Mount Vernon Cancer Centre

⚠ The trust did not ensure that all services consistently used systems and processes to safely prescribe, administer and record medicines.

⚠ The design, maintenance and use of facilities did not always keep people safe.

⚠ The trust did not make sure the design, maintenance and use of facilities, premises and equipment kept people safe. This was challenging due to the complex nature of leasing the premises from another NHS Trust.

⚠ The trust had made improvements to their governance systems and structures which were yet to be embedded across all areas. Leaders had developed effective governance processes; however these were still being embedded.

⚠ The service provided mandatory training in key skills to all staff but did not always make sure everyone completed it. Not all staff had completed their training on how to recognise and report abuse.

⚠ The service did not always manage controlled infection risks well. Staff did not continually use equipment and control measures to protect patients, themselves and others from infection.

⚠ The maintenance and use of facilities, premises and equipment did not always keep people safe.

⚠ Staff did not always carry out daily safety checks of specialist equipment.

⚠ The service did not use systems and processes to safely prescribe, administer and record medicines. Staff did not always escalate the recorded temperature of stored medicines to maintain their safety.

⚠ While leaders operated effective governance processes throughout the service it did not always use the systems to manage performance to improve the quality of its services. Outcomes with mitigating actions were not always completed to reduce or increase risk.

⚠ Records were not always stored securely.

⚠ The design, maintenance and use of facilities, premises and equipment did not always keep people safe.

⚠ Not all internal audits were completed in accordance with the trust’s agreed timetable.

⚠ Governance processes did not support consistent learning from the performance of the service.

⚠ Systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected were not effective. Risks to the service were not always identified or progressed.

⚠ Patients with suspected sepsis were not always treated within an hour.

⚠ Not all computer systems were accessible by staff which meant there was an increased risk some patient information could not be viewed when required. We were not assured that discharge summaries were sent to GPs for all patients discharged.

⚠ The service did not always use systems and processes to safely prescribe, administer, record and store medicines.

⚠ The premises and equipment did not always keep people safe.

⚠ The premises and equipment did not always keep people safe.

⚠ Not all staff were provided with regular opportunities to meet, discuss and learn from the performance of the service.

⚠ We were not assured that all incidents were reported.

⚠ The service did not always identify potential patient safety risks and issues and identify actions to reduce their impact.

⚠ The service did not have enough nursing staff with the right qualifications, skills, training and experience.

⚠ The service did not have enough medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Processes were not in place to regularly review staffing levels and skill mix.

⚠ The service did not make sure all staff completed mandatory training in key skills. The number of staff who completed it did not meet trust targets.

⚠ Records were not always easily available to those providing care. Access to investigations that were undertaken at other hospitals such as the referring hospital were not always available when needed and timely access to the most up to date clinical information was not always available due to the time taken …

⚠ Waiting areas for patients using wheelchairs, were limited and at times wheelchairs compromised access to emergency equipment.

⚠ People could not always access the service when they needed it and sometimes had long waits to see staff at appointments. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were worse than national standards.

⚠ Although the service had made improvements in training staff in the recognition of sepsis, there was a lack of clarity around the treatment for patients with suspected sepsis. A lack of formalised processes meant that there was a risk that life-saving treatment would be delayed.

⚠ Leaders were starting to operate effective governance processes, throughout the service and with partner organisations; however, this was not yet embedded. The service was starting to develop processes and systems to improve the quality of services through audit and triangulation of other quality indicators; however, this was yet to be …

⚠ There were frequent delays in the running of clinics and staff felt pressured to meet the demands of the service due to large waiting lists. Waiting times for cancer patients to start treatment were lower than the England average.

⚠ Patient records were not always available to all staff providing care. Staff across the service reported records were often missing for clinic sessions.