Chartwell 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

Leaders did not always demonstrate the skills and abilities to run the service. Leaders did not operate effective processes for governance, information management and the management of risk, issues and performance. Policies were generic and did not reflect up-to-date national guidance. The service did not have external relationships to support any innovation or service improvements. However, leaders had made improvements to the environment to ensure it was safe for patient use.

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have a clear vision for what it wanted to achieve. In the senior leadership team interview we asked what the vision and strategy was and we were told they wanted to improve the building structure following the flooding a few years ago and they were in discussions about becoming a clinical development centre. However, the registered manager had no clear strategy in how to achieve this. Following the inspection the service provided a strategy document which was created after the inspection. Therefore, there were discrepancies in what we were told by the senior leadership team and what we saw on paper after the inspection. We could not be assured the values and strategy have been developed through a structured planning process in collaboration with people who use the service, staff and external partners

Staff were unaware of any vision or strategy. Therefore, could not understand how their role helps in achieving vision or strategy.

Staff spoke positively about working in the department. They told us that they loved working at the service, and they felt supported by their manager. However, they had been without a lead radiographer and staff were unclear who was leading the department in the interim.

The senior leaders told us the service could be better with two way communication as many informal conversations took place.

Staff told us they did not see senior leaders such as the board of directors and owner, so they were unsure if their voices or feedback was heard at that level.

Not all staff were clear about their roles and accountabilities and it was not clear if the radiology department staff had regular opportunities to meet, discuss and learn from the performance of the service.

Service leaders were approachable and had appraisals. Leaders acknowledged that no meetings had been held for the MRI team, and all-team meetings were not regularly convened.

In the 2024 staff survey, 57% of staff agreed that they had regular meetings to discuss unit matters and other issues, 92% felt well-supported by the management team. Staff feedback included positive comments such as, "The clinical manager is very helpful," though one comment noted that the "Hospital manager sometimes needs to be more understanding." According to the 2024 staff survey, 85% of staff felt they received adequate support while working in their specialised area.

The registered manager was supported by a clinical manager and an executive assistant. At the time of our inspection, the radiology department lacked a lead radiographer, leaving staff unclear about departmental leadership.

The service maintained a risk register, but it was uncertain if it was regularly reviewed, as team meeting minutes did not reflect discussions of identified risks, action points, or improvements.

The provided governance structure outlined the meeting framework but did not clarify reporting lines or define individual job roles clearly. However, staff induction packs did include details on governance and specific job responsibilities. Management reported engaging with staff daily to monitor well-being, helping staff become familiar with the leadership team.

The service had Freedom to Speak Up Champion and staff knew how to contact them if they wanted to raise concerns. Staff felt comfortable raising concerns if they needed to. However, staff we spoke with were not confident their voices would be heard.

We did not see how staff were encouraged to raise their concerns. This was not physically promoted in the service. For example, we did not see any posters on the walls or in the staff areas.

The service is supported by a Speak Up champion who promotes openness and transparency through an open-door policy.

In the latest staff survey 93% of staff said they were able to speak to their managers. 71% said their line manager listened and felt that staff suggestions, comments and ideas were welcomed and acted upon.

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.

During our inspection the senior leadership team (SLT) told us they used a risk database to update their risks onto the risk register. Staff were not clear about their roles and accountabilities as not all staff members would report and log concerns onto the risk register. The SLT told us it was not always at the forefront of staff members mind to prioritise entering the risk database.

All staff spoke highly of the senior leaders and spoke of good teamwork. They commented on the friendliness and visibility of the senior leaders and that they felt able to approach them. However, we were told leaders did not always support staff to develop their skills and take on new roles.

Staff told us the service did not undertake routine clinical and governance audits, which would allow the service to benchmark against other similar providers, and to identify changes that would improve the service based on information.

The leadership team had an understanding of some of the issues, challenges and priorities faced by the service. For example, the building and clinical areas had been made safe by the service following a flood in April 2021 . The service had made the necessary changes and had an action plan in place for the rest of the restoration work to take place.

The service had a risk register, but it was unclear if this was reviewed regularly as we did not see the risks mentioned within minutes of team meetings, action points and any improvement.

The service did not operate effective governance processes. The service did not regularly review or update its policies to ensure they were using the latest guidance, and some policies included irrelevant information.

The service’s meeting schedule included biannual Medical Advisory Committee (MAC) meetings. Most governance meetings had the same attendees and were combined into an Endoscopy User Group (EUG) meeting. Senior management meetings occurred frequently, Leaders maintained incident and accident logs per the hospital’s adverse incident policy. We saw that while the minutes included feedback regarding endoscopy, there was relatively little focus on diagnostic imaging

There was limited evidence of learning and updates within the radiology department regarding incidents, medical alerts, complaints, or patient feedback. The radiology team had no regular meetings, and the staff survey indicated only 57% felt regular meetings were held for team discussions. We requested, but did not receive, minutes for the radiation protection committee meetings, leaving it unclear if these meetings occurred.

The board consisted of five directors, including the owner, Chief Operating Officer, and three non-executive directors. They met monthly and received MAC, governance, senior leadership team minutes, and the hospital dashboard. Discussions included staffing and estate issues, but there was no evidence of incident reviews, risk management discussions, or updates on the risk register, suggesting a lack of risk oversight.

The provider used a secure portal for image transfer and maintained secure electronic patient records, allowing authorised staff easy access when needed. After the inspection, we requested the service’s safety alert policy. The service provided an MHRA alert SOP that did not define MHRA and lacked relevant details on processing safety alerts. The document was modified by the service post-inspection.

Leaders did not consistently collaborate with external stakeholders or agencies. While they worked with the Integrated Care Board (ICB) in 2023 to ensure safe conditions for lifting their suspension and resuming patient care, they did not partner with other key organisations to support service development.

The service reported participating in local intelligence meetings and, following the inspection, provided minutes from the Controlled Drugs Local Intelligence Network meeting for Hertfordshire, West Essex, and Mid and South Essex in November 2023. However, the attendance list indicated that the service had not participated in this meeting, and they did not clarify why they shared these minutes or their relevance to the service.

The service did not have any collaborative working between any other organisations.

The service did not have any processes in place to collaborate or work in partnership with any external stakeholders or agencies.

Leaders did not have a good understanding of how to make improvements happen.

Staff were not supported to develop their skills around improvement and innovation.

Staff and leaders did not engage with external work, for example any participation in research or embedding evidence-based practice in the service.

The service did not have processes in place to ensure learning happens when things went wrong. Leaders did not encourage reflection or collective problem-solving.