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Compliance Plus Report
Customer Service Excellence
The Royal Marsden NHS Foundation Trust
21 December 2012
Successful
15418/125059 4 December 2013Page 1 of 25
The Royal Marsden NHS Foundation Trust Compliance Plus Report
Assessment Summary
Overview
Overall Self-assessment Strong
Overall outcome Successful
10RP2 The Royal Marsden evidenced improvement across all Criteria. It continues to develop its insight,
continues to be very strong in engagement and consultation and continues to record very high levels of
customer satisfaction. Customer focus is still led from the top and 2010 feedback on patient privacy and
dignity warrants a new Compliance Plus in Element 2.1.5. The Trust continues to value staff input to its
customer focus ethos. Chargeable services are well-publicised and the organisation always checks that
patients receive and understand all its information, interaction methods are continually monitored and
improvements made accordingly and clear lines of accountability are set down for arrangements with its
partners. The Trust generally meets its operational standards and publishes data on this. Customer
satisfaction remains very high on promises delivered and planned outcomes achieved. The complaints
procedure was reviewed in 2010 and remains effective in driving improvement although it needs to publicise
these effectively to fully comply with Element 4.5.4. It showed its customer service outcomes are timely and
of high quality, it responds promptly to those making contact, explains delays and takes action on them. The
organisation now monitors performance against all customer service standards, shows it generally meets
them and publicises data.
11RP3 In the last year RMH has demonstrated improvement across all Criteria. It has improved its Customer
Insight, widened its customer focus culture, improved its information, learned from benchmarking and Best
Practice, and showed how it is regarded very highly, nationally and locally, for its quality of customer service.
The organisation cleared the Partial Compliance in the last report under Element 4.3.4, has maintained
Compliance Plus in all reviewed elements and has demonstrated Compliance Plus in two additional
Elements, 3.2.3 and 3.4.3. Further evidence is needed under Elements 2.2.3 and 5.3.3.
12RP1 You have continued to demonstrate improvements across all Criteria during the last year. With action
taken to clear previous Partial Compliances in Elements 2.2.3 and 5.3.3 you are now fully compliant with the
Standard. With the strengthening of existing initiatives and development of new ones you demonstrated
Compliance Plus in four new Elements: 2.1.1, 3.3.1, 4.3.1 and 4.3.4.
1: Customer Insight
Criterion 1 self-assessment Strong
Criterion 1 outcome Successful
10RP2 The organisation has used its insight to seek detailed patient feedback, determined to better support
patients with learning difficulties and appointed a Clinical Research Fellow in Psychosexual Practice to
identify and help appropriate patients to maintain Compliance Plus in 1.1.2. It again evidence improvements
made through consultation with customers and through its range of survey feedback, and continued to
improve customer experiences and journeys.
11RP3 The Trust has continued to engage with disadvantaged groups, showed it reviews all customer
engagement mechanisms on an ongoing basis, as with PCAG, and asked survey questions on all key drivers
and on specific subjects generated from its customer insight.
12RP1 You showed how you have continued to collect information for your customer identification and also
continued to warrant Compliance Plus with regards to your effective engagement and consultation, including
your Board, PCAG and a range of committees, groups and surveys. You are now operating monthly 'Real
Time Surveys' to gather more up to date and effective feedback on inpatient satisfaction and you showed your
performance against challenging and stretching targets for customer satisfaction continues to improve.
2: The Culture of the Organisation
Criterion 2 self-assessment Strong
Criterion 2 outcome Successful
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The Royal Marsden NHS Foundation Trust Compliance Plus Report
11RP3 Its Customer Service Policy and standards remain in place and evidence showed staff are continually
encouraged to promote its customer service culture. Although the Trust has the required mechanisms in
place to set and monitor targets on Customer Focus within its performance management system, further
evidence is needed in Element 2.2.3.
12RP1 With your stronger evidence of your corporate commitment to putting customers at the heart of service
delivery including how your Chief Executive, Chief Nurse, Directors, Consultants and Governing Body support
this you now demonstrate Compliance Plus in Element 2.1.1. Feedback shows that all customers feel they
are treated fairly by your staff and you demonstrated your ongoing commitment to delivering customer
focussed services through your recruitment, training and development of staff. You provided evidence of your
performance management process guidance and completed performance appraisal forms that show you
prioritise customer focus at all levels, clearing the Partial Compliance in Element 2.2.3. Evidence and verbal
feedback to the assessor showed that staff insight and experience is incorporated into internal processes,
policy development and service planning.
3: Information and Access
Criterion 3 self-assessment Strong
Criterion 3 outcome Successful
11RP3 The degree of improvement in improving verbal, documented and web-based information now warrants
Best Practice in 3.2.3 and evidence shows information updating customers remains accurate. The Trust
continues to improve facilities when finances permit and customer feedback confirms they find them clean,
comfortable and confidence building. It continually extends its community interaction and the extent of
worldwide take-up on Cancer advice and information now warrants Best Practice in Element 3.4.3.
12RP1 You continue to develop effective information that customers need and value and present it in ways
that meet their needs and preferences. Improvements to the ways patients, carers and families can access
your services now demonstrates Compliance Plus in 3.3.1 and your ongoing commitment and endeavours to
develop partnerships, including the ICR, GPs and for the offsite production of chemotherapy, to benefit cancer
patients, continues to warrant Compliance Plus in Element 3.4.1.
4: Delivery
Criterion 4 self-assessment Strong
Criterion 4 outcome Successful
11RP3 RMH again involved stakeholders in standards reviews and used benchmarking feedback to improve
services. It continues to use best practice within and outside the Trust to improve services and publishes
them locally and nationally. Staff continue to be trained in complaints handling and staff confirmed they
remain empowered to address them. Successful complainants are asked if they are satisfied with outcomes.
