:

Please note: * Numbers include participants on the Trust induction events, nurse, allied healthcare professional (AHP), healthcare assistant (HCA) and non-clinical staff mandatory training update days, as well as additional separate sessions. ** This includes staff from both The Royal Marsden NHS Foundation Trust and The Institute of Cancer Research (ICR). # Figures have been adjusted for previous quarters as a result of an end of year audit. Discrepancies with previous reported figures occurred to due late receipt of information for input and human error.

Course Name/Category:

Q – compariso

n to Q 3

Q 4 09-10

Q 3 09-10

Q 2 09-10

Q 1 09-10

Year end

2009-10 Q 4 08-09

A - comparison to Year end 08/9

Year end 2008-09

Fire Training*# 423 629 368 438 1868 393 1846 Corporate Induction 113 86 81 89 369 76 282 Managers Induction 0 0 0 8 8 0 25 Nursing Induction 29 72 17 29 147 30 89 Junior Medical Staff Induction

17 39 68 38 162 24 157

Nurse update training# 45 154 149 110 457 63 423

Non Patient Manual Handling (Back Care awareness)

49 73 6 41 169 63 271

Manual Handling*# 136 280 222 172 810 117 871 Basic Life Support (BLS) (including Paediatric BLS)*

153 361 346 222 1089 197 891

Safeguarding Children*# 1564

500 368 336 2768 256 1085

Safeguarding Adults* 268 394 321 315 1298 250 901 Mental Capacity Act* 255 352 329 314 1250 255 790 Conflict Resolution for Frontline Staff

28 35 16 43 122 27 141

Risk Management Awareness*#

339 472 272 278 1361 264 1096

Good Clinical Practice** 63 41 88 67 259 37 167 Infection Control* 320 483 350 258 1411 Not

previously reported

Not previously

reported Equality & Diversity: Managing Fairly 16 33 23 17 89 25 108 Fairness for All ncluding ‘Diversity Awareness’ e-learning package)

40 102 67 62

271 120 362

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5.2.2 The Q column showing up and down arrows indicates whether the numbers

completing the training have increased, decreased or remained the same compared with the previous quarter. The A column shows an annual comparison to the previous year. For Induction courses the numbers are dependent on the number of new starters in that quarter and therefore comparison against previous quarters is not relevant.

5.2.3 Most attendance numbers are down on the previous quarter. However, these figures

are comparable to the same quarter last year. Attendance in this quarter is reflective of the winter holidays, weather conditions, and availability of staff and trainers. Attendance figures at year end have shown a substantial increase in six key topic areas. Manual Handling, Infection Control, Conflict Resolution and Equality and Diversity training have been identified as areas for review in the coming year and we are working with the Subject Matter Experts to this end.

5.2.4 The Safeguarding Children briefing paper initiative issued in February combined with

previous attendance at sessions through the year has significantly increased participation resulting in a year end compliance rate of 91%. NB Total attendances = 2767, includes 341 additions of staff on Honorary Contracts; ICR staff; temporary workers and volunteers.

5.2.5 Continuing Professional Development (CPD) - Diagnostic Radiography CPD

Report 2009/10 5.2.6 The aim of this section of the report is to provide an update on the CPD activity of

different staff groups.

5.2.7 During 2009/10 all Diagnostic Radiographers and radiology nurse completed/attended some form of CPD as identified at appraisal.

5.2.8 This past year the department has continued to focus on developing role extension and in house training programs to support Breast imaging and intervention and the Sutton Ultrasound department. This supports both CPD and role development for diagnostic radiographers and is now an essential service need which improves the efficiency of the service.

5.2.9 Radiology continues to do in-house training for the radiology nurses and radiographers in cannulation techniques required for computerised tomography (CT) and magnetic resonance imaging (MRI) examinations and IM procedures

5.2.10 In addition to the above and attendance at mandatory and in-house training highlights include:

• Support for other modality based MSc courses – CT, MRI, and business management and IT imaging masters

• Participation in study days and partnership courses on Clinical Imaging Developments; Multislice CT scanning; MR and functional MR scanning.

• Four superintendents have attended the National Cancer Leadership program. • Supporting and developing the monthly in house Radiology journal club, allowing

feedback from the staff on relevant courses attended and case studies.

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• Support for achieving the Mammography Certificate; Foundation, Intermediate and Advanced courses in MRI and CT; Advanced Imaging Anatomy certificate.

• Attendance at a range of Health and Safety courses, including Radiation Protection, MR safety and National and Patient Safety guidelines

• Participation and support in the Cancer networking groups • Participation and support of the radiographers in Research projects and specific MRI

breast coil development • Participation and presentation of papers, posters and Oncology lectures in multiple

national and international conferences • Continuation of annual RMH Radiographer lead Study days continues to support

development of radiographers both within the Trust and externally • There is mandatory training requirements for the radiology nurses in Interventional

courses and Advanced Life Support (ALS) courses- 5 radiology nurses in the middle of completion of these courses.

5.2.11 Non-clinical training and development – Learning & Development Department

Course Name/Category:

Q Quarter 4 2009-10

Quarter 3 2009-10

Quarter 2 2009-10

Quarter 1 2009-10

Year end 2009-10

Quarter 4 2008-09

A Year end2008-09

Personal Effectiveness

139 111(previously

reported 109)

83(previously

reported 74)

93 426 144 431

Management Development

142 50 48 64 304 63 325

*Counter Fraud Awareness

113 86 81 89 369 76 282

5.2.12 The end of year report identified that the Personal Effectiveness figures reported for

quarters 2 and 3 were incorrect, this is attributed to retrospective input. The above figures are now accurate for the year.

5.2.13 The Personal Effectiveness figures for Q4 include 27 staff that are currently

undertaking National Vocational Qualifications (NVQs) and two staff completed their NVQs during the year.

5.2.14 The Management Development figures are slightly down on the previous year.

However, the People Management Policy briefing sessions in Q3 are not reflected in the figures for the year. An additional 277 attendances are recorded for sessions held between October to November.

5.3 HUMAN RESOURCES (GOVERNANCE)

INDICATOR TARGET(%)

Q4 09/10 (%)

Consultants who have completed an annual appraisal and have an agreed Personal Development Plan

100 82

Junior doctors complying in full with the New Deal on Junior Doctors’ hours 100 100

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5.4 WORKFORCE INFORMATION

5.4.1 The Trust’s workforce is a major determinant of its performance and success. As the spend on the workforce accounts for approximately two-thirds of total Trust expenditure it is important that we understand some of the key performance indicators around this area and the Trust monitors performance against target for turnover, vacancy levels, sickness, and temporary staffing including agency spend as a percentage of pay.

5.4.2 Turnover measures the average number of leavers in a year and is expressed as a percentage of the average number of staff in post. High turnover can be costly in terms of replacement costs, however, some turnover is healthy and beneficial as it brings new blood and innovation into an organisation and enables change. An optimum level of turnover is considered to be 9% within the NHS. Vacancy levels measure the difference between the Trust’s budgeted establishment and staff in post and this measurement is important as high vacancy levels can lead to increased temporary staffing costs.

5.4.3 Human Resources Performance Indicators 2009/10

Trust Target

Quarter 1

Quarter 2

Quarter 3

Quarter 4

CORPORATE AND PRIVATE PRACTICE

Turnover 9% 12.4% 9.8% 9.3% 8.5%

Vacancies * 10% 15.4% 12.7% 11.7% 10.4% Sickness Absence <3% 2.9% 3.3% 3.4% 3.4%

Agency spend as % of total pay 7.5% 7.6% 10.6% 9.5% 8.3%

CANCER SERVICES

Turnover 9% 12.1% 9.6% 9.6% 8.8% Vacancies * 10% 16.8% 15.3% 14.4% 13.8%

Sickness Absence <3% 2.3% 2.5% 1.8% 2.3%


CLINICAL SERVICES

Turnover 9% 10.4% 10.2% 12.4% 12.1%

Vacancies * 10% 14.1% 14.8% 15.9% 14.1%

Sickness Absence <3% 2.2% 1.8% 2.0% 2.5%


Turnover 9% 11.5% 9.9% 10.7% 10.1%

Vacancies * 10% 15.2% 14.3% 14.1% 12.8% Sickness Absence <3% 2.4% 2.4% 2.3% 2.7%

Agency spend as % of total pay 7.5% 9.1% 10.1% 8.4% 7.8% * difference between budgeted establishment and staff in post

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5.4.4 While turnover and vacancy levels are above target for quarter 4 they have reduced since quarter 1 and are below the average level for the NHS in London. The Human Resources function are leading initiatives such as targeted recruitment campaigns with operational colleagues and modernisation of the recruitment service to support a further reduction in vacancy levels. Sickness absence is below target and also the average for the NHS. Considerable work is being undertaken to reduce the Trust’s spend on temporary staffing especially on agency staff both to ensure a reduction on spend but also to ensure high quality standards of care. In times of change it can be beneficial to employ temporary staff as it provides the organisation with flexibility and this is managed closely. Further information on temporary staffing will be detailed in future reports.

