GenesisCare Windsor NewApproachComprehensive Report

This report describes our judgement of the quality of care at this location. It is based on a combination of what wefound when we inspected and a review of all information available to CQC including information given to us frompatients, the public and other organisations

Ratings

Overall rating for this location Outstanding –

Are services safe? Good –––

Are services effective? Good –––

Are services caring? Outstanding –

Are services responsive? Good –––

Are services well-led? Outstanding –

Mental Health Act responsibilities and Mental Capacity Act and Deprivation of LibertySafeguardsWe include our assessment of the provider’s compliance with the Mental Capacity Act and, where relevant, MentalHealth Act in our overall inspection of the service.

We do not give a rating for Mental Capacity Act or Mental Health Act, however we do use our findings to determine theoverall rating for the service.

Further information about findings in relation to the Mental Capacity Act and Mental Health Act can be found later inthis report.

GenesisCarGenesisCaree WindsorWindsorQuality Report

69 Alma RoadWindsorSL4 3HDTel:01753 418444Website:www.genesiscare.com

Date of inspection visit: 24 to 25 June 2019Date of publication: 02/10/2019

1 GenesisCare Windsor Quality Report 02/10/2019

Overall summary

Genesis Care Windsor is operated by Genesis Cancer CareUK Limited. Services provided are clinical and therapeuticdiagnostics, treatments and consultations.

The centre provides treatment to patients over 18 yearsold, this includes, chemotherapy, outpatientconsultations and minor treatments such as lesionremoval. The centre has a radiology department whichprovides diagnostic imaging to diagnose new cancers,this includes x-ray, ultrasound, fluoroscopy,computerised tomography (CT), positron emissiontomography–computed tomography(PET-CT), a magneticresonance imaging (MRI) and nuclear medicine.

The centre delivers therapeutic radiotherapy, involvingthe planning and delivery of radiotherapy treatments.The service had recently started to deliver a theranosticsservice which combines both therapy and diagnostics.The centre offers a Wellbeing centre and an exerciseclinic.

There are no overnight beds.

We inspected this service using our comprehensiveinspection methodology. We carried out anunannounced inspection on 24 June to the 25 June 2019.

To get to the heart of patients’ experiences of care andtreatment, we ask the same five questions of all services:are they safe, effective, caring, responsive to people'sneeds, and well-led? Where we have a legal duty to do sowe rate services’ performance against each key questionas outstanding, good, requires improvement orinadequate.

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

The main service provided by this hospital was medicine.Where our findings on medicines’, for example,management arrangements – also apply to otherservices, we do not repeat the information but cross-referto the medicines’ service level.

We rated it as Outstanding overall.

• The service had enough staff to care for patients andkeep them safe. The service controlled infection risk

well. Staff assessed risks to patients, acted on themand kept good care records. They managedmedicines well. The service managed safetyincidents well and learnt lessons from them. Staffcollected safety information and used it to improvethe service.

• Staff provided effective care and treatment, gavepatients enough to eat and drink, and gave thempain relief when they needed it. Managers monitoredthe effectiveness of the service and made sure staffwere competent. Staff worked well together for thebenefit of patients, advised them on how to leadhealthier lives, supported them to make decisionsabout their care, and had access to goodinformation.

• Staff treated patients with compassion and kindness,respected their privacy and dignity, took account oftheir individual needs, and helped them understandtheir conditions. They provided exceptionalemotional support to patients, families and carers.

• The service planned care to meet the needs of localpeople and made it easy for people to give feedback

• Leaders had the integrity, skills and abilities to run anoutstanding service. Comprehensive and successfulleadership strategies were in place to ensure andsustain delivery and to develop the desired culture.

• Leaders supported all their staff to develop theirclinical and leadership skills. Managers across thecentre promoted a positive culture that supportedand valued staff, creating a sense of commonpurpose based on shared values. Staff were proud ofthe organisation as a place to work and spoke highlyof the culture.

• Staff understood the service’s vision and values, andhow to apply them in their work. Staff felt respected,supported and valued. Staff were clear about theirroles and accountabilities. The service engaged wellwith patients and all staff were committed toimproving services continually.

Summary of findings


• There was a demonstrated commitment to bestpractice performance and risk management systemsand processes.

• Following this inspection, we told the provider that itshould make other improvements, even though aregulation had not been breached, to help theservice improve. Details are at the end of the report.

Nigel Acheson

Deputy Chief Inspector of Hospitals (London and South)

Summary of findings


Our judgements about each of the main services

Service Rating Summary of each main service

Medical care(includingolder people'scare)

Outstanding –Medical care services were the main proportion ofactivity at the centre.We rated this service as outstanding in caring and wellled and good in safe, effective, and responsive.

Outpatients

Outstanding –

Outpatient services were a very small proportion ofhospital activity. The main service was medical care.Where arrangements were the same, we have reportedfindings in the medical service section.We rated well led as outstanding and safe andresponsive as good. We were unable to rate caring andeffective due to limited data and there were nopatients in the department at the time of ourinspection.

Diagnosticimaging

Good –––

Diagnostic imaging services were a small proportion ofhospital activity. The main service was medical care.Where arrangements were the same, we have reportedfindings in the medical service section.We rated well led as outstanding and safe, caring andresponsive as good. We do not rate the effectivedomain.

Summary of findings


Contents

PageSummary of this inspectionBackground to GenesisCare Windsor 7

Our inspection team 8

Information about GenesisCare Windsor 8

The five questions we ask about services and what we found 10

Detailed findings from this inspectionOverview of ratings 13

Outstanding practice 48

Areas for improvement 48

Summary of findings


Genesis Care. Windsor

Services we looked atMedical care; Outpatients; Diagnostic imaging.

GenesisCare.Windsor

Outstanding –


Background to GenesisCare Windsor

GenesisCare Windsor is operated by Genesis Cancer CareUK Limited. The centre opened in January 2018 and is aprivate service in Windsor, Berkshire. The serviceprimarily serves the communities of the Windsor areahowever, accepts patient referrals from outside the area.

The centre has had a registered manager in post sinceJanuary 2018. At the time of the inspection, a newmanager had recently been appointed and wasregistered with the CQC in January 2019.

GenesisCare UK have treatment centres and clinics acrossthe United Kingdom (UK), Australia and Spain.GenesisCare Windsor is one of 12 UK Genesis CancerTreatment centres.

The centre has services across two floors. The groundfloor has preparation rooms, quiet rooms andsub-waiting areas. It also has:

• One single linear accelerator (LINAC) which is intensitymodulated radiotherapy (IMRT) assisted by imageguided (IGRT), with surface guided (SGRT) and breathhold (DIBH) to accurately treat various types of cancersincluding prostate and breast.

• One positron emission tomography–computedtomography(PET-CT). This is a nuclear medicinetechnique which combines a PET and an x-ray CTscanner, to acquire a sequence of images from bothdevices in the same session, which are combined intoa single superposed image.

• One magnetic resonance imaging (MRI) scanner, thistype of scan uses strong magnetic fields and radiowaves to produce detailed images of the inside of thebody.

The first floor contains four chemotherapy pods, sevenconsultation rooms, two treatment rooms, a recoveryroom, and a pharmacy dispensary. A medical oncologyservice provides systemic anti-cancer therapies (SACT) topatients with solid tumours.

The diagnostic suite has;

• One ultrasound scanner which uses high-frequencysound waves to create an image of part of the insideof the body.

• One x-ray machine. X-rays are a type of radiationwhich create pictures of the inside of the body.

• One fluoroscopy x-ray (not in use). Fluoroscopy is astudy of moving body structures. Contrast dye movesthrough the part of the body being examined whilst acontinuous X-ray beam is passed through the bodypart and sent to a video monitor so that the bodypart and its motion can be seen in detail.

• One echocardiogram. This gives a detailed view ofthe structures of the heart, and can show how wellthe heart is working, by sending out sound waves,which are reflected back by the muscles and tissuesof the heart.

• One electrocardiogram (ECG) a test which measuresthe electrical activity of the heart.

The service also offers a free exercise clinic and aWellbeing complimentary therapy and counsellingservice, supplied by a charity and funded by GenesisCare.

The centre opened in January 2018, this was its firstinspection. We inspected the services which offereddiagnostic and therapeutic radiography, the outpatientsdepartment and the chemotherapy unit and pharmacyservices.

Summaryofthisinspection

Summary of this inspection


Our inspection team

The team that inspected the service comprised a CQClead inspector,one specialist advisor with expertise inoncology and one specialist advisor with experience intherapeutic radiology. The inspection team was overseenby Amanda Williams, Head of Hospital Inspection.

Information about GenesisCare Windsor

The centre is registered to provide the following regulatedactivities:

• Diagnostic and screening procedures

• Treatment of disease, disorder or injury

During the inspection, we visited all areas of the centrethis included the wellbeing centre the exercise and theoutpatients’ clinics, the diagnostic imaging suite and thechemotherapy unit. However, during our inspection, theoutpatients’ department had no patients on the first dayand was closed the second day of our inspectiontherefore we were unable to rate this service.

We spoke with 13 staff including registered nurses, healthcare assistants, reception staff, medical staff and seniormanagers. We spoke with nine patients and threerelatives.

During our inspection, we reviewed four sets of patientrecords.

There were no special reviews or investigations of thehospital ongoing by the CQC at any time during the 12months before this inspection. This was the centres firstinspection since registration with CQC.

In the reporting period March 2018 to February 2019 therewere 367 attendances of care recorded at the service;100% patients were private funded through insurance.

Thirty oncologists, surgeons, physicians and radiologistsworked at the centre under practising privileges. Therewas one regular resident medical officer (RMO) whoattended the clinic on treatment days in chemotherapy,theranostics and contrast scans.

The service was run by one centre leader and employedtwo registered nurses, one health care assistant, fiveradiographers, one physiotherapist and five receptionistand administration staff. The centre also had its ownsmall team of bank staff.

The wellbeing centre had a commercial agreement withGenesis Care to supply well-being services at the centreand was led by one staff member

Track record on safety

• No never events

• Clinical incidents. 32-no harm, 33-low harm,three-moderate harm, 0- severe harm 0-deaths

• No serious injuries

• No incidences of hospital acquiredMeticillin-resistant Staphylococcus aureus (MRSA),Meticillin-sensitive staphylococcus aureus (MSSA),Clostridium difficile (c.diff) or Escherichia coli (E-Coli)

• Five complaints

Services accredited by a national body:

• ISO accreditation for Oncology services

• Macmillan Quality Environment Mark Level Four

Services provided at the hospital under service levelagreement:

• Clinical and or non-clinical waste removal

• Cytotoxic drugs service

• Grounds Maintenance

• Laundry

• Maintenance of medical equipment




• Pathology and histology

• RMO provision

• Complementary treatments.

The chemotherapy nursing team provided a 24-hourtelephone triage line for patients.

The main service provided by this centre was medicine.Where our findings on outpatients and diagnosticimaging– for example, management and staffingarrangements - also apply to other services, we do notrepeat the information but cross-refer to the medicineservice level.




The five questions we ask about services and what we found

We always ask the following five questions of services.

Are services safe?Are services safe?

We rated it as Good because:

• The service had good systems and processes to keep patientssafe.

• Staff managed medicines safely and the service routinelymonitored compliance.

• It was easy to track patients’ care and treatment as recordswere well organised and maintained.

• Staffing levels were safe and staff had the right skills to care forpatients.

• The service controlled infection risk well. Staff used equipmentand control measures to protect patients, themselves andothers from infection.

• The design, maintenance and use of facilities, premises andequipment kept people safe.

• Staff completed and updated risk assessments for each patientand removed or minimised risks. Staff identified and quicklyacted upon patients at risk of deterioration.

• The service managed patient safety incidents well. Staffrecognised incidents and reported them safely. Managersinvestigated incidents and shared lessons learned with thewhole team and the wider service.

However

• Mandatory training was not completed by all members of staff

Good –––

Are services effective?Are services effective?


• The service provided care in accordance with evidence-basedguidance.

• Staff provided good care and treatment, gave patients enoughto eat and drink, and gave them pain relief when they neededit.

• Staff monitored the effectiveness of care and treatment. Theyused the findings to make improvements and achieved goodoutcomes for patients.

Good –––




• The service made sure staff were competent for their roles.Managers appraised staff’s work performance and heldsupervision meetings with them to provide support anddevelopment.

• Staff worked well together for the benefit of patients, advisedthem on how to lead healthier lives, supported them to makedecisions about their care, and had access to good information.

Are services caring?Are services caring?

We rated it as Outstanding because:

• The staff went above and beyond to ensure patients andrelatives/carers received kind and compassionate care andprovided a free wellbeing service.

• Feedback from patients continually confirmed that staff treatedthem well and with kindness.

• The centre had a calm, relaxed and friendly atmospherecontributing to the overall feeling of wellbeing.

• Staff treated patients with compassion and kindness, respectedtheir privacy and dignity, took account of their individual needs,and helped them understand their conditions. They providedemotional support to patients, families and carers.

• A free taxi service was also available for those patientsundergoing daily treatment or feeling too unwell to drive and totake the pressure off family members.

• Staff continually provided emotional support to patients tominimise their distress. Staff we spoke with valued patient’semotional and social needs.

• Patients had their physical and psychological needs regularlyassessed and addressed.

• Staff supported and involved patients, families and carers tounderstand their condition and make decisions about theircare and treatment.

• Staff worked hard to empower patients and their relatives,made sure patients and their relatives were active partners intheir care

Outstanding –

Are services responsive?Are services responsive?