12RP1 A wide range of operational standards for the treatment and care of cancer patients remains in place
and you continue to agree at the outset what customers can expect from your services. Your detailed Action
Plans, as to address problems with your waiting times, and speed of action to address such dips, now
demonstrate Compliance Plus in Element 4.3.1 and, similarly, the extent to which you use formal and
informal complaints to generate improvements warrants Compliance Plus in 4.3.4.
5: Timeliness and Quality of Service
Criterion 5 self-assessment Strong
Criterion 5 outcome Successful
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The Royal Marsden NHS Foundation Trust Compliance Plus Report
11RP3 RMH's effectiveness at identifying and dealing with customer needs at first contact still warrants Best
Practice in 5.2.2 and it continues to share information to enhance the service to patients, whenever
practicable, and updates customers on progress and care plans on an ongoing basis. Although the Trust
compares well with others regarding the quality of customer care, additional evidence is needed in Element
5.3.3 to show it also compares well with regards to the timeliness of customer service.
12RP1 You showed you operate standards for the timeliness of response and quality of customer services on
an ongoing basis and you continue to monitor your performance against them. You also showed that you
take action when problems arise, as with keeping appointments. You provided evidence that your
performance with regards to the timeliness, as well as quality, of customer services compares well with other
organisations, clearing the previous Partial Compliance in Element 5.3.3.
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The Royal Marsden NHS Foundation Trust Compliance Plus Report
1: Customer Insight
1.1: Customer Identification
1.1.2: We have developed customer insight about our customer groups to better
understand their needs and preferences.
StrongApplicant Self Assessment:
Compliance to Standard: Compliance Plus
Active Evidence
This survey of patients across SW London Cancer network shows where patients are diagnosed and highlights
differences in responses between patients with different tumour types.
10:02: SW London Cancer Network patient survey 2009 Assessor Acceptance: Yes
The Trust asks subsets of its patient population for their views, for example patients being treated with
radiotherapy. Once the needs and preferences of patients are known improvements are made to services to
reflect them.
10:03: Radiotherapy patient survey February 2010 Assessor Acceptance: Yes
An annual patient survey is run by a contractor to Care Quality Commission guidelines. The results can be
reported against characteristics of the Trust's patient population including age, gender, ethnicity, ward or
hospital site as here.
10:04: National inpatient survey, 2009, Chelsea results Assessor Acceptance: Yes
The Trust runs a comprehensive clinical audit programme which is based upon the clinical units. Each unit is
responsible for identifying its own audits. These audits provide an insight into patients with particular tumour
types for example experience of specific support groups.
10:05: Clinical audit programme 2009/10 Assessor Acceptance: Yes
The new medical day unit in Chelsea has been designed around the needs of its patients. Improvements
based on the experience of patients using the old unit include provision of electronic entertainment systems to
help pass the time while the infusions are given.
10:06: New ambulatory care centre, Chelsea Assessor Acceptance: Yes
Process mapping identified when colorectal cancer patients should be approached to join the programme (p2).
It was also discovered that not all patients wish to discuss their concerns (p4).
10:57: Cancer Survivorship Programme, colorectal cancer case study Assessor Acceptance: Yes
15418/125059 4 December 2013Page 5 of 25
The Royal Marsden NHS Foundation Trust Compliance Plus Report
1.1.2.1: We have developed customer insight about our customer groups
T08 You have developed a range of focus groups to obtain the views and insight into different tumour patients,
and include those for teenagers and for younger children. This was evidenced through the work carried out with
gynaecological, lung and prostate patients and through surveys to ascertain needs on, for example, a
geographical basis. You also carry out a range of surveys, operate the Viewpoint comment system and hold
one-to-one discussions with patients.
09RP1 Add EvSUR24 and IG7. Evidence shows your insight has led to consideration of palliative care patients,
the relatives of people with cancer and those who suffer psychological effects after cancer treatment.
10RP2 A range of focussed initiatives, such as for Colorectal Cancer patients, Day Care patients, and
Radiotherapy patients, and analyses of survey feedback, such as by tumour type, demonstrate your ongoing
developments in customer insight,
Fully MetEvidence Value:
1.1.2.2: to better understand their needs and preferences.
T08 The depth of your customer insight has enabled you to understand and respond to their needs and
preferences. These have included the adaptation of treatments, reduction in travelling, provision of less-invasive
surgery and reductions in hospital stay durations.
09RP1 In addition to previous year initiatives you have enhanced 'End of Life Care'; are designing 'Care for
children whose parents have cancer'; and provide 'Support around issues affecting sexuality, sensuality and
intimacy following disease and treatment'. This demonstrates Compliance Plus in this Element.
10RP2 The Trust's aims continue to include to better understand patient needs and preferences and in the past
year you have opened the new Ambulatory Care Centre in Chelsea, designed the new Sutton Children and
Young People's facility and identified a preference for Radiotherapy appointments between 9.00 and 12.00.
These ongoing initiatives continue to demonstrate Compliance Plus.
Evidence Value: Fully Met
15418/125059 4 December 2013Page 6 of 25
The Royal Marsden NHS Foundation Trust Compliance Plus Report
1.2: Engagement and Consultation
1.2.1: We have a strategy for engaging and involving customers using a range of methods
appropriate to the needs of identified customer groups.
StrongApplicant Self Assessment:
Compliance to Standard: Compliance Plus
New Evidence
The Patient and Carer Advisory Group held a workshop in June 2012 to identify how it could recruit members
and represent patients receiving care from Sutton and Merton Community Services, following its merger with
the Royal Marsden.
12:03: Patient and Carer Advisory Group - community service workshop Assessor Acceptance: Yes
Includes greater emphasis on making the Foundation Trust membership more representative of the
communities served, especially young people and black and minority ethnic groups. The Council of Governors
has a patient experience sub-group; lay Governors work to improve patient experience (12:87).