5.5 INFORMATION GOVERNANCE 5.5.1 As a key part of the Information Governance agenda, the Department of Health and

the NHS Connecting for Health jointly produced an Information Governance Toolkit. NHS organisations are required to submit a self assessment return via a web-based tool which must be evidenced and available for auditing on an annual basis.

5.5.2 The Toolkit has been made available to assist the Trust and other NHS organisations to achieve the aims of Information Governance, and currently encompasses:

• Information Governance Management • The Confidentiality NHS Code of Practice • Data Protection Act 1998 • Information Security • Information Quality • Records Management • Freedom of Information Act 2000

5.5.3 The Toolkit covers these areas as a set of six initiatives as follows:

• Information Governance Management • Confidentiality and Data Protection Assurance = Confidentiality NHS Code of

Practice and Data protection Act 1998 • Information Security assurance = Information Security Management NHS Code of

Practice • Clinical Information Assurance - Health Records Management and Records

Management NHS Code of Practice • Secondary Use Assurance = Information Quality and Payment By Results • Corporate Information Assurance = Freedom of Information Act 2000, Corporate

Records Management and Records Management NHS Code of Practice

5.5.4 The Toolkit also contains specific organisational views. It is the tool by which organisations can assess their compliance with current legislation, standards and national guidance.

34

5.5.5 The Trust submitted its final submission for 2009/2010 to NHS Connecting for Health as part of its commitment to the Information Governance Assurance Framework on 31 March 2010. The Trust achieved a positive score of 86% compliance, only a slight variation on its previous year’s score of 87%. The next baseline submission for 2010-2011 will be submitted in July 2010.

5.5.6 Comparison of Results between Version 6 and Version 7 The scores below are classified by using the ‘RAG’ (Red, Amber, Green) scoring system. Less than 40% equals Red, 40-69% equals Amber and 70% or over equals Green.

Initiatives Trust attainment level *

2008/2009 (Version 6) 2009/2010 (Version 7)

Information Governance Management 89% (green) 89% (green)

Confidentiality and Data Protection Assurance 87% (green) 83% (green)

Information Security Assurance 93% (green) 88% (green)

Clinical Iinformation Assurance 90% (green) 90% (green)

Secondary Use Assurance 76% (green) 79% (green)

Corporate Information Assurance 92% (green) 92% (green)

Overall results 87% (green) 86% (green)

* Please note percentages are approximations across each initiative. Some initiatives contain more standards than others and the overall results reflect attainment levels across each of the individual standards.

5.5.7 The Information Governance and Medical Records Committee is continuing to focus its attention on improving Information Governance Assurance Framework standards to ensure optimum compliance. Further work is underway which will provide such improvements.

5.5.8 Connecting for Health release a new version of the Toolkit each year and the variation in the Trust’s scores across both 2008/2009 and 2009/2010 does to a certain extent reflect the continuously changing requirements. For Version 8 of the Toolkit, evidence must be uploaded as part of the organisation’s submission and the quality of evidence submitted will be assessed as part of the annual internal audit process.

35

5.6 ACCESS TO HEALTH RECORDS

Standards:

Source Description

Data Protection Act 1998 Patients are given the right of access to and copies of their own medical records.

5.6.1. During the quarter, 24 requests (personal disclosure) for medical notes were received

by the Trust. This excludes notes required by other hospitals and those required for litigation purposes.

Requests for notes (personal disclosure)

0

5

10

15

20

25

30

35

Q1 09/10 Q2 09/10 Q3 09/10 Q4 09/10

Quarter

Num

ber o

f req

uest

s

5.7 FREEDOM OF INFORMATION (FOI) 5.7.1 The Freedom of Information Act 2000 (FOIA) gives the public a general right of

access to information held by public authorities. The Trust has a legal obligation to provide access to information it holds, and to respond to a request for information within 20 working days. This legal obligation is subject to a number of specified exemptions and certain practical and financial constraints.

5.7.2 The chart below (5.7.4) shows a comparative analysis between the number of requests received between January to March in 2008-09 and in 2009-10. The Trust received 43 requests in 2010 during the 4th quarter which compares to 49 in the corresponding quarter in 2009. During the quarter 98% of all requests were answered within 20 working days. Chart 5.7.8 below shows the trend over the last year.

5.7.3 The Trust received no complaints (internal reviews) under the Freedom of Information Act during this quarter.

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5.7.4 Comparative Analysis - 4th Quarter –Requests received under the Freedom of Information Act (2009 and 2010)

0

5

10

15

20

25

January February March

2010

2009

5.7.5 Source of requests The following table shows the source of requests based on the return address provided.

30%

23%19%

15%

9% 4% Commercial Organisations

Public

Press and Media

Research

Political Organisations

NHS/Public Sector

5.7.6 Reasons for refusal

The Trust used four statutory exemptions out of an available 23 exemptions to withhold requested information during the quarter. The trust applied the £450 cost limit on three occasions.

37

5.7.7 The cumulative number of exemptions applied during the quarter is illustrated in the graph below:

0

2

4

6

8

Cost Limit

Exemption - Section 40 - Personal information

Exemption - Section 36 - Prejudice to the Effective conduct of public affairs

Exemption - Section 21 - Accessible by other means

Exemption - Section 22 - Future publication

5.7.8 Number of requests received by the Royal Marsden NHS Foundation Trust

2009-2010

0

5

10

15

20

25

April May

June Ju

ly

Augu

st

Sept

embe

r

Octob

er

Nove

mber

Dece

mber

Janu

ary

Febr

uary

March

38

5.8 RESEARCH GOVERNANCE Part 1: Focus on the Research Governance Standards Focus: All research sponsors are required to have systems in place to ensure obtaining and documenting informed consent complies with the applicable regulatory requirements and should adhere to Good Clinical Practice (GCP) and to the ethical principles that have their origin in the Declaration of Helsinki. Standard fulfilled? Yes Systems in place Since last reporting on this requirement in July 2008, the informed consent process for clinical trials run at the Royal Marsden has been developed by the GCP Compliance Team through a programme of audit and monitoring of RMH/ICR sponsored and other hosted non-commercial drug trials. This programme of work is essential in demonstrating compliance with the Medicines for Human Use (Clinical Trials) Regulations and is an integral part of the corrective action plan agreed with the Medicines and Healthcare products Regulatory Agency (MHRA). The Trust first implemented a Standard Operating Procedure (SOP) in 2007 for obtaining and documenting informed consent in clinical trials at RMH/ICR. This SOP, gSOP-04-01, was updated in 2009 and outlines all of the key processes involved in preparing approvals for informed consent before a trial is opened and how to obtain informed consent from the trial subjects. In order to ensure the informed consent procedures adhere to the applicable regulatory requirements, the GCP team verifies through audit and monitoring functions:

• Committee for Clinical Research (CCR)/Research and Development (R&D) and Ethics have given written approval/favourable ethical opinion for all documentation and subsequent versions to be provided to the trial subjects (consent form and patient information sheet (PIS)).

• Blank copies of all versions of the consent form and PIS are filed in the Trial Master File/Investigator Site File

• The sponsor or investigator has delegated parts of the informed consent duties to appropriately trained and qualified members of the research team by reviewing staff CVs (GCP training with updates every 2-3 years), the study delegation log and staff signatures on consent forms

• All consent forms are present for all patients recruited on to the trial • Original copies of signed consent forms have been filed in the Investigator Site File,

consent boxes have been initialled by the subject and that the subject and consenting doctor have signed and dated on the same day (indicating an informed process took place). Copies of the signed consent form should be placed in the medical notes and a copy also given to the patient

• Details of the informed consent discussion have been noted down on the Hospital Information System (HIS) and patient medical records

• Version of the PIS has been noted on the consent form or a copy of the PIS has been attached to the consent form

• Patients have been re-consented if substantial changes have been made to the consent form/PIS

39

• Eligibility criteria have been met. The consent process is regularly monitored through the Research and Development (R&D) Audit and Monitoring programme. Any consenting issues are identified and where necessary, additional training is provided to staff. Continuing issues and those deemed critical are referred to the Audit Review Group for evaluation and consideration of further action.