• The service planned care to meet the needs of local people,took account of patients’ individual needs, and made it easy forpeople to give feedback.

Good –––




• The service was inclusive and took account of patients’individual needs and preferences. Staff made reasonableadjustments to help patients access services. They coordinatedcare with other services and providers.

• The service planned and provided care in a way that met theneeds of local people. It also worked with others in the widersystem and local organisations to plan care.

• The centre had a holistic and person-centred approach to careand worked with a charity who provided on-sitecomplementary therapy services. This charity took a whole lifeapproach to a patient’s cancer treatment programme. Thispartnership enabled the centre to deliver highly personalised,holistic care based on a patient’s individual needs.

Are services well-led?Are services well-led?

We rated it as Outstanding because:

• There was compassionate, inclusive and effective leadership atall levels.

• The centre leadership team was highly visible and supportive.Staff were proud of the organisation as a place to work andspoke highly of the culture.

• Leaders had a deep understanding of issues, challenges andpriorities in their service, and beyond.

• Staff across all departments understood the service’s vision andvalues, and how to apply them in their work.

• Staff felt respected, supported and valued. They were focusedon the needs of patients receiving care. Staff were clear abouttheir roles and accountabilities.

• Leaders operated effective governance processes and usedsystems to manage performance effectively whichenabled innovative, patient-centred cancer care within a safeand well governed framework.

• There was a demonstrated commitment to best practiceperformance and risk management systems and processes.

• Staff at all levels were clear about their roles andaccountabilities and had regular opportunities to meet, discussand learn from the performance of the service

• GenesisCare UK recognised the importance of developingleadership for clinical and non clinical staff such as doctors andhuman resources staff. Staff across all GenesisCare centres wereencouraged and supported to attend leadership programmesand courses.

Outstanding –




Overview of ratings

Our ratings for this location are:

Safe Effective Caring Responsive Well-led Overall

Medical care(including olderpeople's care)

Good Good Good

Outpatients Good Not rated Not rated Good

Diagnostic imaging Good Not rated Good Good Good

Overall Good Good Good

Notes

Detailed findings from this inspection


Safe Good –––

Effective Good –––

Caring Outstanding –

Responsive Good –––

Well-led Outstanding –

Are medical care (including olderpeople's care) safe?

Good –––

We rated safe as good.

Mandatory training

The service provided mandatory training in key skillsto all staff however not everyone in the centre hadcompleted it.

• Staff accessed their mandatory training by a mixture ofe-learning and practical sessions and receivedmandatory training in a variety of topics such as basiclife support, conflict resolution, infection control, duty ofcandour and fire safety. The centre set a compliancelevel of 100%.

• There were only two members employed in thechemotherapy unit at the time of our inspection, bothwere up to date with all their e-learning mandatorytraining, however neither had completed all theirpractical mandatory training requirements.

• Whilst two out of three members of the radiographydepartment had fully completed all their e-learningrequirements, the practical elements had not been fullycompleted by any of the team. One radiographer hadonly completed one out of five of the required elements.

• The service was supported by five non-clinical staff, onlyone of which was fully compliant with their e-learningand their practical mandatory training.

• We observed during the morning huddle that one teammember had secured dates to attend a train the trainercourse to be able to run the centres practical infectioncontrol mandatory training courses and improve theircompliance.

• The centre employed a resident medical officer (RMOs)through an external agency. The RMO provided cover tothe centre during the clinic hours. As part of theiragreement it was the agency who provided the RMOswith the relevant mandatory training. The centre leadersmonitored this and shared with us the RMO’s mostrecent advanced life support (ALS) training certificatewhich we reviewed and was in date.

• Those staff with practicing privileges had to provideevidence of their appraisal from their substantive NHStrust employer and this included training andrevalidation dates. This information was held on adatabase at the centre which when we reviewed showedall staff had provided in date information.

Safeguarding

Staff understood how to protect patients from abuse.Staff had training on how to recognise and reportabuse, and they knew how to apply it.

• The service provided yearly safeguarding training as anonline training package. Qualified staff receivedsafeguarding adults and children level two. The staff inthe chemotherapy and radiotherapy departments werefully compliant at the time of our inspection.

• Non-clinical staff received level one adult and childrensafeguarding training. Four out of the five non-clinicalstaff had completed both elements of the requiredtraining.

Medicalcare(includingolderpeople'scare)

Medical care (including olderpeople's care)

Outstanding –


• The centre leader had been trained to safeguardinglevel two adults and children and safeguarding adults’level three practical.

• Staff knew the centre leader was the lead forsafeguarding and knew how to contact the corporatesafeguarding lead trained to level four safeguardingadult and children. This met the intercollegiateguidance for safeguarding children.

• Staff knew where to access the centres safeguardingpolicies and had easy access to electronic versions onthe provider’s internal intranet. The policies were indate, version controlled and reflected nationalguidance.

• The staff we spoke with had not been involved in anysafeguarding issues at the time of our inspection.However, all those staff we spoke with demonstrated anunderstanding of their safeguarding responsibilities andprocedures, which included female genital mutilation(FGM), in the event of any concerns. This aligned withthe service’s safeguarding policies for adults andchildren.

• There were no safeguarding concerns reported to CQCover the last twelve months.

Cleanliness, infection control and hygiene

The service controlled infection risk well. Staff usedequipment and control measures to protect patients,themselves and others from infection. They keptequipment and the premises visibly clean.

• The centre had in-date, version-controlled policiesabout effective infection control and hygiene processes.These policies included cytotoxic linen management,antimicrobial stewardship, and single use medicaldevices policy. Staff knew how to access these via thecentres electronic system.

• Supplies of personal protective equipment (PPE), suchas disposable gloves and aprons, were available in eachdepartment. We observed all staff used the correct PPEwhen providing care and treatment to patients.

• Equipment such as observation machines, trolleys andweighing scales were cleaned and a green ‘I am clean’

sticker attached. Every area we visited used the samemethod and every piece of equipment we checked hada green label on it indicating it had been cleaned andwas ready for use.

• We observed consistent infection control bare below theelbow and hand hygiene practice from staff in all theclinical areas we visited. This included hand washing inline with World Health Organisation standards and theuse of hand gel.

• The centre carried out a six-monthly infection controlaudit which included an audit of the generalenvironment, those areas cleaned by staff and cleanersand waste disposal. This was last completed in March2019 and the centre was 100% compliant.

• Staff, patients and visitors had access to wall mountedand portable hand gel dispensers at the entrance to thecentre, every department and relevant pointsthroughout the department. We observed all staff usedthese.

• We reviewed the cleaning rota for the medical linearaccelerator (LINAC) in the radiotherapy department, forthe month of June and all areas were checked andcleaned every day.

• Hand hygiene audits were completed monthly and alight box observational audit completed annually. Thehand hygiene results for May 2019 showed all staff werebare below the elbows and complied with good handhygiene practice. The light box observational toolshowed staff had the correct hand washing technique.

• Staff received e-learning and practical mandatorytraining in infection prevention and control, howevernot all members of staff had completed the practicalelement. This had been recognised and a plan had beenput in place to train a member of the team to deliver thisinternal practical training.

Environment and equipment

The design, maintenance and use of facilities,premises and equipment kept people safe. Staff weretrained to use them. Staff managed clinical wastewell.

• The facilities, environment and equipment were wellmaintained. All the areas we visited were spacious, light,airy and clutter free.



Outstanding –


• The clinic had an open-plan reception/ waiting area onthe ground floor and reception staff always present.Staff would be directed to the departments which allhad waiting areas which were light, airy and visiblyclean.

• Emergency trolleys, which included resuscitationequipment, were available. The trolleys weretamper-evident to reduce the risk of equipment beingremoved and not available in an emergency. Staffcarried out daily and weekly checks of the equipment toensure it was ready for use in an emergency. Wechecked three trolleys across the units and saw all werechecked in line with policy and no dates had beenmissed for the month so far. We saw information waslocated with or above the trolleys, providing guidancefor staff about the emergency procedures and action totake, such as sepsis.

• Stickers on equipment and machinery identified the lastservice date and when the next service was due. Weexamined eight items of equipment which had all beenserviced or maintained within the last 12 months.

• In cleaning storage areas staff had ensuredconsumables were stored off the floor in line withnational guidance.

• The LINAC had private areas for talking to patients andfor coaching patients for deep inspiration breath holdradiation therapy.

• The LINAC had daily quality assurance processes toensure the suite was safe for use. QA processes werecompleted daily by the lead of the departments. Wereviewed the checks for the month of June for theLINAC, all were completed and passed.

• The radiotherapy suite had spacious lockable, privatechanging rooms with disability access and toiletfacilities. The changing rooms had two-way entry/exitwhich allowed patients to enter the linear particleaccelerator (LINAC) privately once changed. This meantthey did not have to sit in the waiting room in theirgown.

• In all areas we inspected staff complied with theDepartment of Health, Health Technical Memorandum07/01, safe management of healthcare waste (2013). Allwaste was segregated in different coloured bags andposters were displayed explaining which item went into

which waste stream. GenesisCare UK had a wastemanagement standard operating policy which outlinedto staff the processes and procedures to be followed toensure compliance.

• Containers were provided for the safe disposal of sharpequipment, such as needles and cannulas. We observedthese were labelled correctly on assembly and whenready for collection. None of the containers wereoverfilled, reducing the potential of needle stick injury.

• The clinic had service level agreements for cleaningschedules, building and medical equipment servicingand maintenance and waste collection.

• There was an in-date version-controlled health andsafety management policy and a Control of SubstancesHazardous to Health (COSHH) policy. Staff storedCOSHH items securely in a locked cupboard.

• There were fire exit signs and fire extinguishersthroughout the premises. All fire exits, and doors werekept clear and free from obstructions. The centre testedfire alarms weekly. Staff completed yearly mandatoryfire safety training. All but one member of staff hadcompleted their fire safety training.

• The facilities, environment and equipment were wellmaintained. All the areas we visited were spacious, light,airy and clutter free. The chemotherapy unit hadrecently received the Macmillan Quality EnvironmentMark (MQEM). The MQEM is a detailed quality frameworkused for assessing whether cancer care environmentsmeet the standards required by people living withcancer. It is the first assessment tool of its kind in the UK.

• The chemotherapy unit were trialling a new wastesealing unit which increased the safe and effectivehandling of hazardous waste, cytotoxic drugs andinfectious waste, as well as odours and aerosols. Thisworked by sealing the waste in an airtight package. Stafftold us this reduced risk of contamination, and as itsuction packed items, it reduced their size and theamount of waste created.

Assessing and responding to patient risk

Staff completed and updated risk assessments foreach patient and removed or minimised risks. Staffidentified and quickly acted upon patients at risk ofdeterioration.



Outstanding –


• The centre had a daily huddle led by the centremanager and attended by all staff. The huddle includedall departments and discussed and identified a varietyof quality and safety issues. During the morning huddle,the centre manager identified who was responsible forwhat role in the event of patient deterioration. Rolesincluded resuscitation, airway, intravenous access,oxygen, runner and scribe. This meant that all staff knewtheir roles in the event of an emergency. Patient activitywas also discussed, and any safety issues identified. Firealarms were discussed and who was the fire marshalthat day was shared with the team.

• Senior staff told us they planned their days around safestaffing and safe treatment of patients in emergencysituations, such as metastatic spinal cordcompression. If a situation arose such as an emergencyreferral then the leaders had the autonomy to makequick decisions to ensure emergency patients receivedprompt treatment. Team members were able tocoordinate transport via private ambulances and taxiservices and arrange out of hours treatment promptly.In the rare circumstance where the centre were unableto treat patients in an emergency, therewere established pathways across the GenesisCare UKnetwork as well as with local NHS hospitals to facilitatethe safe transfer of patients.

• There were in date polices available to guide staff duringclinical oncology emergencies such as metastatic spinalcord compression. This emergency would requireprompt diagnosis and urgent treatment to prevent orreduce the risk of paraplegia.

• As required by the Health and Safety Executive (HSE)who regulate the Ionising Radiations Regulations 2017(IRR99), all areas where medical radiation was usedwere required to have written and displayed local ruleswhich set out a framework of work instructions for staff.These local rules were displayed throughout thedepartment. All relevant staff had read and signed thelocal rules policy, which applied to all persons whocould be exposed to ionising radiations.

• There were processes in place to ensure the right personreceived the right scan at the right time. Staff completeda six-point check of name, date of birth, address, body

part, clinical information and previous imaging checksin line with the legal requirements of IR(ME)R tosafeguard patients against experiencing the wronginvestigations.

• The service had the support of an external radiationprotection advisor (RPA) and an onsite radiationprotection supervisor (RPS).

• The service followed their in-date resuscitation andemergency call policy if a patient deteriorated. Thepolicy highlighted the procedure for staff to follow whendealing with a deteriorating patient. This includedcontacting the emergency services by calling 999,providing life support, and contacting the service toinform them of the patient’s situation.

• Staff received teaching on sepsis during their ImmediateLife support training and used the National EarlyWarning Score (NEWS) system to monitor patients whowere deteriorating and to escalate care. They followedthe sepsis six policy and the United Kingdom OncologyNursing Society (UKONS) management framework forthe initial management of an emergency.

• Staff used ‘prompt’ cards based on the ‘situation,background, assessment and recommendation’ tool.This prompted appropriate and effectivecommunication as it focused the member of staff todiscuss the situation, background, assessment and theirrecommendation (SBAR) during an emergency. The toolallowed effective and timely communication betweenindividuals from different clinical backgrounds andtemplates were kept on the resuscitation trolleys.

