The London Welbeck Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At this inspection, we found that The London Welbeck Hospital had made meaningful improvements in the safety of its clinical practices following our previous concerns. Updated policies, regular observational audits, and staff training had strengthened compliance with infection prevention and control (IPC) standards and the World Health Organisation (WHO) Surgical Safety Checklist. Theatre environments were visibly clean, and staff engagement with safety protocols had improved. However, further work was required to ensure the consistent documentation of swab and instrument counts, including the recording of red tags, and to embed routine stock checks of controlled drugs (CDs) within theatres. These areas required continued oversight to ensure that improvements were sustained and fully integrated into everyday practice.

This service scored 56 (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 Learning culture during this assessment. The score for this quality statement is based on the previous rating for Safe.

At this assessment, we found that the service had taken steps to strengthen its perioperative safety systems. The World Health Organisation (WHO) Surgical Safety Checklist had been revised to align with national guidance (including elements of The Association for Perioperative Practice guidance), and its use was supported by regular observational audits. These audits were completed by clinical leads and shared with relevant staff, including surgeons and anaesthetists, contributing to improved consistency and engagement with safety checks. Staff were generally observed to pause and participate more actively during ‘time out’ and ‘sign out’ stages, and new tools such as debrief forms and checklist adaptations had been introduced to reflect the needs of the service.

There was evidence of improved teamwork and oversight of perioperative processes, including more visible leadership involvement in clinical areas. Debrief forms and updated standard operating procedures were in use, and overall governance of surgical safety had improved.

However, some inconsistencies remained. We observed the 'sign in' process was not always carried out in accordance with the service’s own standard operating procedures, particularly where identity and consent confirmation occurred away from the theatre environment and without the full team present. While swab and instrument counts were taking place, the documentation and verification process did not always align with the policy; for example, red tags were not routinely recorded on the count board.

Overall, the provider had taken steps to improve the safety and reliability of surgical pathways. Continued attention to embedding standardised processes across all teams was needed to ensure that improvements were maintained and that safe systems of care were consistently applied throughout the perioperative journey.

We did not look at Safeguarding during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Involving people to manage risks during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

At this assessment, we found that the service had taken steps to improve its infection prevention and control (IPC) practices following previous concerns. The provider updated key IPC policies, delivered in-house training, and introduced monthly personal protective equipment (PPE) use audits with findings shared across clinical teams. Staff were generally observed wearing appropriate attire and PPE in theatre, and the theatre environment was visibly clean. A cleaning checklist was now used between surgical cases, and the responsibility for IPC oversight has been strengthened with the appointment of a new theatre manager and continued input from an external IPC advisor. While overall compliance had improved, there were a small number of isolated instances where IPC practice could be further strengthened. These included occasional variation in mask use and hand hygiene technique, such as not consistently following best practice drying methods or mask removal processes.

At this assessment, we found that the provider had taken steps to improve medicines management, including the introduction of temperature-controlled storage, updated standard operating procedures, and staff training on controlled drugs (CDs). A new medicines fridge with daily monitoring and alert systems was in place, and standard operating procedures had been revised following a previous incident involving morphine labelling. However, controlled drug stock checks in theatres were not routinely conducted and remained reactive, only taking place when drugs were used. This limited staff’s ability to detect discrepancies, missing stock, or inappropriate access in a timely manner, which are core requirements of safe medicines governance. Without routine reconciliation, the service could not provide full assurance that CDs were being stored and managed safely across all theatre areas.