The London Welbeck Hospital

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture. At our last inspection we rated this key question good. At this inspection the rating has changed to requires improvement. The service was in breach of legal regulation in relation to governance at the service. We assessed one quality statement on governance, management and sustainability. Although the service undertook regular auditing, we were not assured that the audits in place were effective. The service did not undertake observational audits of staff compliance with the completion of the WHO Surgical Safety Checklist. The lack of observational audits meant any improvements in staff practice would not be identified and action taken, placing patients at risk of harm as the WHO surgical safety checklist may not have been completed in line with best practice. However, leaders had the skills and knowledge, experience and credibility to lead the service. They demonstrated their integrity and honesty which was recognised by their staff.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff told us the service carried out regular audits of completed WHO surgical checklist records by reviewing patients’ health records to ensure the documentation was completed correctly. However, we were not assured that these audits were effective, as they had not identified the issues we observed and there was no specific WHO observational audit in place. Therefore, noncompliance with specific aspects of the WHO checklist had not been identified. However, staff were able to describe the arrangements for reporting incidents and how they received feedback. Staff told us there was an effective process in place to share learning from incidents and updated the wider team through email and staff meetings. Senior managers told us that incidents, near misses and complaints were monitored for trends and action plans put in place to drive and monitor improvement. For example, refresher General Data Protection Regulation (GDPR) training was offered to all staff who felt this is required to emphasise the importance of patient confidentiality. Staff we spoke with were aware of recent incidents and complaints across the clinical areas. Staff we spoke with understood what their individual roles and responsibilities were, what they were accountable for and to whom they were accountable. Staff told us that they felt the management team were approachable and could access supplementary training opportunities easily if required.

The service did not always ensure that patient records were maintained in line with good practice. During our site visit, we observed that all elements of the WHO checklists had been signed as completed by theatre staff, however we noted there were instances where this was not correct, for example the time out had not been fully completed but recorded as complete. The failure to maintain accurate patient records is a breach of the professional’s code of conduct and meant records were falsified. However, the governance structure in place included a medical advisory committee (MAC) which reported to the management board. These meetings oversaw governance, risk management and the granting and removal of practising privileges. The hospital clinical manager and medical director met regularly to discuss clinical incidents to ensure risks were assessed and controlled. There were regular safety and quality meetings attended by the clinical manager, which covered a variety of topics including medicines audits and clinical incidents. Managers provided regular feedback to staff via staff meetings. Learning from incidents was shared with staff either in person, via email or in staff meetings. However, there was a lack of evidence about the effectiveness of the systems and processes that the service used, as significant concerns and issues were not identified during our assessment. The hospital maintained a risk register which included the risks that managers identified. We saw evidence of action taken in response to some incidents and learning and outcomes were discussed and recorded. However, risks did not include the issues identified around medicines management and WHO checklists. There was a stable leadership team at the service and low staff turnover. All staff we spoke with were highly motivated and positive about their work. Staff were complimentary about the clinical manager and director. Staff told us the hospital had a culture of open communication.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.