• The centre was open from 8am to 5pm Monday toFriday, however the centre had a telephone hotlinewhich operated 24-hour day, seven days a week. Thiswas in line with UKONS guidelines.

• Patients and carers could access the service for adviceand management on the side effects and complicationsof cancer treatments. All calls were triaged anddocumented on a log sheet and identified as either,needing advice, a 24 hour follow up or a need for urgentassessment.

• The 24-hour triage service was delivered by the twochemotherapy nurses on a rota basis. Activity fromNovember 2018 to January 2019 showed that therewere in total eight calls, three in business hours, three



Outstanding –


out of hours and two after 10pm at night. If a member ofstaff was called several times overnight or for a longperiod of time, they would try to start work later thefollowing day. The service monitored how its staff copedwith these calls especially if they had to work thefollowing day and were considering outsourcing thisservice.

• All patients who were in receipt of chemotherapytreatment were given a comprehensive cancertreatment record, endorsed by a cancer charity, called‘your cancer treatment record’. This booklet containedemergency clinic numbers, details about the patient’streatment, treatment records and patient informationsuch as what to expect and side effects. This bookletwas also a tool to update the GP or local emergencyservices should an emergency situation arise out ofhours. Cancer support booklets endorsed by a cancercharity which explained cancer treatment and sepsiswere given to all patients.

• All patients who were undergoing chemotherapy weregiven a national chemotherapy alert card. This informedpatients to contact the 24hour alert line if they sufferedfrom specific symptoms or present the card to anyonewho was going to treat them.

• The centre had service level agreements (SLA) with alocal NHS trust and were finalising another with a localprivate hospital in case of an emergency or need foradmission. Both SLAs clearly defined the emergencyadmission pathway for those patients who had receivedsystemic anti-cancer treatment (SATC), radiotherapyand theranostics under GenesisCare, Windsor.

• Staff in the chemotherapy unit and radiotherapydepartments completed risk assessments for allpatients such as the risk of venous thromboembolism,pressure ulcer and falls. We saw staff had completedand updated all risk assessments from the four sets ofelectronic records we reviewed. Patient’s electronicrecords showed alerts for any identified clinical risks,such as falls or malnutrition.

• Staff in the exercise clinic completed a full assessmentof their patient’s pre-programme and this included apre-exercise screening tool, a fatigue scale and thehospital anxiety and depression scale (HADS).

• Staff in the wellbeing centre undertook a holistic needsassessment of their patients. This was a process of

gathering and discussing information to develop anunderstanding of what the person living with andbeyond cancer knows, understands and needs. Thisholistic assessment tool was focused on the wholeperson and their entire well-being was discussed.

Staffing

The service had enough nursing and support staffwith the right qualifications, skills, training andexperience to keep patients safe from avoidable harmand to provide the right care and treatment.Managers regularly reviewed and adjusted staffinglevels and skill mix, and gave bank and agency staff afull induction.

• The chemotherapy unit was led by one part time leadchemotherapy nurse (0.7 WTE) supported by one fulltime senior nurse (1 WTE). The service lead told us theywould be recruiting one senior chemotherapy nurse.

• The chemotherapy unit was supported by 1.6 wholetime equivalent (WTE) receptionists based at the mainreception and 1.8 WTE patient administrators

• We attended the daily huddle which was co-ordinatedby the centre leader and attended by all staff. Duringthis meeting staffing for all departments was discussedand any issues identified.

• Weekly operational calls with the director of operations,centre leaders and function leads, supported anyadditional requirements or changes in planned activity.Staffing was discussed and if necessary staff came fromother centres to work.

• Staff told us that the current staffing levels were safe forthe services delivered. Whilst the centre planned toincrease activity, this would only happen alongside thesuccessful recruitment of more specialist staff.

• Therapeutic radiography was led by one lead WTEradiographer and two senior radiographers

Medical staffing

The service had enough medical staff with the rightqualifications, skills, training and experience to keeppatients safe from avoidable harm and to provide theright care and treatment. Managers regularlyreviewed and adjusted staffing levels and skill mixand gave locum staff a full induction.



Outstanding –


• The centre had access to agency resident medicalofficers (RMO). The agency had a service levelagreement with the service which made sure RMOs hadthe skills and competencies to perform their role suchas mandatory training and revalidation. GenesisCare UKalso required that all RMOs must have completed TheResuscitation Council (UK), Advanced Life Support (ALS)training. We saw the latest certificate for the RMO whowas in the centre during our inspection which was indate.

• Staff told us the RMOs were given a full induction to thecentre and this included a health and safety induction.

• RMOs were not routinely in the building and were onsite during treatment days, during theranostics andcontrast scans.

• At the time of our inspection the centre had 30physicians working under practising privileges.Practising privileges are an authority granted to aphysician by a hospital governing board to providepatient care. The medical advisory committee (MAC)monitored all staff with practicing privileges. The centreraised and reported any concerns, includingcompetencies, about consultants through the MAC.

• Practicing privileges were monitored and tracked on acentre compliance sheet and a specific member of staffwould contact any physician whose requirements wereout of date or near renewal. We reviewed thespreadsheet and saw one physician had an indemnitynearly due for renewal, the centre leader told us thisperson would have been written to and would not beable to work once this had lapsed.

Records

Staff kept detailed records of patients’ care andtreatment. Records were clear, up-to-date, storedsecurely and easily available to all staff providingcare.

• The centre used an electronic care records system andonly authorised staff could access these with a securepassword through the centre’s online system. Seniorstaff told us that passwords were managed centrally forsecurity.

• Some paper records of patient contact details andchemotherapy treatments were kept securely onsite.

This meant that in the event of a network outage staffwould be able to proceed with treatment as a papercopy of the approved prescription would be held inaddition to the patient record.

• All consultants with practicing privileges had remoteaccess to the electronic system if they were to see apatient elsewhere. Therefore, reducing the need for hardcopies of patient records to be taken offsite. The centretold us that some consultants kept their own patientrecords and took responsibility for the storage andtransportation of these. Consultants were registeredindependently with the Information CommissionersOffice (ICO), which is the independent regulatory officein charge of upholding information rights in the interestof the public.

• We reviewed four sets of electronic records whichshowed staff had fully completed them, were legible, upto date and stored securely. Each record contained apersonalised care plan and safely updated riskassessments such as the risk of venousthromboembolism, pressure ulcer and falls. And forthose patients undergoing chemotherapy, a toxicityassessment.

• The radiotherapy department used an electronic recordand verify system which was used all along the patientpathway and inter departmentally so that all membersof the multi-disciplinary team could access patientinformation and review what treatment scan wasrequired or had been completed.

• Radiotherapy treatment would not be possible in theevent of network outage as the record-and-verify systemwould not operate under those conditions. The centrewould refer to the local in-date business continuity planshould an incident occur.

Medicines

The service used systems and processes to safelyprescribe, administer, record and store medicines.

• The centre did not keep controlled drugs.

• The chemotherapy suite had four individual 'pods',staffed by a two chemotherapy trained nurses. Thisteam delivered vascular injectable and oral systemicanti-cancer therapy (SACT) to patients. The service wassupported by a pharmacy team who screened



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prescriptions and checked and issued SACT products,which were all prescribed using an electronicprescribing platform and ordered from an externalsupplier.

• The pharmacy team had one on site full-timetechnician, one bank oncology specialist pharmacistand was overseen by the services principal pharmacist.The service was in the process of recruiting a permanenton-site oncology pharmacist.

• A member of the pharmacy team met with patients andtheir relatives prior to the start of their treatments, tohelp build the treatment plan. During this meetingtreatment and side effects experienced during previouscycles were discussed and altered where necessary.

• The pharmacy team built the treatment regimeprescribed by the consultants. The pharmacydepartment had a comprehensive validation process forthe management of chemotherapy prescriptions. Thisincluded checking the correct drug was prescribed withthe right indication, that the drug was tailored to thepatient’s specific parameters, such as renal function,weight and body surface. Part of the process was toverify patient consent, check a referral was in place andto check that the insurance company had agreed thetreatment plan.

• Once this regime had been built it was checked andconfirmed by the consultant and the principalpharmacist, approved electronically and validated.

• Each chemotherapy medication was stored in a patientspecific box. We saw one box with medication made upfor a patient, this was locked away in the dispensary andhad a certificate of conformance to say it had beenvalidated.

• There was a version-controlled medicines managementpolicy which was in the process of being reviewed as ithad expired at the end of May 2019. This policyexplained the roles of the medicines managementcommittee (MMC), classification of medicines and thatno GenesisCare UK sites were registered to holdcontrolled drugs.

• Staff used an electronic chemotherapy prescribingsystem; patients and staff could only update the systemwhen logged in through a secure password. We did notsee any medicines given during our inspection.

• We reviewed one prescription for take homemedications which clearly stated no known drugallergies, what medications should be taken when, whatthey were for, such as stomach protection andadditional information such as take on an emptystomach.

• Medication cupboards in the dispensary were clearlylabelled and locked inside a locked room. Thechemotherapy unit had an extravasation kit and thedispensary kept a second line chemotherapyemergency box and an extravasation kit should the unituse theirs. This ensured there was always emergencytreatment on site. Extravasation occurs whenintravenously infused, and potentially damaging,medications leak into the extravascular tissue aroundthe site of an infusion.

• We observed how the pharmacy technician scannednew medicines in line with Falsified Medicines DirectiveLegislation, which came into force in January 2019. Thisaimed to increase the security of the manufacturing anddelivery of medicines across Europe.

Incidents

The service managed patient safety incidents well.Staff recognised incidents and reported them safely.Managers investigated incidents and shared lessonslearned with the whole team and the wider service.When things went wrong, staff apologised and gavepatients honest information and suitable support.

• GenesisCare UK had an in-date, version-controlledincident, accident and near miss policy which staffaccessed electronically.

• Staff showed a good understanding of incidentreporting and told us how they would raise an incidentusing the electronic reporting system. All staff we spokewith confirmed the service encouraged staff to report allincidents. The senior team told us there had been anincrease in clinical and non-clinical reported incidentswhich demonstrated a positive reporting culture.

• The centre had a daily staff huddle, during which anyincidents from the previous day were discussed.

• The service reported

▪ No deaths or major incidences,



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▪ No reportable incidents had occurred during thereporting period.

▪ 3 moderate incidents

▪ 33 non-clinical incidents,

▪ 33 low harm,

▪ 32 no harm incidents,

• Incidents were discussed during the monthly teammeetings, the senior management team meetings andthen at corporate level at the quality and safety monthlymeeting. We saw how a root cause analysis (RCA) wasdiscussed at the quality and safety meeting and learningshared across all the centres. When root cause analysis(RCA), were completed they included findings,contributing factors, recommendations and were signedoff by the head of the department, centre manager,quality manager and the chief medical officer.

• There was one RCA for radiotherapy;

▪ In January 2019 radiographers had not followed thedocumented procedures when calibrating thepatient dose and did not set the calibrator to thecorrect isotope. The RCA showed a lack of clinicalsupervision of the radiographer in training. Thisrequired policies to be updated and a new policy andprocedure around training for clinical supervision,work to understand competency levels wasimplemented.

• All staff understood the ‘duty of candour’ and describedtheir responsibility related to it. The duty of candour isthe regulation introduced for all NHS bodies inNovember 2014, meaning they should act in an openand transparent way in relation to care and treatmentprovided.

• The medicines management committee met quarterlyand this meeting was attended by all pharmacists anddepartment leads form the genesis UK centre. Wereviewed the minutes from May 2019 meeting and sawthat incidents were a standardised agenda item.

Are medical care (including olderpeople's care) effective?

Good –––

We rated medical care as good.

Evidence-based care and treatment

The service provided care and treatment based onnational guidance and evidence-based practice.Managers checked to make sure staff followedguidance.

• The service used a range of evidence-based guidance,legislation, policies and procedures to deliver care,treatment and support to patients. We saw carepathways followed nationally recognisedrecommendations such as the National Institute forHealth and Care Excellence (NICE) guidance.Chemotherapy treatments were based on the UnitedKingdom Oncology Nursing Society (UKONS).

• Staff we spoke with and patient records showed stafffollowed NICE guidance on falls prevention, cytotoxicmedicines, pressure area care and venousthromboembolism.

• Staff had access to policies and operating proceduresthrough an online system. We reviewed some of theseand all were version controlled, in date and easilyaccessible.

• Staff had access to policies and standard operatingprocedures (SOPs) covering cytotoxic medicines, whichincluded ordering, preparation, prescription,administration and disposal. Staff described theyfollowed the clear guidelines in handling thesemedicines.

• The centre had an exercise clinic which offered andprescribed exercise to its patients as a medicine. Thiswas to reduce the risk of cancer re-occurring, reduceside effects and help some therapies to work better. Thebenefits of this programme were

▪ Improve the effectiveness of treatment,

▪ Increase muscle mass,

▪ Reduce fatigue,

▪ Help the body to produce healing chemicals,

▪ Improve mental health,



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▪ Limit side effects of chemotherapy,

▪ Help patients to recover.

• An electronic platform supported the clinic whichenabled patients to access a tailored exercise regimebased on cancer specific exercises. This platform alsoallowed the clinic lead to monitor patient adherence tothe regimes and collect data relating to the exercisescompleted by the patient.

