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

At this assessment, we found that governance and leadership at The London Welbeck Hospital had strengthened since our previous visit. The provider had taken steps to improve oversight by updating key policies and standard operating procedures, introducing regular audit cycles, and increasing visibility of senior clinical leadership within theatres. Communication of audit findings and action plans had improved, with evidence of shared learning across the team.

This service scored 71 (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.

The service made positive progress in strengthening its governance systems and leadership oversight. The provider had taken steps to respond to previous regulatory concerns by reviewing and updating a number of policies and standard operating procedures, particularly in areas related to surgical safety, infection prevention and control, and the management of medicines. These documents had been revised to reflect current practice and national expectations, and were being disseminated to staff through induction, email updates, and team meetings.

Clinical leadership visibility had improved, with the registered manager and theatre managers playing a more active role in monitoring practice and supporting staff. The introduction of regular observational audits, especially in relation to the World Health Organisation Surgical Safety Checklist and infection control practices, provided the service with a clearer picture of frontline performance. Audit findings were reviewed by the senior team and shared with the wider staff group, creating a feedback loop to support improvement. There was evidence of a senior leadership engagement, with strategic oversight provided through quarterly meetings involving senior clinical and non-clinical leaders.

While policies and protocols had been updated, some documents used vague language (for example, referring to “qualified personnel” without specifying the required qualifications). In addition, key guidance was spread across multiple documents; such as policies, standard operating procedures, and separate checklists or audit forms, which were stored in different locations. This fragmented approach to documentation may hinder staff in accessing and consistently applying the correct procedures. The approach to controlled drug stock checks in theatres also required further development to ensure medicines were managed in a safe and accountable manner.

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.