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April to June 2011 (Q

1) Integrated G

overnance Monitoring R

eport

Radiotherapy and Chemotherapy Services

F538021 & F538022

Life demands excellence

Integrated Governance Integrated Governance Monitoring ReportMonitoring Report

April to June 2011 April to June 2011

Quarter One 2011/12

INTEGRATED GOVERNANCE MONITORING REPORT APRIL TO JUNE 2011

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Contents

1. Introduction...................................................................................................................6

2. Executive summary .......................................................................................................7

3. Performance indicators ................................................................................................11

4. Involvement and information ..................................................................................... 13

4.1. Patient and Carer Advisory Group................................................................... 13 4.2. Patient frequent feedback ................................................................................ 13 4.3. Patient information publications..................................................................... 19 4.4. Interpreting services ........................................................................................ 19 4.5. Equality Impact Assessments ..........................................................................20 4.6. Midnight bed status and occupancy ................................................................ 21 4.7. Ethnic data capture ..........................................................................................22

5. Personalised care, treatment and support ..................................................................23

5.1. Results of same-sex accommodation audit .....................................................23 5.2. Nutrition and catering......................................................................................25 5.3. End-of-life care.................................................................................................29 5.4. Pastoral care ..................................................................................................... 31 5.5. Psychological Support Service .........................................................................32 5.6. Length of stay ...................................................................................................34 5.7. Complex discharge activity ..............................................................................35 5.8. Cooperating with other providers....................................................................37

6. Safeguarding and safety ..............................................................................................40

6.1. Protection and identification of vulnerable adults ..........................................40 6.2. Protection and identification of vulnerable children and young adults ......... 41 6.3. National Patient Safety Agency........................................................................42 6.4. Pressure ulcers .................................................................................................42 6.5. Infection prevention and control .....................................................................47 6.6. Management of medicines ...............................................................................52 6.7. Medical devices ................................................................................................54 6.8. Waste management..........................................................................................55 6.9. Fire....................................................................................................................57 6.10. Estates projects – Chelsea................................................................................59 6.11. Estates projects – Sutton .................................................................................62

7. Suitability of staffing ...................................................................................................63

7.1. Workforce.........................................................................................................63 7.2. Appraisal rates..................................................................................................65 7.3. Mandatory training – cancer specialist services .............................................67 7.4. Mandatory training – Sutton and Merton Community Services (SMCS).......70 7.5. Continuing professional development............................................................. 73 7.6. Non-clinical training and development – cancer specialist services .............. 75 7.7. Non-clinical training and development – Sutton and Merton Community

Services (SMCS) ...............................................................................................76


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8. Quality and management ............................................................................................ 77

8.1. Service developments....................................................................................... 77 8.2. Clinical audit .................................................................................................... 77 8.3. National Institute for Health and Clinical Excellence (NICE) ....................... 80 8.4. Information governance.................................................................................. 80 8.5. Freedom of information................................................................................... 81 8.6. Records – availability of notes.........................................................................83 8.7. Access to health records...................................................................................84 8.8. Radiotherapy ....................................................................................................84 8.9. Chemotherapy ..................................................................................................87 8.10. Human Tissue Authority.................................................................................. 91 8.11. Research governance........................................................................................92 8.12. Clinic waiting times..........................................................................................94 8.13. Outpatient non-attendances ............................................................................95 8.14. Consultant clinics cancelled less than 15 days before planned date ...............96 8.15. Complaints .......................................................................................................97 8.16. Letters of praise.............................................................................................. 103 8.17. Incident reporting summary..........................................................................104 8.18. Incident investigations and serious incident reporting................................. 105 8.19. Incident statistics ...........................................................................................108 8.20. Reporting of Injuries, Diseases and Dangerous Occurrences Regulations

incidents ..........................................................................................................121 8.21. Risk assessments – the Trust risk register .................................................... 122 8.22. NHS Litigation Authority risk management standards for trusts ................ 122 8.23. Claims ............................................................................................................. 123

9. Suitability of management ........................................................................................ 124

9.1. Reports to Monitor and accounts .................................................................. 124

10. Essential standards of quality and safety.................................................................. 125


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1. Introduction

1.1. Welcome to The Royal Marsden NHS Foundation Trust’s Integrated Governance Monitoring Report.

1.2. The Trust monitors safety and assures quality of service through the monthly Quality Account reported to the Trust Board, an annual Quality Account as part of the Trust’s Annual Report, and this Integrated Governance Monitoring Report, which provides a quarterly review of the governance of care, research and infrastructure provided at The Royal Marsden.

1.3. The Care Quality Commission published Essential standards of quality and safety in March 2010 to help providers of health and social care to comply with the regulations of the Health and Safety Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. The Commission assesses organisations against the outcomes defined in Essential standards of quality and safety.

1.4. The report includes details of compliance with key performance indicators in Section 3: Performance indicators.

1.5. The 28 outcomes defined by Essential standards of quality and safety are grouped into the six areas covered in the following sections:

Section 4: Involvement and information

Section 5: Personalised care, treatment and support

Section 6: Safeguarding and safety

Section 7: Suitability of staffing

Section 8: Quality and management

Section 9: Suitability of management.

1.6. The final section of the report, Section 10: Essential standards of quality and safety, lists the 28 outcomes defined by the Care Quality Commission.


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2. Executive summary

2.1. Performance indicators

2.1.1. The Royal Marsden met all the National Cancer Plan targets and the national cancer access targets in Quarter One 2011/12. Patients were able to access cancer care quickly and only 0.3% of patients had their operations cancelled for non-clinical reasons.

2.1.2. There are two infection prevention and control targets, for Clostridium difficile infection (CDI) and meticillin-resistant Staphylococcus aureus (MRSA) bacteraemia. There were four CDI cases (annual target 20) and no MRSA cases (annual target 0).

2.2. Involvement and information

2.2.1. Patient and Carer Advisory Group

The Patient and Carer Advisory Group continued its activities during the quarter, advising on the following areas:

patient information

staff appointments as members of interview panels

the Trust’s annual quality account.

2.2.2. Patient frequent feedback

Work continued to improve the information patients are given about waiting times and delays in response to the findings of the frequent feedback surveys in the Outpatients Departments and the Medical Day Units.

2.2.3. Patient information

The Trust is a Beacon site sharing its learning about the national initiative of information prescriptions, personalised information sets for patients, with other NHS Trusts new to the initiative.

2.2.4. Bed occupancy

Assessed by midnight bed occupancy, Chelsea had an average occupancy of 89.19% and Sutton 77.51%. Both sites had several beds closed.

2.3. Personalised care, treatment and support

2.3.1. Same sex accommodation

One patient responded in a survey that they had shared accommodation with patients of the opposite sex (Admission and Pre-assessment Unit).

2.3.2. Nutrition and catering

In Chelsea 69% and in Sutton 81% of patients surveyed rated the taste of the food as excellent or good.


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2.3.3. End-of-life care

During the quarter 83% of patients had their preferred place of death documented and 84% of patients died in their place of choice. Horder Ward in Chelsea reopened in May 2011. Coordinate my care is a new initiative that coordinates end of life care for patients. The Trust has been appointed host of this service.

2.3.4. Staff support

Cancer care has been demonstrated as being one of the most stressful specialties for healthcare staff. The dedicated staff support counsellors provided 452 individual consultations and 39 group sessions.

2.3.5. Psychological support for patients and families

The psychological support team provided 1179 sessions for patients. The specialist paediatric psychological support team continued to offer emotional and practical support for all members of the family of a child with cancer.

2.3.6. Length of stay

The elective and non-elective length of stay across the Trust has shown no significant changes over the last two years. Slight variations have been caused by a small number of patients who have very long stays in hospital.

2.4. Safeguarding and safety

2.4.1. Protection and identification of vulnerable adults

Two safeguarding alerts were reported by acute services.

2.4.2. Protection and identification of vulnerable children and young adults

This quarter no children were admitted on a child protection plan, no referrals were made to children’s social care and there were no referrals to social care regarding a child in need. There were no incidents reported involving children.

2.4.3. Infection prevention and control

There were four cases of Clostridium difficile infection attributable to the Trust and no cases of meticillin-resistant Staphylococcus aureus (MRSA) bacteraemia. Meticillin-sensitive Staphylococcus aureus (MSSA) bacteraemia started to be monitored. No cases were reported.

2.4.4. Management of medicines

Actions are underway to address the finding from the national cancer patient survey that patients are not fully aware of their entitlement to a prescription exemption certificate. Information is to be provided to every inpatient at discharge and to all outpatients who receive a prescription.


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2.4.5. Fire

There were 24 fire management incidents reported under in the quarter. Only one of these was an actual fire, in a flowerbed. No one was harmed.

2.5. Suitability of staffing

2.5.1. Workforce

Across the Trust the percentage of sickness absence is below the average of most other specialist and similarly sized trusts in London at 2.5% (London trust range: 2.2-4.1%). Agency spend as a percentage of total pay was 5.3% in this quarter.

2.6. Quality and management

2.6.1. Clinical Audit

Seventeen new clinical audits were proposed during the quarter and six new national audits relevant to The Royal Marsden were planned or completed.

2.6.2. National Institute for Health and Clinical Excellence (NICE)

Twenty-nine new guidelines were reviewed. Eight were relevant to the Trust.

2.6.3. Freedom of information

The Trust received 51 requests with 89% answered within 20 days.

2.6.4. Chemotherapy and radiotherapy

Seven radiotherapy audits were completed with 18 corrective actions identified. Three complaints and 95 letters of praise related to chemotherapy were received.

2.6.5. Research governance

Thirty new research projects were approved.

2.6.6. Consultant clinics cancelled less than 15 days before planned date

0.80% of NHS and 3.85% of private patient clinics were cancelled less than 15 days before the planned date. The rate has risen since Quarter Four.

2.6.7. Complaints (8.17)

Responding to complaints within target time improved further to 96% this quarter. There were 57 complaints received this quarter.

2.6.8. Letters of praise (8.18)

Three hundred and seventy-eight letters of praise were forwarded to The Head of the Patient Advice and Liaison Service (PALS), Patient Information and Complaints.


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2.6.9. Incidents (8.20)

Six incidents were reportable under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR).

2.6.10. Claims (8.25)

There were no formal letters of claim for clinical negligence and one personal injury claim.

2.7. Suitability of management (section 9)

2.7.1. Reports to Monitor and accounts (9.1)

The Trust continued to be rated by Monitor, the NHS Foundation regulator, to be low risk in financial terms.


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3. Performance indicators

National Cancer Plan Targets

Indicator Target* 2011/12 (projected)†

2011/12 year to date 2010/11

2011/12 cumulative month

2 weeks

% of patients seen within 2 weeks of urgent GP referral 93.0% 96.6% 96.6% 98.6% Jun

% of patients seen within 2 weeks for breast symptoms 93.0% 95.3% 95.3% 96.9% Jun

31 days

First treatment - % treated within 31 days of decision to treat 96.0% 99.5% 99.5% 99.6% Jun

Subsequent drugs - % treated within 31 days of decision to treat 98.0% 99.8% 99.8% 99.8% Jun

Subsequent surgery - % treated within 31 days of decision to treat 94.0% 97.1% 97.1% 96.9% Jun

Subsequent radiotherapy - % treated within 31 days of decision to treat 94.0% 98.8% 98.8% 99.4% Jun

62 days

All cancers - % treated within 62 days of urgent GP referral 85.0% 87.2% 87.2% 86.8% Jun

Referral from screening - % treated within 62 days of urgent GP referral 90.0% 96.4% 96.4% 92.0% Jun

Consultant upgrade - % treated within 62 days of urgent GP referral 80.0% 100.0% 100.0% 83.3% Jun

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 the referral route from the GP is outside the control of The Royal Marsden and is reflected in these figures.

National Access Targets


2011/12 year to date 2010/11


% of last minute cancelled operations for non-clinical reasons (CQC) 0.8% 0.3% 0.3% 0.3% Jun

Number of last minute cancelled‡ operations for non-clinical reasons - 70 17 63 Jun

% of last minute cancelled operations not admitted within 28 days (CQC) 5.0% 0% 0% 0.0% Jun

Number of last minute cancelled operations for non-clinical reasons not admitted within 28 days - 0 0 0 Jun

Median wait in days of patients requiring admission (18 weeks) § 11 40 35 May

Median wait in days of patients not requiring admission (18 weeks) § 7 18 13 May


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Other National Indicators – Data Quality


2011/12 year to date 2010/11


% of Admitted Patient Records with valid Ethnic Category Code (CQC), (IG) - 94.6% 94.6% 94.8% Jun

Other National Indicators – Infection Prevention and Control


2011/12 year to date 2010/11


Number of diagnoses of Clostridium difficile ║ 20 17 4 34 Jun

Number of diagnoses of meticillin-resistant Staphylococcus aureus (MRSA) bacteraemia 0 0 0 2 Jun

* Target is based on Care Quality Commission targets where published

† 2010/11 figures show the year-to-date position seasonally projected to year-end

‡ 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.

§ Figures calculated using local patient-level data

║Figures calculated according to the Department of Health methodology revised December 2008.

(CQC) Care Quality Commission targets

(IG) Monitored as part of Information Governance


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4. Involvement and information

4.1. Patient and Carer Advisory Group

4.1.1. The Patient and Carer Advisory Group is composed of current and former Royal Marsden patients and carers. The group is chaired by members of its own committee and is serviced by an officer of the Trust. It works with the Trust on a variety of projects where the views of patients and carers can help make the hospital a better place for patients.

4.1.2. The group’s Listening Post continued to be held monthly in patient waiting areas. This ‘stall’ is manned by representatives of the group who collect verbal comments and observations of patients and their families. This information is useful to the group, highlighting areas where the Trust is performing well or where it could do better. This feedback is also provided to Trust staff to ensure that services can be improved. Work developing new promotional material for the initiative continued.

4.1.3. Members reviewed an exercise booklet for men with prostate cancer commenting on its design, clarity and utility.

4.1.4. A representative of the group was on the panel that interviewed candidates for the new post of Concerns and Complaints Manager.

4.1.5. The Trust’s draft annual quality account, 2010/11, was discussed. The document, which describes various measures of clinical care and other indications of quality important to patients, was, in general, considered very good by the group. The draft was modified to make it clearer in response to the feedback.

4.2. Patient frequent feedback

4.2.1. The Royal Marsden NHS Foundation Trust has been working with Picker Institute Europe in capturing patient feedback using Personal Digital Assistant technology. This technology enables the Trust to capture patient feedback on a continuous basis, quickly highlighting areas of need as well as feeding back positive news.

4.2.2. The following charts provide the results for selected questions taken from the frequent feedback questionnaires for the medical day units and outpatient departments (OPDs).

4.2.3. During Quarter One 236 patients from the Medical Day Unit (MDU), Chelsea; private patient MDU, Chelsea; MDU, Sutton; Robert Tiffany MDU, Sutton; and the Sir William Rous Chemotherapy Unit, Kingston have reported their experience whilst undergoing chemotherapy treatment. This survey has been running since summer 2009.

4.2.4. Six hundred and twenty-seven patients completed the questionnaire for the outpatient departments in Chelsea and Sutton. This survey started in autumn 2010.


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4.2.5. Medical day units

Overall, do you feel you were treated with respect and dignity today? (Amongst those who gave a response) New question in October 2010

At the beginning of your treatment, were you given any written or printed information about your treatment? (All respondents)


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In your opinion, how clean is the day unit? (All respondents)

Overall, how would you rate the care you receive at this day unit? (All respondents)


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4.2.6. Outpatient departments

Were you kept informed about your waiting times? (Amongst those who waited over 15 minutes)

In response to this finding work is planned to ensure that patients are kept informed of delays to the start of their appointments. Actions include training for reception staff, increasing the number of information boards and designating a member of staff to communicate with clinics to ensure delays noted on the board are accurate.


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Did the member of staff listen to what you had to say? (All respondents)

How involved did you feel in the decisions being made about your care and treatment?

(All respondents)


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Were you given enough privacy during your consultation? (All respondents)

Overall, how would you rate the care you receive at the Outpatients Department? (All respondents)


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4.3. Patient information publications

Type New title/ new edition Revision Total

Booklets 2 6 8

Factsheets 17 19 36

Leaflets 2 4 6

Pocket booklets 0 1 1

Total 21 30 51

4.3.1. Revisions in the quarter included nine lower gastrointestinal surgery factsheets submitted to NHS Choices and uploaded to the Information Prescriptions site.

4.3.2. New editions made available included the booklet Your guide to The Royal Marsden complemented by the pocket booklet Your health information, your confidentiality. A copy of both of these is sent to each new patient.

4.3.3. New titles included the booklet Keep active: a guide to physical activity for men with prostate cancer. Copies of these can be obtained from the Trust’s Help Centres and website.

4.3.4. The Royal Marsden has been selected as a Beacon site to offer patients and carers personalised cancer information prescriptions. This is information that is specific to each patient and includes details of consultations with healthcare professionals, diagnoses, treatment, care plans, and support. The Royal Marsden is one of 15 Beacon trusts and over the next two years all hospitals in England that provide cancer services will offer personalised information prescriptions. The Royal Marsden is one of the trusts leading the implementation of the programme and has participated in three events to share experience with trusts new to information prescriptions.