• Clinical research and trials were offered to patients andthere were systems and processes in place to ensurethese were safe. Peer reviewed clinical protocols wereavailable for diagnostic tests. Any trials and cases whichfell outside clinical protocols were referred to theclinical advisory team who held virtual peer reviewmeetings in collaboration with clinicians to discuss theevidence behind protocol deviations. The final decisionwas documented in patients' electronic medical record

• The chemotherapy team told us they were taking part ina 12-month pilot study to assess the effectiveness ofhand and foot cooling in preventing the symptoms ofchemotherapy induced peripheral neuropathy (CIPN).This condition is a common side effect of many forms ofchemotherapy and can have a negative impact on thequality of life for cancer survivors. Side effects includenumbness, decreased sensation, pain (of variousintensities in the extremities), gait/balance problems,and difficulty with fine motor skills of the hands andfingers. When CIPN becomes intolerable, optimal dosesof chemotherapy must be reduced or discontinued,which may affect a patient's overall survival. The trialinvolved using a device to deliver cooling treatments tohands and feet and the team were passionate about thebenefits this had for their patients and the support theyhad from GenesisCare senior leadership to completethis trial. The trial was due to conclude in September2019; therefore, outcomes had not yet been concluded,however staff told us feedback was so far positive. Staffsaid they felt if their results were positive then thiswould be a treatment option for all future patients.

• GenesisCare UK were leading on a clinical project forpatients undergoing pelvic radiotherapy and were alsoready to start a study of right breast radiotherapy usingdeep inspiration breath hold and surface guidance, atechnique normally used for left breast cancers. Thiswas due to start at the time of our inspection.

• Patients who took part in clinical trials withinGenesisCare were followed up long-term by the clinicaland research teams and long-term results weredocumented as per trial requirements.

• The centre had installed a Surface Guided RadiotherapyTreatment (SGRT) system which used a system ofcameras to monitor patient movement duringtreatment. This piece of equipment meant the centrecould provide tattoo-less treatment. Staff told us thiswas a positive for many patients who viewed theirtattoos as a constant reminder of their radiotherapytreatment.

• The SGRT system also enabled the centre to use‘faceless’ shells for head and neck treatmentsradiotherapy treatment. This, staff told us was a muchnicer experience for patients as they no longer neededto wear full face masks and could open their eyes andfeel less restricted

• The service used image guided radiotherapy (IGRT)which is the use of imaging during radiation therapy toimprove the precision and accuracy of treatmentdelivery. IGRT is used to treat tumours in areas of thebody that move, such as the lungs. This techniquetargeted the area to be treated, accurately and reducedthe risks of side-effects from radiotherapy.

• Patients could also access intensity-modulatedradiation therapy (IMRT) which helped reduce long-termside-effects of radiotherapy. This was in line with the‘gold standard’ recommendations of the NHScommissioning clinical reference group. IMRT is anadvanced type of radiation therapy used to treat cancerand noncancerous tumours. IMRT uses advancedtechnology to manipulate photon and proton beams ofradiation to conform to the shape of a tumour.

• GenesisCare UK had developed its own performancedatabase which collected quality and performance data.This enabled internal performance benchmarkingacross all 12 UK centres sites. Information includedpatient satisfaction, incidents, complaints, concerns andcompliments. They had plans to add information suchas infection, falls and venous thromboembolism rates.

Nutrition and hydration

Staff gave patients enough food and drink to meettheir needs when patients.



Outstanding –


• All patients who attended the clinic had access to thedietetic service if required.

• Patients undergoing pelvic radiotherapy were reviewedweekly by the clinical team who recorded their nutritionand weight status.

• Nurses reviewed patients’ blood results beforeproceeding with chemotherapy and any evidence ofdehydration would be escalated to the RMO on-site whowould prescribe fluids.

• The centre had a refreshment dispenser which patientsand visitors could access coffee, tea, water and biscuits.

• Staff used the malnutrition universal screening tool toassess the nutrition and hydration needs of patients.This tool is a five-step screening tool to identifymalnourished adults or adults at risk of beingmalnourished. Staff documented the assessmentoutcomes in the patient’s care records. Staff we spokewith described they could escalate to the residentmedical officer for prescription of fluids for patients whoat risk of dehydration.

• Patients were offered sandwiches, snacks and drinks ifthey need to stay in the department between theirinjection and scan. The chemotherapy suite had aselection of snacks they felt those patients who receivedchemotherapy may prefer such as soups and energybars.

• The exercise clinic completed a diet analysis three daysprior to a patient’s initial assessment. This informationwas analysed so staff could recommend increased foodintake of certain food groups, vitamins, minerals andwater.

Pain relief

Staff assessed and monitored patients regularly to seeif they were in pain.

• Staff used a numerical pain score to assess patients’pain and would have pain killers prescribed whennecessary. However, as the centre did not keepcontrolled drugs, if a patient's pain required urgentattention, the RMO or pharmacist would contact thepatient's clinician and/or GP for an urgent painmedication review.

• Staff in the chemotherapy unit recognised that for somepatient’s arriving at the centre, getting out of the car and

being wheeled up the ramp could be uncomfortableand painful. Staff did not wait for patents to arrive insidethe centre but cared for them as soon as they arrived inthe carpark. Nursing staff administered a prescribedpain-relieving gas (gas and air) to settle patients after anuncomfortable journey into the centre.

• The centres’ radiographers were competent inperforming daily reviews and liaised with the RMO, theoncologist, the local hospice or GP, if patients requiredmedical attention for symptom control. All patientsattending radiotherapy had a radiographer review whichincluded pain level and toxicities. These were recordedelectronically.

Patient outcomes

Staff monitored the effectiveness of care andtreatment. They used the findings to makeimprovements and achieved good outcomes forpatients.

• Monthly performance reviews included qualitymeasures such as complaints, concerns, complimentsand the centres’ net promoter score (which representedpatient satisfaction). The number of incidents andwhich department they occurred in were monitoredalongside, severity, status (open or closed) and anytrends or support required.

• The radiotherapy unit contributed data from eachpatient episode to the National Radiotherapy Dataset(RTDS). The purpose of the standard was to collectconsistent and comparable data across providers ofradiotherapy services in England. This would provideintelligence for service planning, commissioning, clinicalpractice and research and the operational provision ofradiotherapy services across England.

• The centre collected Patient Reported OutcomeMeasures to monitor patient progress, facilitatecommunication between professionals and patientsand help to improve the quality of health services. At thetime of our inspection PROMS were collected pre andpost therapies for those patients attending thewellbeing centre. Patients were asked to completequestionnaires on their health and quality of life andfindings showed improvements in patients' main cancerrelated concerns and wellbeing. Results showed 78% ofpatients reported that the wellbeing service helped with



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cancer treatment side effects. Furthermore, one keytheme from this data showed patients appreciatedbeing treated holistically and like a person rather than apatient.

• The exercise clinic which was relatively new to thecentre was not audited fully at the time of ourinspection. However, assessments and dischargereports were completed for patients at their firstchemotherapy appointment and on discharge. Wereviewed four of these reports which all showedenormous health gains post exercise treatments.

• The centre also reported outcomes during radiotherapyand chemotherapy treatment using toxicity scoringtools. Toxicities greater than grade 2 were added to theelectronic incidence reporting system and auditedmonthly by the clinical governance team.

• The centre had recently registered to contributeinformation to the Private Healthcare InformationNetwork (PHIN) for benchmarking purposes. Thisnetwork is the independent government organisationthat holds information about private healthcare toimprove quality.

• The chemotherapy unit submitted Systemic AnticancerChemotherapy (SATC) data. The SACT dataset collectssystemic anti-cancer therapy activity from providers andthe world’s first comprehensive database, whichenabled treatment patterns and outcomes to beunderstood on a national scale.

• All patients received a follow up call two weeks after theend of treatment which was audited. All this informationincluding the PROMs data contributed to thechemotherapy patients end of treatment reports whichpatients and their GP received. Patients were dischargedfollowing treatment from the oncologist back to thereferring surgeon and long-term results were audited bythem.

• The centre had an audit schedule to identify, monitorand drive quality improvement. Audits included,confidentiality, consent, control of substanceshazardous to health (COSHH), health and safety, displayscreen equipment (DSW), infection control, medical gassecurity and medicines management. Out of the 24areas of audit, 14 reached 100% compliance and theremainder had achieved an amber status all of whichwere 75% and above.

• For those areas which failed audits, action plans weredeveloped. We reviewed the action plan for the medicalgas security which had achieved 84% compliance andsaw an action plan to improve training and a policyreview was underway.

Competent staff

The service made sure staff were competent for theirroles. Managers appraised staff’s work performanceand held supervision meetings with them to providesupport and development.

• The service appraisal period ran from June to July eachyear. In the reporting period from June 2018 and July2019, 100% of medical staff, nursing staff and healthcareassistants had completed their appraisals.

• Staff reported they received clinical supervision eachmonth or sooner when required.

• Nurses in the chemotherapy department were expectedto and had completed competencies and nationallyrecognised specialist training in the administration ofchemotherapy treatment.

• Radiographers were trained to assess needs andprovide supportive treatments such as mouthwashesand skin emollients for symptomatic control.

• New consultants and RMOs underwent a registrationprocess to be granted practising privileges and receivedan annual review to ensure their practice remained safeand within scope. The centres registered manager wasresponsible for the annual review of clinician practisingprivileges and responsible for advising the medicaladvisory board (MAC) if there were any concerns. Thisensured clinicians continued to practice within scope,have up to date documentation and there were noissues with integrity or competence.

• All staff including bank members received an inductionprogramme. New starters and bank staff all completed ahealth and safety induction checklist the first day theystarted their job, and this ensured they knew what to doin an emergency. This included for example, radiationsafety, and COSHH. Permanent staff received acomprehensive induction process and completed a60-day induction programme called the 60 day roadmap, the GenesisCare new employee experience.

Multidisciplinary working



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Doctors, nurses and other healthcare professionalsworked together as a team to benefit patients. Theysupported each other to provide good care.

• Multidisciplinary meetings (MDT) to plan the treatmentpathways for patients were the consultant oncologist'sresponsibility. Consultants arranged for patients to bediscussed at the consultants own NHS trust MDT, whichthey accessed as part of their NHS practice.

• The centre told us that to improve the MDT process, anelectronic MDT platform was being piloted at anotherGenesis Care site. The intention was for this to be rolledout to other centres to facilitate the development ofin-house Genesis Care MDT meetings.

• Staff told us they worked well with the consultants andcould contact them at any time if they had concernsabout their patients.

• Staff worked hard to provide a fully MDT approach topatients care and treatment. All the centre staff referredand encouraged patients to take advantage of theexercise clinic and the wellbeing centre.

• Weekly patient treatment reviews were completed bythe radiographers and this included referrals to andinformation from dieticians, speech and languagetherapy and specialist breast care nursing support. Stafftold us there were good links with other Genesis Carecentres to offer specialist nurse support.

Seven-day services

• The centre did not provide overnight beds and openedfrom Monday to Friday from 8am to 5pm. Outside thesehours, the centre provided a 24-hour triage line tosupport cancer patients

Health promotion

Staff gave patients practical support and advice tolead healthier lives.

• Health promotion leaflets were displayed in relevantareas throughout the centre these included healthyeating and advice on stopping smoking.

Consent and Mental Capacity Act.

Staff understood how and when to assess whether apatient had the capacity to make decisions abouttheir care. They followed the service policy andprocedures when a patient could not give consent.

• Staff understood their roles and responsibilities underthe Mental Health Act 1983 and the Mental Capacity Act2005. At the time of our inspection seven out of the ninemembers of staff had completed their mental capacitypractical training and 100% of staff had completed theirpatient e-learning consent training.

• Whilst staff had received training on mental capacitythey said they would not be likely to see patients withmental capacity issues in their service as they would beseen at the local NHS trust. However, should they haveconcerns about a patient’s mental health or capacity toconsent verbally to investigations they would discussthis with the centre manager and the consultant.

• Consent was a two-stage process and was checkedagain when the patient came for any form ofinvestigation or treatment, this was signed by thepatient and radiographer, scanned and uploaded to theelectronic system.

• The centre completed a yearly consent audit and scored100% in June 2019.

Are medical care (including olderpeople's care) caring?

Outstanding –

We rated caring as outstanding.

Compassionate care

Staff truly respected and cared for patients withcompassion. Feedback from patients continuallyconfirmed that staff treated them well and withkindness.

• Feedback from people who used the service, wasconsistently positive about the way staff treated people.Patients told us that staff went the extra mile and theircare and support exceeded their expectations.

• Patients and their carers needs were recognised andprovided for, before they arrived at the centre. A free taxi



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service was available for those patients undergoingdaily treatment or feeling too unwell to drive and to takethe pressure off family members. Staff had recognisedthat the journey from the car park up the steps and intothe centre could be painful for some patients. A rampwas provided to cover the bumps in the pavement andstaff would administer a pain-relieving gas (gas and air)to make the short journey more comfortable.

• We observed all patients were treated with dignity,kindness, compassion, courtesy, respect, understandingand honesty in line with NICE QS15, Patient experiencein adult NHS services, Statement 1. This was reflected inhow the centre was designed which ensured thatpeople’s privacy and dignity needs were understoodand always respected, including during physical orintimate care and examinations. Staff were highlymotivated to provide care that was kind and offereddignity and respect. All staff-maintained privacy, withclosed doors and clear signage indicating the room wasoccupied. There were also curtains within each room toprovide extra dignity and privacy where required. Theclinic had private changing areas for all its departments.In some area’s patients could either exit one way intothe waiting room and or stay in the changing room untilit was time for their appointment and exit directly to thetreatment area. This meant they did not have to sit inthe waiting room.