40

Part 2: Research Sponsor RMH sponsorship: During the period January to March 2010 Trust sponsorship was awarded to the following 14 projects:

Project Ref Project Title Chief Investigator

Single/ Multi-sites

CCR3331 Clinical outcome following risk-reducing mastectomy and immediate breast reconstruction: A prospective study

Mr Gerald Gui Single site

CCR3403 Symptom profiles of children and young people receiving palliative care at CHASE Hospice and The Royal Marsden Hospital

Dr A K Anderson Multi sites

CCR3409 The OBAMMA study (Optimising Bile Acid Malabsorption Management and Assessment): a phase III, multi-centre, randomised, double blind, placebo controlled study of the efficacy and safety of colesevelam vs. placebo in the treatment of bile acid malabsorption/diarrhoea and to optimise the assessment of patients with bile acid malabsorption

Dr Jervoise Andreyev Multi sites

CCR3410 IGF-1R inhibition in the Treatment of RAS/RAF Mutant Advanced Colorectal Cancer: A Randomised Phase II study comparing FOLFIRI plus MK-0646 to FOLFIRI alone in patients with KRAS or BRAF mutant previously untreated advanced colorectal cancer (I-TRAC)

Prof David Cunningham Multi sites

CCR3411 The meaning and descriptions of vaginal symptoms and their relationship with quality of life among women previously treated for cervical cancer

Miss Anna Marie Stevens Single site

CCR3412 Olfactory Rehabilitation in Total Laryngectomy Patients Using Nasal Airflow-Inducing Manoeuver (NAIM)

Mr P Rhys Evans Single site

CCR3413 Molecular Markers Predicting Metastatic Potential in Oral Tongue Squamous Cell Carcinoma

Mr P Rhys Evans Single site

41

Project Ref Project Title Chief Investigator

Single/ Multi-sites

CCR3427 ART DECO- A randomised multicentre accelerated radiotherapy study of dose escalated intensity modulated radiotherapy vs standard dose intensity modulated radiotherapy in patients receiving treatment for locally advanced laryngeal and hypopharyngeal cancers

Dr Chris Nutting Multi site

CCR3428 Molecular studies of candidate prognostic and predictive biomarkers in small cell lung carcinoma of the lung

Dr Mary O’Brien Multi site

CCR3429 Measurement of circulating tumour angiogenesis related cells (CTAC) in children with solid tumours

Dr Stergios Zacharoulis Single site

CCR3430 A study to identify, explore and describe the key issues experienced by the carers of patients living with breakthrough cancer pain

Dr Andrew Davies Single site

CCR3431 The Experiences of New Consultants in Palliative Medicine Dr Andrew Davies Single site

CCR3433 Is reflexology as effective as aromatherapy massage for symptom relief in an outpatient oncology population?

Dr Clare Shaw Single site

CCR3434 The rehabilitation needs of people who have had an upper gastrointestinal or a gynaecological cancer

Dr Clare Shaw Single site

Part 3: Projects status During the period January to March 2010: • Thirty-eight new research projects were approved by the CCR which includes 18 projects

reviewed and approved via the expedited review process. • Two projects were re-submitted to CCR for re-review and approval.

42

Part 4: Suspected Adverse Events (SAEs) and Suspected Unexpected Serious Adverse Drug Reactions (SUSARs) Adverse events are defined as ‘any untoward medical occurrence in a subject to whom a medicinal product has been administered, including occurrences which are not necessarily caused by or related to that product’. The following is a breakdown by study of the seven SUSARs that occurred in the period January to March 2010. Of these, three require further monitoring and one required flagging to the Research Ethics Committee (REC).

Study code

Total number

of SUSARs

Number of follow-up reports

Number of SUSARs

which required

no further action

Number of SUSARS

which required further

monitoring

Number of SUSARs requring

flagging to a REC

IJ9 1 1 1

DD1 1 0 1

RM2 1 0 1

JB40 1 0 1

FD1 1 0 1

SK14 1 0 1

SK19 1 0 1

43

6 PATIENT FOCUS (standards for better health)

6.1 PATIENT COMMENTS RELATING TO CARE AND SERVICE PROVISION

Standards: Source Description Trust local Standard All complainants to receive:

• Personalised acknowledgement within 2 working days • A full response within 25 working days • Beyond 25 working days, regular/frequent progress reports • Information about their right to further redress if not satisfied

NHS Private Patients Grand Total Number % Number % Number %

Letters of complaint received 45 100 13 100 58 100 Complaints acknowledged within two days 41 91 10 77 51 88

Complaints receiving a response within 25 working days 23 51 8 62 31 53

6.1.1 Percentage of responses in 25 working days

6.1.2 NHS complaints categorised by primary care trust (PCT)

PCT Number Bedfordshire 1 Berkshire 2 City and Hackney 1 Croydon 4 Ealing 1 Eastern and Coastal Kent 2 Hammersmith and Fulham 1 Hastings and Rother 1 Kensington and Chelsea 4 Kingston 2 Lambeth 1 Medway 1 Norfolk 1 Peterborough 1 Richmond and Twickenham 3 South East Essex 1

0

20

40

60

80

100

Q1 09/10 Q2 09/10 Q3 09/10 Q4 09/10

Quarter

Res

pons

es (%

)

NHSPP

44

PCT Number Suffolk 1 Surrey 8 Sutton and Merton 1 Wandsworth 2 West Kent 1 West Sussex 3 Westminster 1 (patient not Known) 1 Total 45

6.1.3 Complaint Subject by Triage Level and Service Area (NHS and private patients) 6.1.4 From 1 April 2009 all concerns/complaints are triaged according to the nature of the

issues raised and the level of investigation required. 6.1.5 Each letter of complaint is categorised by the main subject of the complaint. A letter

of complaint may contain more than one subject and relate to more than one service area.

6.1.6 Triage Level 1 – those concerns/complaints resolved by Patient Advice and Liaison

Service (PALS) Officer and not requiring a written response. There were four concerns/complaints at level 1.

6.1.7 Triage Level 2 – those concerns/complaints resolved by Service Manager/Divisional

Director and not requiring a written response. There were two concerns/complaints at level 2.

6.1.8 Triage Level 3 – those concerns/complaints relating to clinical issues and/or requiring

a written response. There were 52 concerns/complaints at level 3 (see table below for details).

Service Area Ref. No. Initial Risk

Rating*

Date Received by Trust

Brief Description of Nature of Complaint

Action Taken and Lessons Learned as Result of Complaint

Breast n/178/09/10 Moderate 5.1.10 Concerns raised regarding treatment decisions

Awaiting confirmation of completed actions.

Breast n/184/09/10 Moderate 14.1.10 Concerns raised regarding surgery delays.

Offered outpatient appointment sooner, patient declined.

Breast n/192/09/10 Moderate 29.1.10 Concerns raised regarding standard of nursing care.

Change leadership on ward (completed February 2010). Monitor agency staff and team meetings to remind staff of the need to treat all patients with respect (completed February 2010). Recruitment of permanent staff (ongoing).

45


Rating*




Breast n/196/09/10 Moderate 1.2.10 Concerns raised regarding delay in diagnosis of secondary cancer


Breast n/198/09/10 Low 5.2.10 Concerns raised regarding standard of care.

Non-slip slippers to be provided for patients at risk of falls. Hoists to be kept on charge when not in use.

Breast n/209/09/10 Low 25.2.10 Concerns raised regarding standard of treatment and surgery delays.


Breast n/219/09/10 Low 15.3.10 Concerns raised regarding standard of nursing care


Critical Care Unit

p/226/09/10 Moderate 18.3.10 Concerns raised about serious complications following surgery

Review process on ward for appraising all staff of special diets and ensure ward hostesses attend ward handover meetings.

Day Surgery n/183/90/10 Moderate 13.1.10 Concerns raised regarding surgical procedure and lack of support.

Patient offered follow up consultation with consultant surgeon. Clinical team could have visited patient on the ward to address any concerns before being discharged.