4.4. Interpreting services

4.4.1. The Trust has a contract with a 24-hour telephone and face-to-face interpreting service.

4.4.2. There were five requests for the telephone translation service this quarter.

Language Serviced

calls Serviced minutes

Arabic 2 58

Mandarin 2 55

Turkish 1 6

Total 5 119


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4.4.3. There were 56 face-to-face interpretation appointments this quarter.

Language pair Appointments

English – Albanian 2

English – Arabic 2

English – Bengali 3

English – Cantonese 4

English – Dari 1

English – Farsi 4

English – Greek 4

English – Gujarati 2

English – Hindi 2

English – Korean 1

English – Kurdish (Sorani) 2

English – Lithuanian 5

English – Mandarin 6

English – Polish 4

English – Russian 3

English – Sign Language 1

English – Slovak 1

English – Spanish 4

English – Tamil 3

English – Urdu 1

English – Vietnamese 1

Total 56

4.5. Equality Impact Assessments

4.5.1. A first stage Equality Impact Assessment is a screening process to enable the Trust to consider the impact that its policies, practices and services may have on equality and diversity.

4.5.2. There were 10 first stage Equality Impact Assessments this quarter. The findings were reported to the Equality and Diversity Operational Group in April 2011 and published on the internet and intranet.

4.5.3. The Equality and Diversity Operational Group reports to the Board-level Equality and Diversity Committee. The group includes representatives from Sutton and Merton Community Services.


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4.6. Midnight bed status and occupancy

Total occupied and reserved

Ward (excluding day units)

Un

occu

pie

d

Occu

pied

Reserved

All patients NHS PP

Occu

pied

/ reserved

as a %

of total available

To

tal

av

aila

ble

b

ed

nig

hts

Un

available

Un

available and

reserved

as a % of

total beds/n

ights

in th

e mon

th

Gran

d total

Total bed

s/nigh

ts d

ivided

by days in

m

onth

= n

um

ber of bed

s in w

ard

Burdett Coutts 138 1,198 5 1,203 1,081 122 89.71% 1,341 24 2.12% 1,365 15

Ellis 192 1,394 5 1,399 1,310 89 87.93% 1,591 47 3.17% 1,638 18

Granard House 0 0.00% 0 1,365 100.00% 1,365 15

Horder 16 141 141 128 13 89.81% 157 901 85.16% 1,058 12

Markus 82 798 798 652 146 90.68% 880 30 3.30% 910 10

Wilson 202 1,229 10 1,239 1,144 95 85.98% 1,441 15 1.72% 1,456 16

Wiltshaw 130 1,484 5 1,489 488 1,001 91.97% 1,619 19 1.47% 1,638 18

Chelsea 760 6,244 25 6,269 4,803 1,466 89.19% 7,029 2,401 25.73% 9,430 104

Bud Flanagan East 95 1,327 16 1,343 1,236 107 93.39% 1,438 18 2.34% 1,456 16

Bud Flanagan West 267 1,119 23 1,142 1,141 1 81.05% 1,409 56 5.39% 1,465 16

Chevallier 0 0.00% 0 1,183 100.00% 1,183 13

Kennaway 330 1,323 1,323 1,318 5 80.04% 1,653 440 21.02% 2,093 23

McElwain 417 1,362 48 1,410 1,311 99 77.18% 1,827 5 2.89% 1,832 20

Oak 145 355 355 350 5 71.00% 500 410 45.05% 910 10

Robert Tiffany 190 977 977 248 729 83.72% 1,167 16 1.35% 1,183 13

Smithers 803 1,194 1,194 1,175 19 59.79% 1,997 96 4.59% 2,093 23

Sutton 2,247 7,657 87 7,744 6,779 965 77.51% 9,991 2,224 18.92% 12,215 134

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).


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4.7. Ethnic data capture

The table lists the ethnic origin of patients newly registered in Quarter One.

Ethnic Origin NHS

Private practice and overseas Total

Asian Bangladeshi 9 9

Asian Indian 55 15 70

Asian Pakistani 23 6 29

Asian (other) 76 8 84

Black African 69 5 74

Black Caribbean 74 74

Black (other) 15 1 16

Chinese 1 1

Mixed White and Asian 5 5

Mixed White and Black African 9 9

Mixed White and Black Caribbean 23 1 24

Mixed (other) 1,868 246 2,114

White British 78 13 91

White Irish 289 72 361

White (other) 27 3 30

Other 17 64 81

Not disclosed 52 68 120

Total 2,690 502 3,192

Ethnic origin information completed* 2,638 434 3,072

Ethnic origin information completed* 98.1% 86.5% 96.2%

*All values except ‘not disclosed’


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5. Personalised care, treatment and support

5.1. Results of same-sex accommodation audit

5.1.1. The Royal Marsden is committed to providing every patient with same-sex accommodation. Same-sex accommodation means:

areas where patients are admitted and cared for on beds or trolleys (even when they do not stay overnight) will only be occupied by patients of the same sex. It therefore includes all admissions and assessment units (including clinical decision units), plus day surgery and endoscopy units.

bathrooms or shower areas for accommodation will be near patients’ rooms or bays and will only be for patients of the same sex.

These criteria will be audited every quarter.

5.1.2. Forty questionnaires out of 100 (40%) were returned by patients in the quarter. Ten out of 40 (25%) patients had single room accommodation; 30 (75%) were accommodated on wards.

5.1.3. Thirty-eight patients out of 40 (95%) responded that they had not shared sleeping accommodation with patients of the opposite sex when first admitted. One patient (2.5%) responded that they had shared accommodation with patients of the opposite sex - the patient stated this was in the Admission and Pre-assessment Unit. One patient (2.5%) did not answer this particular question.

5.1.4. Thirty-three patients out of 40 (82.5%) replied that they had not shared accommodation with patients of the opposite sex when moved to another ward. One patient (2.5%) responded that they had shared accommodation with patients of the opposite sex when moved to another ward. One patient (2.5%) did not answer this particular question. One patient (2.5%) stated that they could not remember. Four patients (10%) stated this was not applicable.

5.1.5. Thirty-five patients out of 40 (87.5%) stated they never used the same bathroom or shower area as patients of the opposite sex. One patients out of 40 (2.5%) stated they had used the same bathroom or shower area as patients of the opposite sex. One patient (2.5%) did not answer this particular question. Three patients (7.5%) stated that they could not remember.


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5.1.6. Percentage of patients sharing a sleeping area or bathroom and shower area with patients of the opposite sex in the last four quarters.

0%

1 %

2%

3%

4%

5%

6%

7 %

8%

9%

Quarter 22010/11

Quarter 32010/11

Quarter 42010/11

Quarter 12011/12

Shared a sleeping area with patients of the opposite sex when first admitted

Shared a sleeping area with patients of the opposite sex if mov ed to other ward(s)

Used the same bathroom or shower area as patients of the opposite sex

The information for Quarters One, Three and Four of each financial year is collected in the Trust’s patient surveys. For Quarter Two the Trust uses responses from the Quality Care Commission Survey of adult inpatients in the NHS. The questionnaire was sent to 850 patients from The Royal Marsden in Quarter Two; 479 returned a completed questionnaire, giving a response rate of 60%.


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5.2. Nutrition and catering

5.2.1. Patient survey results – Chelsea

5.2.2. How would you rate the taste of your meal?

0%

10%

20%

30%

40%

50%

60%

7 0%

80%

90%

100%

Excellent Good Acceptable Poor Very Poor

Quarter 4 2010/11

Quarter 1 2011/12

The taste of the meal was rated as excellent or good by 69% of the patients this quarter. In the previous quarter 76% rated it excellent or good.

5.2.3. How would you rate the temperature of the food?

0%

10%

20%

30%

40%

50%

60%

7 0%

80%

90%

100%


Quarter 4 2010/11

Quarter 1 2011/12

The temperature of the food was rated as excellent or good by 77% of the patients this quarter. In the previous quarter 76% rated it excellent or good.


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5.2.4. How would you rate the appearance of the meals?

0%

10%

20%

30%

40%

50%

60%

7 0%

80%

90%

100%


Quarter 4 2010/11

Quarter 1 2011/12

The appearance of the meals was rated as excellent or good by 82% of the patients this quarter. In the previous quarter 84% rated it excellent or good.

5.2.5. How would you rate your overall satisfaction with the catering service?

0%

10%

20%

30%

40%

50%

60%

7 0%

80%

90%

100%


Quarter 4 2010/11

Quarter 1 2011/12

Overall satisfaction with the catering service was rated as excellent or good by 80% of the patients this quarter. In the previous quarter 72% rated it excellent or good.


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5.2.6. Patient survey results – Sutton

5.2.7. How would you rate the taste of your meal?

0%

10%

20%

30%

40%

50%

60%

7 0%

80%

90%

100%


Quarter 4 2010/11

Quarter 1 2011/12

The taste of the meal was rated as excellent or good by 81% of the patients this quarter. In the previous quarter 84% rated it excellent or good.

5.2.8. How would you rate the temperature of the food?

0%

10%

20%

30%

40%

50%

60%

7 0%

80%

90%

100%


Quarter 4 2010/11

Quarter 1 2011/12

The temperature of the food was rated as excellent or good by 77% of the patients this quarter. In the previous quarter 88% rated it excellent or good.


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5.2.9. How would you rate the appearance of the meals?

0%

10%

20%

30%

40%

50%

60%

7 0%

80%

90%

100%


Quarter 4 2010/11

Quarter 1 2011/12

The appearance of the meals was rated as excellent or good by 84% of the patients this quarter. In the previous quarter 85% rated it excellent or good.

5.2.10. How would you rate your overall satisfaction with the catering service?

0%

10%

20%

30%

40%

50%

60%

7 0%

80%

90%

100%


Quarter 4 2010/11

Quarter 1 2011/12

Overall satisfaction with the catering service was rated as excellent or good by 90% of the patients this quarter. In the previous quarter 90% rated it excellent or good.


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5.3. End-of-life care

5.3.1. The Hospital2Home service at The Royal Marsden has completed over 300 case conferences. Patients are actively involved in making decisions about symptom control and place of care and death. The Trust has participated in the National Liverpool Care of the Dying Patient Pathway audit that commenced in April 2011 and the results from this will be available later in 2011. The Hospital2Home team are developing case conferencing by telephone so that the service is available to those patients who live outside the area served by the home visiting service. So far 27 telephone case conferences have been completed.

5.3.2. Actual place of death

0%

10%

20%

30%

40%

50%

60%

7 0%

80%

90%

100%

Home(including

NursingHome)

Hospice Hospital Other Unknown


30

5.3.3. Preferred place of death documented

0%

10%

20%

30%

40%

50%

60%

7 0%

80%

90%

100%

Y es No

5.3.4. Preferred place of death achieved

0%

10%

20%

30%

40%

50%

60%

7 0%

80%

90%

100%

Y es No

5.3.5. The Trust has completed an audit to explore palliative care needs of patients with end-stage interstitial lung disease at the Royal Brompton Hospital. Marie Curie Cancer Care is funding a Hospital2Home clinical nurse specialist to work for a two-year period from May at the Royal Brompton Hospital.

5.3.6. Coordinate My Care is a service that coordinates end-of life-care between multiple providers in London. The service allows each patient to have their preferences for end-of-life care recognised by all who need to hear them, leading


31

to individualised high quality end-of-life care. The next step in the development of this service is the creation of a common record template for London healthcare providers that can be shared across all organisations.

5.3.7. Horder Ward re-opened in May 2011 and has been designed for specialist palliative care of patients and their families.

5.3.8. The Palliative Care Team at the Royal Brompton Hospital is piloting the Liverpool Care Pathway for the Dying Patient in two wards.

5.3.9. The Palliative Care Team is currently working with Sutton and Merton Community Services (SMCS) to integrate end-of-life services. A workshop for community nurses has taken place and further workshops for key staff from acute services and SMCS is planned for September with the goal of improving the services.

5.4. Pastoral care

5.4.1. Chaplaincy service

The chaplaincy service provides pastoral, spiritual and religious care for patients, their families and friends, and staff. The Chaplaincy team is committed to the spiritual care of all, irrespective of religious belief. This is effected through:

assessing the emotional and spiritual needs of patients, relatives and staff and arranging the appropriate response with available resources

providing continuing support while a patient is receiving treatment at the Trust

being a spiritual, pastoral and religious resource to the Trust.

The Chaplaincy advises on matters relating to other faiths and contacts relevant faith-leaders when needed.

The two hospital chapels are at the heart of the chaplaincy service. Each week services are held which include Church of England communion and Roman Catholic mass. Popular lunchtime concerts are held on both sites. Twenty-four-hour access allows patients, relatives and staff to enjoy a quiet space to pray, reflect and meditate.

The hospital has two prayer rooms used mainly by Muslim patients, relatives and staff. These rooms are well-used and accessible at all times.

On 7 May memorial services were held at St John’s, Belmont and St Luke’s, Chelsea. Both services were well attended and appreciated.


32

5.4.2. Staff support

The staff support service offers counselling and other activities:

Quarter 2 2010/11

Quarter 3 2010/11

Quarter 4 2010/11

Quarter 1 2011/12

One-to-one sessions 504 372 395 452

Groups 34 33 42 39

Mediation 2 0 4 4

Debriefing 0 2 0 0

One-to-one supervision 10 16 33 30

5.5. Psychological Support Service

5.5.1. Adult psychological support

A confidential psychological support service is available for patients and their families.

A team of specially trained, experienced nurses, doctors and clinical psychologists provides the service. Members of the team discuss practical ways to help patients cope, and to help them live as full a life as possible.

Issues for adult patients include:

anxiety

depression

problems with personal relationships

body image difficulties

talking to their young children

acute state of confusion

self-harm

psychotic illness

cognitive and memory problems

pain management

sexual-health difficulties

alcohol addiction.

5.5.2. Paediatric psychological support

A confidential service for paediatric patients is provided at the Sutton hospital by child and adolescent clinical psychologists and a child psychiatrist. The aim is to meet every family where cancer has been diagnosed in a child or young person, and to offer emotional and practical support to all members of the family throughout diagnosis and treatment or in bereavement. The diagnosis of cancer can be a major challenge to families and the Trust's intent is to offer the amount of advice and support appropriate to each family.


33

Issues include:

adjustment to diagnosis

anxiety and depression in any member of the family

behavioural problems such as anger, extreme tantrums, sleeping and eating problems and aggression

relationship problems

procedural problems such as needle phobia and non-compliance with treatment

developmental issues

social issues

changes in personality

identity and body image problems

school issues including academic issues, memory issues, learning problems, special educational needs and neuropsychological problems.

5.5.3. Psychological support services activity

Of the 587 patients seen, 229 were in Chelsea and 358 in Sutton.

One-to-one sessions Chelsea Sutton Total

First sessions 105 124 229

Subsequent sessions 324 626 950

All sessions 429 750 1179

Patient status Chelsea Sutton Total

Inpatients 79 83 162

Outpatients 350 667 1017

All sessions 429 750 1179


34

5.6. Length of stay

5.6.1. Average length of stay for NHS patients – Trust

0

1

2

3

4

5

6

7

8

9

10

11

Quarter 12009/10

Quarter 22009/10

Quarter 32009/10

Quarter 42009/10

Quarter 12010/11

Quarter 22010/11

Quarter 32010/11

Quarter 42010/11

Quarter 12011/12

Ave

rage

len

gth

of s

tay

(day

s)

ElectiveNon-electiveAll NHS patients

5.6.2. Average length of stay for NHS patients – Chelsea

0

1

2

3

4

5

6

7

8

9

10

11

Quarter 12009/10

Quarter 22009/10

Quarter 32009/10

Quarter 42009/10

Quarter 12010/11

Quarter 22010/11

Quarter 32010/11

Quarter 42010/11

Quarter 12011/12

Ave

rage

len

gth

of s

tay

(day

s)

ElectiveNon-electiveAll NHS patients


35

5.6.3. Average length of stay for NHS patients – Sutton

0

1

2

3

4

5

6

7

8

9

10

11

Quarter 12009/10

Quarter 22009/10

Quarter 32009/10

Quarter 42009/10

Quarter 12010/11

Quarter 22010/11

Quarter 32010/11

Quarter 42010/11

Quarter 12011/12

Ave

rage

len

gth

of s

tay

(day

s)

Elective

Non-elective

All NHS patients

5.7. Complex discharge activity

There were 126 complex discharges in Quarter One: 53 patients in Sutton and 73 in Chelsea. These patients required additional support to enable them to return home including referrals to their local authority social services departments, applications for NHS Continuing Care funding, referrals to district nurses and referrals to Community Palliative Care. Many of these patients had complex needs as they required end-of-life support in the community.

5.7.1. Chelsea

One patient was discharged to each of the following authorities and primary care trusts: Berkshire East, Bexley, Bromley, Buckinghamshire, City and Hackney, East Sussex Downs and Weld, Eastbourne, Elmbridge, Enfield, Greenwich, Hackney, Hampshire, Harrow, Luton, Merton, Northamptonshire, Oxfordshire, Poole, Slough, Southwark, West Berkshire, West Kent, West Sussex, West Wiltshire, Wiltshire.