• Patients emotional and social needs were seen as justas important as their physical needs. Freecomplementary therapies were offered to patients, atthe wellbeing clinic. We spoke with one patient who wasinitially very sceptical about therapies. However, after aninitial appointment with the wellbeing consultant andthe information given the patient was ‘impressed by thewhole experience’. Another patient told us theatmosphere was calm and serene, and all staff were‘professional, caring and approachable’. We spoke withanother patient who had received reflexology who said,‘it was a lovely facility, staff were very professional, theycould not ask for better’.

• Interactions between staff, patients and visitors wererespectful and considerate. We observed that all staffintroduced themselves to their patients in line with NICE

QS15, Statement 3. The centre had designated quietrooms where staff, patients and their relatives couldhave private conversations or wait for treatments awayfrom the waiting areas.

• Patients could have a chaperone and there were postersand laminated leaflets displayed across all thedepartments informing patients about their availability.

• The centre had a calm, relaxed and friendly atmospherecontributing to the overall feeling of wellbeing. Staff toldus that there was a choice of music during treatments,there was access to television with movie channels,board games and jigsaws, in the treatment rooms andwaiting areas.

• Patients across all the departments completedsatisfaction surveys and results were analysed andactions taken. In the exercise suite patient satisfactionquestionnaire prompted a review of the bookingprocess which was adjusted.

• For those patients who were attending the exercise suitethe service had recently secured discounted rates at alocal gym.

Emotional support

Staff continually provided emotional support topatients to minimise their distress. Staff we spokewith valued patient’s emotional and social needs.Staff embedded these in their care and treatment.

• Patients individual needs and preferences were alwaysreflected in how their care was delivered. Patientsphysical and psychological needs were regularlyassessed and addressed, including nutrition, hydration,pain relief, personal hygiene and anxiety. This was in linewith National Institute for Health and Care Excellence,QS15 Patient experience in adult NHS services,Statement 10.

• Throughout all the patient and relative interactions,from reception through to discharge we observed howstaff understood the impact a person’s care, treatmentor condition could have on their wellbeing, bothemotionally and socially. This was evident from thecomplimentary wellbeing service delivered to patientsand their relatives, the taxi service to relieve the burdenof driving, and personalised care plans with patientcentred goals such as the ability to run after the dog.



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• The patients we spoke with in the departments wereoverwhelmingly positive about the department and thestaff. We spoke with one patient who told us staff were‘very efficient, lovely, I have total confidence in them’.One other patient told us how they went above andbeyond to accommodate their treatment when one ofthe machines had a problem, whilst this was fixedalmost immediately, staff had alternative plans and ataxi arranged to attend another clinic.

• All the patients we spoke with told us staff gave themsupport and time to discuss their treatment. Onepatient told us ‘the people make it, they put their heartand soul into this work’

Understanding and involvement of patients and thoseclose to them

Staff supported and involved patients, families andcarers to understand their condition and makedecisions about their care and treatment.

• Patients and their relatives were empowered to beactive partners in their care. Patients and their relativestold us they found all the staff reassuring and theyreceived good explanations about their care. They saidthere was always time during the appointment and thatthey were never rushed.

• All patients and relatives were involved in thedevelopment of their ‘plan of care’ .These plansincluded relevant up-to-date information to supportpatients’ understanding of their care and includedtreatments, therapies and exercise.

• Patients told us they were satisfied with the verbal anddocumented information staff provided them. They alsotold us that when they called the department with aquestion, staff were always quick to answer withdetailed information. Patients found it a comfort to havea 24-hour helpline and that they knew the nurse on theend of the phone was reassuring.

• In addition to offering free complementary therapies topatients, the centre also offered free relaxation serviceto patients’ carers. Staff saw this as part of the patients’wellbeing.

• The centre used feedback collected from thecomplementary therapy sessions and exercise classes tofurther improve the experience of patients and thoseclose to them.

• Staff also signposted patients to other services whenrequired and had strong links with the local hospice andNHS Trust.

Are medical care (including olderpeople's care) responsive?

Good –––

We rated responsive as good.

Service delivery to meet the needs of local people

The service planned and provided care in a way thatmet the needs of local population. It also worked withothers in the wider system and local organisations toplan care.

• The services provided reflected the needs of thepopulation and ensured flexibility, choice and continuityof care. Staff worked around their patients work andfamily commitments to offer treatments.

• The staff on the chemotherapy unit worked with thelocal NHS Trust and a local private provider to ensuresafe patient referral in the event of a patient’sdeterioration or need to be admitted into the inpatient’sunit.

• Staff would also contact and work alongside the localhospice to ensure patients were supported in thecommunity and there was continuity of care.

• The service continually ensured the clinic met patients’needs, patient opinion was gathered through a varietyof channels – patient focus groups, informal verbalfeedback, patient experience survey and patientcomplaints. This feedback was discussed at group,centre and team meetings and used to inform serviceimprovement and redesign projects.

• The facilities and premises were appropriate for theservices delivered. There was ample private parking forpatients, staff and their relatives and a taxi service freeof charge. The centre was light and airy withconsultation rooms, treatment rooms, a recovery roomand plenty of quiet/ private areas for patients to sit.Drinks machines were available on each floor.



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• All rooms were clearly identified and had signsindicating when a room was occupied. Toilets had clearsigns, and each had an alarm bell to call for staff.

Meeting people’s individual needs

The service was inclusive and took account ofpatients’ individual needs and preferences. Staffmade reasonable adjustments to help patients accessservices. They coordinated care with other servicesand providers.

• Staff ensured arrangements were put in place to takeaccount of individual needs of people being discharged.For example, a patient had complex pain issues and thestaff contacted the local hospice and arranged a homevisit to review symptom management.

• Patients and their carers could have a tour around thedepartment during their pre-treatment appointment.

• The centre had an induction loop for hard of hearingpatients and clear signage throughout, disabled parkingand wheelchair access throughout. There were lifts toreach each floor and space in the changing rooms forwheelchair users.

• Translation services were available, however staff toldus they had never required this service. Writteninformation was available in large print and easy readmaterials could be obtained when required

• The centre had business support staff who helpedpatients understand their private medical insurance.

• Specialist equipment such as ‘cold caps’ (scalp coolingtreatment), were available and a recent trial forperipheral neuropathy was in the process of beingcompleted. Information leaflets about wig services wasavailable throughout the centre.

• The centre was designed with the needs of its patientsin mind and there was adequate space for privateconsultations. The service had a lead and seniorchemotherapy nurse who would be available during thistime and were in the process of advertising for furthersenior nurses as the service grew and expanded.

• The centre had a holistic and person-centred approachto care and worked with a charity who provided on-sitecomplementary therapy services. Staff carried outholistic needs assessment to make sure patientsreceived their preferred choice of therapy.

• Weekly patient treatment reviews were completed bythe radiographers and this included referrals to andinformation from dieticians, speech and languagetherapy (SALT) and specialist breast care nursingsupport. Staff told us there were good links with otherGenesisCare centres to offer specialist nurse support.

• There was effective verbal and electroniccommunication between the physiotherapist in theexercise department and the radiographers to ensurethat a patient exercise plan did not impact onradiotherapy treatments.

• Feedback from patients and carers was used to shapethe services and provision of care and treatment at thecentre. All patients who finished their treatmentpathway were asked to complete a comprehensivequestionnaire, the information from this is collated ontoa dashboard to centre leaders and shared with staffduring monthly staff meetings. Free text commentarywas also shared with the hope this would open a topicfor a focus group discussion in the centre to improvepractice.

Access and flow

People could access the service when they needed itand received the right care promptly.

• Detailed reporting on ‘time to treat’ was a keyperformance indicator for GenesisCare Windsor, as wellas at a wider corporate level. The centre dashboardidentified trends and outliers, and benchmarkingagainst internal key performance indicators (KPIs) aswell as against national guidelines. We reviewed thedashboard from January to June 2019 where detailedreporting was undertaken at each step in the bookingprocess, as well as at an individual doctor level. Thecentre assessment to treatment time was 6.6 days,compared to 7.7 days nationally.

• The service used data in dashboard reports such as‘time to treat’ to support the development of improvedpathways for their patients. Technology to improveresponsiveness had recently been implemented in the



Outstanding –


form of a messaging service for doctors. This went livewith Radiotherapy and informed doctors of three keystages in a patients pathway. When the CT appointmentwas booked, when the CT scan was ready to contourand when the plan for the treatment was ready toreview. This improved the pathway time forpatients which, prior to inspection had been over 10days and at the time of inspection was 7.8 days.

• Time to treat’ performance was discussed in multipleforums, this included the weekly centre leaderdashboard meetings, monthly operations meetings andone-to-one reviews with the centre team.

• The centre monitored patient wait times once they hadarrived at the centre. This information was tracked onthe centre dashboard and showed the month of April2019 that most patients were seen either as soon asthey arrived or within five minutes of arrival.

• The service contacted patients within an hour todiscover the reason for non-attendance, if a patientfailed to attend their clinic appointment.

• There were three cancelled procedures within thereporting period of March 2018 to February 2019. Ofthese cancellations 67% of patients were offeredanother appointment within 28 days of cancellation.

Learning from complaints and concerns

It was easy for people to give feedback and raiseconcerns about care received.

• The service treated concerns and complaints seriously,investigated them and shared lessons learned with allstaff. The service included patients in the investigationof their complaint.

• The service received five complaints in the reportingperiod from March 2018 to February 2019 to November2018. None of these had been reported to the ISCAS(Independent Healthcare Sector ComplaintsAdjudication Service). We did not receive informationabout which service these were attributed to.

• Complaints and lessons learned were shared at thedaily huddle to inform staff if there were any open,needing investigation or had closed and then more indepth at the monthly senior management teammeeting. There was also the opportunity to discuss anycomplaints and learning for the wider team at either the

monthly operational meeting or the monthly safety andquality committee meeting. Staff told us of recentchanges, after a complaint was made on how thereception team welcomed patients into the building.This was discussed as a team in terms of language andexpectation and a format agreed. Senior staff told usthat they planned to arrange either in-house or externalcustomer service training.

• A poster was displayed in the reception area informingpatients how to make a complaint.

• Staff had access to the GenesisCare UK corporateconcerns and complaints policy which was in date andversion controlled. Staff told us they would refer to thispolicy should they have a complaint but would try toresolve a complaint at local level before it wasescalated.

• The registered manager of the centre, the operationsdirector and the quality manager were all responsiblefor the oversight and management of complaints. Thecentre reported all complaints to the corporate’s chiefmedical officer. The team worked in collaboration toensure patients were informed, lessons learned and thatthe complaint was managed in line with policies forexample, closed within 21 days.

Are medical care (including olderpeople's care) well-led?

Outstanding –

We rated well led as outstanding.

Leadership

Leaders had the integrity, skills and abilities to runthe service. They understood and managed thepriorities and issues the service faced. They werevisible and approachable in the service for patientsand staff. Comprehensive and successful leadershipstrategies were in place to ensure and sustain deliveryand to develop the desired culture. Leaders had adeep understanding of issues, challenges andpriorities in their service, and beyond.



Outstanding –


• There was compassionate, inclusive and effectiveleadership at all levels. The centre had a clearaccountability and leadership structure. Managers at alllevels had the right skills and abilities to run the serviceproviding high-quality sustainable care

• The centre had dedicated leads for each clinical servicewho reported to the centre leader. The centre leaderreported to the Director of Operations who sat withinthe GenesisCare UK Leadership Team.

• The centre leader was highly visible and workedalongside staff to address any immediate issues thatchallenged the centre, such as demand and capacity. Toachieve this the centre leader held a daily stand-uphuddle to trouble shoot any issues and problem-solvefor that day. Staff told us they liked the morning huddle,it ensured safety issues were identified and risksreduced.

• There was a system of leadership development andsuccession planning for all members of the team. Staffat the centre told us they had been supported to attendcourses and develop their skills. These courses ran overseveral months and combined workshops, coachingand individual quality improvement projects.GenesisCare UK had also invested in training cliniciansto evolve into frontline leaders in the NHS and privatesector through a Consultant Leader Course.

• Senior staff at the centre had been supported to attenda week long residential course designed to enableparticipants to be more effective within their role, whilesupporting succession planning and talentdevelopment. 360˚ feedback was undertaken duringthe programme, with a six month action plan andregular feedback sessions. We were told two furthermembers of the Windsor team had been nominated toattend the second intake of the course in November2019.

Vision and strategy

The centre had a vision for what it wanted to achieveand a strategy to turn it into action. The vision andstrategy were focused on sustainability of services.Leaders and staff understood and knew how to applythem and monitor progress.

• GenesisCare UK had a vision to create great careexperiences and to get the best possible life outcomesfor patient, this was underpinned by four key values:

▪ Empathy for all

▪ Partnership for all

▪ Innovation every day

▪ Bravery to have a go

• To achieve this vision all GenesisCare UK centres hadtheir own strategy which fitted in with GenesisCare UKoverarching ‘Service of the Future’ (SOF). The SOF wasan innovative, continuous development andimprovement strategy which allowed centres to definebest practice and adopt new innovations specific totheir centres and monitor their strategy. SOF linked towork streams under three pillars;

• Quality• Access• Efficiency• The SOF strategy was co-created following staff

engagement across the whole business, led by adesignated SOF lead whose responsibility it was to workwith the centre leaders, drive the strategy and ensureengagement at all levels within the organisation. A faceto face roadshow was run as an opportunity for everymember of the GenesisCare Windsor team to feedinto the patients’ care pathway.

• One of the key aims was to grow the service forGenesisCare Windsor and this included building thename and recruiting more specialists.