12:06: Foundation Trust Membership recruitment, engagement and involvement strategyAssessor Acceptance: Yes
The Trust website lists many ways that patients and their families can feed back to the Trust including on-line
feedback forms, writing a review at NHS Choices and joining a patient/carer group.
12:07: Compliments, complaints and feedback section of Trust website Assessor Acceptance: Yes
Trust website users are asked to complete an on-line form to suggest ideas for future cancer research.
12:08: Website - suggestions for research Assessor Acceptance: Yes
PCAG, with patients and carers as members, reflects the views of patients to the Trust. At this meeting a
patient survey (52/12) and the Listening Post comment collection scheme (55/12) are reported as well as
feedback from a member who sits on Trust Equality and Diversity Committee (55/12).
12:09: Patient and Carer Advisory Group notes, July 2012 Assessor Acceptance: Yes
An example of an action plan that is developed to remedy shortfalls identified by patients in a survey.
12:10: National outpatient survey 2011, action plan Assessor Acceptance: Yes
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The Royal Marsden NHS Foundation Trust Compliance Plus Report
1.2.1.1: We have a strategy for engaging and involving customers
T08 Your comprehensive consultation strategy remains in place and is supported throughout the Trust and
includes the Clinical Audit Committee (CAC) and the Membership Council.
09RP1 The Consultation Strategy is still in place and operates on a continuous basis.
12RP1 Your Foundation Trust Membership recruitment drive, internet developments and engagement and
involvement strategy initiatives demonstrate your continued compliance here.
Fully MetEvidence Value:
1.2.1.2: using a range of methods
T08 You have continued to consult using a range of methods including through the Patient and Carer Advisory
Groups, the Viewpoint comments scheme, the Listening Post monthly forum, emails and complaints.
09RP1 Your range of methods includes: meetings, surveys, (now also monthly by ward), and Focus Groups (as
for patients with pancreatic or hepatobiliary cancers), Listening Post sessions, and more Viewpoint stations are
programmed at the Chelsea site. This range of methods represents Compliance Plus here.
12RP1 Your range of methods remains in place for engaging with patients, carers and relatives across all sites,
and additions such as use of the internet and the PCAG Workshop held in June 2012 show you continue to
warrant Compliance Plus in this Element.
Evidence Value: Fully Met
1.2.1.3: appropriate to the needs of identified customer groups.
T08 The Trust encourages lay representatives, patients and carers to become involved in consultation and
comprise over 50% of the Councillors on the Membership Council, which acts as the Board of Governors.
In-patients and outpatients take part in focus groups to cover all ages and the Viewpoint comments scheme is
available throughout the hospital. Complaints and emails can be used by discharged patients.
09RP1 All methods take account of patients' and carers' needs, such as the range and scheduling of meetings,
carrying out of surveys and PALS advisors attending at patients' bedside. This was confirmed by group and
Council members who spoke with the assessor during the visit.
12RP1Your methods of engagement continue to be appropriate to the needs of identified customer groups,
taking account of such aspects as gender, accessibility, disability, age, ethnic groups and geography. You
survey Outpatients and Inpatients, and the latter by Ward and Cancer Group.
Fully MetEvidence Value:
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The Royal Marsden NHS Foundation Trust Compliance Plus Report
1.3: Customer Satisfaction
1.3.5: We have made positive changes to services as a result of analysing customer
experience, including improved customer journeys.
StrongApplicant Self Assessment:
Compliance to Standard: Compliance Plus
Active Evidence
Improvements are listed (p5) following a survey of patients receiving radiotherapy including work around
appointment times and target for start of treatment.
10:03: Radiotherapy patient survey February 2010 Assessor Acceptance: Yes
After a review of pharmacy services (p14), involving patient surveys, a number of new initiatives are being
introduced to improve access including home delivery of drugs and pharmaceutical services closer to clinical
areas. A new haemato-oncology unit also offers improved patient experience (p10).
10:13: RM Magazine, summer 2010 Assessor Acceptance: Yes
A new larger, better appointed medical day unit has opened in Chelsea (p18). It has been designed around the
experience of patients using the previous unit. Each chair has more space and its own entertainment centre.
There is a refreshment bar and an area dedicated to fast track quick infusion.
10:14: RM Magazine, autumn 2010 Assessor Acceptance: Yes
The Trust is in the process of deciding whether to take over running Sutton and Merton community services.
The key reason for taking on these services is to ensure continuity of care for patients with long-term
conditions including cancer (p6) and a safe and speedy discharge to community services.
10:19: Board minutes, September 2010 Assessor Acceptance: Yes
The Trust is moving away from routine follow up for breast cancer patients to a system where the patient is
supported to take control of their own follow up. This will improve patient experience. Patients have been
involved in taking this project forward.
10:20: Open access follow-up project Assessor Acceptance: Yes
After reviewing patient experience of current services the Trust is introducing Cyberknife robotic radiotherapy
and considering managing Sutton and Merton community services to respectively improve patient choice and
cut waiting times (p10) and improve patient pathways (p6).
10:59: Board Minutes, April 2010 Assessor Acceptance: Yes
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The Royal Marsden NHS Foundation Trust Compliance Plus Report
1.3.5.1: We have made positive changes to services as a result of analysing customer experience,
T08 Positive changes to services in the last year include the 're-assessment of prostate cancer treatment at
early diagnosis' for men and 're-assessment of the number and size of radiotherapy treatments to women with
early breast cancer'.
09RP1 Add EvPEER4 Positive changes in the past year include: 'End of Life Care', treatments for prostate
cancer, and measures arising out of the Gynaecology Tumour Working Group.
10RP2 Customer experience drives changes to the Trust's services on an ongoing basis.