36

More than one patient was discharged to each of the following authorities and primary care trusts:

0 1 2 3 4 5 6

Br en t

Ca m den

Cr oy don

Ea lin g

Ha m m er sm ith a n d Fu lh a m

Ha r in g ey

Hou n slow

Ken sin g ton a n d Ch elsea

Kin g ston

La m beth

Rich m on d

Su r r ey

Su tton

Wa n dsw or th

Number of patients discharged

5.7.2. Sutton

One patient was discharged to each of the following authorities and primary care trusts: Canterbury, East and Coastal Kent, Enfield, Wandsworth.

More than one patient was discharged to each of the following authorities and primary care trusts:

0 4 8 12 16

Su tton

Mer ton

Kin g ston u pon Th a m es

Cr oy don

Su r r ey

West Su ssex

Rich m on d u pon Th a m es

Ha r r ow

Number of patients discharged


37

5.8. Cooperating with other providers

5.8.1. The Trust works with primary care trusts, local authorities and other statutory and voluntary community service providers to develop assessment tools. Some are based on national or network models (such as the NHS Continuing Health Care process), the Community Care and Delayed Discharge Act, and Community Palliative Care Referrals.

5.8.2. Other tools have been designed specifically for the needs of patient groups, such as Community Care Referrals for District Nurses.

5.8.3. The Trust has safeguards in place to ensure that patients have consented to their information being shared and that the information is shared in a secure manner. For example, the Trust has Community Care and Delayed Discharge Tracking officers who ensure that discharge documentation is sent to the appropriate team in a local authority. The tracking team has developed a database of contact details and a process is in place to monitor and amend it.

5.8.4. A patient’s need for community health and social care services is assessed and reviewed throughout their treatment at the Trust. Appropriate referrals are made when a specific service is required. When there is more than one service (such as District Nurse, Community Palliative Care Team or Social Services) involved in the patient’s care, the Trust ensures that they know of each other’s involvement and coordinate the services and communication. Patients served by more than one community service are provided with a Discharge Information Sheet, which lists all the services involved in their care and the contact number and arrangements for each service.

5.8.5. All The Royal Marsden’s discharge documentation contains the information described in Essential standards of quality and safety (see page 125); the exception is “known preferences” - although all care needs are included.

5.8.6. External agencies are contacted as early as possible before patients are discharged as they may require extensive notice to set up the necessary service. The information is provided to the outside agencies mainly by fax. Copies are kept in the medical notes with a copy held securely on the ward so that the information is accessible when the medical notes have been filed.

5.8.7. The Trust is an active participant in developing policies and procedures with community partners for patient specific groups, such as the Learning Disability Health Partnership Board and the Safeguarding Adult Executive Board.

5.8.8. The Trust continues to work with other providers at a strategic level to develop cancer services for the future, for example, service reconfiguration for the provision of services for rare cancers.

5.8.9. The Royal Marsden works in partnership with Kingston Hospital and Macmillan Cancer Support to provide a service close to home for patients diagnosed with a solid tumour cancer at Kingston and Queen Mary’s Hospitals. The Sir William Rous Unit at Kingston Hospital is a purpose-built development providing diagnostic and supportive services, as well as a medical day unit for the delivery of systemic therapy. The medical day unit is staffed and run by The Royal Marsden and provides care to patients from the Kingston area with breast,


38

gastrointestinal, urological and lung cancers. The service is jointly managed by The Royal Marsden and Kingston Hospital, and is overseen by the Kingston Partnership Board.

5.8.10. Specialist multidisciplinary teams – oesophago-gastric, hepatic-pancreatic-biliary and urological cancer services

In accordance with the improving outcomes guidance from the National Institute for Health and Clinical Excellence (NICE), specialist multidisciplinary teams for oesophago-gastric, pancreatic, hepatic-pancreatic-biliary, and urological cancers are established in the South West London Cancer Network. The gastrointestinal teams are hosted by The Royal Marsden, and the urology team is hosted jointly by The Royal Marsden and St George’s Healthcare NHS Trust.

5.8.11. Referrals to the gastrointestinal specialist multidisciplinary teams come from Epsom and St Helier, Croydon, Kingston, St George’s, Chelsea and Westminster and West Middlesex hospitals. The urology team’s referral catchment area includes Epsom and St Helier, Croydon, Kingston, and St George’s hospitals.

5.8.12. The local multidisciplinary teams diagnose new cases of cancer and discuss all new diagnoses being considered for radical treatment at the weekly specialist multidisciplinary team meetings. Referrals from the local units are presented by a member of the local team who is also a member of the specialist team and a recommended management decision is determined at the specialist team meeting in accordance with the South West London Cancer Network clinical guidelines. Some investigations, such as computed tomography (CT), are undertaken locally, as is palliative care.

5.8.13. The Trust works in collaboration with these hospitals within South West London Cancer Network and West London Cancer Network to provide specialist care for patients. The Royal Marsden’s oncologists travel out to the network hospitals for local multidisciplinary team meetings and clinics, working with the local clinicians to provide a seamless pathway for patients. One of the gastrointestinal clinical nurse specialist posts is jointly held by The Royal Marsden and the Epsom and St Helier University Hospitals NHS Trust. Network Multidisciplinary Team Navigators are in post at The Royal Marsden to ensure that patients are discussed at the multidisciplinary team meetings and that their care is coordinated between providers.

5.8.14. South East England Testicular Supranetwork Multidisciplinary Team

The South East England Testicular Supranetwork is a collaboration of four cancer networks covering the majority of the population of Surrey, Sussex and Kent (estimated population 5.6m) for the management of testicular cancer. The majority of patients will be treated under the auspices of one of four centres each covering one of the networks:

Maidstone NHS Trust (Kent and Medway Cancer Network)

The Royal Marsden NHS Foundation Trust (South West London Cancer Network)


39

Royal Surrey County Hospital NHS Trust (Surrey, West Sussex and Hampshire Cancer Network)

Royal Sussex County Hospital NHS Trust (Sussex Cancer Network).

5.8.15. The Royal Marsden NHS Foundation Trust acts as the Supranetwork centre and manages all cases of advanced germ cell tumours or cases requiring complex surgical or medical management. All patients within the Supranetwork will be discussed at the Supranetwork multidisciplinary team meeting held twice a month at The Royal Marsden.

5.8.16. Patients are referred to and first seen at their local hospital where initial diagnosis is undertaken, and where they are reviewed by the local urology team. They are then referred to the local oncologist in their Network at the relevant Cancer Centre. If a patient has Stage I disease or a good prognosis, they will be managed locally. If they have intermediate disease or a poor prognosis they will be managed at The Royal Marsden or under shared care arrangements.

5.8.17. Sutton and Merton Community Services (SMCS)

SMCS work closely with the local authority social services departments and the GPs and practice nurses in the 54 GP practices in Sutton and Merton.

There are key relationships with a number of acute hospitals to facilitate hospital discharge:

Epsom and St Helier Hospitals

St George’s Hospital

Mayday Hospital

Kingston Hospital.

5.8.18. SMCS work in partnership with St. Helier Hospital where provides acute inpatient treatment is provided. The rapid response intervention teams in the accident and emergency departments at St Helier and St George’s hospitals provide holistic assessment to ensure patients are appropriately discharged.

5.8.19. There is a unique partnership with the local authorities for children’s services and children’s safeguarding is managed through the Local Safeguarding Children’s Board.

5.8.20. SMCS also work with voluntary services:

the Community Neurotherapy Team has strong links with the Stroke Association

the Podiatry Service works closely with Age UK Sutton and Age UK Merton.


40

6. Safeguarding and safety

6.1. Protection and identification of vulnerable adults

6.1.1. Alerts

In Quarter One there were two safeguarding adult alerts in the Trust excluding Sutton and Merton Community Services (described below). In both cases a safeguarding referral was made to the patient’s local authority following reports of threats of abuse/neglect against the patient.

In one of the cases a patient reported physical abuse from their carer but did not wish to take any further action.

In the other case the Trust reported a safeguarding alert after a patient required admission from a nursing home with evidence of neglect. Neglect was confirmed by the local authority’s Social Services Department.

There were thirteen safeguarding adult alerts in Sutton and Merton Community Services (including five referrals to the local authority’s Social Services department).

Seven were from patients expressing their wish to end their life. All of these cases were referred back to the patient’s GP for urgent follow up.

Three alerts were about patient needs not being met either by the family, by the nursing home, or due to the lack of cooperation of the patient. These were resolved by support from social services.

Two alerts were concerns for patient safety as contact could not be made. These were resolved through communication with GPs.

The final incident related to a relative giving a palliative care patient large doses of a controlled drug. This is currently being investigated.

6.1.2. Training and education

In Quarter One 412 staff attended safeguarding adult training, compared with 460 for the same period last year (excluding Sutton and Merton Community Services described below). Although this is slightly lower than the previous year, it is higher than Quarters Three and Four of 2010/11. All clinical and non-clinical staff receive level 1 training as part of their Trust induction. All nurses and allied health care professionals receive level 2 training at induction and at mandatory training. The teaching is provided by either the Trust’s Safeguarding Adult Lead, the Nurse Practice Educators using case scenarios, or recorded presentations. Participants score the training highly.

In Sutton and Merton Community Services 21 staff received level 1 training and 31 received level 2 or above. Last year there was a big emphasis on staff training and 629 out of 835 staff (75%) were trained. The training requirements are slightly different to the rest of the Trust: level one is for all staff, level 2 for clinical staff working with adults and Levels 3 and 4 are for managers involved in supervising staff involved in safeguarding cases and managing investigations.


41

6.2. Protection and identification of vulnerable children and young adults

6.2.1. Performance monitoring indicators

Quarter 3 2010/11

Quarter 4 2010/11

Quarter 1 2011/12

Children admitted with Child Protection Plan (CPP) 3 2 0

Children admitted with allocated social worker or Looked After Child (LAC) 4 2 1

Common Assessment Frameworks (CAFs) completed 0 1 0

Number of child protection medicals completed 0 0 0

Referrals to Children’s Social Care (CSC) 4 3 0

Referrals/CAFs to CSC Child in Need 0 1 0

Staff involved in dealing with safeguarding cases given supportive sessions to learn from their experience and develop their expertise 3 4 3

6.2.2. Safeguarding children - training

Eligible staff who have completed safeguarding training

Quarter 3 2010/11

Quarter 4 2010/11

Quarter 1 2011/12

Safeguarding Children Level 1 85% 84% 80%

Safeguarding Children Level 2 60% 65% 81%

Number of staff attending inter-agency safeguarding children training (at any level) 0 1 2

6.2.3. Safeguarding children - governance

Quarter 3 2010/11

Quarter 4 2010/11

Quarter 1 2011/12

Number of serious incidents involving children 0 0 0

Allegations made against staff 0 0 0

Allegations referred to Local Authority Designated Officer 0 0 0

Active Serious Case Reviews / Independent Management Reviews 0 0 0


42

6.3. National Patient Safety Agency

6.3.1. The National Patient Safety Agency is responsible for safety alerts, rapid response reports and patient safety recommendations.

6.3.2. There were no new alerts this quarter.

6.3.3. Action plans that review compliance against the requirements of these alerts are monitored by the Trust’s Integrated Governance and Risk Management Committee.

6.4. Pressure ulcers

6.4.1. The number of pressure ulcers affecting patients 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.

6.4.2. Figures for Quarter One now include Sutton and Merton Community Services division unless indicated otherwise.

6.4.3. Pressure ulcers are graded according to the Sterling pressure ulcer classification at the Trust’s inpatient wards and by the European Pressure Ulcer Advisory Panel (EPUAP) classification for the community services division (see the tables on page 45). It is planned to implement the EPUAP system throughout the Trust later in the year.

6.4.4. There were eight pressure ulcers at grades 3 and 4 from Sutton and Merton Community Services requiring reporting under the national serious incident reporting system.

April 2011

May 2011

June 2011

All pressure ulcers 26* 116 140

Pressure ulcers acquired at the Trust 8* 12 27

All pressure ulcers graded below 1.2 7* 6 9

All pressure ulcers graded 2.0 to 2.4 1* 3 13

All pressure ulcers graded 3.0 to 3.4 0 3 4

All pressure ulcers graded above 4.0 0 0 1

* figures for SMCS pressure ulcers at grade 2 and below were not available for April.


43

6.4.5. Trust-acquired pressure ulcers

0

5

10

15

20

25

30

April

May

Jun

e

July

Au

gust

September

October

Novem

ber

Decem

ber

Janu

ary

Febru

ary

March

2009/102010/112011/12

6.4.6. The number of patients who acquired pressure ulcers at the Trust is presented in the following tables. The tables are ordered by severity and show the wards and (in SMCS) clusters where the ulcers developed.

6.4.7. The number of patients may be lower than the number of pressure ulcers because a patient may develop more than one pressure ulcer.

6.4.8. Number of patients with ulcers graded 1.2 and below – Chelsea

Ward April 2011

May 2011

June 2011

Wilson 1 1 2

Wiltshaw 3 1 0

Critical Care Unit 1 1 1

Burdett Coutts 0 1 1

Total 5 4 4


44

6.4.9. Number of patients with ulcers graded 1.2 and below – Sutton

Ward April 2011

May 2011

June 2011

Smithers 1 0 0

Bud Flanagan West 0 0 1

Total 1 0 1

6.4.10. Number of patients with ulcers graded 1 – SMCS

District Nurse April 2011

May 2011

June 2011

Cluster 1 1 0 0

Cluster 2 0 0 1

Cluster 3 1 0 2

Cluster 4 0 1 0

Cluster 7 0 0 2

Cluster 10 1 0 1

Cluster 12 0 0 1

Total 3 1 7

6.4.11. Number of patients with ulcers graded 2.0 to 2.4 – Chelsea

Ward April 2011

May 2011

June 2011

Burdett Coutts 1 0 0

Total 1 0 2

6.4.12. Number of patients with ulcers graded 2.0 to 2.4 – Sutton

Ward April 2011

May 2011

June 2011

Smithers 0 1 0

Wilson 0 0 2

Robert Tiffany 0 0 1

Total 0 1 3


45



May 2011

June 2011

Cluster 1 1 0 1

Cluster 3 0 0 2

Cluster 4 2 1 0

Cluster 7 0 1 3

Cluster 8 0 0 1

Cluster 10 2 0 0

Total 5 2 7

6.4.14. Number of patients with ulcers graded 3.0 to 3.4 – Chelsea and Sutton

No patients acquired ulcers graded 3.0 to 3.4 in Chelsea or in Sutton.



May 2011

June 2011

Cluster 4 0 2 0

Cluster 8 0 0 3

Cluster 10 0 1 1

Total 0 3 4

6.4.16. Number of patients with ulcers graded 4.0 and above – Chelsea and Sutton

No patients acquired ulcers graded 4.0 or above in Chelsea or in Sutton.



May 2011

June 2011

Cluster 8 0 0 1

Total 0 0 1


46

6.4.18. Sterling pressure ulcer grades

Sterling Description of stage

0 No clinical evidence of a pressure ulcer

0.1 Healed with scarring

0.2 Tissue damage not assessed as pressure ulcer

1.1 Non-blanching hyperaemia

1.2 Blue/purple/black discolouration

2.0 Partial thickness skin loss – epidermis and/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

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

EPUAP Description of stage

1 Non blanching redness of intact skin

2 Partial thickness skin loss or blister

3 Full thickness skin loss (fat visible)

4 Full thickness tissue loss (muscle/bone visible)


47

6.5. Infection prevention and control

6.5.1. Clostridium difficile infection (CDI)

There have been four cases of Clostridium difficile infection (CDI) attributable to the Trust this year.

Sutton Chelsea Total

April 0 1 1

May 0 1 1

June 1 1 2

Total 1 3 4

The Trust target is to have no more than 4.8 cases by the end of Quarter One.

0

5

10

15

20

25

April

May

Jun

e

July

Au

gust

September

October

Novem

ber

Decem

ber

Janu

ary

Febru

ary

March

CD

I ca

ses

sin

ce 1

Apr

il 2

011

Trust target

Sutton

Chelsea

Trust cumulative total


48

Root cause analysis for the four attributable cases of CDI in Quarter One.

0

1

2

3

4

A ppr opr ia tea n tim icr obia l

th er a py

Tim ely isola t ion Su r g ica l Medica l

6.5.2. Meticillin-resistant Staphylococcus aureus (MRSA) bacteraemia

There have been no cases of meticillin-resistant Staphylococcus aureus (MRSA) bacteraemia (bacterial presence in the blood) in the quarter. The Trust target is to have no cases.

6.5.3. Occupation of beds by patients with MRSA

0

20

40

60

80

100

120

140

April May June

Inpa

tien

t da

ys

Sutton

Chelsea


49

6.5.4. Trust wide compliance with MRSA screening

90% 90% 89%

0%

10%

20%

30%

40%

50%

60%

7 0%

80%

90%

100%

April May June

These compliance rates do not account for any delays in the specimens reaching the laboratory and are therefore thought to be 5% higher than reflected.


50

6.5.5. Ward MRSA screening admission compliance

(Horder ward opened in June).