Day Surgery n/201/09/10 Very low 10.2.10 Concerns raised about attitude of staff

Discussed with staff concerned. Confusion with admission date as a result of lack of communication and administration error. Staff member who spoke to the patient believed hospital procedure was being followed and has apologised for appearing abrupt.

Gastrointestinal n/180/09/10 Moderate 12.1.10 Concerns raised regarding standard of medical care


Gastrointestinal n/186/09/10 Low 12.1.10 Concerns raised regarding staff communication.

Recommended that patient changes their next of kin information, as complainant is not listed as such and no patient information will be given to him. (Immediate, January 2010)

Gastrointestinal n/194/09/10 Low 29.1.10 Concerns raised regarding attitude of staff on Ellis ward, CCU and MDU


Gastrointestinal n/220/09/10 Moderate 12.3.10 Concerns raised regarding standard of care


Gastrointestinal n/231/09/10 Moderate 29.3.10 Concerns raised regarding infection control.


Genetics n/174/09/10 Very low 4.1.10 Concerns raised regarding letters being copied to General Practitioner, against patient's wishes.

General Practitioner’s surgery contacted and requested for copies of letters sent in error to be returned as soon as possible and for electronic copies of letters to be destroyed. Genetics Team has apologised to patient and has now annotated the electronic patient record to indicate that in future, any correspondence sent to patient should not be copied to General Practitioner.

Genetics n/213/09/10 Low 1.3.10 Concerns raised regarding appointment delays.

Lead Rapid Diagnostic and Assessment Centre receptionist to alert clinical staff if patients raise issues regarding time restrictions.

46


Rating*




Granard House Outpatients

p/229/09/10 Low 24.3.1.0 Concerns raised regarding lack of information regarding clinic location

New clinic timetables issued to reception staff. - Phone number highlighted for queries. - Signage to be improved in lobby regarding Wiltshaw Ward. - Friends of the Royal Marsden volunteers to provide directions where possible.

Gynaecology n/223/09/10 Low 16.3.10 Concerns raised regarding standard of nursing care


Head and Neck n/203/09/10 Low 10.2.10 Concerns raised about attitude of staff when discussing treatment options.

To encourage the patient to seek urgent second opinion and treatment as there is malignant tumour present.

Lung n/190/09/10 Low 25.1.10 Concerns raised regarding attitude of staff.

Member of staff to attend additional communication skills training and will further reflect on the impact that her interaction with patients and their families has on them. Completed February 2010.

Medical Day Unit

n/228/09/10 Low 24.3.1.0 Concerns raised regarding spillage of hot tea and attitude of staff


Medical Records

n/210/09/10 Low 25.2.10 Concerns raised regarding missing medical notes.

Missing notes procedure is in place and was followed by medical records. Need to reinforce importance of informing Medical Records office when notes are moved from the original location that they were tracked out to.

Neuro-oncology

n/193/09/10 Low 29.1.10 Concerns raised regarding slow response of doctor to telephone enquiry

Complaint withdrawn.

Nuclear Medicine

n/200/09/10 Low 10.2.10 Concerns raised about general environment of Positron Emission Tomography and Computed Tomography Laboratory.

Incident investigated with Nuclear Medicine. Technologist responsible for patient was aware that there had been an issue and accepted the patient’s comments without question. All aspects of patient’s concerns were discussed in staff meeting along with review of current procedures and ways to ensure that this does not happen again.

Nursing p/216/09/10 Moderate 11.3.10 Concerns raised regarding standard of nursing care in Granard House


Nursing n/217/09/10 Low 11.3.10 Concerns raised regarding the handling of an emergency out of hours telephone call.

Audit all emergency admissions and of plan of care.

Outpatients n/211/09/10 Low 25.2.10 Concerns raised regarding late running clinics.

Incident form completed for absence of consultant without notification and late running of clinic with only Registrar present. Request to Service Manager to remind clinical team of importance of notifying of absence in advance of clinic.

Pharmacy n/181/09/10 Low 13.1.10 Concerns raised regarding Pharmacy delays.

Better communication about outpatient clinic numbers required to allow pharmacy to plan workload. Pathway and process review required.

47


Rating*




Pharmacy n/187/09/10 Very low 15.1.10 Concerns raised regarding Pharmacy delays.

Review staff assigned to cover when regular staff are away from the outpatients desk Ensure they have appropriate knowledge and skills. Emphasise that if away for longer than expected that this is communicated to the relevant manager.

Pharmacy n/191/09/10 Moderate 26.1.10 Concerns raised regarding Pharmacy delays and mislabelled drugs.

Pharmacy team continuing to reassesses the processes for efficiency. Changes to labels made for 10mg dose bottle. In discussions with pharmacy companies and also piloting oral chemotherapy diary.

Pharmacy p/208/09/10 Low 24.2.10 Concerns raised regarding dispensing errors.

Incident discussed with Pharmacy staff and reminded to ask patients who are given pre-printed prescriptions if they already have supplies at home. Issue of correct procedure for amending prescriptions has been highlighted to the Prescriber concerned

Pharmacy p/214/09/10 Low 9.3.10 Concerns raised regarding a prescribed drug not dispensed from pharmacy

No further action.

Pharmacy n/227/09/10 Low 9.3.10 Concerns raised regarding pharmacy delays.


Pharmacy n/221/09/10 Low 16.3.10 Concerns raised regarding chemotherapy waiting times

Continue to monitor waiting times performance through the Medical Day Unit steering group

Private Patients p/179/09/10 Very low 11.1.10 Concerns raised regarding written communication

No further action.

Private patients p/188/09/10 Very low 19.1.10 Concerns raised regarding lack of private bed availability.


Private Patients p/195/09/10 Low 1.2.10 Concerns raised regarding attitude of a member of staff

Medical staff to be encouraged to attend advanced communication training course.

Private Patients p/206/09/10 Low 16.2.10 Concerns raised regarding standard of care.


Rapid Diagnostic and Assessment Centre

n/176/09/10 Low 5.1.10 Concerns raised regarding communication between Electrocardiography department and Medical Day Unit.

Resident doctor to co-ordinate obtaining results. Medical secretary reminded of importance of prompt reporting.

48


Rating*




Rehabilitation n/182/09/10 Low 13.1.10 Concerns raised regarding attitude of staff.

The patient information leaflet clearly states that we provide a list of suppliers and do not recommend one particular supplier. This was not evident in this case. This issue has been highlighted to the Head of Occupational Therapy, the Hairdresser and the Appliance Officer who will ensure that in future, patients are provided with a list of suppliers to give them a greater choice. Written procedure is now being developed for the provision of other suppliers’ details to ensure consistency in service provision. Staff have also been asked to ensure that if a patient is provided with alternative details, this interaction should be clearly documented. A written list of suppliers and alternative sources of wigs that clearly outlines the patient/ supplier responsibility and the responsibility of The Royal Marsden hospital is being produced and will be provided to patients in future

Robert Tiffany n/189/09/10 Low 21.1.10 Concerns raised regarding attitude of staff.

Staff member reminded of need to ensure empathy and care at all times.

Robert Tiffany p/232/09/10 Low 23.2.10 Concerns raised regarding cystogram procedure and physiotherapy charges.


Robert Tiffany p/222/09/10 Moderate 10.3.10 Concerns raised regarding nursing intravenous procedure.


Sarcoma n/204/09/10 Low 10.2.10 Concerns raised about attitude of staff during consultation


Telecoms n/199/09/10 Low 8.2.10 Concerns raised regarding bedside telephone charges for incoming calls from outside United Kingdom.

No further action

Transitional Care Unit

n/177/09/10 Low 5.1.10 Concerns raised regarding standard of care during overnight stay.

Windows have been sealed and additional heaters placed. Facilities to ascertain whether windows need replacing. Patient advised to speak to nurse on arrival regarding appropriate food during next treatment.

Transport n/175/09/10 Low 4.1.10 Concerns raised regarding carer's eligibility for transport.

Patient to contact transport team if she feels she requires an escort and her request will be reviewed by the Transport team for each journey.

Transport n/202/09/10 Low 9.2.10 Concerns raised regarding transport delays and communication.

Delivery company to remind staff not to discuss issues over sickness or workload with patients. RMH transport staff reminded of the importance of effective communication with patients and to inform patients if long delays are expected and update them of progress regularly. Transport staff informed to seek further clarification from wards/ departments if the mobility or transport requirements are not clear.

49


Rating*




Transport n/212/09/10 Low 26.2.10 Concerns raised regarding carer’s eligibility for transport.

