Hendon Hospital

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that people and communities had the best possible outcomes because their needs were assessed. We checked that people’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring people were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

At our last assessment we did not rate this key question. At this assessment the rating has changed to good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

We have not awarded this service a score for Effective.

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

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Staff used a range of tools to assess and review people’s health needs. The tools were standardised, so staff understood how to use them. We reviewed 6 patient notes and found that physical and mental health needs were identified.

The service aimed to meet each patient’s individual needs. Staff reported that in an event that they had not been told about a communication issue or other access needs prior to the appointment they would endeavour to ensure the needs were met. For example, if they were not aware an interpreter was required they would arrange an interpreter at short notice using the services telephone interpreting service.

Facilities and premises met the needs of a range of people who used the service. The service was accessible to patients who used mobility aids. Accessible facilities included but were not limited to; accessible parking, entrances, bathrooms and treatment room facilities.

The evidence showed a good standard. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Staff followed up-to-date policies to plan and deliver high quality care in line with national guidance and best practice. We reviewed policies that reflected NICE guidance, GDPR requirements and other relevant professional standards. Including the safeguarding, safe management of medicines, management of records, and mental capacity restrictive practice and found these were clear and accessible to all staff.

Leaders shared updates to national guidance and corporate policies with the relevant heads of the department. These were then cascaded to staff through handovers, weekly clinical update posters and team meetings.

The hospital undertook clinical audits and monitored their performance against key performance indicators (KPI’s) to evidence they were performing to a good standard and identify areas for improvement and action. Examples of KPI’s relevant to the outpatient’s department were; deaths within 30 days of outpatient attendance, unplanned returns to treatment rooms, healthcare associated infections related to outpatient activity and unplanned transfers to other units.

The service took part in a monthly clinical performance and quality improvement exercise, with the other 51 hospitals within the Circle Health Group. This provided a valuable benchmarking opportunity, enabling the service to compare their performance against other services of similar size, service profile and geographic region. This also supported shared learning by allowing teams to share best practice.

The hospital achieved accreditation for the adult endoscopy joint advisory group (JAG) on gastrointestinal endoscopy accreditation, aseptic non-touch technique (ANTT) gold accreditation, VTE (Venous Thromboembolism) exemplar accreditation and the association for perioperative practice (AFPP) accreditation.

The service worked well across teams and services to support people. This included situations where people moved between different services.

The teams had effective working relationships, including good handovers, with other relevant teams within the organisation. We observed a comprehensive handover within the outpatient department where staff shared information about staffing and patients prior to opening the department. This information was also documented in an outpatient department daily huddle sheet that all staff could access. This sheet included but was not limited to information on total expected patients, expected procedures, staffing, incidents, complaints and departmental communication.

This information then fed into the daily hospital‑wide safety huddle, contributed to providing an overview of the hospital’s activity and allowed senior leaders and staff to collaboratively put mitigations in place if necessary.

We observed staff within the outpatient department working well together to support a seamless patient journey through all relevant departments. This involved joint working with administrative, nursing, medical, portering and diagnostic staff. We saw a patient move between the outpatient and imaging departments after seeing a consultant. The patient was supported by a portering staff who made the transfer seamless.

Staff across all roles, including nurses, consultants and administrative staff, told us there was good communication between professionals at all levels. For example, in the absence of the clinical service manager, nursing staff were comfortable to raise concerns regarding delays to the director of clinical services and request additional support where needed. Staff also reported that they felt confident to challenge clinical teams or managers if they had concerns about a patient or questions about decisions or processes.

The service had established links with local NHS services and were aware of formal protocols around patient transfers to local acute NHS trusts.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

Staff supported patients to live healthier lives through physiotherapy programmes, personalised exercise plans and advice to support recovery and independence. For example, patients who accessed the physiotherapy department after surgery were provided a bespoke care plan with exercises that were available in accessible formats. The gym within the department had various exercise equipment, including an anti-gravity treadmill and exercise bike.

A patient reported that the physiotherapists were very responsive and supportive. They detailed how they were supported to have an active recovery through their bespoke care plan and access to the gym within the physiotherapy department.

We also observed a consultation where a doctor provided 3 treatment plans to allow the patient to choose the option that best aligned with their lifestyle. Allowing the patient to maximise their independence, choice and control. The service also provided all patients with a patient passport with information on aftercare and frequently asked questions.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

The service routinely monitored people's care and treatment through monthly audits. These included but were not limited to audits of medicine management, care records and clinical outcomes. Clinical key performance indicators and performance data between June 2025 and May 2026 included 0 deaths within 30 days of outpatient attendance, 0 unplanned returns to the treatment room, 0 healthcare associated infections, 0 unplanned transfers to other units and 0 unplanned returns to the outpatient department.

Leaders submitted information to the Private Healthcare Information Network (PHIN) and met statutory reporting requirements to the Care Quality Commission, local authority and accreditation bodies.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff followed policies on patient consent and on specific measures to accommodate those with extra requirements, including people with a physical and/ or mental health need. There was also guidance on gaining consent from those who might need assistance with communication. We observed staff request consent just before a procedure, to check that patients were still comfortable in going ahead.

Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. Staff understood the relevant consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act 2005. The service also had an in date mental capacity act and deprivation of liberty safeguards (DoLS) policy for staff to refer to. Staff reported that if a patient was identified as requiring an interpreter for a procedure, this was arranged.

We reviewed 6 patients records and found that all patients had a signed consent form before treatment where appropriate.

The service also had a chaperone policy for all staff to refer to. Chaperones were mandatory for all patients during intimate examinations or procedures. The inability to facilitate this due to staffing would require escalation to the registered health professional in charge of the department. Staff did not report any concerns in relation to this.