0% 20% 40% 60% 80% 100%

Bu r dett Cou tts

Ellis

Hor der

Ma r ku s

Su r g ica l Un it

Tr a n sit ion a l Ca r eUn it

Wilson

Wiltsh a w

Bu d Fla n a g a n Ea st

Bu d Fla n a g a n West

Ken n a w a y

McElw a in

Oa k

Rober t Tiffa n y

Sm ith er s

April May June


51

6.5.6. Meticillin-sensitive Staphylococcus aureus (MSSA) bacteraemia

Quarter One saw the introduction of mandatory surveillance of meticillin-sensitive Staphylococcus aureus (MSSA) bacteraemia. There is no target set for this. No MSSA bacteraemia was reported in this quarter.

6.5.7. Hand hygiene by staff group

80%

85%

90%

95%

100%

Ap

ril Week 1

Ap

ril Week 2

Ap

ril Week 3

Ap

ril Week 4

May W

eek 1

May W

eek 2

May W

eek 3

May W

eek 4

Jun

e Week 1

Jun

e Week 2

Jun

e Week 3

Jun

e Week 4

Doctors

Nurses

Allied health professionals


52

6.5.8. High impact intervention compliance.

High impact intervention audits or care bundles are undertaken monthly on all clinical areas. This quarter has seen low compliance in antimicrobial prescribing, this is being addressed in training and weekly antimicrobial rounds are now in place to raise awareness and feedback issues to prescribers

0% 20% 40% 60% 80% 100%

CVAD* insertion

CVAD* ongoing

Peripheral catheter Insertion

Peripheral catheter Ongoing

Prev enting SSI† peri-operativ e

Prev enting SSI† pre-operativ e

Ventilated patients suctioning

Ventilated patients care bundle

Urinary catheter insertion

Urinary catheter ongoing

Antimicrobial prescribing

Equipment

April May June

* CVAD: Central venous access device † SSI: Surgical site infection

6.6. Management of medicines

6.6.1. Pre-admission

Pharmacists continue to provide support to multidisciplinary pre-admission clinics at Chelsea to accurately record the medicines that patients are taking. This ensures that the medicines are accurately prescribed and available when patients are admitted to hospital. It is now planned to extend this to Sutton.


53

6.6.2. Medicines management

The Trust is developing procedures to support changes in the way medicines are managed, such as:

management of controlled drugs

patients’ own drugs on admission

dispensing for discharge

patient self-administration of medicines on pilot wards.

Following audits in the last quarter to identify the reasons behind pharmacy staff interventions when screening prescriptions, a number of recommendations are in the process of implementation. These include the redesigning of inpatient, outpatient and discharge prescription forms and recommendations to be sent to every prescriber to remind them of simple steps to safer prescribing.

An audit to review storage of medicinal products in the Trust has been completed and recommendations made to ensure safe and secure storage of drugs and medical gases.

Following findings from the national cancer patient survey that patients were not fully aware of their entitlement to a prescription exemption certificate a number of measures have been introduced. Information is to be provided to every inpatient at discharge and to all outpatients who receive a prescription. Posters are being displayed in clinics and information displayed on the electronic notice boards in the outpatients departments and in pharmacy.

The integration of The Royal Marsden NHS Foundation Trust and Sutton and Merton Community Services Medicines Management policies is continuing. The potential for development of services is being scoped. A collaborative approach to pharmacy and medicines services is being developed with adjoining sectors of Community Services pharmacy teams.

A project to determine the feasibility and the impact on efficiency and safety of providing pre-prepared injectable medication to wards is underway.

6.6.3. Home delivery of medicines

The home delivery service for oral anti-cancer agents continues to expand and 125 patients are registered to receive the service. It is planned to extend the model to other supportive medicines to maximise benefit to patients.

A pilot of administration of Trastuzumab (Herceptin) in patients’ homes is underway with 16 patients now registered. If successful, the service will be extended to more patients and medicines.

6.6.4. Discharge planning

Following the results of a discharge audit in the last quarter a wider range of pre-dispensed medication packs are being introduced to improve the efficiency of supply of medications at discharge and enable supply of certain medications direct from the ward.


54

6.6.5. Audits

A number of internal audits have been conducted in the quarter, resulting in recommendations to improve efficiency, reduce patient waiting times and minimise risks. Recommendations from these audits will be implemented in the next quarter.

These included:

pharmacy prescription intervention

clinical trial prescription processes and workflows

review of dietetic product supplies to patients.

External auditors audited pharmacy dispensary and procurement services as part of the British Standards Institute ISO 9001 accreditation. This is a regular governance audit undertaken every two years. There were no deficiencies identified.

6.7. Medical devices

There were 33 incidents in Quarter One related to medical devices. Data from Sutton and Merton Community Services (SMCS) has been included starting with this quarter, which may account for the increase on the previous quarter. None of the incidents resulted in harm to patients or staff.

There was an increase in the unavailability of equipment from two to seven. This was mainly in Chelsea but was varied and was not related to any one area or any one piece of equipment.

6.7.1. Medical device incidents by site

0 4 8 12 16

Equipmentunavailable

Damaged/faultyequipment

Used wrongequipment or

dev ice

User errorChelseaSuttonSutton and Merton Community Serv ices


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6.7.2. Medical device incidents compared with the previous quarter

0

5

10

15

20

25

Quarter 4 2010/11 Quarter 1 2011/12

Equipment unavailableDamaged/faulty equipmentUsed wrong equipment or dev iceUser error

6.7.3. Evaluation of new devices

There were 13 proposals to evaluate new equipment. Four evaluation reports were presented and all were approved for purchase.

6.8. Waste management

6.8.1. Clinical Waste – Chelsea

High temperature incineration and alternative treatment have increased since Quarter One 2010/11.

0

1

2

3

4

5

6

7

8

April 2011 May 2011 June 2011

Ton

nes

High temperature incinerationAlternative treatment


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6.8.2. Clinical waste – Sutton

The amount of waste processed by alternative treatment has increased by 4.5%. Offensive waste is being managed separately in the Day Nursery to comply with the action required following the Environment Agency visit.

0

1

2

3

4

5

6

7

8


Ton

nes

High temperature incinerationAlternative treatment

6.8.3. Domestic waste – Chelsea

The overall tonnage is down by 1%.

0

5

10

15

20

25

30

35


Ton

nes

LandfillRecy cling

6.8.4. Domestic waste – Sutton

The total amount of domestic waste produced at Sutton has been reduced by 23% since Quarter One 2010/11 following the introduction of an internal


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recycling scheme for unwanted furniture and internal audits that have identified waste streams more accurately.

0

5

10

15

20


Ton

nes

LandfillRecy cling

6.9. Fire

6.9.1. Statutory compliance

All premises that the Trust owns, occupies or manages have fire risk assessments in compliance with the Regulatory Reform (Fire Safety) Order 2005.

The Trust has developed a capital fire infrastructure programme for both sites with the London Fire and Emergency Planning Authority (LFEPA) to eliminate or reduce fire risk to as low as reasonably practicable.

The Trust has not been subject to any enforcement action by LFEPA.

The Trust has no unresolved enforcement actions to implement.

The Trust complies with the Department of Health’s Fire Safety Policy contained within health technical memorandum (HTM) 05-01.

The Trust is confident that, in relation to design and layout, where premises are altered or their use is changed, the continued safety and suitability of the premises has been maintained.

Appropriate fire safety measures are incorporated into project design as required by the Department of Health’s Firecode guidance document.

6.9.2. Fire risk assessments

All fire risk assessments are reviewed annually and regular risk register update meetings are held.


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6.9.3. Fire preparedness

The Trust maintains fire preparedness. It tests the use and function of the fire detection systems, fire alarms and fire extinguishing equipment; prepares employees for competent performance during a fire emergency; ensures employees are aware of potential fire hazards; and promotes a safe environment for patients, employees, students and all other visitors.

6.9.4. Pre-planned evacuation procedures

The Trust operates a two-stage fire alarm system in support of its planned procedure of progressive horizontal evacuation. Sounding of the continuous alarm indicates that there may be a fire in the local zone. Sounding of the intermittent alarm indicates that there may be a fire in an adjacent zone.

6.9.5. Simulated evacuations

Simulated evacuation exercises are undertaken every year with records of learning outcomes maintained. Clinical areas and operating theatres carry out ‘table-top’ exercises rather than evacuation exercises.

6.9.6. Fire events

There were 24 fire incidents in the quarter, none of which resulted in harm to patients or staff. This included one actual fire:

Fire in external flowerbed: extinguished by water extinguishers (risk grade – insignificant).

0 1 2 3 4 5 6 7 8 9 10 11 12

Actual fire

Call point activ ated - accidentallyoperated

Damage - call points

Detector activ ated - dust, smoke,building works

Detector activ ated - electrical equipment

Detector activ ated - kitchens

Detector activ ated - ov erheating of area

Detector activ ated - water leak

Sy stem fault - detectors cov ered


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6.9.7. Number of fire incidents in the last five quarters

0 4 8 12 16

Actual fire

Call point activated - accidentally operated

Damage - call points

Detector activated - dust, smoke, building works

Detector activated - electrical equipment

Detector activated - kitchens

Detector activated - overheating of area

Detector activated - toaster

Detector activated - water leak

Sy stem fault - detectors covered

Sy stem fault - fire alarm sy stem

Quarter 1 2010/2011

Quarter 2 2010/2011

Quarter 3 2010/2011

Quarter 4 2010/2011

Quarter 1 2011/2012

6.10. Estates projects – Chelsea

6.10.1. Horder Ward

Horder Ward has provided inpatient palliative care since the 1970s. The ward design and layout needed to be modernised to provide an effective environment to continue the Trust’s excellent level of care whilst respecting patients’ privacy and dignity.

A two-phase project started on site in January 2010. Phase One comprises the ward refurbishment and reconfiguration and Phase Two consists of a new


60

extension providing a patient and visitor day room and palliative care team offices.

Phase One was completed in May 2011. The new ward design provided

improved patient facilities

improved patient privacy and dignity

improved patient focus

increased infection control and patient safety.

Phase Two - the new extension - will be completed in November 2011 when roof work associated with the positron emission tomography (PET) scanner is complete.

6.10.2. Cyberknife

In 2010, the Trust decided to replace its old brachytherapy suite with a CyberKnife, the latest in radiotherapy technology for delivering highly conformal, image-guided, adaptive and high-dose radiotherapy. The CyberKnife precisely delivers pencil thin beams of radiation from a large number of angles, the major advantages of the system being that it continuously tracks and corrects for movement of both the patient and the tumour and can deliver radiotherapy with 0.5mm accuracy.

6.10.3. Cyberknife – works in progress

Breaking out of existing area for installation of floor slab for pit for new machine

Reinforcement and service ducts placed in the excavation.

The first layer of reinforcement received the concrete infill, and the second layer of reinforcement was applied, along with the formwork for the final pit.

The machine supplier installed the necessary bases and the contractor installed the final set of reinforcement bars. The base was filled with concrete and the machine bases were installed to the concrete pit.


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6.10.4. Cyberknife – lead shielding

The installation of this state-of-the-art machine highlighted that the existing shielding was insufficient. Lead chevrons, flexible enough to work within the existing structure of the bunker, with thicknesses varying from 20mm to 150mm, were installed to provide the necessary increased bunker shielding requirements. The interlocking bricks, 93 tonnes of them in total, lined the existing concrete walls.

The junction between the new lead chevron walls and the existing steel roof required an innovative solution from both a design and installation perspective to ensure that this critical point, potentially a source of radiation leak, was efficiently sealed to preserve the integrity of the bunker.

Lead bricks Lead chevrons Lead door

The final component of this project was the installation of a 1500mm wide shielded automatic swing door, weighing 800kg and with 10mm of lead shielding.

Cyberknife treatment bunker Cyberknife ceiling feature in treatment bunker

6.10.5. Education and conference area

Following the fire in January 2008 and the building of the staff refectory, the Trust identified that the education and conference area was without suitable facilities to support the Trust’s programme of study days, conferences and hospitality events to maintain the already successful revenue stream.

A programme of works, funded by the Royal Marsden Cancer Charity, was established to provide the following facilities:

a new meeting and refreshment area

a function room to accommodate over 90 guests

upgraded and redesigned toilet facilities

redesigned wheelchair-access toilet facilities

upgraded audio visual equipment

a redesigned reception area.


62

Work started on site date in November 2010 and this project was successfully completed in April 2011, with the first event, fundraising, held in May.

6.10.6. Electrical infrastructure works

Wallace Wing

Work continues on the permanent interconnector that will allow additional power to the Chelsea Wing.

Chelsea Wing

Works continue next to Oratory Building for the new Chelsea Wing generator to provide the necessary oil storage capacity. Works are now scheduled for completion in September 2011.

Horder Ward

The Horder Ward project incorporates much needed infrastructure support and will be served by new installations located on the Granard House roof. This includes rationalisation of water storage, relocation of boilers to roof level, improved medical gas installations, installation of a new waste-disposal lift and the existing lift made into to a full size bed and fire-fighting lift. In order to accelerate the Horder Ward programme, essential plant services such as heating and hot and cold water services were provided in advance of the completion of the new installations.

6.10.7. Fire works

The upgrade of the automatic fire alarm is scheduled for completion in early 2012.

6.11. Estates projects – Sutton

No major projects were completed between April 2011 and June 2011.

6.11.1. Infrastructure – high voltage ring

The purpose of the high voltage ring is to provide increased electrical resilience to the site. Phase One has been completed and Phase Two of the ring is due for completion as an element of the Centre for Molecular Pathology development.

6.11.2. Fire works

East and West Staircases

Fire works to the East Staircase were completed in April 2011. The West Staircase is under design and the works are scheduled to begin early 2012. The project also raises the level of protection to patient areas of this stair to the standard required by the Firecode health technical memorandum (HTM) 05-01.


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7. Suitability of staffing

7.1. Workforce

Human resources performance indicators for the most recent four quarters

Trust target

Quarter 2 2010/11

Quarter 3 2010/11

Quarter 4 2010/11

Quarter 1 2011/12

CORPORATE AND PRIVATE PRACTICE

Turnover* 9% 9.0% 10.9% 9.9% 12.4%

Vacancies† 10% 12.1% 11.4% 10.6% 12.7%

Sickness absence‡ <3% 2.6% 2.9% 3.8% 3%

Agency spend as % of total pay‡

7.5% 6.8% 8.3% 7.2% 8.6%

CANCER SERVICES

Turnover* 9% 8.8% 10.6% 8.0% 7.3%

Vacancies† 10% 11.0% 12.5% 9.6% 9.7%

Sickness absence‡ <3% 2.2% 1.9% 2.1% 2.4%

Agency spend as % of total pay‡ 7.5% 5.8% 4.5% 5.8% 4.4%

CLINICAL SERVICES

Turnover* 9% 9.8% 10.7% 10.0% 10.5%

Vacancies† 10% 10.9% 11.7% 10.0% 8.4%


Agency spend as % of total pay‡ 7.5% 5.8% 5.3% 5.6% 4%

TRUST TOTAL

Turnover* 9% 9.2% 10.7% 9.9% 10.3%

Vacancies† 10% 11.3% 11.7% 9.6% 10.1%


Agency spend as % of total pay‡

7.5% 6.0% 5.8% 6.1% 5.3%

* annualised † difference between budgeted establishment and staff in post ‡ average percentage for quarter


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7.1.1. Workforce comparators against similar sized and specialist trusts in London April 2011

Trust name (similar sized trusts)

Staff in post*

Paybill cost of staff in post

Average cost per employee

Staff turnover

Staff sickness

Chelsea and Westminster Hospital NHS Foundation Trust 2,849 £11,883,875 £4,171 0.7% 2.8%

Croydon Health Services NHS Trust 3,016 £11,475,591 £3,805 1.1% 3.2%

Hillingdon Hospital NHS Foundation Trust 2,426 £9,166,754 £3,779 0.6% 3.5%

Homerton University Hospital NHS Foundation Trust 3,052 £11,664,113 £3,821 0.7% 3.2%

Kingston Hospital NHS Trust 2,422 £9,444,571 £3,900 0.8% 2.7%

Lewisham Hospital NHS Trust 2,879 £11,190,656 £3,887 0.7% 3.6%

Newham University Hospital NHS Trust 2,307 £7,720,062 £3,346 0.9% 3.6%

North East London NHS Foundation Trust 2,239 £8,211,684 £3,668 0.8% 4.1%

North Middlesex University Hospital NHS Trust 2,193 £8,505,551 £3,878 1.0% 3.4%

Whittingon Hospital NHS Trust 3,643 £13,686,759 £3,757 0.9% 2.8%

Trust name (specialist Trusts)

Staff in post*

Paybill cost of staff in post

Average cost per employee

Staff turnover

Staff sickness

Great Ormond Street Hospital for Children NHS Trust 3,433 £14,534,681 £4,234 0.9% 2.3%

Royal Brompton and Harefield NHS Foundation Trust 2,817 £12,196,159 £4,330 1.3% 2.2%

The Royal Marsden NHS Foundation Trust† 2,545 £10,129,391 £3,980 1.1% 2.5%

Royal National Orthopaedic Hospital NHS Trust 1,089 £4,281,910 £3,930 1.3% 3.1%

* whole time equivalent † not including Sutton and Merton Community Services (SMCS).


65

7.2. Appraisal rates

7.2.1. The appraisal rate for Quarter One was 78%. Performance management reports are circulated to individual managers, the Management Executive and the Board.