Transport Team leader telephoned patient to discuss complaint. Further information was obtained from patient which indicated that they were eligible to have an escort travel with then on hospital transport. This information was not initially given by the patient when they were first assessed by transport in January. Patient advised that they are now eligible and to contact transport on the 14 March to arrange booking for next appointmentt on 14 April.

Transport n/230/09/10 Low 25.3.10 Concerns raised regarding transport organisation


Transport and Radiotherapy

n/205/09/10 Low 15.2.10 Concerns raised regarding transport eligibility and radiotherapy side effects.

Complaint withdrawn.

Urology n/224/09/10 Low 16.3.1.0 Concerns raised regarding inadequate information and surgery delays.


Wiltshaw p/225/09/10 Moderate 18.3.10 Concerns raised regarding standard of nursing care.


The prefix n in the complaint number denotes an NHS complaint, p, a private patient complaint.

* Initial Risk Rating - the risk rating for a complaint may change following further investigation. 6.1.9 Complaints by risk rating

Triage Level 1 Triage Level 2 Triage Level 3

Risk Rating Number NHS

Number PP

Number NHS

Number PP

Number NHS

Number PP

Total

Very low 1 8 3 12 Low 4 1 25 6 36 Moderate 7 3 10 High

Total 4 0 1 1 40 12 58

Potential Severity Consequence Insignificant minor moderate major catastrophic

Likelihood 1 2 3 4 5Almost Certain 5 yellow yellow orange red red

Likely 4 yellow yellow orange red redPossible 3 green yellow orange red redUnlikely 2 green green yellow orange redRare 1 green green yellow orange red

50

6.1.10 Complaints by division

0

2

4

6

8

10

12

14

16

18

20

Cancer Services Division Corporate Services and PrivatePractice

Clinical Services Division

Num

ber o

f com

plai

nts

Very lowLowModerateHigh

6.1.11 Complaints by subject

0

1

2

3

4

5

6

7

8

Cancer Services Division Corporate Services and PrivatePractice

Clinical Services Division

Num

ber o

f com

plai

nts

Administration

Attitude of staff

Hospital charges

Clinical care

Communication issues

Delays receivingappointment/treatment

Diet and nutrition

Expenses incurred

Nursing care

Prescribing issues

Privacy

General transportation, comfort,delays

51

6.1.12 Complaints by subject by ward/department

0

1

2

3

4

5

6

All loc

ation

s

Burdett

Cou

tts

Sutton

car p

ark

Critica

l Care

Day Surg

ery

Electro

cardi

ograp

hy Ellis

Granard

Hou

se

Intrav

enou

s

Kenna

way

Markus

Medica

l Day

Unit

Medica

l Rec

ords

Outside

hosp

ital g

round

sOthe

r

Nuclea

r Med

icine

Outpati

ents

Pharm

acy

Rapid

Diagno

stic a

nd A

sses

smen

t Cen

tre

Physio

therap

y

PP Outp

atien

ts

Rehab

ilitatio

n Serv

ices

Robert

Tiffany

Transit

ional

Care U

nit

Transp

ort

Wiltsha

w

Administration

Attitude of staff

Hospital charges

Clinical care

Communication issues

Delays receivingappointment/treatment

Diet and nutrition

Expenses incurred

Nursing care

Prescribing issues

Privacy

General transportation,comfort, delays

6.2 LETTERS OF PRAISE 6.2.1 Staff are encouraged to send any letters of praise they receive to the Head of Patient

Advice and Liaison Services (PALS), Patient Information and Complaints, for noting in this report and also to help identify any members of staff to whom personal thanks for their work can be given by the Chief Executive.

6.2.2 In this quarter, 276 letters of praise were received by the Head of PALS, Patient

Information and Complaints. 6.2.3 Some examples of the comments made in the letters of praise:

To the Radiotherapy Department:

“I greatly feel so lucky at being cared by such a lovely, caring and reassuring team, ready to help at all times…there’s no lie in the Royal Marsden advertisement that “We are not afraid of….” Well done guys. “You made me feel like a human being, I could not ask for more. You have all been wonderful.” To the porters:

“This is to say thank you for looking after me and wheeling me down that long corridor, I would never have made it on my own”

52

To the consultant:

“I am fully aware that you and your team have done your upmost to help me through my cancer journey and have gone out of your way for me to receive the best treatment available. I once told you that I have faith in the drugs you give us, but to see you is like the ‘placebo effect’, Thank you.”

6.3 FOOD AND NUTRITION 6.3.1 Nutrition

• An audit of Protected Mealtimes on the wards indicated that 91% of inpatients found the ward atmosphere pleasant, relaxed and conducive to eating meals.

• 76% of patients had not experienced interruptions at lunchtime and 90% of patients had not experienced interruptions at supper time. It was acknowledged that some interruptions were essential for patient care.

• An audit of nutrition screening showed that 79% of all patients undergo nutritional screening within 24 hours of admission.

6.3.2 Catering

Tom Aitken, celebrity chef, opened the new Mulberry Tree Refectory and tasty samples of Tom’s recipe were distributed to staff.

• New menus developed by catering with a trial of dishes with hospital staff. • The new Arabic menu has been developed in association with the Arabic

advocates. • The Catering Department has been awarded The British Pork Award from

Sustain presented by Rosie Boycott, Chair of London Food at The London Assembly.

• Monthly monitoring report including patient satisfaction. Average figures indicate that of the patients surveyed 72% in Chelsea and 95% in Sutton rate the food as excellent or good.

• Continued monitoring of patient food is undertaken by a joint group with representation from catering, nursing and dietetics.

• Ward catering hostesses have received additional training to undertake preparation of ward cocktails on a daily basis (Chelsea).

6.4 PATIENT INFORMATION 6.4.1 A total of 34 publications have been produced and reviewed this quarter.

Information type New title New edition Revision Total

Booklets 1 1 2 Factsheets 17 15 32 Total 18 1 15 34

53

6.5 INTERPRETING SERVICES 6.5.1 Since 1 April 2010 the trust has been using a single provider for face-to-face, written

and telephone translation in order to enhance the service for both patients and staff. 6.52 There were 40 requests for the face-to-face translation service this quarter.

Language Number of requests

Spanish 1 Arabic 4 Urdu 3 Portuguese 6 Nepalese 3 Farsi 1 Tigrinya 3 Russian 3 Tamil 3 Latvian 1 Mandarin 1 Greek 3 Polish 2 Kosovan 1 Romanian 1 Gujerati 1 South Korean 1 British Sign Language 2

Total 40

54

7 ACCESSIBLE AND RESPONSIVE CARE (standards for better health)

7.1 ACCESS TIMES Access times are shown in the Performance Indicator Summary on page 8.

7.2 CANCELLED OPERATIONS

Cancelled operations are shown in the Performance Indicator Summary on page 8. 7.3 DELAYED TRANSFERS OF CARE

7.3.1 Definition of a delayed transfer of care: Patients who no longer need clinical care in a comprehensive cancer centre, but who stay in the Hospital because of delayed or lack of appropriate community/social care services, or internal failures to plan the discharge appropriately.

7.3.2 There was one delayed transfer of care in Chelsea and there were none in Sutton. 7.4 MIDNIGHT BED STATUS AND OCCUPANCY: ALL WARDS SUMMARY

TOTAL OCCUPIED + RESERVED

WARD (EXCLUDING DAY UNITS

UN

OC

CU

PIED

OC

CU

PIED

RESER

VED

TO

TA

L O

CC

UPIE

D +

RE

SER

VE

D

NHS PP

Occupied / R

eserved as a % of

Total Available

TO

TA

L A

VA

ILA

BL

E

BE

DN

IGH

TS

UN

AV

AILA

BLE

Unavailable and reserved as a

% of Total beds/nights in the

month

Grand Total

Total beds/nights divided by days in m

onth = number of

beds in ward

BURDETT COUTTS

169 1,174 5 1,179 1,107 72 87.46% 1,348 2 0.52% 1,350 15

ELLIS 156 1,456 4 1,460 1,413 47 90.35% 1,616 4 0.49% 1,620 18

GRANARD HOUSE PP 14 0 0.00% 14 1,336 98.96% 1,350 15

HORDER 0 0.00% 0 1,170 100.00% 1,170 13

MARKUS 88 816 816 574 242 90.27% 904 86 8.69% 990 11

WILSON 174 1,239 8 1,247 1,163 84 87.76% 1,421 19 1.88% 1,440 16

WILTSHAW 125 1,445 1,445 644 801 92.04% 1,570 50 3.09% 1,620 18 CHELSEA - GENERAL WARDS 726 6,130 17 6,147 4,901 1,246 89.44% 6,873 2,667 28.13% 9,540 106