• GenesisCare UK invested in training clinicians to evolveinto frontline leaders in the NHS and private sectorthrough a Consultant Leader Course; this underpinnedtheir mission to become the outstanding and preferredUK oncology provider and employer.

Culture

Staff felt respected, supported and valued. They werefocused on the needs of patients receiving care. Theservice promoted equality and diversity in daily workand provided opportunities for career development.The service had an open culture where patients, theirfamilies and staff could raise concerns without fear.



Outstanding –


• Managers across the centre promoted a positive culturethat supported and valued staff, creating a sense ofcommon purpose based on shared values. Staff wereproud of the organisation as a place to work and spokehighly of the culture.

• There were high levels of satisfaction reported, as staffsaid they really enjoyed working at the centre and toldus of how they felt valued by the company and theirlocal leader. Staff gave us many examples of how thiswas shown such as family fun days, service of the future,off site meetings, weekly staff fruit delivery and giftvouchers for recognition of hard work. Staff also told usthat when the chief executive officer visited the countryand the centre he spent time with all the teamdiscussing their thoughts and ideas on service deliveryand improvement.

• Staff were involved in the development of the Service ofthe Future (SOF) and were encouraged to sign up forinclusion into a work stream depending on area ofinterest and/or expertise. Several projects were definedunder each work stream. Quarterly roadshows wereheld across the centres to provide progress updateswith more regular communication in a monthly posterhighlighting key activities that month. We were told thisinclusive attitude for all members of the team hadresulted in improvements in the recent staffengagement survey. Results nationally showed a 13%improvement up to 67%, and locally at Windsor, theengagement score was 81.4%.

• The centre nominated a team of the month who wererecognised for going above and beyond anddemonstrating the company values. Staff couldnominate those colleagues they would like to putforward to be recognised as living one or more of ourvalues, these were collated and shared in a 'Feel GoodFriday' email to all staff. Staff were encouraged to sendvalue postcards to anyone they wish to recognise forliving one or more of the company values.

• Staff received training in the duty of candour at the timeof our inspection 94% had completed this training. Allstaff we spoke with understood their role within the dutyof candour.

Governance

Leaders operated effective governance processes,throughout the service and with partner

organisations. Staff at all levels were clear about theirroles and accountabilities and had regularopportunities to meet, discuss and learn from theperformance of the service.

• GenesisCare UK aimed to have a clear and consistentgovernance process across all its centres. Monthly safetyand quality committee meetings were held to covercorporate, clinical and information governance andbenchmark against the other centres. Information wasfed into these meetings from eight sub-committees,these were;

▪ Medicines management committee

▪ Infection prevention control committee

▪ Radiation protection service committee

▪ Resuscitation committee

▪ Health and safety committee

▪ Nursing advisory committee

▪ Imaging service committee

▪ Radiotherapy and technical committee

• Each subcommittee met either, monthly, quarterly oryearly and had an identified list of attendees, whichincluded a lead and representation from each centre.

• The radiation protection committee met yearly. Wereviewed the minutes from the most recent meeting inMarch 2019 which included an annual update, radiationrisk assessments, international updates and radiationincidents.

• There was effective corporate oversight of performanceregarding antimicrobial prescribing and stewardship.This was a discussed during the medicine’smanagement committee meetings and documented inthe minutes.

• Information was fed up from the safety committee tothe GenesisCare UK leadership group and then up to theglobal executive leadership group. Centre leaderscascaded information to their teams by monthly teammeetings or skype meetings. This forum was wherecentre leaders would update on issues anddevelopments.

• A monthly Senior Management Team (SMT) meeting washeld in Windsor for all the centre leaders.



Outstanding –


• GenesisCare UK had four clinical reference groups(CRGs) which provided medical and clinical leadershipto the GenesisCare UK board in the areas of clinicalprotocol standardisation, research and innovation,clinical governance, and quality. The CRGs supportedfour service lines: radiotherapy, urology, breast andhaematology. The groups met monthly via videoconferencing and face-to-face on a quarterly basis. Thecentre provided us with the four CRGs headlineachievements and focus for the year ahead. We saw forexample, how the CRGs had supported the initial rollout of the theranostics at the GenesisCareWindsor, which combines both therapy and diagnosticradiotherapy.

• To monitor clinician’s competence a medical advisoryboard (MAC), consisting of seven clinical oncologists, thechief medical officer, quality manager and practisingprivileges coordinator was established. Meetings in thisformat started in February 2019 and prior to this therewas an ad-hoc mini MAC. The centre told us they hadgrown as a company and as clinicians were performingmore complex treatments a more established MACmeeting was required where more extensive discussionsabout consultant practices and new practicing privilegereviews would happen. This took place quarterly and wereviewed the minutes for May 2019 and saw howpractising compliance with privileges were discussedalongside new consultants for review.

• The chemotherapy unit had developed a service levelagreement (SLA) with the local NHS trust and werefinalising an SLA with a local private hospital. Wereviewed both documents which were clear and set outthe scope, purpose and how the effectiveness andcompliance would be monitored.

Managing risks, issues and performance

Leaders used systems to manage performanceeffectively. They identified and escalated relevantrisks and issues and identified actions to reduce theirimpact. They had plans to cope with unexpectedevents.

• There was a demonstrated commitment to best practiceperformance and risk management systems andprocesses. The organisation reviewed how they

functioned and ensured staff at all levels had the skillsand knowledge to use those systems and processeseffectively. Problems were identified and addressedquickly and openly.

• A risk and safety working group (RSWG); consisted offront line clinicians and clinician managers. Delivered incollaboration with the wider European team, the RSWGprovided strong and professional leadership in risk andsafety practice. Senior staff told us the workinggroup led to an efficient, multi-disciplinary approach torisk management, risk analysis and incidence review, aculture of continuous improvement and sharedlearning, as well as clinical standardisation.

• The centre had an in-date, version-controlled riskmanagement policy which outlined identifying anddetermining risk, local and corporate risk registers andhow compliance with the policy would be monitored.

• Staff at all levels were encouraged to raise risks to thelocal risk register which was reviewed and updated bythe centre leader. Risks identified across the networkwere raised to the safety and quality committee andadded to the corporate risk register, this was clearly setout in the risk management policy.

• We reviewed the local risk register which had clinical,operational, environmental and moving and handlingrisks identified. Each risk was identified as beingreviewed or approved and was rated as low or medium.

• The centre had risk assessments for example theControl of Substances Hazardous to Health (COSHH). Wereviewed the schedule of COSHH risk assessments andsaw all were in date and had a review date

• There was an in-date business continuity plan whichidentified what should be done in the case of a businessor major incident, who the major incident team were,contact details of local utility companies and relevantprivate contractors.

Managing information

The service collected reliable data and analysed it.Staff could find the data they needed, in easilyaccessible formats, to understand performance, make



Outstanding –


decisions and improvements. The informationsystems were integrated and secure. Data ornotifications were consistently submitted to externalorganisations as required.

• An application was in the process of being developed forpatients referred to the exercise clinic. To maintainconfidentiality only those referred would be given theopportunity to opt in to use the app and only staff linkedwith the exercise clinic could access the app throughindividual authentication. The centre leads told us inaccordance with data protection requirements, a dataprotection impact assessment was being developed.

• GenesisCare UK had a consistent approach to managingand reporting on performance measures across all itscentres. Performance dashboards were used for staff todiscuss and monitor performance at monthly seniormanagement team meetings.

• Staff showed us how they accessed meeting minutesand policies on the electronic platform and told us therewere enough computers available.

Engagement

Leaders and staff actively and openly engaged withpatients, staff and local organisations to plan andmanage services. They collaborated with partnerorganisations to help improve services for patients.

• The centre recognised staff achievements and hardwork through an employee of the month initiative. Staffwere encouraged to submit nominations for colleaguesrecognised to have practiced the centre’s values. Thecentre collated and shared these in a ‘feel good Friday’email to all staff.

• GenesisCare UK had involved all staff in thedevelopment of their vision and strategy. The recentstaff engagement survey results showed animprovement at nationally to a 13% improvement to67%, and locally at Windsor to 81%.

• The centre met with the local NHS trust and a localprivate hospital to develop streamlined services for itspatients, should an admission be required.

• All patients completed a comprehensive questionnaireand information was collated onto a dashboard. Thecentre leader shared this with staff during monthly staffmeetings.

Learning, continuous improvement and innovation

All staff were committed to continually learning andimproving services. They had a good understanding ofquality improvement methods and the skills to usethem. Leaders encouraged innovation andparticipation in research.

• The corporate service improvement strategy, called'Service of the Future' supported each centre’simprovement goals and development projects to ensurea coordinated and multi-disciplinary approach wasmaintained.

• The chemotherapy unit were conducting a study on aspecific piece of equipment for the prevention andtreatment of symptoms of chemotherapy inducedperipheral neuropathy.

• Technology to improve responsiveness had recentlybeen implemented in the form of a messaging servicefor doctors. This went live with Radiotherapy andinformed doctors of three key stages in a patientspathway.



Outstanding –


Safe Good –––

Effective Not sufficient evidence to rate –––

Caring Not sufficient evidence to rate –––



Are outpatients services safe?

Good –––


Mandatory training

The service provided mandatory training in keyskills to all staff.

• Staff accessed their mandatory training by a mixture ofe-learning and practical sessions and receivedmandatory training in a variety of topics such as basiclife support, conflict resolution, infection control, dutyof candour and fire safety.

• We asked for a breakdown of department specificcompliance. There was only one staff memberemployed in the outpatients’ department at the timeof our inspection. This showed the lead for outpatientswas compliant in all e-learning and practicalrequirements apart from immediate life support (ILS).This element had only just expired, and dates werebeing organised for training.

Safeguarding

Staff understood how to protect patients fromabuse. Staff had training on how to recognise andreport abuse, and they knew how to apply it.

• The service provided yearly safeguarding training asan online training package. Non-clinical staff receivedlevel one adult and children safeguarding training.

Healthcare professionals received level two adult andchildren’s safeguarding. The lead of outpatients hadcompleted e-learning safeguarding adults andchildren level two.

• There were no safeguarding concerns reported to CQCover the last twelve months.


The service controlled infection risk well. Staff usedequipment and control measures to protectpatients, themselves and others from infection.They kept equipment and the premises visibly clean.

• Supplies of personal protective equipment (PPE), suchas disposable gloves and aprons, were available in thedepartment.

• Equipment in the outpatient department such as,trolleys and weighing scales were cleaned and a green‘I am clean’ sticker attached.

• In the outpatient’s department each consultationroom and treatment room had a handwash sink withhand hygiene products and full paper toweldispensers mounted on the walls. Cleaning wascompleted daily and recoded in a log, we reviewedthis and saw all cleaning for the month had beencompleted when the clinic was in use.

• Staff, patients and visitors had access to wall mountedand portable hand gel dispensers at the entrance tothe centre, every department and relevant pointsthroughout the department.

• The lead for the outpatient’s department was up todate with infection control e-learning and practicalrequirements.

Outpatients

Outpatients

Outstanding –



The design, maintenance and use of facilities,premises and equipment kept people safe. Staffwere trained to use them. Staff managed clinicalwaste well.

• The facilities, environment and equipment in theoutpatients’ department were well maintained. All theareas we visited were spacious, light, airy and clutterfree.

• The clinic had an open-plan reception/ waiting areaon the ground floor and reception staff alwayspresent. Staff would be directed to the outpatient’sdepartment which had its own waiting area.

• There were fire exit signage and fire extinguishersthroughout the premises. All fire exits, and doors werekept clear and free from obstructions. The centretested fire alarms weekly. The lead for outpatients wasfully compliant with their mandatory trainingrequirements at the time of our inspection.

• Emergency trolleys, which included resuscitationequipment, were available on each level. The trolleyswere tamper-evident to reduce the risk of equipmentbeing removed and not available in an emergency.Staff carried out daily and weekly checks of thisequipment to ensure it was ready for use in anemergency. We checked the trolley in the outpatient’sdepartments which was checked in line with policy, nodates had been missed for the month so far. We sawinformation was located with or above the trolleys,providing guidance for staff about the emergencyprocedures and action to take, such as sepsis.

• Stickers on equipment and machinery identified thelast service date and when the next service was due.We examined four items of equipment which hadbeen serviced or maintained within the last 12months.

• In cleaning storage areas, staff had ensuredconsumables, were stored off the floor in line withnational guidance.

• In all areas we inspected staff complied with theDepartment of Health, Health Technical Memorandum07/01, safe management of healthcare waste (2013).All waste was segregated in different coloured bagsand posters were displayed explaining which item

went into which waste stream. GenesisCare UK had awaste management standard operating policy whichoutlined to staff the processes and procedures to befollowed to ensure compliance.

• Containers were provided for the safe disposal ofsharp equipment, such as needles and cannulas. Weobserved these were labelled correctly on assemblyand when ready for collection. None of the containerswere overfilled, reducing the potential of needle stickinjury.



• Patients who were having an outpatient proceduresuch as a skin biopsy were given patient informationleaflets which explained some of the terms used andthe possible side effects such as bleeding andinfection.

• The outpatient’s department had a procedure recordwhich included pre-procedure checks, sign in, drugsgiven by the consultants, diagnostic intervention,specimen check, skin closure, sign out and postprocedure checks. This was based on the World HealthOrganisations (WHO) surgical safety checklist. At thetime our inspection the service did not audit theirperformance of the WHO checklist, however told usthis would be added into their audit schedule.