7.2.2. It is not possible currently to report on the Sutton and Merton Community Services appraisal rate but a system for monitoring and reporting is being established and the figures will be reported in Quarter Two.

7.2.3. The chart below shows the appraisal rates for all staff groups for the last two years, for the three divisions and consultants.

0

10

20

30

40

50

60

7 0

80

90

100

Quarter 22009/10

Quarter 32009/10

Quarter 42009/10

Quarter 12010/11

Quarter 22010/11

Quarter 32010/11

Quarter 42010/11

Quarter 12011/12

Per

cen

t co

mpl

eted

Overall Trust appraisal rateCancer Serv ices Clinical Serv ices Private Patients Consultant appraisal rate

7.2.4. The overall Trust appraisal rate has remained steady. Whilst there has been a slight decline in the rate for Cancer Services Division, there has been an increase in the rate for Clinical Services.

7.2.5. The consultant appraisal rate remains stable at 79%.

7.2.6. The Trust is putting in place arrangements for the revalidation of doctors, which includes strengthening appraisals and ensuring that all doctors in the Medical Director’s responsibility have an annual appraisal. The current appraisal rate for those doctors is 60% and actions are being taken to ensure all doctors have an appraisal.


66

7.2.7. The chart below shows the appraisal rate by directorates and teams over the last two years.

0

10

20

30

40

50

60

7 0

80

90

100

Quarter 22009/10

Quarter 32009/10

Quarter 42009/10

Quarter 12010/11

Quarter 22010/11

Quarter 32010/11

Quarter 42010/11

Quarter 12011/12

Per

cen

t co

mpl

eted

Finance

Workforce and Corporate Affairs

Performance and Strategy Implementation

Nursing, Risk and Quality

Facilities

Capital Projects & Estates

Clinical Research and Development

7.2.8. Whilst there has been some variation in the appraisal rates over the period, the rate remains high for most of the directorates. There is greater fluctuation and lower appraisal rates for the directorates with smaller numbers of staff; Clinical Research and Development and Capital Projects and Estates.


67

7.3. Mandatory training – cancer specialist services

7.3.1. The following charts show mandatory training attendance over the last two years.

7.3.2. Fire Training is mandatory for all clinical staff every year, and for staff working in non-clinical areas every two years. Quarter One fire training attendance shows a favourable increase on the previous two quarters. Training in manual handling for all patient handlers is mandatory annually and attendance rates remain higher than in the previous quarter. Non-patient handling for non-clinical staff is mandatory every three years and attendance has decreased slightly over the past year. An e-learning package has been approved as a method for updating training in this area and is expected to increase compliance over time. Details of e-learning courses available will be given to staff in the next quarter.

0

100

200

300

400

500

600

7 00

800

900

Quarter 22009/10

Quarter 32009/10

Quarter 42009/10

Quarter 12010/11

Quarter 22010/11

Quarter 32010/11

Quarter 42010/11

Quarter 12011/12

Nu

mbe

r of

Sta

ff

Nurse mandatory trainingNon-patient manual handling (back care awareness)Manual handlingFire training


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7.3.3. Annual Infection Control training is a mandatory requirement for all staff. Attendance figures for this quarter have increased from the previous quarter. Attendance figures for Risk management training remain high, supported by the ongoing additional training on the online Datix Web tool, the new incident reporting system. Basic life support (BLS) training each year is mandatory for all clinical staff and attendance continues to rise. All clinical staff involved in research are required to attend mandatory training in good clinical practice.

0

100

200

300

400

500

600

7 00

800

900

1000

Quarter 22009/10

Quarter 32009/10

Quarter 42009/10

Quarter 12010/11

Quarter 22010/11

Quarter 32010/11

Quarter 42010/11

Quarter 12011/12

Nu

mbe

r of

sta

ff

Basic life support (including paediatric BLS)Infection prevention and controlRisk management awarenessGood clinical practice

7.3.4. Attendance rates for Safeguarding Children, Vulnerable Adults and Mental Capacity Act training this quarter have remained steady and following a similar pattern compared with the previous year. This training is mandatory for nursing staff annually and for all other staff every three years.

0

200

400

600

800

1000

1200

1400

1600

1800

Quarter 22009/10

Quarter 32009/10

Quarter 42009/10

Quarter 12010/11

Quarter 22010/11

Quarter 32010/11

Quarter 42010/11

Quarter 12011/12

Nu

mbe

r of

sta

ff

Safeguarding childrenSafeguarding adults Mental Capacity Act


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7.3.5. Attendance at Conflict Resolution training has shown a drop in attendance numbers this quarter due to less courses being scheduled for this period, however attendance is similar to the same period in the previous year. This training is mandatory for frontline staff only. Attendance at Equality and Diversity training (mandatory for all staff every three years) has dropped slightly compared to the previous quarter. An e-learning package is being developed for equality and diversity, scheduled for release in Quarter Three. The format and availability of both of these mandatory training topics has been restructured to enable staff to attend both topics in one day instead of separate days. It is envisaged that this will help to increase compliance. Attendance at Cultural Competence in Caring for Muslim Patients is included in the Equality and Diversity figures.

0

20

40

60

80

100

120

140

160

Quarter 22009/10

Quarter 32009/10

Quarter 42009/10

Quarter 12010/11

Quarter 22010/11

Quarter 32010/11

Quarter 42010/11

Quarter 12011/12

Nu

mbe

r of

Sta

ff

Equality and diversity trainingConflict resolution for frontline staff


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7.4. Mandatory training – Sutton and Merton Community Services (SMCS)

The chart below shows mandatory training attendance for 2010/11 for Sutton and Merton Community Services (SMCS). Data for 2009/10 is not available in this format. Mandatory training requirements for Community Services staff in accordance with the SMCS Mandatory Training Policy differ in some cases from requirements for specialist cancer staff. Key differences include that SMCS staff are only expected to attend conflict resolution, equality and diversity, and risk management training at induction. The frequency of attendance for SMCS staff for the different mandatory training topics is being reviewed through the Mandatory Training Monitoring Group.

0 100 200 300 400 500 600

Mental Capacity Act

Non-patient Manual Handling

Conflict Resolution for Frontline Staff

Equality and Diversity

Risk Management Awareness

Safeguarding Children (Level 1 and 2)

Safeguarding Children (Level 2+ and above)

Safeguarding Adults (Level 1)

Safeguarding Adults (Levels 2 and above)

Manual Handling

Infection Control

Fire Training

Basic Life Support (including Paediatric BLS)

Attendances


71

7.4.1. The rates for Equality and Diversity and Conflict Resolution are very similar as attendance is a requirement for all new starters and thus the rates reflect the numbers of staff attending induction. It is proposed to introduce an update programme for conflict resolution during 2011/12 for existing staff.

0

10

20

30

40

50

60

7 0

80

Quarter 12010/11

Quarter 22010/11

Quarter 32010/11

Quarter 42010/11

Quarter 1 2011/12

Nu

mbe

r of

Sta

ffEqu a lity a n d div er sity tr a in in g

Con flict r esolu tion for fr on t lin e sta ff

7.4.2. The rates for Manual Handling and Fire training mirror each other as for clinical staff these topics are included in mandatory training days. The peak represents a concerted push from senior and clinical managers to ensure that their staff have attended mandatory training. The figures for Non-Patient Manual Handling (e-learning) have dipped significantly over the last three quarters however the requirement to update is three yearly. A publicity campaign to highlight the need for staff to complete this is planned.

0

50

100

150

200

250

300

Qu a r ter 12 01 0/1 1

Qu a r ter 22 01 0/1 1

Qu a r ter 32 01 0/1 1

Qu a r ter 4 2 01 0/1 1

Qu a r ter 1 2 01 1 /1 2

Nu

mbe

r of

Sta

ff

Non -pa t ien t m a n u a l h a n dlin g (ba ck ca r e a w a r en ess)

Ma n u a l h a n dlin g

Fir e tr a in in g


72

7.4.3. The rates for Basic Life Support and Infection Control mirror each other over the last five quarters as they are delivered as part of mandatory training days for clinical staff working with both adults and children. The lowest attendance was in Quarter One of 2010 whilst the Education Department was moving base and establishing a new training centre resulting in less sessions running. The rates then rose, peaking in Quarter Three and dropping off in Quarter Four. The Quarter One 2011/12 rates are higher than in 2010/11 but are below the peak as fewer people are due their annual update in Quarter One. Plans are in place to have additional mandatory training sessions in Quarter Two and Quarter Three to meet the demand for annual updates.

7.4.4. SMCS staff are required to complete Risk Management training once at induction. The dip in Quarter Two represents the seasonal dip in recruitment over the summer holiday period.

0

50

100

150

200

250

300

Quarter 12010/11

Quarter 22010/11

Quarter 32010/11

Quarter 42010/11

Quarter 12011/12

Nu

mbe

r of

sta

ff

Basic Life Support (including paediatric BLS)

Infection Control

Risk Management Awareness

7.4.5. The Safeguarding Adults data shows the range of training needed for SMCS staff at levels 1 to 4. The training requirement is more extensive than for staff in the hospitals due to the level of involvement of staff caring for vulnerable patients in the community. Level 1 is for all staff and level 2 for clinical staff working with adults. Levels 3 and 4 are for managers supervising staff involved in safeguarding cases and managing investigations. Currently at level 1 staff receive a taught session at induction and take the level 1 e-learning programme hosted by the London Borough of Sutton. Data for attendance at London Borough of Sutton courses is incomplete and this is being followed up. The levels mirror those for the induction of new staff. At level 2 there was a peak in Quarter Four due an intensive internal programme delivered for clinical staff while ongoing updates are delivered by the boroughs. The numbers of managers who need to do levels 3 and 4 are very small so are grouped with the level two figures.

7.4.6. The Safeguarding Children training consists of several levels of training required for different types of staff. The training is more extensive than for staff


73

in the hospital setting due to the significant role of staff working with vulnerable children in the community. Level 1 and 2 training is required for all staff and is completed at induction and by e-training. Level 2+ is taught internally. Levels 3 and above are attained using a range of borough-based multidisciplinary updates for clinical staff working with children and a programme delivered by King’s College London for supervisors and managers. The attendance peak during Quarter Three is due to the timing of these sessions.

7.4.7. The Mental Capacity Act training is delivered by e-learning hosted by the London Borough of Sutton and by taught sessions at St Helier for the staff based there. Data from these external providers is incomplete and the June figures are not included. The levels for this are consistently low.

0

50

100

150

200

250

300

Qu a r ter 12 01 0/1 1

Qu a r ter 22 01 0/1 1

Qu a r ter 32 01 0/1 1

Qu a r ter 42 01 0/1 1

Qu a r ter 12 01 1 /1 2

Nu

mbe

r of

sta

ff

Sa feg u a r din g ch ildr en (Lev els 1 & 2 )

Sa feg u a r din g ch ildr en (Lev els 2 + & a bov e)

Sa feg u a r din g a du lts (Lev el 1 ) *

Sa feg u a r din g a du lts (Lev els 2 & a bov e)

Men ta l Ca pa city A ct

* Some data will be counted twice as on separate systems

7.5. Continuing professional development

7.5.1. This section describes continuing professional development in different staff groups each quarter. This quarter considers the Physics Department and Cancer Therapy Services, which includes Complementary Therapy, Nutrition and Dietetics, Lymphoedema, Occupational Therapy, Physiotherapy and Speech and Language Therapy.

7.5.2. The Physics Department currently accepts medical physics trainees working towards the Association of Clinical Scientists Certificate of Attainment required for statutory registration as a Clinical Scientist, under the Institute of Physics and Engineering in Medicine Part I and Part II Training Schemes. As from October 2011, the Physics Department will be involved with training of medical physicists under the new Modernising Scientific Careers training scheme.

7.5.3. Courses related to the fundamental physics of four of the major specialities practised within the Department have been run over the past year. These offered both taught and practical sessions, and were attended by an international


74

audience of external delegates, as well as by staff, internal PhD students and MSc students from King's College London.

7.5.4. A specialist course on Intensity Modulated and Image Guided Radiotherapy in Clinical Practice was run and was well attended by both external delegates and staff. The course was accredited by the Royal College of Radiologists.

7.5.5. The Physics Department on both sites continues to run a program of lunchtime seminars, with both internal and invited external speakers. These seminars are open to all staff and students.

7.5.6. In Cancer Therapy Services 11 therapists are undertaking PhDs, MScs with associated research studies and postgraduate certificates with a view to convert to MSc certified qualifications.

7.5.7. Therapists have attended modules at the Royal Marsden School of Cancer Nursing and Rehabilitation; mandatory training including information governance, various programmes run by Learning and Development, and relevant external courses and conferences. Senior therapists successfully completed a bespoke Allied Health Professionals Leadership programme.

7.5.8. Members of the therapy team have participated in and presented at various national and international conferences.

7.5.9. Departments have continued to work with the School of Cancer Nursing and Rehabilitation to teach on various modules and study days and therapists have provided input to the GP education programme.

7.5.10. Therapists provide education in ward and multidisciplinary team settings.

7.5.11. Therapists have fulfilled many external lecturing, post-graduate and undergraduate level teaching invitations and provided external supervision for other therapists.

7.5.12. Therapy teams have continued to support undergraduate student placements for Nutrition and Dietetics, Occupational Therapy, Speech and Language Therapy and Physiotherapy students and supported postgraduate overseas visitors on placement.

7.5.13. Publications include Nutrition and Cancer, published by Wiley 2010, a chapter in the newly published 2nd Edition of Breast Cancer nursing - Care and Management and various journal publications, including primary research in journals. Many therapists have participated in chapter writing for the new edition of the Royal Marsden Hospital Manual of Clinical Nursing Procedures.


75

7.6. Non-clinical training and development – cancer specialist services

7.6.1. Courses in Personal Effectiveness and Management Development completed in the last two years:

0

50

100

150

200

250

300

Quarter 22009/10

Quarter 32009/10

Quarter 42009/10

Quarter 12010/11

Quarter 22010/11

Quarter 32010/11

Quarter 42010/11

Quarter 12011/12

Nu

mbe

r of

sta

ff

Per son a l Effect iv en ess

Ma n a g em en t Dev elopm en t

7.6.2. Due to the extended Easter holiday period less training was scheduled in Quarter One than in previous quarters. Attendance figures were higher for personal effectiveness than in the same period last year.

7.6.3. A number of specific management development programmes and appraisal briefings were run in the previous year, which increased attendance figures. It is expected that this year the numbers will be a little lower.

7.6.4. The new Learning to Lead Programme for line managers and team leaders was launched in April.


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7.7. Non-clinical training and development – Sutton and Merton Community Services (SMCS)

7.7.1. The Management Development data shows a consistent programme of development for managers at all levels. The number of attendees has risen substantially in Quarter Four and Quarter One for the Personal Effectiveness programme. This increase is due to an extensive programme of courses, notably IT, time management and assertiveness being run from January to June.

0

10

20

30

40

50

60

7 0

80

90

100

Qu a r ter 12 01 0/1 1

Qu a r ter 22 01 0/1 1

Qu a r ter 32 01 0/1 1

Qu a r ter 42 01 0/1 1

Qu a r ter 12 01 1 /1 2

Nu

mbe

r of

sta

ff

Personal effectivenessManagement development


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8. Quality and management

8.1. Service developments

8.1.1. 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 85% at Chelsea and 95% at Sutton. This is a significant increase against performance three years ago of 15% and 20% respectively. Work is now underway to improve this position further by reducing the overall length of stay.

8.1.2. Initiatives to improve patient experience and reduce waste

A new process for the delivery of chemotherapy currently being designed across both sites.

Further work to develop the ambulatory mode of care for patients at Sutton.

Continued development of new initiatives to reduce typical lengths of stay such as the 25-hour breast surgical project.

8.2. Clinical audit

8.2.1. The Clinical Audit Committee co-ordinates, evaluates and reviews all clinical audits in the Trust.

8.2.2. Seventeen new clinical audit proposals were submitted to the committee for review. Six national audits were noted:

National oesophago-gastric cancer audit (continuation) collecting data on patients diagnosed from 1 April 2011 onwards

Royal College of Physicians’ national audit of occupational health management of back pain: round 2 incorporating a new record-keeping audit section

Cervical cancer audit (database now installed)

Royal College of Radiologists’ national audit of breast boost 2011

National Cancer Intelligence Network: pilot of the collection of data on breast cancer recurrence and metastasis

national comparative audit of bedside transfusion practice 2011.

8.2.3. Audits conducted at Chelsea and Sutton

Title Findings Actions

Outpatient prescribing of oral nutritional supplements

41% of general practitioners were notified that the patient had received oral nutritional supplements.

Generate standard letter for general practitioners informing them that oral nutritional supplements have been prescribed.


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Assessment of gemcitabine, cisplatin and methyl-prednisolone (GEM-P) in T-cell lymphoma and relapsed or refractory Hodgkin lymphoma

GEM-P in T-cell lymphoma: overall response rate was 73%

GEM-P in relapsed or refractory Hodgkin lymphoma: overall response rate of 84.2%.

Good practice confirmed.

Gastrointestinal Unit: performance status documentation audit

Performance status for gastrointestinal patients is poorly recorded.

