The inspection focused on cancer services provided by The London Clinic. During this inspection we visited wards in the Duchess of Devonshire Wing, the colorectal and breast cancer wards and the radiotherapy unit. We spoke with 23 staff, including nurses, ward managers, clinical nurse specialist’s, pharmacists, dieticians and senior managers. We also spoke with five patients and three relatives of people using the service who were available during our inspection or had contacted us prior to it.

The majority of patients were very positive about the care and treatment they had received, however two people raised concerns about their experiences of care on one ward.

We found people received safe, effective care that was planned in a way that ensured their safety and welfare. Peoples' needs were assessed and reviewed by a multi-disciplinary team. Information was provided in a format that met people's needs to ensure they understood and were able to make decisions. Patients had mixed views about the standard of food available but the majority were satisfied with the quality and choices available.

There were arrangements in place to deal with medical emergencies. Treatment protocols and procedures reflected national guidelines and medications were safely administered. Medicines were stored securely.

There were sufficient staff available to meet the needs of people but we noted there was a concentration of agency staff working in the ward people had raised concerns about which may have contributed to people’s poor experience. There were systems in place to monitor the quality of service provided.

People who had used the service told us that they were given information about their care and treatment before they underwent procedures. They said that staff were "very professional", "welcoming" and "very attentive".

People who had used the service described it as "very good" and "fantastic". Appropriate medical checks were undertaken before people received treatment and they received appropriate aftercare. Staff had been trained in what to do in a medical emergency and there were emergency drugs and equipment available.

Staff were trained in safeguarding vulnerable adults and child protection on an annual basis. There was a policy and procedure in place for how to report any concerns, including to the local authority.

When staff started working at the service they received an induction. Staff undertook mandatory training on an annual basis, including safeguarding and what to do in a medical emergency. There was a procedure in place for them to undergo annual appraisals where their performance would be discussed and targets set for the coming year.

Staff at the service monitored the clinical outcomes of the treatment of patients. Regular patient feedback questionnaires were completed. People using the service told us that they would be happy to raise any concerns with staff if they had any.

Patients were extremely positive about the healthcare provided at the The London Clinic. Comments from patients included "excellent care", "Staff are wonderful" and "the best hospital I have stayed in".

The people we spoke with told us that they received relevant information prior to their surgical procedure. They said that anaesthetists, surgeons and nurses were very helpful and explained everything, including the risks and benefits of different anaesthetics and surgical procedures to them. We saw a range of patient information leaflets displayed at the hospital.

We spoke with many people who use the service during our visit and they all commented that the staff were very helpful and supportive and they were treated with dignity and respect by the staff. When we visited other wards where people were not able to talk with us for various reasons, we spent time observing how care and support was delivered to them, we noted that the staff were polite and courteous in caring and dealing with them.

As a charitable hospital since 1935, The London Clinic is governed by the Trustees of The London Clinic Limited. The hospital provides a range of services to the local population of London, as well as overseas patients. The hospital has on average 23,000 inpatient episodes and 110,000 outpatient attendances.

The hospital is licensed to provide diagnostics and screening; treatment of disease, disorder or injury; surgical procedures; management of supply of blood and blood derived products.

The original hospital at 20 Devonshire Place has seven main and three additional operating theatres, and six dedicated specialty wards for a range of surgery, including: urology, gynaecology, thoracic surgery, orthopaedics and spinal procedures. They also provide neurosciences and digestive diseases treatment and care, and have an Intensive Care Unit.

The Duchess of Devonshire Wing provides a dedicated cancer centre, including a radiotherapy department, a medical oncology inpatient ward, a breast and reconstructive surgical ward, medical and haematology oncology, chemotherapy outpatients (including apheresis) and a stem cell transplant unit.

We carried out an announced inspection on 22 to 24 November, and an unannounced visit on 1 December 2016. The inspection covered medicine, surgery, critical care, end of life and the outpatients and diagnostic service.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led?

Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

We rated The London Clinic as good overall. Medicine, Surgery and Critical Care and outpatients were rated as good overall. Surgery needed to make some improvements in the safety domain.

The outpatient services were rated as outstanding for effective and good for the remaining three domains we currently rate. We rated end of life care services as outstanding for responsive, caring and well-led, and outstanding overall. The London Clinic had responded to the withdrawal of the Liverpool Care Pathway by introducing an evidence based individualised care plan. Staff had access to a well-resourced and highly knowledgeable team who were described as being visible. The palliative and specialist care team were held in high regard by referring clinicians, nursing and allied health staff. The appointment of a substantive consultant was seen as pinnacle in driving the end of life care agenda across the London Clinic. 

We found good areas of practice including;

• Patients received individualised care in a compassionate and caring manner. They were treated with dignity and respect and their choices and preferences were taken into account at all stages. 
• The service was accessible, whilst taking into account any precluding risks. Patient’s preferences and choices were respected with regard to their admission, treatment and care. They were consulted throughout and kept informed of their progress and changes in treatment, including any risks and the management of these.
• There was a range of expert clinical and other support for patients who required additional input to enable their individual needs to be met.
• Staff understood their responsibilities to report adverse events and felt able to do so in an open and honest way. They received feedback on investigations and applied changes to their practice as a result of the associated learning.
• There were well established governance arrangements for overseeing quality and risk. Actions arising from audit and day to day monitoring of required standards contributed to service improvements. 
• Staff were provided with mandatory safety training, which included infection prevention and control, and basic life support, the Mental Capacity Act, and Deprivation of Liberty Safeguards.
• Patient risk assessments and safety checks were carried out. There were formal procedures which enabled staff to identify and respond to sepsis or a deterioration in the patients' health.
• The staffing arrangements including the skills of such individuals supported the delivery of safe, effective and responsive treatment and care. 
• The international office managed all aspects of the overseas patients and their hospital admission and repatriation. Interpreter services were readily available, along with information in other languages.
• Staff demonstrated adherence to the principles of the Mental Capacity Act (2005), and consent processes were embedded in practice.
• A multidisciplinary approach across the service facilitated the delivery of a responsive service in the majority of areas. Patients were cared for by a range of professionals who co-ordinated care, through discussion and on-going engagement. This was overseen by consultants with practising privileges, each of whom were responsible for their own patients, supported by a resident medical officer and suitably skilled clinical staff.
• A number of theatre staff had received additional training to fulfil the role as first assistants.
• There was provision for medical cover at an appropriate level of seniority 24-hours, seven days a week. Emergency and general procedures were established for out of hours.
• Staff had access to resources to enable them to provide an effective and responsive service. In addition to on-site services such as pharmacy, physiotherapy, pathology and diagnostics, this included professional guidance, a range of equipment, information technology, and clinical expertise. Staff also had access to additional training to support the development of competencies.
• Prescribed medicines were managed safely, medicines were stored in locked cupboards or temperature controlled environments in the majority of areas. 
• The environment in which patients received care was visibly clean and staff were supported by professional guidance to follow infection prevention and control practices, which were subject to monitoring.
• Staff reported their local leadership within departments was good. Managers were approachable, supportive and staff were proud to work at the hospital. Staff understood the values of the hospital and were keen to ensure patients received the best care.
• There were opportunities for professional development and staff were recognised for their contributions. The hospital actively engaged with staff through open staff forums, and valued their contributions and feedback.

We identified some areas where improvements could be made as follows:

• The completion of surgical safety check lists in theatres was not to a consistent standard.
• Information provided by consultants in order to update their practising privileges was not always complete.  
• Greater consideration should be given to evaluating clinical outcomes across all specialities 

Amanda Stanford

Deputy Chief Inspector (I)