BUD FLANAGAN EAST 75 1,324 22 1,346 1,148 198 94.72% 1,421 19 2.85% 1,440 16

BUD FLANAGAN WEST 185 1,207 13 1,220 1,186 34 86.83% 1,405 395 22.67% 1,800 20

CHEVALLIER 326 782 782 739 43 70.58% 1,108 62 5.30% 1,170 13

KENNAWAY 429 1,536 5 1,541 1,530 11 78.22% 1,970 95 4.84% 2,065 23

McELWAIN WARD 462 1,161 14 1,175 1,048 127 71.78% 1,637 23 2.23% 1,660 18

OAK 145 314 314 311 3 68.41% 459 441 49.00% 900 10

ROBERT TIFFANY 291 854 1 855 102 753 74.61% 1,146 24 2.14% 1,170 13

SMITHERS 580 1,320 1,320 1,294 26 69.47% 1,900 170 8.21% 2,070 23 SUTTON - GENERAL WARDS 2,493 8,498 55 8,553 7,358 1,195 77.43% 11,046 1,229 10.46% 12,275 136

TOTAL FOR GENERAL WARDS 3,219 14,628 72 14,700 12,259 2,441 82.04% 17,919 3,896 18.19% 21,815 242

PLEASE NOTE Six beds in Bud Flanagan West are not "actual" beds. They exist on the Bed Board (ward layout for flexibility in recording bed occupancy in Bud Flanagan West, where bed bays frequently change to accommodate 2, 3 or 4 beds

55

7.5 INTERNAL TARGETS

7.5.1 In-clinic waiting times Standard: At the outpatient clinic 90% of patients should be seen within 30 minutes of appointment time.

INDICATOR Q4 09/10

Q3 09/10

Q2 09/10

Q1 09/10

Total number of patients seen in all OP clinics in quarter 34,444 34,217 34,841 33,715

Number seen in 30 minutes or less 27,509 27,001 27,353 25,680

Seen in 30 minutes or less (%) 79.9 78.9 78.5 76.2

Number seen after 30 minutes and up to 1 hour 5,107 5,276 5,422 5,566

Seen after 30 minutes and up to 1 hour (%) 14.8 15.4 15.6 16.5

Number seen in more than 1 hour 1,828 1,940 2,066 2,469

Seen in more than 1 hour (%) 5.3 3.7 5.9 7.3

Size of monitoring sample: NHS patients included in the computerised booking system (excluding Bud Flanagan outpatients and invalid records) including the clinic types: consultant, nurse and Professions Allied to Medicine e.g. physiotherapy.

Waiting times in outpatient departments(target 90%)

0

10

20

30

40

50

60

70

80

90

100

Q1 09/10 Q2 09/10 Q3 09/10 Q4 09/10Quarter

% o

f pat

ient

s se

en w

ithin

30

min

utes

56

7.5.2 Cancelled consultant clinic sessions

Clinics cancelled less than 15 days before the planned date

0

1

2

3

4

Q1 09/10 Q2 09/10 Q3 09/10 Q4 09/10

Quarter

% c

linic

s NHS

PP

NHS PP Total

Comments/reason Number Affected appointments Number Affected

appointments Number Affected appointments

Clinic day changed 6 65 6 65 Doctor attending conference 1 1 1 1 Doctor attending meeting 12 44 5 22 17 66 Doctor on annual leave 7 34 9 28 16 62 Doctor on study leave 1 5 1 5 Staff sick leave 2 59 2 59 Unexpected emergency 7 56 1 1 8 57

Total 35 259 16 56 51 315

7.6 AVAILABILITY OF MEDICAL NOTES IN OUTPATIENTS CLINICS7.6.1 An audit based on one week’s worth of clinics was undertaken at the Chelsea site of

the Trust. Of a total of 717 expected patients, notes for 659 patients were available (92%).

7.6.2 Results from audits in Chelsea and Sutton will be presented in alternate quarters.

7.7 QUALITY SYSTEMS

The 6-monthly continuing assessment against BSI ISO9001:2008 was carried out by an assessor from the British Standards Institution (BSI) in March 2010 and registration was successfully renewed for both Radiotherapy and Chemotherapy Services.

7.8 RADIOTHERAPY 7.8.1 The Quality Assurance in Radiotherapy Committee (QART) met twice during the

period. The committee is chaired by the Radiotherapy Services Manager The meeting follows a standard agenda format including revision of documentation, audit, patient feedback, non-conformities, permits, concessions, risk management, authorisation of doctors to prescribe radiotherapy treatment, waiting times and resource availability. Other subjects discussed have been the progress with the use of “in vivo dosimetry” for radiotherapy treatments, the forthcoming Radiotherapy Peer Review cycle, the implementation of the national R-PORT radiotherapy capacity management software,

57

a revised induction programme for Specialist Registrars and the use of a new coding system for non-conformance/incident reporting.

7.8.2 The scheduled programme of audits is proceeding well. Seven audits were completed in the period and fifteen corrective action requests raised. The majority of the actions relate to document updates and withdrawals to take into account change in practice and revision of procedures, as well as reminders to staff on correct procedures.

7.8.3 A total of nine non-conformances (incidents) were raised in the quarter compared with nine in the previous quarter. Non-conformances are now coded using the Towards Radiotherapy Classification System which allows comparable reporting across the industry. Five were rated as minor radiation incidents, three were rated as near misses, and one was rated as “other” non-conformance. Trend analysis is undertaken regularly and preventive action implemented based on this information.

7.8.4 The Quality Assurance Team undertook a patient experience survey of patients currently undergoing radiotherapy on both sites during February 2010, the results of which will be reported back in May 2010.

7.8.5 The next BSI assessment is due to take place on 6 and 7 September 2010 at both sites. The assessor will be visiting the workshops and brachytherapy at Chelsea, Physics quality assurance and calibration of equipment and Pre-Treatment at Sutton as well as the standard assessment of the quality management system.

7.8.6 Since April 2005, all radiotherapy waiting times for both palliative and radical treatment have been within the 14 day and 28 day target (as set out in the Manual of Cancer Standards) respectively. The graphs below show the continued trends in waiting times. Average waiting times for radical treatment rose slightly in the last two months of the year while palliative treatment has remained consistent for a long period of time.

Average Radiotherapy Waiting Times - Sutton

0

2

4

6

8

10

12

14

16

18

20

Mar-09

Apr-09 May-09

Jun-09 Jul-09 Aug-09

Sep-09

Oct-09 Nov-09 Dec-09

Jan-10 Feb-10

Mar-10

Ave

rage

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Average Radiotherapy Waiting Times - Chelsea

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7.8.7 The number of appointments has increased slightly over the year with between 350 and 450 appointments taking place over both sites each month. The graph below shows the number of radical, palliative, urgent and total number of appointments.

Total number of appointments - Chelsea & Sutton

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7.9 CHEMOTHERAPY 7.9.1 The ISO Chemotherapy Committee, co-chaired by the Nurse Consultant (IV Therapy)

and the Chief Pharmacist met twice during the period and was attended by multi-disciplinary staff representing clinical delivery and support units as well as medical staff. The meeting follows a standard agenda format including results from audit, patient feedback, report back from other related meetings, risk management and incident reporting, waiting times and resource availability. Other items under discussion were the Chemotherapy Peer Review measures, changes to the chemo-

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embolisation service at the Trust, the implementation of the national C-PORT Chemotherapy capacity management software.

7.9.2 Incidents are reported in accordance with the Trust’s policy, and the Datix Incident Reporting System is used to analyse those incidents relating to chemotherapy services. There were 38 chemotherapy related incidents reported in the period January to March 2010 and as a percentage of the total chemotherapy administered during the quarter this equates to 0.15%. In accordance with the Trust policy actions are agreed to ensure lessons are learned following any incident.

7.9.3 The two year rolling audit schedule for Chemotherapy Services is proceeding well and a number of audits have been carried out. Corrective actions raised are discussed at the time and are monitored by the Quality Manager.