Nurse staffing

The service had enough nursing staff, with the rightmix of qualification and skills, to keep patients safeand provide the right care and treatment.

• We attended the daily huddle which was co-ordinatedby the centre manager and attended by all staff.During this meeting staffing for all departments wasdiscussed and any issues identified.

• The outpatient’s department was managed by onewhole time equivalent lead nurse who was supported,when required by one fully inducted qualified banknurse.

Medical staffing

Outpatients

Outpatients

Outstanding –


See information under this sub-heading in the medicalcare service section.

Records

There were no patients in the outpatients’ department atthe time of our inspection. Please see the medicinessection of this report for information on records.

• For those times when paper records were used forexample in outpatients and medicines administrationall records were scanned and uploaded to theelectronic system and then shredded once completed.

Medicines


• Medications were stored safely. Medications were keptin temperature-controlled fridges and monitoreddaily. The dispensary had air conditioning whichallowed the ambient room temperature to remain at aconsistent level. We reviewed monitoring charts forthe fridges in the outpatient’s department and thedispensary and saw that the fridges had been checkeddaily and recorded for the whole of June 2019.

• The outpatient’s department had a log of allmedications stored and administered. We reviewedthe medications stored in the fridge and saw all werein date. Any other medications would be ordered asand when needed from pharmacy. All medicationswere prescribed on a paper prescription chart andscanned into the patient’s electronic record.

• Staff stored outpatient prescription pads safely inlocked cupboards.

Incidents

The service managed patient safety incidents well.Staff recognised incidents and reported them safely.Managers investigated incidents and shared lessonslearned with the whole team and the wider service.When things went wrong, staff apologised and gavepatients honest information and suitable support.

• Staff showed a good understanding of incidentreporting and told us how they would raise an incidentusing the electronic reporting system. All staff wespoke with confirmed the service encouraged staff toreport all incidents.

• Staff reported one incident in outpatients whichrelated to non-formulary prescribing of ahomeopathic medicine. The incident was reported viathe electronic incident system and discussed with thecentre lead. Action plans were put in place to ensurethis was not repeated

Are outpatients services effective?

Not sufficient evidence to rate –––

We inspected but did not rate effective in this service aswe do not collect sufficient information to make ajudgement.



• The service used a range of evidence-based guidance,legislation, policies and procedures to deliver care,treatment and support to patients.

• Staff had access to policies and operating proceduresthrough an online system. We reviewed two standardoperating procedures (SOPs) from the outpatient’sdepartment, running a clinic and minor proceduresunder local anaesthetic. Both were in-date andversion controlled and followed nationally recognisedrecommendations such as the National Institute forHealth and Care Excellence (NICE) guidance and NHSEngland’s National Safety Standards for InvasiveProcedures (NatSSIPs).


Staff gave patients enough food and drink to meettheir needs.

• Staff told us that patients were not generally offeredfood for a clinic consultation; however, the centreoutpatients waiting area had a drinks machine,biscuits and water for patients and their carers/relatives attending the department.

Pain relief

Outpatients

Outpatients

Outstanding –


Staff assessed and monitored patients regularly tosee if they were in pain.

• The service did not generally provide pain relief topatients who attended outpatients’ consultations, butduring a procedure it could be prescribed. Staffinformed us they made sure patients werecomfortable throughout their appointment.

• For those patients who had had a minor procedurethere were patient information leaflets whichexplained about what to do when or if post-operativepain was experienced.

Patient outcomes


Competent staff

The service made sure staff were competent for theirroles. Managers appraised staff’s work performance andheld supervision meetings with them to provide supportand development.

• See information under this sub-heading in the medicalcare service section.

• The outpatient’s department had a departmentspecific induction checklist for permanent and bankstaff and included how to register new patients, dailyquality checks and use of specific equipment.

• The lead for the outpatients’ department had receiveda recent appraisal.



Seven-day services


Health promotion

• Health promotion leaflets were displayed in relevantareas throughout the centre these included healthyeating and advice on stopping smoking.

Consent and Mental Capacity Act


• Staff understood their roles and responsibilities theMental Capacity Act 2005. At the time of our inspectionthe lead for outpatients had completed all requiredmandatory training.

• The lead for the department had received training onmental capacity but told us they had not seen anypatients with mental capacity issues in their service.However, should they have concerns about a patient’smental health or capacity to consent verbally toinvestigations they would discuss this with the centremanager and the consultant.

• Written consent was obtained from the patient by theconsultant and then re-checked prior to anytreatment. We were unable to observe this process asthere were no patients in the department at the timeof our inspection.

Are outpatients services caring?


We did not see any examples of caring as there were nopatients in the department during our inspection. Therewe have been unable to rate this key question.

Compassionate care


Emotional support


Understanding and involvement of patients andthose close to them


Are outpatients services responsive?

Outpatients

Outpatients

Outstanding –


Good –––



The service planned and provided care in a way thatmet the needs of local population. It also workedwith others in the wider system and localorganisations to plan care.

• The services provided reflected the needs of thepopulation and ensured flexibility, choice andcontinuity of care. The service provided patientsplanned appointments for consultations and scans attheir convenience through the choice of appointmentdays and times to suit their needs.


Meeting people’s individual needs.

The service was inclusive and took account ofpatients’ individual needs and preferences. Staffmade reasonable adjustments to help patientsaccess services. They coordinated care with otherservices and providers.


Access and flow




It was easy for people to give feedback and raiseconcerns about care received.

• There had been no complaints attributed to this coreservice at the time of our inspection.


Are outpatients services well-led?

Outstanding –


Leadership

Leaders had the integrity, skills and abilities to runthe service. They understood and managed thepriorities and issues the service faced. They werevisible and approachable in the service for patientsand staff. Comprehensive and successful leadershipstrategies were in place to ensure and sustaindelivery and to develop the desired culture. Leadershad a deep understanding of issues, challenges andpriorities in their service, and beyond.


• The outpatient centre had a lead nurse who reportedto the centre leader. At the time of our inspection theoutpatient’s department employed one bank staff onan ad-hoc basis. The service was in the process ofemploying further bank nurses as the service grew.

Vision and strategy

The centre had a vision for what it wanted to achieveand a strategy to turn it into action. The vision andstrategy were focused on sustainability of services.Leaders and staff understood and knew how toapply them and monitor progress.


Culture

Staff felt respected, supported and valued. Theywere focused on the needs of patients receivingcare. The service promoted equality and diversity indaily work and provided opportunities for careerdevelopment. The service had an open culturewhere patients, their families and staff could raiseconcerns without fear.


Outpatients

Outpatients

Outstanding –


• Staff received training in the duty of candour at thetime of our inspection, the lead for outpatients hadcompleted duty of candour mandatory training. Allstaff we spoke with understood their role within theduty of candour.

Governance

Leaders operated effective governance processes,throughout the service and with partnerorganisations. Staff at all levels were clear abouttheir roles and accountabilities and had regularopportunities to meet, discuss and learn from theperformance of the service.



Leaders used systems to manage performanceeffectively. They identified and escalated relevantrisks and issues and identified actions to reducetheir impact. They had plans to cope withunexpected events.



The service collected reliable data and analysed it.Staff could find the data they needed, in easily

accessible formats, to understand performance,make decisions and improvements. The informationsystems were integrated and secure. Data ornotifications were consistently submitted toexternal organisations as required.


• Staff showed us how they accessed meeting minutesand policies on the electronic platform and told usthere were enough computers available.

Engagement

Leaders and staff actively and openly engaged withpatients, staff and local organisations to plan andmanage services. They collaborated with partnerorganisations to help improve services for patients.



All staff were committed to continually learning andimproving services. They had a good understandingof quality improvement methods and the skills touse them. Leaders encouraged innovation andparticipation in research.


Outpatients

Outpatients

Outstanding –


Safe Good –––

Effective Not sufficient evidence to rate –––

Caring Good –––



Are diagnostic imaging services safe?

Good –––


Mandatory training

The service provided mandatory training in keyskills to all staff however not everyone hadcompleted it.

• Mandatory training was delivered by a mixture ofe-learning and practical sessions. However not all staffin the department had completed their trainingrequirements.

• Staff had read the local radiation protection rules(local rules) and understood their roles andresponsibilities.All appropriate staff had signed to saythey had read them. Staff told us they had receivedrelevant training on radiation risks.


Safeguarding

Staff understood how to protect patients from abuseand the service worked well with other agencies todo so. Staff had training on how to recognise andreport abuse, and they knew how to apply it.

• All the staff in the PET-CT and MRI department hadcompleted level two, adult and child safeguardingmandatory training.

• Staff we spoke with knew the escalation processshould they need to report a safeguarding concernand would contact the safeguarding lead at the centrewith any queries or concerns.



The service controlled infection risk well. Staff usedequipment and control measures to protectpatients, themselves and others from infection.They kept equipment and the premises visibly clean.

• The CT and MRI departments were all visibly clean andtidy. We reviewed the cleaning rota the MRI and thePET-CT suite for the month of June and all areas werechecked and cleaned every day. This included thescanning unit equipment imaging coils, headphonesand working stations.

• Supplies of personal protective equipment (PPE), suchas disposable gloves and aprons, were available ineach department. We observed all staff used thecorrect PPE when providing care and treatment topatients.

• Patients received healthcare from staff whodecontaminated their hands immediately before andafter every episode of direct contact or care, this wasin line with NICE QS61 Infection Prevention andControl Statement 3.



Diagnosticimaging

Diagnostic imaging

Good –––


The design, maintenance and use of facilities,premises and equipment kept people safe. Staffwere trained to use them. Staff managed clinicalwaste well.

• The centre offered diagnostic services andtheranostics with the use of the following equipment;

▪ One positron emission tomography–computedtomography(PET-CT)

▪ One magnetic resonance imaging (MRI) scanner.▪ One ultrasound scanner.

▪ One x-ray machine.

▪ One fluoroscopy x-ray (not in use).

▪ One echocardiogram.

▪ One electrocardiogram (ECG).

• The clinic had an open-plan reception/ waiting areaon the ground floor and reception staff were alwayspresent. Access to areas such as the MRI and the CTscanning unit were restricted. Only certain members ofstaff had access to the scanning units and all otheraccess required fob access or staff/patients wouldhave to ring a bell.

• Every changing room/ toilet and patient area withinthe department had alarm bells which staff told usthey checked daily to ensure they worked.

• Quality assurance processes were completed daily bythe lead of the departments. The PET-CT qualityassurance checks included helium levels, oxygen level,chiller temperature. We reviewed the checks for themonth of June for both the PET-CT, and the MRI, andall were completed and recorded as passed.

• The PET-CT had a record of its latest service, whichhad passed, and when the next service was booked. Inthe event any of the machines would fail these checksthere were numbers to contact for the nuclear medicalphysics departments or the suppliers.

• We reviewed the environmental agency permit for thePET-CT suite and saw this was in date and there hadbeen no breaches during the last inspection.

• The PET-CT suite had a monitoring process/waste logwhich ensured only those sharps bins that containeddecayed radioactive waste were removed for disposalby a contracted firm.

• The PET-CT unit had a spillage policy which was indate but due for renewal at the end of the month.Senior staff were aware this was required and had ameeting to renew all the polices which were due forrenewal. The unit had a spillage kit, which wasaudited/checked monthly, we saw the checks fromJanuary to July had all been completed.



• As required by the Health and Safety Executive (HSE)who regulate the Ionising Radiations Regulations 2017(IRR99), all areas where medical radiation was usedwere required to have written and displayed localrules which set out a framework of work instructionsfor staff. These local rules were displayed throughoutthe department.

• All relevant staff had read and signed the local rulespolicy, which applied to all persons who could beexposed to ionising radiations.

• The PET-CT had adapted the relevant local rules in linewith Regulation 17 of the Ionising RadiationsRegulations 2017. In the PET-CT suite we saw localrules displayed in the Hot Toilet where the radioactivewaste would be excreted. There were strict rules tofollow in the cleaning and making safe of this roomafter use, ensuring the correct signage was displayedto ensure the correct precautions were taken onentering.

• The service had the support of an external radiationprotection advisor (RPA) and an onsite radiationprotection supervisor (RPS).

• There were procedures in place for the collapse of apatient in the MRI and these were practiced. Staff whohad not received radio-protection training, were notallowed into the suite and would not be on the officialaccess list. In case of an emergency, the daily huddleidentified who would be allocated to which area. Thisensured there was no confusion should an emergencyoccur in the suite.

• The service had recognised the risks that some of itspatients could present to other NHS professionals and

Diagnosticimaging

Diagnostic imaging

Good –––


members of the public in the event of an emergencytransfer by ambulance to another facility. The PET-CTstaff had an injected dose information sheet whichrecorded the dose of radioactivity, which site it wasinjected and how long the patient would remainradioactive. This would be completed and handed tothe ambulance staff and on to the hospital staff andfollowed up with a phone call.

• We observed staff using the radiation monitoringdevice to check radiation on their shoes and clothes.

• There were processes in place to ensure the rightperson received the right scan at the right time. Staffcompleted a six-point check of name, date of birth,address, body part, clinical information and previousimaging checks in line with the legal requirements ofIR(ME)R to safeguard patients against experiencing thewrong investigations.

• There were posters and signs which informed patientswho were, or who could be pregnant, to let a memberof staff know. This was included in the CT safetyquestionnaire sheet and again at the consent stage.These were scanned into the patient record and thenshredded.

• There were risk assessments in line with theapplication of the Ionising Radiations Regulations2017. These risk assessments covered the injection ofPET-CT patients, contamination risks, potential ofbleeding after cannula removal and care of a fastingdiabetic patients, all of which were in date.