Fully MetEvidence Value:
1.3.5.2: including improved customer journeys.
T08 You continually implement change to improve customer journeys. In the past year you have opened the
Rapid Diagnostic and Assessment Centre (RDAC) on the Chelsea site, usually providing screening, tests and
results on the same day. You have opened a new Chemotherapy Unit at Kingston Hospital and you review
radiotherapy pathways on an ongoing basis. I consider these initiatives warrant Compliance Plus.
09RP1 Add EvSUR21 and EvNHSSUR19. Further developments intended to improve customer journeys,
including Telephone Counselling, Ambulatory Service review, and the Operating Theatre suite design
(observed), continue to demonstrate Compliance Plus in this element.
10RP2 Improvements include the consideration of customer journeys, which in the last year include the Open
Access Follow Up project for breast cancer patients, taking over the running of Sutton Community Services and
home delivery of drugs.
Evidence Value: Fully Met
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The Royal Marsden NHS Foundation Trust Compliance Plus Report
2: The Culture of the Organisation
2.1: Leadership, Policy and Culture
2.1.1: There is corporate commitment to putting the customer at the heart of service
delivery and leaders in our organisation actively support this and advocate for
customers.
StrongApplicant Self Assessment:
Compliance to Standard: Compliance Plus
New Evidence
The Trust Chief Executive makes the statement: 'The quality of patient and family care is at the centre of
everything we do at The Royal Marsden'. A corporate objective for 2012/13 is to 'Improve patient experience'
(p4).
12:18: Quality Account 2011/12 Assessor Acceptance: Yes
The Chief Nurse highlighted to other Board members a patient survey, where 100% of patients had described
patient transport as ‘excellent’ and an improvement in chemotherapy waiting times (p5; item 21/12).
12:19: Board minutes, March 2012 Assessor Acceptance: Yes
The importance that directors place on service delivery is shown by the decision to discuss complaints about
unsatisfactory customer service and remedy at this meeting of a Board sub-committee (p2; item 87/11).
12:20: Quality, Assurance and Risk Committee minutes, December 2011 Assessor Acceptance: Yes
The Trust actively recruits patients and carers as members of key committees and projects throughout the
Trust giving them the power to influence service delivery. The support that Trust leaders give to this
empowerment is demonstrated here (p2; 302/12). The patient group reports to IGRM (12:88).
12:21: Integrated Governance and Risk Management Committee (IGRM) minutes, October 2012Assessor Acceptance: Yes
Governors and Board Directors actively advocate on behalf of patients and promote the central position of
patients in the work of the Trust egs section 14.1, p8, September 2012 minutes and section 8, p6, May 2012
minutes.
12:22: Council of Governors minutes 2012 Assessor Acceptance: Yes
One of the Trust's Governors describes his aims for the next year to include "to increase engagement with
carers who can offer many insights to improve standards and the patient experience" (p28).
12:83: RM Magazine Spring 2012 Assessor Acceptance: Yes
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The Royal Marsden NHS Foundation Trust Compliance Plus Report
2.1.1.1: There is corporate commitment to putting the customer at the heart of service delivery
T08 The corporate commitment to putting patients and carers at the heart of service delivery is set down in
'What you can expect from the RMH'.
09RP1 Your corporate commitment is well-documented and re-stated on an annual and ongoing basis by your
Board.
12RP1 Your Quality Account includes the statement 'The quality of patient and family care is at the centre of
everything we do at the Royal Marsden' and amongst your Trust Objectives is 'To improve patient experience'.
Fully MetEvidence Value:
2.1.1.2: and leaders in our organisation actively support this and advocate for customers.
09RP1 Leaders, including your Chairman, Board and Chief Executive, actively support customer care on an
ongoing basis, and annually in Reports. All leaders seek ways to lead on this and advocate for customers as a
team and individually. The Chief Nurse has become involved through the PCAG to drive 'Support around issues
affecting sexuality, sensuality and intimacy following disease and treatment' for cancer patients.
12RP1 The Trust Chief Executive sets down your ongoing commitment in your Quality Account as your
'Statement' and it is one of your fundamental 'Trust Objectives'. This has been strengthened further by your
Chief Nurse, Directors, Governors, 'Quality, Assurance and Risk Committee' and your 'Integrated Governance
and Risk Management Committee'. The level of commitment and support that leaders in your organisation
demonstrate warrants Compliance Plus in this Element.
Evidence Value: Fully Met
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The Royal Marsden NHS Foundation Trust Compliance Plus Report
2.1.5: We protect customers’ privacy both in face-to-face discussions and in the transfer
and storage of customer information.
StrongApplicant Self Assessment:
Compliance to Standard: Compliance Plus
Active Evidence
A committee has responsibility for ensuring that best practice in information governance is followed to protect
the confidentiality of patient records and other information. The Trust scored 71% against the national
information toolkit in 2010, which was second highest amongst London acute Trusts.
10:26: Information Governance and Medical Records Committee report Assessor Acceptance: Yes
Sets out the principles for protecting the privacy of patients. Each year the policy is reviewed to ensure it is
consistent with current best practice.
10:27: Patient privacy and dignity policy Assessor Acceptance: Yes
Outlines the security arrangements of information, information systems, software applications, networks, user
devices, the physical environment and information management staff. This is one of a series of policies about
information governance.
10:28: Information management and technology security policy Assessor Acceptance: Yes
All staff are required to undertake information governance training. This is a requirement of the national
information governance toolkit.
10:29: Mandatory information governance training e-mail Assessor Acceptance: Yes
Literature reminding staff of their responsibilities around data protection.
10:30: Data protection leaflet Assessor Acceptance: Yes
Procedures to ensure the confidentiality of patient information and data protection.