7.9.4 At the March BSI assessment the assessor visited the Private Patients Day Units at Chelsea and Robert Tiffany Day Unit and In-patients Ward at Sutton, the Equipment Library at Sutton and the Infection Control team. The report was positive but the assessor did raise six minor-nonconformities. An action plan was produced and the issues have already been resolved and closed. The next BSI assessment is due to take place on 8 September 2010 and the assessor will be returning to the Sir William Rous unit at Kingston and visiting Pharmacy at Chelsea, as well as the standard assessment of the quality management system.

7.9.5 Waiting times for receipt of chemotherapy on the day of administration were still the most frequently raised area of concern with patients. The graph below shows the 5 hour waiting time figures for each treatment unit. The target set by the Patient and Carer Advisory Group (PCAG) was that only 5% of patients should wait over five hours for their treatment.

7.9.6 The graph below shows the median waiting times in minutes for the all treatment units. All areas have shown a slight rise over the last three months and the IV Team at Sutton has been relatively high for some time. The Quality Manager is investigating the reasons for this and will report her findings to the ISO Chemotherapy Committee. Figures for Oak unit continue to fluctuate, but this is the area where most clinical trial regimens are administered and longer waits are to be expected.

7.9.7 The number of patients over all three sites treated in March 2010 was 2,330.

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Patients treated outside of 5 hour target by Treatment Unit

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Children's Day Unit Oak Unit Kingston

7.9.8 The graph below shows the percentage of patients treated outside the 5 hour target by clinical unit. The Drug Development Unit figures are generally high as the clinical trial regimens frequently take a long time to make and administer and the number of patients is low, giving a high percentage. Paediatrics has the lowest median waiting time of any of the units, which can be attributed to the high percentage of pre-prescribing for paediatric cases. Gastrointestinal (GI) and Lung unit waiting times have been rising slightly since September, while all other units fell or remained stable.

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7.9.9 The graph below shows that the number of chemotherapy appointments is rising overall and on all three sites.

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IV Chemotherapy Administration Total Appointments

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7.10 HUMAN TISSUE AUTHORITY (HTA) LICENCE COVERING HUMAN

APPLICATION

7.10.1 The Haematopoietic Stem Cell Transplant facility continues to adhere to HTA regulations governing procurement, processing, testing, storage, distribution and import/export of stem cells for therapeutic use. This ensures that high standards of quality and safety in the service provided.

7.10.2 The HTA requires a documented system of quality management and audit. As part of the ongoing quality improvement plan, the clinical and laboratory elements of the transplant programme have been working closely to implement improvements. This has included auditing of key practices and procedures such as critical aspects of stem cell collection and monitoring feedback from episodes of stem cell infusion.

7.10.3 It is an HTA regulatory requirement that staff are appropriately qualified and trained in techniques relevant to their work and are continuously updating their skills. The Stem Cell Laboratory operates an ongoing review of all documents, policies and standard operating procedures (SOPs). During this quarter, a complete revision of all SOPs has been undertaken with team involvement to ensure consistency of practice.

7.10.4 The unit collates, evaluates and investigates errors, accidents and incidents according to Trust’s protocol but must also report serious adverse events and reactions via the HTA reporting system. In this quarter two incidents have been reported.

7.10.5 The HTA regulates the standards of facilities and premises to ensure that they are fit for purpose. The processing unit has benefited from refurbishment of the flooring which has brought the facility up to standard in terms of Health and Safety for operators.

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7.11 ETHNIC DATA CAPTURE Ethnic minority data - summary of new registrations by Trust categories

Ethnic origin NHS PP/ Overseas Total

Asian Bangladeshi 7 1 8 Asian Indian 64 10 74 Asian Pakistani 22 5 27 Asian (other) 58 8 66 Black African 53 10 63 Black Caribbean 52 52 Black (other) 26 3 29 Chinese 13 1 14 Mixed White and Asian 3 1 4 Mixed White and Black African 5 2 7 Mixed White and Black Caribbean 9 1 10 Mixed (other) 17 1 18 White British 1,889 258 2,147 White Irish 42 11 53 White (other) 240 73 313 Other 34 66 100 Not disclosed 64 37 101

Total 2,598 488 3,086 Ethnic origin information completed* 2,534 451 2,985 Ethnic origin information completed* (%) 97.5% 92.4% 96.7% *(All values except “Not disclosed”)

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7.12 PATIENT AND PUBLIC INVOLVEMENT 7.12.1 Patient and Carer Advisory Group (PCAG) 7.12.2 Representatives of PCAG work with the Trust on a number of projects and

committees including: • Patient Advice and Liaison Service/Patient Information Officer - interview. A

representative was part of the interview panel for a Patient Advice and Liaison Service team post.

• Customer Service Excellence steering group. Two PCAG members are part of the steering group for the Customer Service Excellence standard. The representatives are identifying examples of patient comments and resultant Trust actions for highlighting in local areas of the Trust

• Patient Environment Action Team. Two members joined the Trust’s team to assess the Trust’s patient environment including food, décor and cleanliness at Sutton and Chelsea over two days in January 2010. Both sites were rated very highly.

• Patient’s and Rapid Diagnostic and Assessment Centres guides – ordering of content. Members were consulted about the ordering of the content in the revised patient guides for the Trust and Rapid Diagnostic and Assessment Centres.

• Equality and Diversity Committee. A PCAG member and a Membership Councillor are the lay representatives on this committee.

• RM magazine. There are dedicated pages in the new Trust magazine which carry news and stories suggested by the group. Two members liaise with the Trust’s Marketing and Communication Team about magazine content

• Peer review internal validation process. Members of the group work with staff to ensure that the self assessment of services against national measures has been carried out accurately

• Freedom of Information Act – website pages. Members commented on the content of the Trust website pages about how to request information under the arrangements of the Freedom of Information Act

7.12.3 The group’s Listening Post continued to be held monthly in patient waiting areas.

This ‘stall’ is manned by representatives of PCAG who collect informally the comments and observations of patients and their families. This information is used to highlight areas to the Trust where it is performing well or where it could do better.

7.13 SERVICE DEVELOPMENTS 7.14.1 Hospital2Home

This project continues for all palliative care patients at The Royal Marsden. It has led to over 150 people being supported within the model to die in their preferred place of choice. A brochure explaining the service has been produced and this has been sent to general practices and to community healthcare providers. The brochure will also be available at the Trust for patients and relatives to read. Data is being collected prospectively to understand the impact this service has and to ensure that it is meeting the needs of all patients. The project and a detailed audit of its work to date was formally launched in September 2008 by Professor Lord Darzi. It has subsequently been supported by NHS London and a number of high profile health bodies as an

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example of good practice. The service has been generously supported by the Royal Marsden Cancer Campaign for another three years and is now being rolled out across the NHS as a national pilot scheme.

7.14.2 Same-day admission for surgery The same-day admissions system is working well across both sites. Bed management, admissions and operating theatre scheduling are all being managed by a central team to improve utilisation and avoid cancellations. Same day admission is now 58% at Chelsea and 80% at Sutton, a significant increase against performance two years ago of 12.2% and 14.4% (respectively). The average length of stay across the Trust has fallen since the fire of 2 January 2008. The average length of stay for both elective and non elective patients is now 5.6 days as opposed to 6.5 days for the same period two years ago. Further work is underway to improve this position and to improve the overall quality of patient experience.

7.14.3 Joint working with Network Trusts A number of key developments are underway with other local providers with the intention of ensuring the highest level of local on-site support at The Royal Marsden. An on-site diabetology service is now being provided by Chelsea and Westminster Hospital NHS Foundation Trust along with a dermatology and urology diagnostic service through the Chelsea Rapid Diagnostic and Assessment Centre (RDAC). At Sutton a number of initiatives are underway linked to the provision of primary care skin cancer with colleagues from the Epsom and St Helier University Hospitals NHS Trust. The Royal Marsden now manages all palliative care patients at The Royal Brompton Hospital in a partnership which is proving very successful.

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8 CARE ENVIRONMENT AND AMENITIES (standards for better health) HEALTH AND SAFETY (Board) 8.1 RISK ASSESSMENTS – TRUST RISK REGISTER 8.1.1 The Trust risk register contains risks that score above 12. This continues to be

reviewed and updated on a quarterly basis. 8.1.2 All risks that score 12 and above remain on the divisional registers and those whose

scores have been reduced through preventative action have been removed. 8.1.3 Departmental risk assessments, incident reports and other areas that identify

significant risks are added as new risks. 8.2 PATIENT ENVIRONMENT ACTION TEAM (PEAT) INSPECTION 8.2.1 There is a requirement for every NHS organisation to conduct an annual PEAT

inspection of its clinical and public areas and to score its patient environment across a range of criteria, including: general cleanliness, toilet and bathroom cleanliness, infection control, general environment, access, external areas, food and food service, and privacy and dignity.