Clinic letter to include performance status and updated reasons for attendance for every attendance. A rolling audit has been implemented.

Snap-shot audit of Smartcard usage and Registration Authority

364 unused smartcards stored safely

appropriate records kept of 34 registrations

registration and closing of accounts performed appropriately.

Registration Authority managers to re-audit after transition into User Identity Manager.

Rolling audit of clinical information on radiology computed tomography (CT)request forms

There were improvements in documentation of requester name and requester contact telephone number.

A new Radiology Information system with electronic requesting is due to be introduced. This system will require completion of mandatory data fields.

Re-audit of intravenous contrast infiltration in computed tomography (CT) scanning

No long term complications were observed and no patients had further treatment

Good practice confirmed. No actions required.

Audit of Radiology reporting: To assess discrepancy rate in computed tomography (CT) reports

There was no significant difference in discrepancy rate between consultant and specialist registrar reports.


Audit of outcome in non-small cell lung cancer patients with symptomatic brain metastases at diagnosis and in particular looking at the use of subsequent chemotherapy in these patients

Median survival: 5 months (early chemotherapy) 10 months (delayed chemotherapy) 2 months (no chemotherapy).

The difference reflects the time from first treatment until the start of chemotherapy.


Customer Service Excellence: telephone monitoring audit

82% internal calls dialled from the Quality Assurance Team were answered within three rings.

43% of staff observed are aware there is a customer service policy and know where to find it.

Managers to be informed of the key findings and to remind staff that there is a customer service policy.

Customer Service Excellence: e-mail response audit

Of e-mails received by Patient Advice and Liaison Services (PALS) 99% were responded to and closed

in two days 1% were responded to and closed in

four days.

Audit other department areas that receive e-mails via the website

Head and Neck thyroid peer review of documentation

27% of patients had a signed and completed checklist in the medical notes

7% of patients had a part-completed checklist.

To review the checklist and key worker documentation process


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Smoking cessation audit Compliance met with 92% of new patients being assessed.

Smoking cessation template forms to go on electronic patient records system.

8.2.4. Audit conducted at Sutton


Patient experience of the pager system in Rapid Diagnostic and Assessment Centre (RDAC)

The cost of the pagers is justified. Recommended that one-stop diagnostic clinics in other departments consider use of pagers.

Music therapy patient feedback, second survey

Patients value the service and would recommend it to other patients. Patients want to continue having music therapy.

Extension of funding for the music therapy post has been applied for

Music therapy staff survey 97% think it adds to the ambience positively or somewhat positively

An audit of Medical Day Unit and Critical Care Unit staff about music therapy will be undertaken.

Minimal residual disease monitoring by flow cytometry in patients with acute myeloid leukaemia undergoing allogeneic transplant

The standard was not met. Need for more samples to be sent

for flow cytometry during the operation.

Increase the number of bone marrow samples sent for flow cytometry before and after transplant.

Audit of standard run-time apheresis collections compared with individually tailored patient/donor apheresis collections

The use of individually tailored apheresis collections improves the patient/donor experience.

Use prediction data to continue with individual patient/donor based collections

8.2.5. Audit conducted at Chelsea


Parenteral nutrition prescribing and monitoring on the Critical Care Unit

Low compliance with Trust guidelines.

Changes made to electronic prescribing to ensure clear documentation.

New guidance for out-of-hours prescribing for Critical Care Unit

Audit to evaluate whether the use of high fidelity simulation can improve performance and adherence to guidelines in the Intensive Care Unit.

The simulation session improved staff confidence.

Targeted teaching session on the cardiac arrest and airway trolleys for nursing staff.

Redesigning of the Intensive Care Unit work area.

Accrual of new renal and melanoma patients to clinical trials 2009 to 2010 and comparison with numbers 2007 to 2008

28% of patients entered trials in 2009; 12% in 2010.

Some patients refused; some patients had no information about joining trials.

Improve accrual rate. Improve documentation about taking part in trials.


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8.3. National Institute for Health and Clinical Excellence (NICE)

8.3.1. The National Institute for Health and Clinical Excellence (NICE) provides guidance, sets quality standards and manages a national database to improve people’s health and prevent and treat ill health. Further details about NICE and its work programmes are available at the NICE website www.nice.org.uk.

8.3.2. Twenty-nine items of guidance from NICE were presented to the Integrated Governance and Risk Management Committee (IGRM) in Quarter One. After the guidance was reviewed eight items were identified as relevant to the Trust.

Type of guidance

Seen at IGRM

Not applicable

Under review

Reviewed and deemed

relevant

Reviewed and deemed not relevant

Clinical 7 0 1 5 1

Interventional Procedures 17 10 5 2 0

Public Health 3 1 2 0 0

Cancer Service Guidelines 0 0 0 0 0

Medical Technologies Guidance 2 1 0 1 0

Totals 29 12 8 8 1

8.3.3. IGRM reviewed the latest Quality Standards issued by NICE. Quality Standards are specific concise statements that act as markers of high quality, cost-effective patient care, covering the treatment and prevention of different diseases and conditions. IGRM discussed the following NICE Quality Standards:

Chronic kidney disease

Depression in adults

Diabetes in adults

Glaucoma.

8.4. Information governance

8.4.1. Information governance is the framework of requirements, standards and best practice that applies to the handling of information, particularly sensitive and personal information.

8.4.2. The Information Governance Toolkit is a performance tool that the Department of Health requires NHS organisations to complete annually to measure compliance. Returns are made in three stages through the financial year:

at the end of July (baseline submission),

at the end of October (performance update) and

at the end of March (final submission).

http://www.nice.org.uk/�


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8.4.3. The overall score for the final 2010/11 submission was 82%. The Trust achieved level 2 on all requirements resulting in an Information Governance Toolkit rating of ‘Satisfactory’.

8.4.4. Trusts’ submissions are available to bodies such as

The National Information Governance Board for Health and Social Care

Monitor

the Care Quality Commission

the Information Commissioner’s Office.

8.5. Freedom of information

8.5.1. The Freedom of Information Act 2000 gives the public a general right of access to information held by public authorities. The Trust has a legal obligation to provide access to the 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.

8.5.2. The Trust received 51 requests during Quarter One compared to 55 in Quarter Four. Eighty-nine per cent of all requests were answered within 20 working days.

8.5.3. One request for internal review under the Act was received during the quarter. The review resulted in the original decision being upheld.

8.5.4. Requests received under the Freedom of Information Act 2000

The Trust received 51 requests this quarter compared to 26 in the same quarter in the last year. The chart shows the number of requests by month in these quarters.

0

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2011/12


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8.5.5. Source of requests

Total 51 requests

1

19

9

12

4

6

Commercial organisations

PublicPress and media

Research

Public sectorStaff

8.5.6. Request by directorate and division

0 2 4 6 8 1 0 1 2 1 4

Cancer Serv ices Div ision

Clinical Serv ices Div ision

Facilities Directorate

Performance Strategy and Implementation

Nursing Risk and Quality Directorate

Workforce and Corporate Affairs

Directorate of Finance

Projects and Estates

Priv ate Patients

Clinical Research and Dev elopment

Sutton and MertonCommunity Serv ices


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8.5.7. Reasons for refusal

The Trust used two of the 23 statutory exemptions to withhold requested information during the quarter. The exemptions were applied on four occasions. The Trust applied the £450 cost limit on four occasions.

0

1

2

3

4

5

Cost LimitExemption - Section 40 - Personal informationExemption - Section 21 - Accessible by other means

8.6. Records – availability of notes

8.6.1. An audit based on one week’s clinics was undertaken at the Chelsea site of the Trust. Of 705 sets of paper records requested, notes for 520 patients were available (74%).

8.6.2. The results from audits in Chelsea and Sutton will be presented in this report in alternate quarters.


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8.7. Access to health records

8.7.1. Standard

Source Description

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

8.7.2. During the quarter 16 requests for personal disclosure of medical notes were received by the Trust. This excludes notes required by other hospitals and those required for litigation purposes.

0

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20

25

Quarter 22010/11

Quarter 32010/11

Quarter 42010/11

Quarter 12011/12

8.8. Radiotherapy

8.8.1. The Multiprofessional Team Quality Assurance in Radiotherapy Committee (MPT QART) met once during the period. The committee is chaired by the Radiotherapy Services Director and is attended by a multidisciplinary team of clinical oncologists, physicists, therapy radiographers and quality officers. 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 implementation of intensity modulated radiotherapy (IMRT) for new treatment sites, the Radiotherapy Peer Review assessment in early April, and the installation of new equipment and software at both sites (e.g. the CyberKnife project, RapidArc, upgrades to ExacTrac and Calypso).

8.8.2. The scheduled programme of audits is proceeding well. Seven audits were completed in the period and 18 corrective action requests raised. 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


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procedures. The Quality Manager (ISO and JACIE) presented the results from two audits on the consent process and the completion of Planning Referral forms at the Radiotherapy Audit Day in May. This is a twice-yearly meeting with presentations from clinical audits, physics, radiographers, clinicians and the quality team.

8.8.3. Eleven non-conformances (incidents) were raised in the quarter compared with eight in the previous quarter. Non-conformances are coded using the Towards Radiotherapy Classification System, which allows comparable reporting across the industry. Four were rated as minor radiation incidents, three as near misses and four as other non-conformance. Trend analysis is undertaken regularly and preventive action implemented based on this information. A trend was identified and documentation was amended in line with recommendations from the committee. All non-conformances are discussed at MPT QART as part of root cause analysis.

8.8.4. There were no letters of complaint regarding Radiotherapy during the quarter and 98 letters or cards of praise for the service were received.

8.8.5. Chelsea Radiotherapy service was reviewed against the Ionising Radiation (Medical Exposures) Regulations (IR(ME)R) legislation on 16th December 2010. The final report was received in April 2011. They found no areas of concern regarding IR(ME)R compliance or risk management of medical exposures during the inspection. Only one recommendation was raised relating to external reporting of incidents. The Trust procedure was amended in line with their recommendations

8.8.6. The national Radiotherapy Peer Review cycle has been completed. The Radiotherapy Department was assessed on 5 and 6 April 2011. The final report was received in July 2011 and the Trust received an extremely positive report highlighting the many areas of good practice in the department. The assessors raised four areas for concern;

1. There should be an implementation programme for succession planning for clinical oncologists.

2. The equipment replacement programme should be defined with the Network Board.

3. Prostate brachytherapy numbers are just in line with required numbers and this should be monitored.

4. Gynaecological brachytherapy should have cross-site cover arrangements in place for referring patients out of the network.


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8.8.7. 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 fluctuate slightly while palliative treatment has remained consistent.

8.8.8. Average radiotherapy waiting times – Sutton (days)

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Palliative AllPalliative No DelayRadical AllRadical No Delay

8.8.9. Average radiotherapy waiting times – Chelsea (days)

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Palliative AllPalliative No DelayRadical AllRadical No Delay

8.8.10. 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


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below shows the number of radical, palliative, urgent and total number of appointments.

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-11PalliativeRadicalUrgentAll appointments

8.9. Chemotherapy

8.9.1. The ISO Chemotherapy Committee, co-chaired by the Nurse Consultant (Intravenous Therapy) and the Chief Pharmacist met twice during the period and was attended by multidisciplinary 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 subjects discussed at the committee were the recommendations from the National Patient Safety Agency on patient safety incidents following anti-cancer medicines, the use of the Network Oral Chemotherapy diary, the implementation of the Chemotherapy Capacity Planning Tool (C-PORT), a review of consent forms, the authorised prescribers list for the Trust and the forthcoming round of Peer Review.

8.9.2. 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. In the quarter, 83 incidents relating to the administration of chemotherapy were reported. In accordance with Trust policy actions are agreed to ensure lessons are learned following any incident.

8.9.3. There were three complaints received in Quarter One. Ninety-five letters of praise were received.

8.9.4. 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 (ISO and JACIE).


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8.9.5. The scheduled BSI assessment took place on 2 and 3 March 2011 and the assessor audited the Medical Day Units at Chelsea, Bud Flanagan Unit at Sutton and the laboratories on both sites, as well as the standard assessment of the quality management system. The assessor raised five minor non-conformances and 20 observations. An action plan was created and all items have now been closed. The next assessment visit will take place on 12 September 2011 at Sutton and the assessor will visit the Medical Day Unit, Equipment Library and Pharmacy, as well as looking at the management of the quality management system as a whole.

8.9.6. Waiting times have been monitored for a number of years. The graph below shows the median waiting times in minutes for the all treatment units. Kingston and the Children’s Day Unit show the most consistently low waiting times and Bud Flanagan Outpatients has shown a marked improvement since the new facilities opened. Oak unit (clinical trials) continues to fluctuate due to the low number of patients and the complicated regimens.

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-11

MDU (London)

Priv ate MDU (London)

IV team (Sutton)MDU (Sutton)

Robert Tiffany (Sutton)

Bud Flanagan AC

Children's Day UnitOak Unit

Kingston


89

8.9.7. The graph below shows the 5-hour waiting time figures for each treatment unit (per cent). The target set by the Patient and Carer Advisory Group (PCAG) was that only five per cent of patients should wait more than five hours for their treatment.

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Medical Day Unit (Chelsea)PPMDU (Chelsea)IV team (Sutton)Medical Day Unit (Sutton)Robert Tiffany (Sutton)Bud Flanagan ACChildren's Day UnitOak UnitKingstonTarget 5%


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8.9.8. The graph below shows the percentage of patients treated outside the 5-hour target by clinical unit (per cent). The Drug Development Unit figures fluctuate 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. There is also concern that there may be some coding adjustments required to accurately reflect waiting times. 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. Waiting times in the Lung unit are higher than other units, which remained relatively stable.

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-11

Breast GIGy nae Haemato-OncologyLung UrologyOther PaediatricsDrug Development Target 5%

8.9.9. The graph below shows that the number of chemotherapy appointments is staying rising slightly across all sites. The number of patients at all three sites treated in June 2011 was 2,565.

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ChelseaSuttonKingstonTotal


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8.10. Human Tissue Authority

8.10.1. Human Tissue Authority inspection follow-up

The Haematopoietic Stem Cell Transplant facility was inspected by the Human Tissue Authority in November 2010. The inspection focussed on consent, governance and quality, premises, facilities and equipment and disposal of stem cells. The Human Tissue Authority is satisfied that all shortfalls have been addressed. The unit has implemented additional environmental monitoring as required and have particle counting instrumentation on order for the Stem Cell processing suite.

8.10.2. Quality improvement – audits

The audit and quality management programme in the laboratory and clinical areas for transplantation continues as an integral part of departmental work. In the human application sector, quality assurance and improvement is a requirement of the Human Tissue Authority.

Audits conducted over the last quarter include:

Individual patient-based apheresis collection. This audit demonstrated that an individualised approach to stem cell harvesting has logistic benefits as target doses of stem cells can be obtained more frequently in one collection episode. Optimised stem cell harvesting gives better overall stem cell yields and thus improves patient and donor experience due to reduced need for repeat collections.

Audit of batch control logging. Batch control in the Stem Cell Transplant Laboratory is essential to enable tracking of all equipment, reagents and consumables used during processing, storage and issue of cellular material for clinical use. Refinements to practice have been implemented as a result of the audit.

Audit of environmental monitoring and trend analysis. Following a review of environmental microbial monitoring performed in April 2011, that took into account current legislation and the practices of the Stem Cell Transplant laboratory, a retrospective analysis of environmental monitoring over the period 2009-2010 was performed. Levels of microbial contamination in all areas were well below recommended limits for clean room processing zones within the laboratory. This finding is reassuring in terms of staff working practice, product quality assurance and Human Tissue Authority compliance.

Quarterly health and safety audit of equipment and fixtures. The audit did not highlight any issues and confirmed best practice.

8.10.3. Adverse events, reactions and incidents

The unit collates, evaluates and investigates errors, accidents and incidents according to Trust protocol and in order to comply with Human Tissue Authority regulations. Five serious adverse events were reported to the Human Tissue Authority this quarter. All the incidents related to apheresis stem cell harvesting on Bud Flanagan out patients department and McElwain ward with four involving disposable kit failures and one due to operator error. The company that manufactures the apheresis machines and disposable kits has investigated three of the kit failure incidents, but was unable to identify the


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cause of the failures. The remaining kit failure is under investigation. The unit managed the situation locally by kit batch changes and ensuring that stem cell harvesting equipment was inspected and passed by the manufacturer before further use.

8.11. Research governance

The Trust has systems in place to review and approve new research proposals.

The policy on obtaining approval to conduct clinical research is agreed by the Committee for Clinical Research (CCR) and the Clinical Research Directorate (CRD).

The policy supports quick approval with greater focus on sponsored trials which are a higher risk to the organisation and rapid setup of externally sponsored studies. The policy distinguishes two categories of research:

Research requiring sponsorship by the Royal Marsden NHS Foundation Trust, the Institute of Cancer Research (ICR) or both.

Research with an external sponsor (not the Trust or ICR) that has the approval of a research ethics committee (REC) and, where applicable, of the Medicines and Healthcare products Regulatory Authority (MHRA)

Studies requiring Trust or ICR sponsorship are reviewed and approved by the Committee for Clinical Research prior to submission to REC and, where appropriate, MHRA for clinical trials involving an investigational medicinal product (CTIMPs). All issues identified by the CCR must be fully addressed and approved before an application is submitted to REC or MHRA.

