Hendon Hospital

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• 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

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

At our last assessment we rated this key question as good. At this assessment, the rating stayed the same.

Leaders and the culture they created promoted high-quality, person-centred care. Staff and leaders demonstrated a positive, compassionate, and listening culture. Leaders had the skills, knowledge, experience, and credibility to lead effectively. The senior management team had a good understanding of these risks which they regularly discussed.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

The service had a shared vision, strategy, and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people.

Staff described a positive and supportive culture. Staff worked within a small team environment and told us they knew each other well. Staff spoke positively about their colleagues and demonstrated a shared focus on providing safe patient care. Observations and staff feedback indicated strong teamwork and collaborative working relationships.

Staff appeared committed to delivering personalised patient care and demonstrated pride in the service they provided. We did not identify cultural concerns during this review.

Leaders had developed a clear strategic direction focused on key specialties, including urology, gynaecology, general surgery, and orthopaedics, and included plans to strengthen community engagement and referral pathways. Leaders engaged with consultants in shaping the strategy and had begun engaging with primary care stakeholders to align services with local demand. They told us they planned to further develop patient engagement mechanisms to support co-design of services.

Leaders had taken steps to communicate the strategy to staff, including holding a whole-site town hall event and sharing information through simplified one-page summaries. However, they acknowledged that embedding the vision across the workforce was ongoing and not yet fully established, with variable staff attendance at engagement events. Staff we spoke with did not know the service vision or strategy.

Leaders promoted a positive, open, and inclusive culture. Staff described a strong sense of belonging, teamwork, and collaboration, with examples of supportive leadership and compassionate management practices. Leaders promoted a “people-first” approach and prioritised staff wellbeing, recognising the link between staff experience and patient care.

There was evidence of strong staff development and internal progression, with multiple examples of staff moving into more senior roles or undertaking formal training, including apprenticeships and professional qualifications. Leaders supported staff through flexible working, wellbeing initiatives, and individualised support where needed.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience, and credibility to lead effectively. They did so with integrity, openness, and honesty.

There was a clear management structure with clear lines of responsibility and accountability. Leaders demonstrated appropriate experience, visibility, and engagement within the service. The senior management team (SMT) described a strong, supportive leadership approach and reported regular engagement with corporate leaders, including executive visits and direct interaction with staff. Leaders described feeling supported by corporate teams and reported that investment needs had been recognised and were progressing through formal approval processes.

Leaders showed awareness of service pressures and risks, including infrastructure and equipment challenges, and had taken steps to escalate these through corporate governance routes. However, some timelines for key capital improvements remained dependent on central processes, which limited local control over implementation.

Staff told us leaders were well respected, visible, approachable, and supportive.

Staff wellbeing initiatives included access to clinical supervision, wellbeing days, and informal support mechanisms. Leaders told us they had an open-door approach to staff, if staff needed to raise any concerns.

The service fostered a positive culture where patients felt they could speak up and their voice would be heard.

Staff and leaders demonstrated openness, honesty, and transparency. Staff told us they felt able to speak up and were confident managers would listen and respond appropriately. They said they would be supported if they raised concerns and did not fear negative consequences.

The service had a Freedom to Speak Up Guardian and a designated whistleblowing lead. Staff working in wards and theatres knew who they were and how to contact them.

During our inspection we saw information displayed on staff noticeboards that explained the Freedom to Speak Up process and provided contact details for the Guardian.

We saw the Freedom to Speak Up policy which was up-to-date and version controlled. The policy explained how staff could raise concerns and detailed clear reporting and escalation processes, including options for raising concerns externally if staff felt issues had not been addressed. This showed the service promoted a culture where staff could raise concerns and be treated fairly.

The service valued diversity in their workforce. Staff worked towards an inclusive and fair culture by improving equality and equity for everyone.

Staff felt supported by their managers and could raise either work or personal concerns, as managers had an open-door policy.

The service had an inclusive staff team and worked within a diverse community.