POL11: Confidentiality policy Assessor Acceptance: Yes
2.1.5.1: We protect customers’ privacy both in face-to-face discussions
T08 Trust policies set down the commitment to protect patients' privacy and the latest survey results show 95%
of patients (well above the national average of 88%) felt given enough privacy (Ev ANRPT3). This was confirmed
by patients who spoke with the assessor.
10RP2 Add Ev 10:4. Your Trust policies and procedures remain in place to ensure privacy is protected in
face-to-face discussions and all survey feedback shows it still happens. Customer satisfaction with regards to
this is so high (97/98%) you demonstrate Compliance Plus in this Element.
Fully MetEvidence Value:
2.1.5.2: and in the transfer and storage of customer information.
T08 The Trust's Data Protection Policy and Confidential Policy ensure the privacy of customers is protected
with regards to the transfer and storage of customer information.
10RP2 The same evidence shows that you continue to comply with regards to the transfer and storage of
patient information.
Evidence Value: Fully Met
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The Royal Marsden NHS Foundation Trust Compliance Plus Report
2.2: Staff Professionalism and Attitude
2.2.2: Our staff are polite and friendly to customers and have an understanding of
customer needs.
StrongApplicant Self Assessment:
Compliance to Standard: Compliance Plus
Active Evidence
100% of patients surveyed found reception staff in the radiotherapy department courteous and polite (p2;
question 9).
10:03: Radiotherapy patient survey February 2010 Assessor Acceptance: Yes
Over 93% of patients asked in the national outpatient survey (p93) said they were treated with respect and
dignity whilst visiting the Trust's outpatient department.
10:32: National outpatient survey, 2009 Assessor Acceptance: Yes
Training for staff about how to provide excellent customer service including identifying the skills needed to
understand service user expectations.
10:34: Putting people first - training outline Assessor Acceptance: Yes
A statement by a member of staff which shows an understanding of customer needs corroborated by
testimonials from customers.
10:35: Staff NVQ customer care testimonial Assessor Acceptance: Yes
Action plans to improve basic care have been coordinated by the Essence of Care Steering Group. They cover
privacy and dignity benchmarking, protected mealtimes and spiritual needs. A patient is a member of the
steering group.
10:73: Essence of Care initiative Assessor Acceptance: Yes
Patients and their families write over 800 letters of praise to the Trust a year. Often the letters identify
individual staff for particular thanks.
COMP10: Thank you cards/letters Assessor Acceptance: Yes
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The Royal Marsden NHS Foundation Trust Compliance Plus Report
2.2.2.1: Our staff are polite and friendly to customers
In addition to Induction training the Trust's commitment is set down in the Patient Privacy/Dignity Policy.
Survey results show that staff are polite and this was confirmed during the assessor's visit. - The Inpatient
Survey 2004 showed that 93.3% of respondents said they were always treated with respect and dignity. T08
Patient feedback during 2007/8 shows that staff follow Trust policies in being polite and friendly to
patients/carers/families. All people the assessor spoke with during the visit agreed that staff are polite and
friendly.
09RP1 Add EvNHSSUR19 Inpatient Survey results show that patients and carers find staff polite and friendly.
10RP2 Your commitment and mechanisms, including internal training and NVQ courses, remain in place to
encourage staff to be polite and friendly to customers. Patient feedback across the Trust and within discrete
services, such as Radiotherapy (100% satisfaction), shows that this continues to happen.
Fully MetEvidence Value:
2.2.2.2: and have an understanding of customer needs.
T08 Patient feedback also confirms that staff at all levels have an understanding of customer needs. You
continually strengthen this through training provision, such as your 'Enhancing Customer Experience'. I
consider the Trust demonstrates Compliance Plus in this element.
09RP1 Add EvNHSSUR19 The Inpatient Survey results also show people feel that staff have an understanding
of patient and carer needs. This was supported by patients and carers spoken with during the visit who praised
staff so highly that it warrants Compliance Plus in this Element.
10RP2 Your evidence also shows that customers believe staff continue to have an understanding of their needs
and you continue to demon strate Compliance Plus here.
Evidence Value: Fully Met
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The Royal Marsden NHS Foundation Trust Compliance Plus Report
3: Information and Access
3.2: Quality of Information
3.2.3: We have improved the range, content and quality of verbal, published and web
based information we provide to ensure it is relevant and meets the needs of customers.
StrongApplicant Self Assessment:
Compliance to Standard: Compliance Plus
Active Evidence
Describes the review, audit and evaluation of information materials as well as their production to ensure
patients receive information of the highest quality. The policy is reviewed and signed off by PCAG when revised
(eg January 2011; evidence 11:36).
11:31: Information for patients - provision and production policy Assessor Acceptance: Yes
The Trust is working towards having all the patient information it produces accredited against the Information
standard. When first accredited the Standard only applied to one series of booklets, at the second
assessment further literature was accredited. All will be covered by 2013.
11:32: Information standard accreditation Assessor Acceptance: Yes
Examples of entries in the patient information database, showing review schedule and patient comments
included in revisions.
11:33: Patient information database Assessor Acceptance: Yes
The guide, Directory Plus, was originally published with a questionnaire at the back. The feedback from this
questionnaire and patient group members was used to compile the revised version: Your guide to support,
practical help and complementary therapies.
11:34: Your guide to support, practical help and complementary therapies Assessor Acceptance: Yes
Patients, carers and members of the public are consulted in the production and review of patient literature. In
this case (item 20/1, p1) the leaflet 'Being open' was presented to the patient group for comment and sign off.
11:35: PCAG notes March 2011 Assessor Acceptance: Yes
The Patient and Carer Advisory Group reviews draft patient literature to ensure content is clear, relevant and
meets the needs of patients of the Trust. For example the smoking cessation and family psychology service
leaflets.