The committee reviews applications in detail including a presentation by the applicant. All requests in the outcomes letter must be satisfied before REC and MHRA applications submissions. The CCR outcomes letter will also identify additional issues that must be addressed prior to the study commencing but that do not need to be responded to prior to submitting the application for REC and MHRA approval. Once these have been satisfactorily responded to, the Clinical Research and Development (R&D) Office will grant approval. No study may commence until approval has been granted.

Externally sponsored studies are managed via the expedited review process which consists of two stages. Stage 1: pre-study setup stage named ‘pre-expedited review’ and stage 2: a fast-track R&D approval process named the ‘expedited review’ process.

When first received, an application is sent, where applicable, to finance, the contracts team, pharmacy and radiology for review. Full governance review is conducted and outstanding issues followed up directly by the R&D Team. In addition, the protocol is sent to a member of CCR for review. The reviewer, focusing on the key areas of risk, will complete a short proforma. The proforma would also allow the reviewer to recommend an application for alpha star status.

The reviewer is required to return comments to the R&D Office within 2 weeks of submission of the application. If they have significant concerns regarding patient safety or scientific validity, the reviewer will contact the local principal investigator to discuss and resolve the concerns. They will document the


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discussion and submit it to the Clinical R&D Office with the completed proforma.

If the reviewer continues to have concerns regarding the study despite discussion with the principal investigator, the study is referred to the next CCR meeting. If subsequently, the committee rejects an application, the Director of Clinical R&D is notified before the rejection letter is issued to the principal investigator.

Externally sponsored ‘first in man’ CTIMPs will also be subject to expedited review as described above. However, the Chair of CCR will review the study in addition to one other member of the committee. Both the Chair and the additional reviewer will complete a full risk assessment of the study in addition to the expedited review proforma. All other procedures described above for externally sponsored CTIMPs will apply.

Each month, CCR receives a list of studies approved through the expedited process and any issues or comments raised by the reviewer.

8.11.1. Research sponsor

Trust sponsorship was awarded to the following nine projects:

Reference number Title

Single or multiple centre

CCR3654

Study of pleural effusions to characterise signal transduction kinase pathways in non small cell lung cancer (NSCLC) and malignant mesothelioma (PLUCK) Multiple

CCR3655 Computer-delivered cognitive behaviour therapy for cancer patients: CCBTCa development and evaluation project Single

CCR3656

A Phase I/II, open label, multi-centre trial to evaluate the safety, tolerability and efficacy of the combination of AZD8931 (pan-HER inhibitor) and AUY922 (HSP90 inhibitor) in patients with HER-2 amplified breast cancer or EGFR mutant lung cancer Multiple

CCR3664

Does a post-treatment rehabilitation interview improve gynaecological cancer patient's quality of life and self efficacy? A mixed methods pilot study Single

CCR3666

A prospective research study to evaluate chemotherapy-naïve breast cancer patient’s experiences of 3 different systems of scalp cooling Single

CCR3667

A phase I/II multi-centre trial of the combination of AZD2014 (dual TORC1 and TORC2 inhibitor) and weekly paclitaxel in patients with platinum-resistant ovarian, fallopian, or primary peritoneal cancer Multiple

CCR3676

Identification of genes significant in the development and progression (including recurrence and differentiation) of Liposarcomas (including microRNAs) Single

CCR3669

A fast-track randomised controlled trial to evaluate a Hospital2Home palliative care service for patients with advanced Progressive Idiopathic Fibrotic Interstitial Lung Disease Multiple

CCR3675 POUT - Peri-operative chemotherapy or surveillance in upper tract urothelial cancer Multiple


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8.11.2. Status of projects

Thirty new research projects were approved by the Committee for Clinical Research including 21 projects was reviewed and approved via the expedited review process

One project was resubmitted to the Committee for Clinical Research for re-review and approval.

8.11.3. Suspected unexpected serious adverse drug reactions

The following is a breakdown by study of the six suspected unexpected serious adverse drug reactions (SUSARs) that occurred in the quarter.

Study code Total SUSARs

Follow-up reports

SUSARs requiring no further action

SUSARs requiring further monitoring

SUSARs requiring flagging to a REC*

JB48 1 0 0 1 0

DD2 1 0 1 0 0

AT1 1 1 1 0 0

MG12 2 0 TBC† TBC TBC

JB47 1 1 1 0 0

DC21 1 0 TBC TBC TBC

* REC: Research Ethics Committee † TBC: to be confirmed

8.12. Clinic waiting times

Standard: At the outpatient clinic 90% of patients should be seen within 30 minutes of appointment time.

Quarter 2 2010/11

Quarter 3 2010/11

Quarter 4 2010/11

Quarter 1 2011/12

Total patients seen in all outpatient clinics in quarter 35,116 35,837 35,837 35,083

Patients seen in 30 minutes or less 28,130 28,818 28,818 28,422

Patients seen in 30 minutes or less (%) 80.1 80.4 80.4 81.0

Patients seen after 30 minutes and up to 1 hour 4,880 4,956 4,956 4,769

Patients seen after 30 minutes and up to 1 hour (%) 13.9 13.1 13.8 13.6

Patients seen in more than 1 hour 2,106 2,063 2,063 1,892

Patients seen in more than 1 hour (%) 6.0 5.8 5.8 5.4

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.


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8.13. Outpatient non-attendances

8.13.1. Non-attendance at first appointment

(Per cent of all first appointments)

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8.13.2. Non-attendance at subsequent appointment

(Per cent of all subsequent appointments)

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8.14. Consultant clinics cancelled less than 15 days before planned date

8.14.1. In Quarter One 0.80% of all NHS clinics and 3.85% of private practice clinics were cancelled less than 15 days before the planned date. The percentage has risen since Quarter Four for both NHS and private practice clinics. An action plan is being developed to address the number of cancellations.

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8.14.2. Consultant clinics cancelled less than 15 days before planned date – reasons for cancellation

NHS Private practice Total

Reason

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ics ca

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d

Clinic day changed 1 5 2 7 3 12

Doctor attending conference 4 27 1 1 5 28

Doctor attending meeting 8 48 18 53 26 101

Doctor an annual leave 9 41 17 50 26 91

Unexpected emergency 7 52 7 52

Staff sick leave 1 5 1 3 2 8

Bank holiday 1 3 1 3

Total 30 178 40 117 70 295


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8.15. Complaints Source Description

Trust local standard:

All complainants to receive

personalised acknowledgement within 2 working days a full response with a deadline within 25 working days

or as agreed with the complainant after 25 working days, regular/frequent progress

reports information about their right to further redress if not

satisfied.

8.15.1. All concerns and complaints are triaged according to the nature of the issues raised and the level of investigation required. The triage levels are explained in sections 8.15.8 to 8.15.10.

8.15.2. 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. The most frequent subjects of complaint are shown in section 8.15.15; service areas are given in the tables of complaints in sections 8.15.11 and 8.15.12.

8.15.3. From April 2011 concerns and complaints relating to Sutton and Merton Community Services (SMCS) are included in the reported figures.

8.15.4. Number of complaints by financial year

0

50

100

150

200

250

2008/9 2009/10 2010/11 2011/12 (Quarter 1 only )

NHS patientsPrivate patientsSMCS patientsAll patients

From the year 2009/10 onwards, the Trust changed the way concerns and complaints were recorded. This was in line with guidance from the Parliamentary and Health Service Ombudsman. Concerns resolved by the Patient Advice and Liaison Service (PALS) Officers and Service Managers which were previously not recorded in the complaints figures were now to be included. From 2010/11, following clarification of the guidance, concerns resolved by PALS Officers were no longer required to be included. Concerns resolved by Service Managers remain within the complaints figures. (From 2010/11, only complaints at triage levels 2 and 3 are shown).


98

8.15.5. Summary of complaints in triage levels 2 and 3

NHS patients

Private patients

SMCS patients Total

Letters of complaint received 33 (100%) 5 (100%) 19 (100%) 57 (100%)

Complaints acknowledged within two working days 33 (100%) 5 (100%) 17 (89%) 55 (96%)

Complaints receiving a response within agreed deadline 27 (96%) 5 (100%) 17 (100%) 49 (99%)

8.15.6. Responses within agreed deadline for triage levels 2 and 3

0%

10%

20%

30%

40%

50%

60%

7 0%

80%

90%

100%

Quarter 22010/11

Quarter 32010/11

Quarter 42010/11

Quarter 12011/12

NHS patientsPrivate patientsSMCS patientsAll patients


99

8.15.7. NHS complaints at triage levels 2 and 3 categorised by the patient’s primary care trust

Primary care trust Complaints

Berkshire East 1

Brent Teaching 1

Croydon 7

City and Hackney 1

Hammersmith and Fulham 1

Haringey 1

Hastings and Rother 1

Hertfordshire 1

Hounslow 2

Kingston 2

Milton Keynes 1

North East Essex 1

Surrey 4

Swindon 1

Wandsworth 1

Waltham Forest 1

Westminster 1

West Sussex 2

Not known 3

Total 33

In addition to the above, there were 19 complaints relating to SMCS in the quarter.

8.15.8. Concerns and complaints at triage level 1 (NHS and private patients)

Triage level 1 consists of those concerns and complaints resolved by Patient Advice and Liaison Service (PALS) Officers and not requiring a written response. There were 68 concerns and complaints at level 1.


Triage level 2 consists of those concerns and complaints resolved by Service Manager/Divisional Director and not requiring a written response. There were 14 concerns and complaints at level 2, of which seven were for Sutton and Merton Community Services.


Triage level 3 consists of those concerns and complaints relating to clinical issues, requiring a written response, or both. There were 43 concerns and complaints at level 3. The details are shown below for the 20 complaints


100

referring to Chelsea, for the 11 complaints referring to Sutton, and for the 12 referring to Sutton and Merton Community Services.

8.15.11. Chelsea

Service area Risk grade Concern Action taken

Breast Low Clinical care Explanation provided and meeting to be arranged to discuss further. (n22/11/12)

Breast Moderate Clinical care Explanation of care given. (n24/11/12)

Cancer Services Low Changed diagnosis Under investigation. (n35/11/12)

Endoscopy Low Delays Changes in policy and procedure. (n08/11/12)

Gastrointestinal Moderate Standard of care Outpatients department to be made aware of transfer procedure between the Trust and a partner hospital. (n07/11/12)

Gynaecology Moderate Intravenous procedure Review of current practice. Ward nurses reminded of importance of identifying intravenous and subcutaneous lines. Additional staff training to be given. (n16/11/12)

Haemato-oncology

Low Standard of care Explanation about care given. (n01/11/12)

Haemato-oncology

Low Delay in receiving treatment

Under investigation. (n18/11/12)

Medical Day Unit Low Waiting times Explanation given about delays. (n36/11/12)

Medical Day Unit Low Delay in receiving treatment

Team reminded of procedure for cross-matching blood. (n20/11/12)

Neurology Low Attitude of staff Member of staff reminded of need to maintain professional standards. (n19/11/12)

Pathology Low Histology specimen missing.

Staffing changes and training. Protocol changed. (n21/11/12)

Private Patients Low Delay in receiving treatment

Apology and explanation given. (p17/11/12)

Private Patients Low Private patients’ accommodation and care

Explanation of care provided and decisions taken. (p34/11/12)

Private Patients Low Communication by consultant

Explanation given. (p23/11/12)

Private Patients Low Standard of accommodation

Under investigation. (p32/11/12)

Transitional Care Unit

Low Incorrect administration of chemotherapy

Explanation given about discharge policy and delays in obtaining bed. Review of procedure. (n29/11/12)

Urology Low Lack of information Clinical Nurse Specialists to ensure private patients offered their support. (n03/11/12)

Urology Low Attitude of staff and clinical decisions

Explanation given by staff. (n14/11/12)

Urology Low Cancellation of appointment

Review of short-notice cancellations and patients to be offered telephone consultations. (n15/11/12)


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8.15.12. Sutton


Breast Low Communication, care appointments and meeting request

Under investigation. (n30/11/12)

Head and Neck Low Management of clinical care

No action required – the correct procedure was followed. (n06/11/12)

Leukaemia and Myeloma

Low Attitude of staff and method of communicat10n

Apology and offer to refer complainant to dietitian. (n31/11/12)

Lung Low Delays and incorrect chemotherapy

Assess feasibility of clinics on bank holidays. Reflection by staff. (n33/11/12)

Lymphoedema Low Sudden death of relative Detailed explanation of illness and disease progression given. Details given of bereavement support and pastoral care. (n37/11/12)

Paediatrics Low General organisation of care

Housekeeping reminded of need to keep areas tidy. (n11/11/12)

Pharmacy Low Pharmacy waiting times and parking costs

Improve patient information to raise awareness of length of time clinical trial prescriptions can take. Raise awareness of prescribers and research nurses to ensure consistency of information to patients. (n09/11/12)

Pharmacy Low Medical Day Unit waiting times

Review of waiting times and consideration of 2-stop visit for patients. (n10/11/12)

Private patients Low Standard of care Discussed with staff the necessity of escalation to senior nurse when necessary. (p26/11/12)

Smithers Low Nursing care provided on ward and attitude of staff to patient

Review of how patients are greeted. Management of chemotherapy process already under review and comments noted. (n05/11/12)

Transport Low Transport delays Length of appointment to be checked at point of booking rather than using a default time. Transport Control staff instructed to keep all departments fully aware of delays. If patient waiting for a long time, Control Room Supervisor will be notified in order to resolve situation quickly. (n02/11/12)

8.15.13. Sutton and Merton Community Services


District Nursing Low Treatment provided to patient with learning difficulties

Partner trust responded with an apology for failing to give adequate explanation on discharge. (c08/11/12)

Family Planning Low Insertion of implant Reassurance given. (c01/11/12)


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Health Visitors Low Breach of confidentiality Explanation of referral procedure; team reminded of importance of explaining process to client. (c15/11/12)

Occupational therapy

Low Care provision while at another hospital and following discharge

Apology and explanation. (c17/11/12)

Physiotherapy Low Physiotherapy provided for inpatient

Comment obtained but not sent to partner trust as no consent. (c04/11/12)

Podiatry Low Change of appointment and location

Apology provided and home visit organised. (c03/11/12)

Podiatry Low Attitude of podiatrist to elderly patient

Discussed with member of staff; alternative member of staff allocated to patient for future appointments. (c05/11/12)

Physiotherapy Low Failure of physiotherapy provision for disabled child

Appointment system and rebooking reviewed; regular checks of equipment available to take place. (c06/11/12)

Physiotherapy Low Physiotherapy provided Appointment booked to review treatment. (c07/11/12)

Physiotherapy Low Physiotherapy service Service not provided by SMCS staff. Response from partner trust sent. (c13/11/12)

Rehabilitation/ Physiotherapy

Low Rehabilitation provided Policy for provision of physiotherapy amended. (c16/11/12)

Speech and Language Therapy

Low Delay in referral and appointment provided

Referral system reviewed and referrals to SMCS team to be highlighted by Stroke Unit. (c10/11/12)

8.15.14. Complaints received this quarter categorised by risk grade

Risk grade NHS Private SMCS Total

Very low 8 3 9 20

Low 20 2 9 31

Moderate 5 0 1 6

High 0 0 0 0

Total 33 5 19 57


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8.15.15. Complaint subjects: main themes by financial year

0

10

20

30

40

50

60

2008/9 2009/10 2010/11 2011/12(Quarter 1 only )

Com

plai

nts

Attitude Clinical issuesCommunicationDelay s

8.15.16. Complaints raised in previous quarters completed this quarter (triage levels 2 and 3)


Housekeeping – Private patients

Low Staff attitude Staff reminded of need to provide accurate information to patients

Breast and Radiotherapy

Low Standard of Care Advanced communication training for relevant staff

8.16. Letters of praise

8.16.1. Staff are encouraged to send any letters of praise they receive to the Head of the Patient Advice and Liaison Service (PALS), Patient Information and Complaints, for noting in this report and to help identify any members of staff to whom personal thanks for their work can be given by the Chief Executive.

8.16.2. In this quarter 378 letters of praise were received by the Head of PALS, Patient Information and Complaints.

8.16.3. Some examples of the comments made in the letters of praise:

For IV Team staff:

Thank you all for looking after me. You are all great staff. Very compassionate; caring, you are all blessed; God give you more patience; love to us. Always grateful.


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For Private Practice Day Unit staff:

I feel privileged to have been looked after by such wonderful, lovely nurses. You are all FANTASTIC thank you for much.

For Medical Urology staff:

This letter comes with thanks and praise for the fantastic care given to my father during his stay with you. Each member of staff has been courteous, interested in his well being and patient. I would like to say thank you to all those involved from the doctors, nurses, Occupational Therapists and discharge team. Thanks also to all those other staff who contribute to a very clean and hospitable environment for patients and their relatives.

For Sir William Rous Unit staff:

Thank you all for being so kind and understanding, You make an unpleasant chapter in my life more bearable. You’ve all shown great kindness and patience. Keep up the good work.