The service had clear responsibilities, roles, systems of accountability at location level, and good governance systems. The hospital used a national digital safety tracking system, and accountability was managed under the parent company's structures. Locally, they used the arrangements to manage and deliver good quality, sustainable care, treatment, and support. Staff responded to information about risk, performance, and outcomes, and shared this securely with others when appropriate.

Staff understood their role and responsibilities. Managers were accountable for their actions, behaviours, and performance of staff. There were clear and effective governance, management, and accountability arrangements.

Leaders had systems and processes in place to support oversight of patient care and risk management. Consultants retained accountability for their patients throughout admission and staff described clear escalation processes. Regular planning meetings supported oversight of admissions, bed occupancy, and staffing requirements.

Staff demonstrated understanding of clinical responsibilities and escalation arrangements. Leaders had established governance systems to support oversight of quality, safety, and performance. They used an electronic incident reporting system to capture and manage incidents, with clear processes for escalation, investigation, and feedback.

Leaders provided examples of learning from incidents resulting in changes to practice. For example, following a surgical cancellation caused by unavailable equipment, leaders implemented strengthened pre-operative checking processes and shared learning across teams. They monitored compliance with actions through the incident management system.

Leaders maintained a programme of audits, which were reviewed locally and at corporate level. They benchmarked performance against other organisations in the group and used findings to inform quality improvement. Leaders demonstrated oversight of audit completion and validity, including re-auditing where results appeared inconsistent.

Leaders maintained an effective system for identifying, assessing, and managing risks across the service. The risk register was detailed, regularly reviewed, and reflected both operational and clinical risks facing the hospital. Risks were assigned to named owners, had clear review dates, and included documented mitigating actions and controls. Evidence showed that risks were escalated appropriately and monitored through governance processes.

The service-maintained oversight of a broad range of risks, including patient safety, equipment failures, workforce vacancies, governance concerns, financial risks, and information management risks. Risks were scored according to severity and likelihood, with target scores identified to demonstrate the level of risk reduction expected.

Leaders demonstrated a proactive approach to risk management. They had implemented mitigating controls for all significant risks and monitored progress through regular reviews. For example, where the nurse call system and emergency communication systems were not fully functioning, staff introduced alternative escalation processes, increased observations, provided access to desktop telephones for emergency calls and secured capital funding for replacement systems.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for patients. Staff shared information and learning with partners and collaborated for improvement.

Leaders and staff worked collaboratively with external partners to support the delivery of safe, effective, and sustainable care. They maintained constructive relationships with commissioners and other stakeholders and used these partnerships to monitor service performance, address challenges, and drive improvement.

Leaders engaged regularly with the Integrated Care Board (ICB) through formal contract review and monthly partnership meetings. These meetings provided oversight of service quality, performance, activity levels, waiting times, finance, contractual arrangements, and patient outcomes. The service and commissioners reviewed performance information together and agreed actions where improvements were required.

The service shared quality and performance information with commissioners and discussed key quality indicators, incident reporting, patient waiting times and compliance with mandatory clinical training. Leaders acted in response to feedback from partners and used meetings as an opportunity to share learning and improve services. For example, the service discussed overdue incident reports and opportunities for shared learning from patient safety events across providers.

The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. The service actively contributed to safe and effective practice.

Leaders promoted a culture of learning, improvement, and innovation across the service. Staff used quality improvement and safety improvement methodologies to identify areas for development, implement changes and monitor outcomes. Leaders supported improvement work and encouraged staff to review performance, learn from incidents, and embed good practice.

Staff demonstrated a proactive approach to learning and problem solving. For example, leaders convened a multidisciplinary resuscitation group to review emergency response arrangements and ensure compliance with policy and best practice. Staff identified areas for improvement, agreed actions, and implemented changes immediately. These included reviewing team roles, strengthening clinical support during emergency responses, introducing daily resuscitation huddles, and providing clearer role allocation arrangements. Leaders monitored the effectiveness of these changes through audits, incident reviews, and feedback from training scenarios. Staff told us the process helped provide assurance that emergency response systems remained effective and safe.