8.2.2 The annual return has to be submitted to the National Patient Safety Agency (NPSA),

who oversee the process. This is a very important assessment for hospitals because the quality of the patient environment makes a real difference to the experience of care. The assessment results are also used by the Care Quality Commission (CQC) in their annual health check and registration assessment.

8.2.3 The Trust conducted its PEAT inspections on Thursday 21 January in Chelsea and

Monday 25 January in Sutton. The PEAT team is required to consist of senior Trust managers and patient representatives. Our PEAT inspections were facilitated by the Head of Facilities but led by the Chief Nurse, and included various senior managers and two patient representatives from the Trust's Patient and Carer Advisory Group (PCAG). The Chelsea PEAT inspection also included an independent validator allocated by the NPSA.

8.2.4 The January PEAT self-assessments resulted in a score of "excellent" for both sites.

This is consistent with previous years (last year the scores were also "excellent"). 8.2.5 The NPSA normally writes to NHS Chief Executives in June each year to ratify that

year’s scores, and the national results are published in July.

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9 PUBLIC HEALTH (standards for better health) 9.1 PARTNERSHIP WORKING

9.1.1 Since May 2009 the Trust has been working alongside the Royal Brompton NHS

Foundation Trust (London site) by providing palliative care support. This service has now been formalised and the Trust now provides a Palliative Care service to the Royal Brompton NHS Foundation Trust (London site). This includes a medical consultant, specialist sister and nurse consultant. Currently policies and referral forms are being formalised. Patients are referred via a bleep system and telephone answer system. In this quarter 50 new referrals at the Royal Brompton have been seen by the Royal Marsden Palliative care team from January to March 2010.

9.1.2 The Trust’s Patient and Carer Advisory Group (PCAG) discussed with the Sutton Local Involvement Network (LINk), the Kensington and Chelsea LINk and the South West London Cancer Network Partnership how relations between these patient and public involvement organisations will develop.

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APPENDIX Standards for Better Health Core Standards C1 Healthcare organisations protect patients through systems that: a) identify and learn from all patient safety incidents and other reportable incidents,

and make improvements in practice based on local and national experience and information derived from the analysis of incidents

b) ensure that patient safety notices, alerts and other communications concerning patient safety which require action are acted upon within required timescales

C2 Healthcare organisations protect children following national child protection guidelines within their own activities and in their dealings with other organisations

C3 Healthcare organisations protect patients by following National Institute for Clinical Excellence (NICE) interventional procedure guidance

C4 Healthcare organisations keep patients, staff and visitors safe by having systems to ensure that:

a) the risk of healthcare acquired infection (HAI) to patients is reduced, with particular emphasis on high standards of hygiene and cleanliness, achieving year on year reductions in meticillin-resistant Staphylococcus aureus (MRSA)

b) all risks associated with the acquisition and use of medical devices are minimised c) all reusable medical devices are properly decontaminated prior to use and that the

risks associated with decontamination facilities and processes are well managed d) medicines are handled safely and securely e) the prevention, segregation, handling, transport and disposal of waste is properly

managed so as to minimise the risks to the health and safety of staff, patients, the public and the safety of the environment

C5 Healthcare organisations ensure that a) they conform to National Institute for Health and Clinical Excellence (NICE)

technology appraisals and, where it is available, take into account nationally agreed guidance when planning and delivering treatment and care

b) clinical care and treatment are carried out under supervision and leadership c) clinicians continually update their skills and techniques relevant to their clinical

work d) clinicians participate in regular clinical audit and reviews of clinical services C6 Healthcare organisations cooperate with each other and social care organisations to

ensure that patients’ individual needs are properly managed and met C7 Healthcare organisations: a) apply the principles of sound clinical and corporate governance b) actively support all employees to promote openness, honesty, probity,

accountability, and the economic, efficient and effective use of resources c) undertake systematic risk assessment and risk management (including compliance

with the controls assurance standards) d) ensure financial management achieves economy, effectiveness, efficiency, probity

and accountability in the use of resources e) challenge discrimination, promote equality and respect human rights f) meet the existing performance requirements as set out in Appendix 1 C8 Healthcare organisations support their staff through: a) having access to processes which permit them to raise, in confidence and without

prejudicing their position, concerns over any aspect of service delivery, treatment or management that they consider to have a detrimental effect on patient care or on the

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Core Standards delivery of services

b) organisational and personal development programmes which recognise the contribution and value of staff, and address, where appropriate, under-representation of minority groups

C9 Healthcare organisations have a systematic and planned approach to the management of records to ensure that, from the moment a record is created until its ultimate disposal, the organisation maintains information so that it serves the purpose it was collected for and disposes of the information appropriately when no longer required

C10 Healthcare organisations a) undertake all appropriate employment checks and ensure that all employed or

contracted professional qualified staff are registered with the appropriate bodies b) require that all employed professionals abide by relevant published codes of

professional practice C11 Healthcare organisations ensure that staff concerned with all aspects of the provision

of healthcare a) are appropriately recruited, trained and qualified for the work they undertake b) participate in mandatory training programmes c) participate in further professional and occupational development commensurate

with their work throughout their working lives C12 Healthcare organisations which either lead or participate in research have systems in

place to ensure that the principles and requirements of the research governance framework are consistently applied

C13 Healthcare organisations have systems in place to ensure that: a) staff treat patients, their relatives and carers with dignity and respect b) appropriate consent is obtained when required, for all contacts with patients and

for the use of any confidential patient information c) staff treat patient information confidentially, except where authorised by

legislation to the contrary C14 Healthcare organisations have systems in place to ensure that patients, their relatives

and carers: a) have suitable and accessible information about, and clear access to, procedures to

register formal complaints and feedback on the quality of services b) are not discriminated against when complaints are made c) are assured that organisations act appropriately on any concerns and, where

appropriate, make changes to ensure improvements in service delivery C15 Where food is provided, healthcare organisations have systems in place to ensure

that: a) patients are provided with a choice and that it is prepared safely and provides a

balanced diet b) patients’ individual nutritional, personal and clinical dietary requirements are met,

including any necessary help with feeding and access to food 24 hours a day C16 Healthcare organisations make information available to patients and the public on

their services, provide patients with suitable and accessible information on the care and treatment they receive and, where appropriate, inform patients on what to expect during treatment, care and after care

C17 The views of patients, their carers and others are sought and taken into account in designing, planning, delivering and improving healthcare services

C18 Healthcare organisations enable all members of the population to access services equally and offer choice in access to services and treatment equitably

C19 Healthcare organisations ensure that patients with emergency health needs are able to

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Core Standards access care promptly and within nationally agreed timescales, and all patients are able to access services within national expectations on access to services

C20 Healthcare services are provided in environments which promote effective care and optimise health outcomes by being:

a) a safe and secure environment which protects patients, staff, visitors and their property, and the physical assets of the organisation

b) supportive of patient privacy and confidentiality C21 Healthcare services are provided in environments which promote effective care and

optimise health outcomes by being well designed and well maintained with cleanliness levels in clinical and non-clinical areas that meet the national specification for clean NHS premises

C22 Healthcare organisations promote, protect and demonstrably improve the health of the community served, and narrow health inequalities by:

a) cooperating with each other and with local authorities and other organisations b) making an appropriate and effective contribution to local partnership arrangements

including local strategic partnerships and crime and disorder reduction partnerships c) ensuring that the local Director of Public Health’s annual report informs their

policies and practices C23 Healthcare organisations have systematic and managed disease prevention and health

promotion programmes which meet the requirements of the national service frameworks (NSFs) and national plans with particular regard to reducing obesity through action on nutrition and exercise, smoking, substance misuse and sexually transmitted infections

C24 Healthcare organisations protect the public by having a planned, prepared and, where possible, practiced response to incidents and emergency situations which could affect the provision of normal services

The Trust would welcome your comments on this report. If you wish to make any comment or require further copies please contact: Craig Mortimer Quality Officer Quality Assurance The Royal Marsden NHS Foundation Trust 203 Fulham Road London SW3 6JJ Tel: 020 7808 2176 E-mail: [email protected]

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