8.17. Incident reporting summary

8.17.1. The introduction of the Datix intranet-based incident reporting system in December 2010 has had a positive impact on reporting rates. The chart shows an increase of 62% from June 2010 to June 2011 in the number incidents reported each month.

240

148

0

100

200

300

Dec-0

9

Jan-10

Feb

-10

Mar-10

Ap

r-10

May-10

Jun

-10

Jul-10

Au

g-10

Sep

-10

Oct-10

No

v-10

Dec-10

Jan-11

Feb

-11

Mar-11

Ap

r-11

May-11

Jun

-11

8.17.2. In 2008/9, there was an 18.05% increase in the number of incidents, and a 57.63% increase in the number of near misses compared to the previous year.

In 2009 /10 there was a 6.90% increase in the number of incidents, and a 15.00% decrease in the number of near misses compared to the previous year.

In 2010/11 there was an 8.48% increase in the number of incidents, and a 73.16% increase in the number of near misses compared to the previous year.


105

8.17.3. The top ten categories of incidents/near misses reported over the last 4 years remains unchanged on both sites, although the order of the categories has changed slightly as some have been used more than others.

8.17.4. New subcategories have been added this quarter. The new additions are to record overpayments for leavers and to record events involving smart cards. The Sutton and Merton Community Services (SMCS) codes have been added to the list and since 1 April all incidents have been recorded on the Trust system.

8.17.5. Community incidents have been included in the graphs that follow this summary. There are only incidents on the system for the current reporting quarter as the data for previous periods was not recorded in the same way. Comparative data will be shown as it accumulates.

8.17.6. Community staff are currently reporting incidents via the paper method with data being uploaded by the Risk Management Team. A training plan to enable these staff to use the intranet-based reporting is underway and will be rolled out once intranet access for all staff is fully available in all locations.

8.18. Incident investigations and serious incident reporting

8.18.1. Incident investigations and serious incidents (SIs) declared new

Incident investigation number Description

Investigation panel date

No 1 Incorrect disposal of radioactive material 23 May 2011

No 2 Delay in the review of a biopsy result 4 May 2011

No 3 Complaint regarding the monitoring of calcium levels

12 May 2011

No 4 Potential claim 8 June 2011

No 5 Pressure ulcers (SMCS) 24 June 2011

No 6 Serious incident related to transfer and resuscitation

31 May 2011

No 7 Destruction of medical records 7 July 2011

No 8 Medication incidents 29 June 2011

No 9 Controlled drug incident (SMCS) 21 July 201

No 10 Guided drain insertion out of hours 27 July 2011

No 11 Medication incidents 20 July 2011


106

8.18.2. Incident investigations including SIs completed

Incident investigation number and grade Description

Outcome of investigation

Action taken following investigation

No 28

Orange

Medication incidents involving a drug trial

Four out of the six incidents related to the patient self-medicating an incorrect dose. The different dose tablets were dispensed in bottles that were identical in appearance.

Staff to be made aware that the bottles are to be highlighted using a marker pen to indicate the order of administration and patients are to be asked to repeat the instructions back to confirm they have understood the instructions.

No 29

Orange

Works undertaken without a water permit

Three cases of non- compliance with policy and procedures relating to permit to work.

Trust to write to contractors outlining the permit to work system and the lack of adherence to Trust policy regarding this

No 30

Yellow

Delay in a patient undergoing an emergency procedure in the operating theatre

Communication issues were identified relating to the arrival of on call staff and the methods of transport used.

Raise awareness with staff regarding the deadline of one hour for on-call staff to arrive at the hospital and the use of an appropriate method of transport.

No 31

Orange

Meticillin-resistant Staphylococcus aurea (MRSA) bacteraemia

Screening did not take place the day the patient was admitted. Contamination of the specimen could not be ruled out as the cause of the positive MRSA result.

Raise awareness that patients with a history of MRSA should be screened on admission even if previous results have been clear. Highlight the importance of maintaining ‘Best Practice’ when carrying out venepuncture to obtain blood samples.

No 32

Red

Deterioration in a patient’s condition

The patient’s elevated Modified Early Warning Score (MEWS) was not communicated as required by Trust policy. Documentation in the medical records to support appropriate examination of the patient was not available.

Additional training to be provided on the MEWS system for both nursing and medical staff. The importance of the documentation of patient reviews to be emphasised during induction and at ongoing teaching sessions.

Raise the importance of completing a systematic assessment of the patient especially when a MEWS score has triggered a medical review.


107




No 33

Red

Complications with an ascitic drain

At the time of the incident there was a lack of guidance on which drain insertions needed to be carried out under ultrasound guidance and which clinicians were responsible for elective drain insertion.

Uniformity regarding the processes and responsibility for ascitic drain insertion. Update of the policy to reflect the changes agreed with communication and dissemination of the information to junior doctors. Review of the consent form to include complications of drain insertion.

No 34

Orange

Unsterile sizing device used in theatre

The packaging of the new device was very similar to the packaging used for sterile equipment. The expiry date was not checked prior to use.

A standard operating procedure has been written regarding equipment use in theatre. Additional question added to the World Health Organisation (WHO) Surgical Safety Checklist which clarifies that the scrub nurse and circulating nurse have both checked the product before use.

No 1

Orange

Incorrect disposal of radioactive material

Due to misinterpretation of verbal advice the amount of substance disposed down a drain was above the amount agreed on the Trust Disposal Licence issued by the Environment Agency.

The Environment Agency was informed.

All non-standard disposal instructions to be in writing and made in advance.

Staff to be updated appropriately.

No 2

Orange (to be confirmed)

Delay in the review of a biopsy result

The result had a low level of suspicion and the patient had not been given a follow-up appointment apart for one for six months. The Histopathology alerts and acknowledgement policy was not being adhered to.

Circulate information about the process for checking outstanding records on the electronic patient record.

Reinstate the system that tells staff of the presence of alerts when they access electronic patient records and also sends e-mails.

Monthly audit of Histopathology results.


108




No 3 Complaint regarding the monitoring of calcium levels

It was agreed by the panel that this was not an incident and there was no evidence of inappropriate behaviour or responses.

The investigation panel acknowledged that the version of events described by the patient’s relative differed from that of the clinical team.

8.19. Incident statistics

8.19.1. Total incidents – SMCS

There were 186 reported incidents in Quarter One 2011/12.

8.19.2. Total incidents by financial year – Chelsea and Sutton sites

0

400

800

1200

1600

2000

2400

2008/9 2009/10 2010/11 2011/12(Quarter 1)


109

8.19.3. Total incidents by quarter – Chelsea and Sutton sites

0

100

200

300

400

500

600

7 00

Quarter 12010/11

Quarter 22010/11

Quarter 32010/11

Quarter 42010/11

Quarter 12011/12


110

8.19.4. Incidents – top ten categories – SMCS

0 10 20 30 40 50 60

Equ ipm en t / Fa cilit ies

/ In fr a str u ctu r e

Clin ica l ca r e a n d tr ea tm en t

Pr essu r e u lcer

Pa tien t in for m a tion / a ppoin tm en ts

/ m edica l r ecor ds

Sa feg u a r din g

In for m a tion g ov er n a n ce / Da ta pr otect ion

/ Con fiden t ia lity br ea ch es

Pa t ien t fa lls

A cciden ts th a t h a v e or m a y h a v e r esu lted

in per son a l in ju r y

Medica t ion

Secu r ity

Quarter 1 2011/12


111

8.19.5. Incidents – top ten categories by financial year – Chelsea site

0 50 100 150 200 250 300

Medication

Equipment / Facilities

/ Infrastructure

Blood transfusion / Pathology / Specimens

Patient falls

Accidents that have or may have resulted

in personal injury

Clinical care and treatment

Patient information / appointments

/ medical records

Fire

Operations and procedures

Inappropriate behaviour

2008/92009/102010/112011/12 (Quarter 1)


112

8.19.6. Incidents – top ten categories by financial year – Sutton site

0 50 100 150 200 250 300

Medication


in personal injury

Patient falls



/ Infrastructure



/ medical records


Security

Stem Cell and Stem Cell Transplantation

2008/92009/102010/112011/12 (Quarter 1)


113

8.19.7. Incidents – top ten categories by quarter – Chelsea site

0 20 40 60 80

Medication


/ Infrastructure




in personal injury

Patient falls

Fire


/ medical records



Quarter 1 2010/11Quarter 2 2010/11Quarter 3 2010/11Quarter 4 2010/11Quarter 1 2011/12


114

8.19.8. Incidents – top ten categories by quarter – Sutton site

0 20 40 60 80

Medication


/ Infrastructure




in personal injury

Patient falls

Fire


/ medical records





115

8.19.9. Clinical incidents – top ten categories – Chelsea and Sutton sites

0 30 60 90 120 150 180

Medication

Blood transfusion/ Pathology/ Specimens

Patient falls

Clinical care andtreatment

Equipment/ Facilities

/ Infrastructure

Patient information/ appointments

/ medical records

Operations andprocedures

Pressure ulcer

Infection control

Radiotherapy



116

8.19.10. Clinical incidents – top ten categories – SMCS

Quarter 1 2011/12

0 5 10 15 20 25

Clin ica l ca r e a n d tr ea tm en t

Pr essu r e u lcer

Pa t ien t in for m a tion/ a ppoin tm en ts

/ m edica l r ecor ds

Sa feg u a r din g

Equ ipm en t/ Fa cilit ies

/ In fr a str u ctu r e

Pa t ien t fa lls

Medica t ion

In for m a tion g ov er n a n ce / Da ta pr otect ion

/ Con fiden t ia lity br ea ch es

Blood tr a n sfu sion/ Pa th olog y/ Specim en s

In fect ion con tr ol

Quarter 1 2011/12


117

8.19.11. Clinical incidents by risk grade – Chelsea and Sutton sites

0

50

100

150

200

250

300

Very low Low Moderate High


8.19.12. Clinical incidents by risk grade – SMCS

0

10

20

30

40

50

60

7 0


Quarter 1 2011/12


118

8.19.13. Medication incidents by risk grade – Chelsea and Sutton sites

0

20

40

60

80

100

120

140



8.19.14. Medication incidents by risk grade – SMCS

0

1

2

3

4

5

6

7

8


Quarter 1 2011/12


119

8.19.15. Patient falls by subcategory – Chelsea and Sutton sites

0 5 10 15 20 25

From a height - bed

On same lev el - confusion

On same lev el

From a height - toilet

On same lev el - unsuitable footwear

From a height - chair

From a height - commode

Emergency - fit, faint, seizure

From a height - bath

From a height - wheelchair

On same lev el - incontinence

On same lev el - trip hazard

On same lev el - wet floor



120

8.19.16. Patient falls by subcategory – SMCS

0 1 2 3 4 5 6 7 8 9

On same lev el

From a height - bed

From a height - chair

Quarter 1 2011/12

8.19.17. Non-clinical incidents by category – Chelsea and Sutton sites

0 1 0 20 30 40 50 60 7 0

Accidents that hav eor may hav e resulted

in personal injury

Equipment/ Facilities

/ Infrastructure

Fire

Inappropriate behav iour

Information gov ernance/ Data protection

/ Confidentiality breaches

Manual handling

Security

Quarter 1 201 0/1 1Quarter 2 201 0/1 1Quarter 3 201 0/1 1Quarter 4 201 0/1 1Quarter 1 201 1 /1 2


121

8.19.18. Non-clinical incidents by category – SMCS

0 10 20 30 40 50

Accidents that hav eor may hav e resulted

in personal injury


/ Infrastructure

Inappropriate behav iour

Information gov ernance / Data protection

/ Confidentiality breaches

Manual handling

SecurityQuarter 1 2011/12

8.20. Reporting of Injuries, Diseases and Dangerous Occurrences Regulations incidents

8.20.1. Six incidents have been reported under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR).

8.20.2. One incident was a fall resulting in a patient transfer to an accident and emergency department. The patient had tripped in the road and fallen in the Sutton site while walking to attend an appointment. The white markings have subsequently been reapplied on the ramp outside the building compound.

8.20.3. One incident was a chemical burn to the eye when preparing disinfectant. The eye was irrigated and the member of staff was transferred to an emergency eye clinic. Risk assessment was performed and staff have been advised to wear protective goggles when carrying out disinfection.

8.20.4. Four incidents have resulted in an absence from work of more than three days:

1. A member of staff member collapsed, hit their head on a trolley and was taken to an accident and emergency department. The cause of the collapse was found to be associated with a known medical condition and no further action was required.

2. Flooring contactors left paper sheeting on a newly laid floor in order to protect the surface. A member of staff slipped on the sheeting and fell and dislocated their knee. The sheeting was removed immediately and replaced with a fixed protective cover.

3. A chef was in the process of stir frying food in the main restaurant, hot oil was in contact with the left hand causing a prominent burn. This is the


122

second incident of this nature for the member of staff. Before being allowed to do similar work further training will be undertaken.

4. Contracted member of staff hit their head on the patient call phone card machine whilst cleaning the floor. Risk assessment undertaken and judged to be low risk.

8.21. Risk assessments – the Trust risk register

8.21.1. The Trust risk register contains risks that score a risk rating above 12. The register continues to be reviewed and updated each quarter. All risks that score 12 and above remain on the divisional registers and those whose scores have been reduced through preventative action are removed.

8.21.2. Departmental risk assessments, incident reports and other areas that identify significant risks are added as new risks.

8.22. NHS Litigation Authority risk management standards for trusts

8.22.1. The NHS Litigation Authority’s aim is to promote the highest possible standards of patient care and to minimise suffering resulting from any adverse incidents.

8.22.2. The risk management standards and assessment process are designed to provide a structured framework within which to focus effective risk management activities 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, inspecting bodies and stakeholders, including patients.

8.22.3. 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.

8.22.4. There are five standards and in each standard there are ten criteria. To achieve each level, 40 criteria must be satisfied, and at least seven satisfied in each standard.

8.22.5. The Trust is currently at Level 2 and 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 12 months work is being undertaken to embed the risk management processes currently in place and monitor and develop action plans to address any deficiencies in preparation for assessment at Level 3.


123

8.23. Claims

8.23.1. There were no formal letters of claim relating to clinical negligence in Quarter One.

8.23.2. There was one personal injury claim.


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9. Suitability of management

9.1. Reports to Monitor and accounts

9.1.1. Monitor is a non-departmental public body established in 2004 to authorise and regulate NHS foundation trusts. As a regulator its role is to ensure that foundation trusts are well-led, that their leaders are focused on the quality of care patients get and that they are financially strong. Monitor looks particularly at whether foundation trusts are meeting the required quality standards, as judged by the Care Quality Commission, and at trusts’ financial strength. These two things are essential if they are to provide quality services for patients and value for money for taxpayers. Monitor ensures that foundation trusts comply with their terms of authorisation, a set of detailed requirements governing how foundation trusts must operate.

9.1.2. In Quarter One the Trust has submitted the following as part of these requirements:

Annual Plan 2011/12 to 2013/14 sent to Monitor 31 May 2011, available on Monitor’s website www.monitor-nhsft.gov.uk.

Schedule 2 Mandatory Goods and Services sent to Monitor 31 May 2011, available on Monitor’s website.

Schedule 3 Mandatory Education and Training sent to Monitor 31 May 2011, available on Monitor’s website.

Annual Report and Accounts 2010/11 sent to Monitor 6 June 2011, available on Monitor’s and the Trust’s website.

9.1.3. The Royal Marsden has consistently maintained a financial risk rating of 4 (where 5 is the highest and 1 is the lowest). This means that the Trust is considered by Monitor to be low risk in financial terms.

www.monitor-nhsft.gov.uk�


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10. Essential standards of quality and safety

This table lists the 28 outcomes in the six key areas.

Involvement and information

Outcome 1: Respecting and involving people who use services

Outcome 2: Consent to care and treatment

Outcome 3: Fees

Personalised care, treatment and support

Outcome 4: Care and welfare of people who use services

Outcome 5: Meeting nutritional needs

Outcome 6: Cooperating with other providers

Safeguarding and safety

Outcome 7: Safeguarding people who use services from abuse

Outcome 8: Cleanliness and infection control

Outcome 9: Management of medicines

Outcome 10: Safety and suitability of premises

Outcome 11: Safety, availability and suitability of equipment

Suitability of staffing

Outcome 12: Requirements relating to workers

Outcome 13: Staffing

Outcome 14: Supporting workers

Quality and management

Outcome 15: Statement of purpose

Outcome 16: Assessing and monitoring the quality of service provision

Outcome 17: Complaints

Outcome 18: Notification of death of a person who uses services

Outcome 19: Notification of death or unauthorised absence of a person who is detained or liable to be detained under the Mental Health Act 1983

Outcome 20: Notification of other incidents

Outcome 21: Records


126

Suitability of management

Outcome 22: Requirements where the service provider is an individual or partnership

Outcome 23: Requirement where the service provider is a body other than a partnership

Outcome 24: Requirements relating to registered managers

Outcome 25: Registered person: training

Outcome 26: Financial position

Outcome 27: Notifications – notice of absence

Outcome 28: Notifications – notice of changes

Reference: Care Quality Commission: Guidance about compliance Essential standards of quality and safety March 2010.

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 Fulham Road London SW3 6JJ Telephone: 020 7808 2176 E-mail: [email protected]

April to June 2011 (Q

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