11:37: PCAG review of draft patient literature Assessor Acceptance: Yes
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The Royal Marsden NHS Foundation Trust Compliance Plus Report
3.2.3.1: We have improved the range, content and quality of verbal,
SV06 You launched your new website to meet patients', carers and the public's needs. Trust produced or
revised 115 patient information leaflets and two new booklets ('Cancer of the Prostate' and 'Clinical Trials'). Ev
308N. SV07 Patient and Carers Advisory Group minutes confirm you improved information regarding 'charges
for telephone calls using hospital equipment'. T08 The Information for Patients Policy sets down how staff
should communicate with customers and you continually compare the levels of verbal information given by
doctors to what patients want, to demonstrate continuous improvement.
11RP3 Your monitoring of patient feedback on clinical and administrative information continues through surveys
and questionnaires and improvements are evaluated. Your presentations to GP conferences continue to develop
and improve.
Fully MetEvidence Value:
3.2.3.2: published
T08 You endeavour to improve published information by seeking feedback from patients, their families and
potential patients. As a result of feedback regarding the Clinical Governance Annual Report extra information on
pastoral care has been added to subsequent issues. Last year 15 leaflets/booklets were revised and an
Information Sheet has been changed to clarify how 'blood sample' and 'genetic influences' relate to DNA.
11RP3 You continue to improve published information on an ongoing basis, as evidenced through 'Being Open'
and 'Your Guide to Support, Practical Help and Complementary Strategies'. You are now a Certified Member
under The Information Standard and demonstrate Best Practice in this Element.
Evidence Value: Fully Met
3.2.3.3: and web based information we provide to ensure it is relevant and meets the needs of
customers.
T08 In the last year you have added prominent links to your home page, such as for GP referrals, services
offered and using clearer, less NHS-centric language. You have created a simplified
comments/complaints/compliments area, incorporating a feedback form.
11RP3 You also continually improve your web based information in line with customer feedback, as
demonstrated in the Patient Information Database and addition of PCAG minutes.
Fully MetEvidence Value:
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The Royal Marsden NHS Foundation Trust Compliance Plus Report
3.3: Access
3.3.1: We make our services easily accessible to all customers through provision of a
range of alternative channels.
StrongApplicant Self Assessment:
Compliance to Standard: Compliance Plus
New Evidence
Lists the Trust's telephone and fax numbers and address as well as information about clinical units. There is a
facility to contact the Trust by e-mail.
12:39: Trust's website Assessor Acceptance: Yes
Has tel numbers, maps of each site and public transport info. The Trust has a contract with a telephone
interpreting service. Hearing loops, amplifiers for earpieces and hearing aid compatible phones are available.
PALS is a service able to support patients in accessing services.
12:40: Your guide to the Royal Marsden Assessor Acceptance: Yes
The Trust has set up a social network site for its young patients where information can be disseminated and
the patients can socialise with their peers.
12:51: Teenagers' social network Assessor Acceptance: Yes
A system for patients to contact their specialist neuro-oncolgy nurse through texting is being set up in
response to patients' request. Patients can also reach the nurse by e-mail and telephone.
12:48: Texting protocol for neuro-oncology Assessor Acceptance: Yes
Under the new open access system patients attend for a mammogram once a year, but no other appointments
are booked. The patient can return to see the clinical team at any time. Most patients prefer this rather than
attend unnecessary routine appointments. The service review is also described.
12:52: Open access following end of treatment for breast cancer patients Assessor Acceptance: Yes
Following a review of services a Centre for Personalised Care is to be built to deliver treatments in new ways, to
more actively support patients returning to their work and home life and provide for currently unmet needs of
patients.
12:53: Centre for Personalised Care Assessor Acceptance: Yes
3.3.1.1: We make our services easily accessible to all customers through provision of a range of
alternative channels.
The Trust is accessible by phone, fax, letter, email and personal visit. Treatment requires personal attendance
and patient transport is available. There is a 'drop-in' service. SV A shuttle bus has been set up between sites.
09RP1 You make services easily available through delivery across three sites and accommodate private
patients as well as NHS. Contact can be made by phone, fax, letter, email and via the website, as well as
personal visit. Psychological Therapy advice is now available by phone and you have launched a new online
course on 'Malignant mesothelioma'.
12RP1 All your previous channels for gaining access to services remain in place and you now offer texting,
'Outreach' services, 'Open access arrangements following end of treatment for breast cancer patients' and you
are in the early stages of setting up Teenage Social Network arrangements. You now warrant Compliance Plus
in this Element.
Fully MetEvidence Value:
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3.4: Co-operative working with other providers, partners and communities
3.4.1: We have made arrangements with other providers and partners to offer and supply
co-ordinated services, and these arrangements have demonstrable benefits for our
customers
StrongApplicant Self Assessment:
Compliance to Standard: Compliance Plus
New Evidence
The users of the non-emergency patient transport service provided by a partner have been surveyed. Questions
include one asking for an overall rating of experience of the service.
12:54: Non-emergency patient transport survey Assessor Acceptance: Yes
The organisation of cancer service pathways in London is being revised to improve care (p2, 63/12). London
performs less well than the rest of England. The London Cancer Alliance will cover half of the capital and
consist of 17 Trusts. The new arrangements will improve outcomes for patients.
12:55: PCAG meeting notes, September 2012 Assessor Acceptance: Yes
This response to a complaint made about the service provided by the Trust's non-emergency patient transport
partner led to improvements to the service with extra failsafes introduced to prevent bookings being missed.
12:56: Complaint patient transport Assessor Acceptance: Yes
This new initiative ensures that out-of-hours doctors, nurses and emergency services have important
information about the medical condition and personal wishes of patients nearing the end of their lives. Patients
are reassured that their wishes will be met for their end-of-life care.