• We saw evidence that film badges and X-ray leadgowns were regularly tested. A lead gown is a type ofprotective clothing that acts as a radiation shield. Afilm badge is a dosimeter used for monitoringcumulative radiation dose.

Radiology staffing

The service had enough radiology staff with theright qualifications, skills, training and experienceto keep people safe from avoidable harm and toprovide the right care and treatment.

• Staff told us there were enough staff to safely run theservice and although the service wanted to grow andexpand it would not do so until adequate staffingratios were in place. At the time of our inspection, theservice employed;

▪ MRI- one whole time equivalent (WTE)radiographer.

▪ PET-CT- one WTE radiographer.

▪ MRI and PET-CT- one WTE health care assistant

• The centre lead told us they had secured one PET-CTsenior radiographer and one senior therapyradiographer both due to start in August. They werealso in the process of recruiting a further MRIradiographer.

• We attended the daily huddle which was co-ordinatedby the centre manager and attended by all staff.During this meeting staffing for all departments wasdiscussed and any issues identified.

• Weekly operational calls with the Director ofoperations, Centre leaders and function leads supportany additional requirements or changes in plannedactivity, during these calls staffing would be discussedand if necessary staff would come from other centresto work.

Medical staffing

• The RMO was booked to attend the departmentduring treatment days when theranostics,radio-isotopes and CT contrast were in use.

• For further details, see information under thissub-heading in the medicines’ service section.

Records

Staff kept detailed records of patients’ care andtreatment. Records were clear, up-to-date and easilyavailable to all staff providing care.

• Staff managed patient care records in a way thatprotected patients from avoidable harm. Electronicrecords were available through the centre’s computersystem and were only accessible by authorised staffwith a secure password.

• Radiologists had remote reporting facilities to allowfor diagnostic imaging reporting. Whilst IT support waslargely provided in-line with working hoursarrangements could be made for support out of hoursif required.

Diagnosticimaging

Diagnostic imaging

Good –––


• Staff updated the electronic records after they hadcompleted the scan and submitted the scan imagesfor reporting. Any paper records, such as consent, andchecklists were scanned into the system and then thepaper records were shredded

• The service used secure imaging and archiving systemand had password protection. Each staff member hadtheir own personal identifiable password to access thesystem. We saw staff logged out the system after use.

Medicines


• The provider provided nuclear medicine treatment.This branch of medicine deals with the use ofradioactive substances in research, diagnosis, andtreatment. There were two nuclear medicineconsultants who delivered services at the centre suchas theranostics and both held an Administration ofRadioactive Substances Advisory Committee (ARSAC)licence.

• All radioisotopes therapy injections were stored in ametal locked box in the PET-CT department. We didnot have access to this box.


Incidents

• The PET-CT had reported two serious incidents whichhad required investigation and prompt action. None ofwhich had required reporting to the CQC, IRMER or theHealth and Safety Executive (HSE).

• Root cause analysis (RCA), were completed andincluded findings, contributing factors,recommendations and were signed off by the head ofthe department, centre manager, quality manager andthe chief medical officer.

• There were two RCA completed in the reportingperiod. These incidents were;

▪ March 2019-CT contrast administered to a patientthat was not requested by the oncologist. The RCAprompted a review of process, for example, therapyradiographers would assign a member of staff toliaise with the diagnostic team each day to go

through the patient’s technique, booking form anddataset, to ensure everyone was fully aware of thework load. This also included briefing the RMOwhen needed.

▪ December 2018-Concerns raised by RPA in relationto patient that was scanned by bank staff that hadnot been signed off as fully competent in allaspects of ordering and performing a PET CTexamination. The result of the RCA triggered areview which included competency sign off fordose ordering, quality assurance, dose calibrationand involvement of the ARSAC licence holder instaff competence.

• For further details, see information under thissub-heading in the medicines’ service section.

Are diagnostic imaging serviceseffective?


We inspected but did not rate effective in this service aswe do not collect sufficient information to make ajudgement.



• The service used a range of evidence-based guidance,legislation, policies and procedures to deliver care,treatment and support to patients. We saw carepathways followed nationally recognisedrecommendations such as the National Institute forHealth and Care Excellence (NICE) guidance.diagnostic scans were based on the Ionising Radiation(Medical Exposure) Regulations (IR(ME)R) and RoyalCollege of Radiologists (RCR) guidance.

• The service applied the Public Health Englandguidance on national diagnostic reference levels whensetting their local diagnostic reference levels (DRLs).

Diagnosticimaging

Diagnostic imaging

Good –––


• Staff had access to policies and guidelines through anonline system. All the guidelines we reviewed wereeasily accessible through an online system and wereup to date.


Staff gave patients enough food and drink to meettheir needs and improve their health.

• Drinks were available for all patients and relativesvisiting the MRI and PET-CT departments.

• There were in date risk assessments in line with theapplication of the Ionising Radiations Regulations2017. These risk assessments covered care of a fastingdiabetic patients.

Pain relief

Staff assessed and monitored patients regularly tosee if they were in pain.

• Staff asked patients during their scanningappointment if they were comfortable


Patient outcomes

Staff monitored the effectiveness of care andtreatment.

• The centre had an audit programme to identify,monitor and drive quality improvement. The auditschedule included control of radioactive sources. Thiswas a six-monthly audit and the centre scored 100% inApril 2019.

• The centre audited and reviewed their diagnosticreference levels (DRL) and ensured they were alignedto national DRLs.

• The centre had just started to review image qualitymonthly, no data was available at the time of ourinspection.

Competent staff

The service made sure staff were competent for theirroles. Managers appraised staff’s work performanceand held supervision meetings with them to providesupport and development.

• In addition to mandatory training, staff completedcompetencies for all modality of scans provided at thecentre. Staff told us they had good support for theirdevelopment and training. Staff could access trainingthe centre provided, as well as training anddevelopment by external companies if required.

• All members of the department had a recent appraisalby the centre leader.

• Two incidents requiring root cause analysishighlighted some work around competency for bankand clinical supervision was required. The centreacted swiftly and new polices were in place to protectpatients and staff.



Seven-day services


Health promotion


Consent and Mental Capacity Act


• Consent was a two-stage process and was checkedagain when the patient came for any form ofinvestigation or treatment, this was signed by thepatient and radiographer, scanned and uploaded tothe electronic system.

• Patient consent mandatory training had beencompleted by all members of the department. MentalCapacity ACT and Deprivation of Liberty Safeguardingmandatory training (practical) had been completed byall members of the department.


Diagnosticimaging

Diagnostic imaging

Good –––


Are diagnostic imaging services caring?

Good –––

We rated caring as good.

Compassionate care

Staff truly respected and cared for patients withcompassion. Feedback from patients continuallyconfirmed that staff treated them well and withkindness.

• We observed all patients were treated with dignity,kindness, compassion, courtesy, respect,understanding and honesty in line with NICE QS15,Statement Patient experience in adult NHS Services 1.Interactions between staff, patients and visitors wererespectful and considerate. We observed that all staffintroduced themselves to their patients in line withNICE QS15, Statement 3.

• The centre was designed to ensure that people’sprivacy and dignity needs were understood andalways respected. All staff-maintained privacy, withclosed doors and clear signage indicating the roomwas occupied.

• In some area’s patients could either exit one way intothe waiting room and or stay in the changing roomuntil it was time for their appointment and exit intodirectly to the treatment area. This meant they did nothave to sit in the waiting room.

• The centre had designated quiet rooms where staff,patients and their relatives could have privateconversations or wait for treatments away from thewaiting areas.

• Patients could have a chaperone and there wereposters and laminated leaflets displayed across all thedepartments informing patients about theiravailability.

• For further details, see information under thissub-heading in the medicines’ service section

Emotional support

Staff continually provided emotional support topatients to minimise their distress. Staff we spokewith valued patient’s emotional and social needs.Staff embedded these in their care and treatment.

• Throughout all the patient and relative interactions,from reception through to discharge we observed howstaff understood the impact a person’s care, treatmentor condition could have on their wellbeing, bothemotionally and socially.

• Patients told us they were satisfied with the verbal anddocumented information staff provided them.


Understanding and involvement of patients andthose close to them


Are diagnostic imaging servicesresponsive?

Good –––



The service planned and provided services in a waythat met the needs of local people.

• The centre was open from 8am to 5pm Monday toFriday, however we saw that to accommodate somepatients’ investigations the MRI or PET-CT scanningdepartment would run over and stay open. For this tobe safe, two members of staff remained in thedepartment and in the case of theranostics the RMOwould be present. This reflected the choice of thepatients.

• The environment in the department was comfortable,there was enough seating, plenty of toilet facilities,and drinks machines available for patients andrelatives.


Diagnosticimaging

Diagnostic imaging

Good –––


Meeting people’s individual needs

The service was inclusive and took account ofpatients’ individual needs and preferences. Staffmade reasonable adjustments to help patientsaccess services. They coordinated care with otherservices and providers.

• The diagnostic team met the patients and showedthem round the department. This allowed them toidentify any issues which could affect their treatmentsuch as mobility issues.

• Staff told us that relationship with consultants workedwell, even when they were off site. All consultantscould be contacted if any patient problems requiredescalating.

• There were quiet areas in all departments wheresensitive conversations could be carried out.


Access and flow


• The centre audited the time a patient arrived to whenthey were seen, please see the medicine section ofthis report.

• The service did not audit the number of plannedpatients seen within 48 hours, however it did trackthese on an electronic system.

• The centre lead told us they would see those patientswith the potential of cord compression or similarwithin 48 hours.

• If there were any problems with the machines at thecentre, staff would arrange an appointment at anotherclinic, and provide a taxi to transport the patient.



Are diagnostic imaging services well-led?

Outstanding –


Leadership

Leaders had the integrity, skills and abilities to runthe service. They understood and managed thepriorities and issues the service faced. They werevisible and approachable in the service for patientsand staff. Comprehensive and successful leadershipstrategies were in place to ensure and sustaindelivery and to develop the desired culture. Leadershad a deep understanding of issues, challenges andpriorities in their service, and beyond.

• The centre had a clear accountability and leadershipstructure. Managers at all levels had the right skills andabilities to run the service providing high-qualitysustainable care.

• The senior MRI and PET-CT staff reported to an overalllead radiographer who in turn reported to the centreleader. The centre leader reported to the Director ofOperations who sat within the GenesisCare UKLeadership Team.

• The centre leader understood the challenges toquality and sustainability. The centre leader told us togrow their own service they employed a consultantphysician in nuclear medicine who offeredthe specialist cancer medicine, theranostics.Theranostics is a field of medicine which combinestherapy and diagnostics. With a key focus on patientcentred care, theranostics provides a transition fromconventional medicine to a contemporarypersonalised and precision medicine approach.

• Staff told us that the department lead was highlyvisible and worked alongside staff to deliver safe andeffective care.

Vision and strategy

The centre had a vision for what it wanted to achieveand a strategy to turn it into action. The vision andstrategy were focused on sustainability of services.Leaders and staff understood and knew how toapply them and monitor progress.

Diagnosticimaging

Diagnostic imaging

Good –––



Culture

Staff felt respected, supported and valued. Theywere focused on the needs of patients receivingcare. The service promoted equality and diversity indaily work and provided opportunities for careerdevelopment. The service had an open culturewhere patients, their families and staff could raiseconcerns without fear.


Governance

Leaders operated effective governance processes,throughout the service and with partnerorganisations. Staff at all levels were clear abouttheir roles and accountabilities and had regularopportunities to meet, discuss and learn from theperformance of the service.

• Lead radiographers from both diagnostics and theradiotherapy department attended the monthly safetyand quality committee meeting.



Leaders used systems to manage performanceeffectively. They identified and escalated relevantrisks and issues and identified actions to reducetheir impact. They had plans to cope withunexpected events.

• We reviewed the local risk register which had clinical,operational, environmental and moving and handlingrisks identified. Each risk was clearly identified asbeing reviewed or approved and was rated as low ormedium. Risks on the register reflected what staff toldus for example, the hot lab had no emergency button,to mitigate this a telephone was installed.

• The service had business continuity plans to supportsudden IT failures and power outages.



The service collected reliable data and analysed it.Staff could find the data they needed, in easilyaccessible formats, to understand performance,make decisions and improvements. The informationsystems were integrated and secure. Data ornotifications were consistently submitted toexternal organisations as required.


Engagement

Leaders and staff actively and openly engaged withpatients, staff, the public and local organisations toplan and manage services. They collaborated withpartner organisations to help improve services forpatients.



All staff were committed to continually learning andimproving services. They had a good understandingof quality improvement methods and the skills touse them. Leaders encouraged innovation andparticipation in research.

• The corporate service improvement strategy, called'Service of the Future' support each centre’simprovement goals and development projects toensure a coordinated and multi-disciplinary approachwas maintained.

• The centre offered theranostics which was a specialistfield of medicine combining therapy and diagnostics.

Diagnosticimaging

Diagnostic imaging

Good –––


Outstanding practice

We found outstanding practice for caring in all themedicine service we rated.

• The service provided patients taxi transfers fromhome to the centre, for their treatment.

• The staff worked hard to ensure their patientsreceived highly individualised care to support theirtreatment.

• The staff considered their patients comfort needsbefore they stepped into the building.

Areas for improvement

Action the provider SHOULD take to improve

• All staff should have completed their mandatorytraining.

• The service should audit their performance of theWHO surgical safety checklist.

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


Documents

GenesisCare Windsor NewApproachComprehensive Report