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Inspection Summary

Overall summary & rating

Updated 20 January 2015

The London Welbeck Hospital is a 14 bedded private hospital. The hospital employs the majority of staff on a bank, zero hours contract basis and has 14 substantive staff’. It provides a range of cosmetic surgery procedures such as abdominoplasty, breast augmentation and rhinoplasty and outpatient services. These are two which two of the eight core services that are always inspected by the Care Quality Commission (CQC) as part of its new approach to hospital inspection. The other six core services that are not provided by this hospital are critical care, medical care, children and young people services, urgent and emergency care, maternity and family planning, and end of life care.

The London Welbeck Hospital is based in Marylebone, London. The hospital has three operating theatres, 14 en-suite bedrooms and a very small outpatient department with two consultation rooms. The hospital provides surgery to both male and female patients aged 18 to 65 years, however, at the surgeon's discretion surgery may be offered to patients over the age of 65 years.

The hospital was selected for inspection as an sample of a small specialist private hospital trust in our wave 1 pilot of independent healthcare. The team of five included CQC inspectors, an anaesthetist, nurse and a senior manager from another private hospital. The inspection took place on 22 October 2014 with an unannounced visit on the 31 October 2014.

 Our key findings were as follows: 


  • There was a paper based incident reporting system that staff were aware of and all incidents were investigated and findings feedback to staff to ensure learning.
  • Medicines were stored securely to ensure that unauthorised personal did not have access to them. However, we found one out of date oxygen cylinder,
  • The principles of the ‘Five steps to safer surgery’ checklist were embedded into practice and surgical safety checklist  paperwork was completed..
  • There was no current and up to date theatre instrument and equipment list to identify when individual items were purchased.


  • The outcomes for patients who had undergone elective surgery were not monitored by the hospital.
  • Procedures and treatments were not reviewed against national clinical guidelines, and while patients received information about their procedures, there was no evidence this was referenced to best practice.
  • Staff were encouraged and supported with their continual professional development and there was a range of opportunities for staff to develop their skills, including completing degree and master’s level studies.


  • Staff were caring and treated patients and their relatives with dignity and respect.

  • Patients commented positively about their care and treatment. The majority of responses to the provider's patient satisfaction survey were positive .


  • Patient admissions were arranged in a timely manner with minimal delays for patients.
  • Complaints were responded to within the timescales identified in the hospital’s policy.


  • The provider did not have a documented vision and clinical strategy to support innovation and growth of the service that had been shared with all staff.
  • There was identified leadership in both theatre and on the wards and staff feedback positively about the support they received. There was no designated medical director, medical leadership was provided by the chair of the MAC and the responsible officer.
  • There were some governance arrangements in place and evidence of actions taking place following MAC and governance meetings.

We saw outstanding practice including:

The quality of hospital's response to patient complaints was noted to be of a high standard. This included responses prepared that artfully made a direct connection between the issue raised and the action taken.

Importantly, the hospital must:

  • The hospital must ensure there are arrangements in place for the care of level 1 patients and ensure all staff are aware of these arrangements.
  • The hospital must consider the risks of anaesthetic assistants drawing up anaesthetic drugs before the theatre list commenced taking into account NRLS 'Signal Injectable medicines in theatres' 

 In addition the hospital should:

  • The hospital should explore how it utilises the longer term patient feedback collected by the individual surgeons to demonstrate the experience and outcomes for patients using the service.
  • In line with best practice should review the consent forms used to ensure patients are provided with a copy of their consent document.
  • The level of safeguarding children and adults training and the attended by staff should be reviewed to ensure it is appropriate for the individual staff member's role.
  • Patient information should be reviewed to ensure it reflects current best practice
  • The hospital should draw up an up to date theatre instrument and equipment list to identify when individual items were purchased and when they are due to be replaced.
  • The competencies required for the role of scrub nurse and HCA working in theatres should be identified and the individuals undertaking these roles skills.

Professor Sir Mike Richards

Chief Inspector of Hospitals

Checks on specific services


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.


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.