12:57: Coordinate my Care Assessor Acceptance: Yes
The contract for off-site production of chemotherapy includes, key performance indicators, turnaround and
pre-ordering targets, monitoring and monthly meetings, guarantees and complaints arrangements. Having
production off site, delays for patients have reduced due to less pressure on the pharmacy.
12:58: Off site production of chemotherapy Assessor Acceptance: Yes
Five of seven below average findings in the national cancer patient survey (p5, item 8, September minutes)
relate to the patient's experience with their GP and primary care. The Trust is working with these partners to
improve the pathway.
12:22: Council of Governors minutes 2012 Assessor Acceptance: Yes
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The Royal Marsden NHS Foundation Trust Compliance Plus Report
3.4.1.1: We have made arrangements with other providers and partners to offer and supply
co-ordinated services,
Arrangements made with many partners to provide a co-ordinated service. Include the Institute of Cancer
Research, SWLCN, the contract with the Primary Care Trust, Social Services, cleaning contractor, GPs and
District Nurses.
09RP1 The Trust has made more arrangements in the past year with other providers and partners to offer and
supply co-ordinated services. Partners who spoke with the assessor related how professional you are to deal
with, how the partnerships are valued and about the effectiveness from their point of view.
12RP1 You showed you continually seek partnerships to improve services to patients. Recent additions
include: the London Cancer Alliance; 'Co-ordinate my Care'; off-site production of chemotherapy; and enhanced
liaison with GPs.
Fully MetEvidence Value:
3.4.1.2: and these arrangements have demonstrable benefits for our customers
09RP1 You seek new partnerships on an ongoing basis to benefit cancer patients. Recently you have extended
the cleaning contract due to its success, set up a joint palliative care service with the Royal Brampton
Foundation Trust, made joint appointments of Gastroenterologist and Consultant Radiologist with the Chelsea
and Westminster Hospital and with the Institute of Cancer Research and GlaxoSmithKline to enable funding to
help Inflammatory Breast Cancer sufferers. This demonstrates Compliance Plus.
12RP1 All partnerships are entered into to benefit patients, as evidenced through: improving experiences and
outcomes for patients across London; improving end-of-life care; reduced waiting times for chemotherapy; and
improvements to pathways between Primary Care and GPs. You continue to demonstrate Compliance Plus
here.
Evidence Value: Fully Met
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The Royal Marsden NHS Foundation Trust Compliance Plus Report
3.4.3: We interact within wider communities and we can demonstrate the ways in which we
support those communities.
StrongApplicant Self Assessment:
Compliance to Standard: Compliance Plus
Active Evidence
Beyond the direct service it provides to patients referred to it for treatment the Trust presents to community
groups that are disproportionately affected by cancer, encouraging them to attend screening eg people with
learning disabilities and here minority ethnic groups.
11:05: Presentations to minority ethnic groups Assessor Acceptance: Yes
Staff are supported by the Trust to volunteer for work in the wider community (p7-8).
11:44: Special leave procedure Assessor Acceptance: Yes
The Trust is organising a 2011 Christmas Fayre at its Sutton site and is actively inviting local residents and its
neighbours to attend.
11:62: Christmas Fayre, Sutton Assessor Acceptance: Yes
92,128 visits to the cancer information section of the website came from 171 countries/territories between
October 2010 and November 2011. This is beyond the direct service the Trust provides for its patients. There
were 64,861 visits from UK 882 cities/towns in the same period.
11:63: Worldwide access to cancer information section of Trust website Assessor Acceptance: Yes
Work experience is arranged for students and staff give lessons/talk to schools.
11:89: Student placements and school talks Assessor Acceptance: Yes
Local residents can apply for a permit to park on the Sutton hospital site.
COMM3: Parking form for local residents, Sutton Assessor Acceptance: Yes
3.4.3.1: We interact within wider communities and we can demonstrate the ways in which we support
those communities.
SV07 The positive effect of initiatives was further evidenced through the Hospital Garden transformed by Blue
Peter (Ev 329) and by the operation and popularity of Radio Marsden (Ev 330). - Trust has been involved with
the community for many years, as evidenced by 40th Summer Fair in Sutton, staff giving talks to Rotary Clubs
and schools, and its annual 'celebrate a Life' event. T08 You have continued to be involved in the wider
community, as with the Belmont Community Ward Panel and Chelsea Fire Service.
11RP3 You continue to interact with communities around the Trust sites, including through school
presentations and work experience, links with ethnic groups and art promotions, and your Special Leave
procedure remains in place. The extent of countrywide and worldwide 'take up' in accessing the Cancer
information on your website, evaluated through 'hits', now demonstrate Best Practice in this Element.
Fully MetEvidence Value:
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The Royal Marsden NHS Foundation Trust Compliance Plus Report
4: Delivery
4.3: Deal effectively with problems
4.3.1: We identify any dips in performance against our standards and explain these to
customers, together with action we are taking to put things right and prevent further
recurrence.
StrongApplicant Self Assessment:
Compliance to Standard: Compliance Plus
New Evidence
Describes the procedures to keep patients and relatives informed, including an emergency helpline (p12), in the
event of a major incident.
12:64: Major incident plan Assessor Acceptance: Yes
Actions to remedy shortfalls identified by the patient frequent feedback survey include improved information
about waits in the medical day unit (p15). Actions in response to complaints (pp90-95) and incidents (97-100)
are also included. The report is a public document widely available.
12:65: Integrated Governance Monitoring Report, July-September 2012 Assessor Acceptance: Yes
Actions in response to complaints and comments are available on the Trust's website as are the annual
Quality Account and quarterly Integrated Governance and Risk Management reports which include performance
monitoring data.
12:39: Trust's website Assessor Acceptance: Yes
Long waits for outpatients are being addressed by a comprehensive action plan.
