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Inspection Summary

Overall summary & rating

Updated 30 March 2017

The London Welbeck Hospital is operated by Welbeck Health Care Limited. It is normally open from Monday to Friday 7am until 8pm but has arrangements to accommodate overnight patients. The hospital has 14 beds. Facilities include two operating theatres, a ward, a minor operations theatre and two consulting rooms for pre and post-operative checks.

The hospital provides cosmetic surgery procedures including abdominoplasty, breast augmentation and reduction and rhinoplasty.

We carried out an announced inspection on 23 November 2016. The hospital was previously inspected in October 2014 and we found the hospital had taken some action to address the concerns we found during that inspection.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

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

We do not currently have a legal duty to rate cosmetic surgery services or the regulated activities they provide but we highlight good practice and issues that service providers need to improve.

We found the following areas of good practice:

  • We saw good infection prevention and control (IPC) practices with housekeeping and clinic staff ensuring all areas of the hospital were clean and tidy. Staffs personal IPC practices were carried out to the highest standard.

  • Staff were overwhelmingly positive about the local and senior leadership teams and felt they were listened to when they had concerns or suggestions for change.

  • There was a service level agreement with both a local NHS and local independent hospital for those patients requiring level 2 and 3 critical care. This allowed patients a choice of NHS or private care if they became unwell.

However, we also found the following issues that the hospital needs to improve:

  • We found that only scrub nurses and some healthcare assistants had signed competency booklets. No other staff had signed competencies and senior staff could not be assured that all staff had the correct skills to carry out procedures.

  • Staff in theatres were drawing up anaesthetic drugs in advance of anaesthetists being present in theatre. Although there were hospital prescriptions for these drugs they were not in line with best practice.

  • Patient observation charts that we reviewed were not always completed fully and could put patients at risk of not being escalated for review by the relevant clinicians.

  • An audit in June 2016 had highlighted poor compliance in documenting post-operative consultant visits but we could not view an action plan for this.

  • Compliance with mandatory training including basic life support was variable across staff groups.

Following this inspection, we told the provider that it should make other improvements, even though a regulation had not been breached, to help the service improve. These can be found at the end of the report.

Deputy Chief Inspector of Hospitals

Professor Edward Baker

Checks on specific services

Outpatients and diagnostic imaging

Updated 20 January 2015

Outpatient services at the London Welbeck Hospital were held when requested and were arranged to meet the needs of surgeons and their patients. The clinics were ad-hoc and surgeons or external referring providers arranged the patient appointments and liaised with the hospital about the arrangements.

There had been no incidents in the service and we saw there were systems to manage infection prevention and control, maintenance of the environment and clinical risks for patients. Patient privacy and dignity was maintained. Records were always available and appropriately storage. There was an integrated system of governance in the hospital to review patient safety and experience data. 


Updated 30 March 2017

  • Staff knew how to report incidents and there was evidence of learning and steps taken to prevent reoccurrence of incidents. Staff understood the duty of candour and we saw good evidence of adherence to the duty of candour regulation.
  • Staff were trained in safeguarding adults to a level appropriate to their job role.
  • The hospital reported patient outcomes in accordance with Private Health information and National Breast Registry. Care was delivered in line with relevant national guidelines such as National Institute for Health and Care Excellence and the Royal College of Surgeons.
  • The hospital had a local audit programme and where issues were raised action plans for change were completed and change implemented.
  • There were adequate numbers of both nursing and medical staff across the hospital.
  • Patients had effective and timely pain relief.
  • Both nursing and medical staff felt supported with supervision and revalidation and were given opportunities for further study.
  • There was good multidisciplinary team (MDT) working both within the hospital and with other local NHS and private hospitals.
  • Staff across the service were friendly, caring and professional, and patients were treated with dignity.
  • Patient flow from admissions, through theatres and onto to surgery wards was satisfactory and bed availability was not an issue.
  • We found a strong and supportive local and senior management team, with well-established members of staff across surgery services. Staff were proud and positive about working for the hospital.
  • There were comprehensive governance and risk management processes in place that fed back to both clinical and non-clinical staff to ensure an embedded learning culture.
  • Both patients and staff were given opportunities to provide feedback to the hospital. Where feedback was less than excellent the hospital managers would look at ways to improve care and working and provide solutions and improvements.


  • Medical and nursing records were generally well completed and stores safely. However, patient observation charts that we reviewed were not always completed fully and may have meant patients were not escalated for review by medical staff.

  • An audit in June 2016 had highlighted poor compliance in documenting post-operative consultant visits but we could not view an action plan for this.

  • Some theatre staff were drawing up anaesthetic drugs prior to the anaesthetist being present. This was not in line with best practice guidance.

  • Compliance with mandatory training including basic life support was variable.