12:66: Outpatient waiting time improvement action plan Assessor Acceptance: Yes
This committee which includes patient members, discusses action plans (p2) and receives reports about
inspections (p2) and other performance info eg about cleanliness (p2), complaints (p2) and recommendations
following incident investigations (pp3-4). The minutes are available on request.
12:67: Integrated Governance and Risk Management Committee minutes, July 2012Assessor Acceptance: Yes
Patient and carers are part of project groups that work to improve performance, in this case, for the outpatient
departments and Rapid Diagnostic and Assessment Centres. Improvements in informing patients, reducing
'did-not-attends' and controlling over running are a few of the aims.
12:68: Request for PCAG volunteers to join Trust outpatient and RDAC project groupAssessor Acceptance: Yes
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The Royal Marsden NHS Foundation Trust Compliance Plus Report
4.3.1.1: We identify any dips in performance against our standards
Dips in performance are identified immediately through ongoing monitoring of performance and 'complaints'.
SV07 You identify dips on an ongoing basis, as with 'in-clinic chemotherapy waiting times'.
09RP1 The Trust continues to identify any dips on an ongoing basis, such as on theatre usage.
12RP1 Mechanisms, such as your Major Incident Plan, complaints procedure, 'frequent feedback surveys', and
ongoing monitoring, such as for 'Outpatients Waiting Times', show how you identify dips in performance,
Fully MetEvidence Value:
4.3.1.2: and explain these to customers,
Quarterly Monitoring Reports show dips and are made available to the public on notice boards. These were
observed by the assessor. Performance reports explain dips, as with 'Discharge delays' and 'Medication
Incidents'. SV06 You also explain dips in performance through letters, notices and in the annual Reports, as
with patients not seeing the same doctor at every visit. SV07 Explanations on in-clinic chemotherapy waiting
times were given to the Clinical Governance Executive, Patient and Carer Advisory Group and patients.
09RP1 You continue to explain dips to customers through groups, such as the PCAG, the Board,
noticeboards and reports.
12RP1 You explain any dips on an ongoing basis, through committees, groups, noticeboards, reports and your
quarterly magazine, as you did with regards to waits in the Medical Day Unit.
Evidence Value: Fully Met
4.3.1.3: together with action we are taking to put things right and prevent further recurrence.
SV07 You also explained action taken. In this case you explained you have changed working methods at
Chelsea Medical Day Unit so that patients are given a time for treatment to begin rather than waiting an
indeterminate time.
09RP1 You showed you explain action taken to put things right and prevent further recurrence, such as through
the review of working methods within operating theatres to improve the percentage usage figures.
12RP1 You continue to communicate action taken, as with: the comprehensive Action Plan to address
Outpatient Waiting Times; reduction of Pharmacy Waiting Times; and improving diagnostic processes through
the development and building of the Molecular Diagnostics facility in partnership with the Institute of Cancer
Research. You demonstrate Compliance Plus in this Element.
Fully MetEvidence Value:
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The Royal Marsden NHS Foundation Trust Compliance Plus Report
5: Timeliness and Quality of Service
5.2: Timely Outcomes
5.2.2: We identify individual customer needs at the first point of contact with us and
ensure that an appropriate person who can address the reason for contact deals with the
customer.
StrongApplicant Self Assessment:
Compliance to Standard: Compliance Plus
Active Evidence
Any patients identified with a learning disability prior to contact with the Trust or on admission, will be noted on
the electronic patient records system. This will enable all staff to support the patient’s specific needs.
11:01: Protocol for supporting people with learning disabilities Assessor Acceptance: Yes
Patients are asked to complete and bring this assessment form with them when they are admitted to wards so
that staff understand their needs and respect and support them appropriately. Clinical Nurse Specialists also
assess the holistic needs of patients living with/beyond cancer (11:95).
11:66: Cultural and religious needs assessment Assessor Acceptance: Yes
Patients with a learning disability are offered at registration a ‘buddy’. The 'buddy' acts as an advocate for the
patient and their carer ensuring they receive information in a way they can understand and that their additional
needs are met.
11:68: Learning disability buddy role requirements Assessor Acceptance: Yes
All patients are assigned a key worker on diagnosis. This member of staff coordinates the patient’s care and
promotes continuity, ensuring the patient knows who to access for information and advice in relation to a
cancer diagnosis.
11:69: Key worker operational policy Assessor Acceptance: Yes
Patients who may have cancer are assessed in the Rapid Diagnostic and Assessment Centre. Individual needs
are assessed before surgery in the Admissions and Pre-assessment Unit.
11:70: Unit specific literature Assessor Acceptance: Yes
The Trust audits the assignment of key workers. 60/60 of patient records audited showed a key worker been
provided.
11:92: Key worker audit Assessor Acceptance: Yes
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The Royal Marsden NHS Foundation Trust Compliance Plus Report
5.2.2.1: We identify individual customer needs at the first point of contact with us
T08 Individual needs are identified at the first appointment when attending the RDAC or Transitional Care Unit
(TCU) or at first admittance.
11RP3 Trust policies and procedures remain in place to identify individual customer needs at the first point of
contact and patients who spoke with the assessor confirmed this happens.
Fully MetEvidence Value:
5.2.2.2: and ensure that an appropriate person who can address the reason for contact deals with the
customer.
T08 Patients are met by relevant members of staff, such as a Clinical Nurse Specialist, and all patients are
assigned a 'key worker' who acts as a link between the patient and hospital and will originate documents, such
as a 'written case note'. The Trust demonstrates Compliance Plus in this element.
11RP3 Ongoing initiatives and role development, as with receptions, Clinical Nurse Specialists, 'Buddies', 'Key
Workers', the RDACs and the Admissions and Pre-Assessment Unit ensure you continue to demonstrate Best
Practice in allocating an appropriate person to each patient. Audits show you achieve your targets here.
Evidence Value: Fully Met
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