Hendon 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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also ensured that people’s liberty was protected when it was in their best interests and in line with legislation.

At our last assessment, we rated this key question as requires improvement. At this assessment the rating has changed to good. This meant people were safe and protected from avoidable harm.

At the previous assessment the service was in breach of safe care and treatment in relation to patient confidentiality and infection, prevention and control. Since then, the service had made improvements and is no longer in breach of this regulation. This was because the service now had a separate plaster and wound dressing room, hand basins in all consulting rooms and complied with the Data Protection Act 1998 in relation to confidentiality of patient information.

We have not awarded this service a score for Safe.

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

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff knew what incidents to report and how to report them. They raised concerns and reported incidents and near misses in line with the provider policy. Staff told us they received feedback from incidents they reported, and learning from incidents was shared in safety huddles, monthly meetings and by email. We reviewed meeting minutes from February, April and May 2026 which corroborated the discussion of incidents reported as no harm and action taken in response.

The service had an in-date incident management policy and investigated incidents using the patient safety incident response framework (PSIRF). They also had a patient safety incident response plan in place which outlined a planned response to specific patient safety events. The service had reported 0 significant patient safety events or never events in the past 12 months.

To support staff learning from incidents, the service had an intranet page dedicated to patient safety. This page included PSIRF lunch and learn sessions on patient safety investigations to support staff. The service also published and displayed weekly clinical update posters, to ensure all staff were aware of clinical changes. These included but was not limited to updates on new training and the introduction of new equipment or consumables.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong. The service had 0 incidents that required duty of candour in the last 6 months.

The service encouraged feedback from staff and patients and there was evidence that changes had been made as a result. We observed ‘you said, we did’ posters around the service. For example, the service received feedback that it was important that consultants checked patients understood the information being given. In response the service shared the feedback with consultants to ensure ‘checking for understanding’ was a core part of every appointment. Staff reported that they met to discuss feedback and changes in response at monthly meetings and they were reported during safety huddles.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care however, patient notes were not always clear, up to date and comprehensive.

The service worked with people and their partners to ensure care was planned, coordinated and delivered safely. However, patient notes were not always clear and comprehensive. The service used a mixture of paper and electronic patient notes. Paper notes were scanned onto the electronic patient record (EPR) system that was used across the wider hospital. We reviewed 6 patient records and found that consultants did not always produce clear and comprehensive notes for each consultation. This was escalated to senior leadership who reported that as consultants usually followed each patient, they stored notes on their personal electronic drive. This was an area of concern as patient information may not always be readily accessible to other clinicians involved in the patient's care if the consultant was not available. This could affect continuity of care and treatment planning.

In response to this the service escalated this information to all consultants with an aim to improve documentation. The service did not provide further update on this.

The service provided outpatient services at the main outpatient’s department, the ophthalmology clinic and the physiotherapy department, which was facilitated by doctors and physiotherapists. The service provided services to both privately funded and NHS patients who had been referred. The referral and admission processes ensured that all essential information about the patient was received, to determine if the patient’s needs could safely be met. All new patients completed a registration form on their first appointment.

Each patient was then allocated to a consultant who would undertake a consultation and identify whether treatment was needed. There was good oversight of how long patients had been waiting to be seen for appointments, through tracking check-in times and intentional staff rounding. Follow up appointments were booked immediately by administrative staff in the outpatient department and clinical staff in other areas. This prevented patients being lost in the system and ensured they were followed up by the appropriate speciality team.

There were appropriate policies and procedures to guide staff when transferring patients. This included arrangements for clinically unwell adults, as well as non‑emergency transfers.

Leaders and staff told us there were strong working relationships between clinical and non‑clinical teams. All staff in the outpatient’s department worked well together. We observed continuity of care being maintained when patients moved between services, such as outpatients, diagnostics and physiotherapy.

We saw evidence of effective checks and handovers within the service. The information discussed at handovers was then fed into the daily hospital‑wide huddle, which was attended by the senior management team and a representative from each department in the hospital. All staff contributed to provide an overview of the hospital’s activity. Any relevant information was taken back to each department and cascaded to the team.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The service shared concerns quickly and appropriately.

Staff knew and understood how to identify people at risk of, or suffering, significant harm and worked with other agencies to protect them. Staff we spoke with could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

The hospital had a safeguarding lead, and staff knew how to contact them for advice and support. They also knew how to make a safeguarding referral. Safeguarding referrals were then made to the appropriate agencies; we saw evidence of appropriate safeguarding referrals being submitted to the local authority.

The hospital only provided care to patients over the age of 18 years old. They had a safeguarding adult’s policy and a safeguarding children and young people policy, both of which were in date and comprehensive. Staff had a good understanding of deprivation of liberty safeguarding practices (DoLS) and the mental capacity act (MCA).

The service provided safeguarding training on how to recognise and report abuse and had the appropriate level training for their role. Overall staff compliance with safeguarding adults training level 1 to 3 was 98% and 99% for children safeguarding level 1 to 3. Both of which exceeded the provider target of 90%.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. We observed patient information boards with posters that signposted patients with required additional communication needs to request support.

Staff were aware of each patients risks and supported patients to make decisions about their care. Consultants had access to all patient’s medical history prior to all consultations but also confirmed the information at each contact. We observed an outpatient’s consultation where the consultant was aware of the patient’s medical history, provided information on treatment options and supported the patient to make an informed decision.

All other patients we spoke with said procedures were clearly explained, including risks and benefits, and that they felt able to ask questions and make informed decisions. They also reported that they understood their care and treatment.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service detected and controlled potential risks in the care environment. Staff made sure equipment, facilities and technology supported the delivery of safe care. The main outpatient’s department was in a separate area which was a 1-minute walk from the main hospital. While the ophthalmology clinic and physiotherapy department were located within the main hospital. The design of the environment followed national guidance. The main outpatient department was made up of a waiting area with 26 chairs, 7 consultation rooms, a treatment room, a plaster room, a phlebotomy room, a clinical room and 3 toilets. The separation of the treatment and plaster room was an improvement from the last assessment.

Security arrangements were in place to ensure only authorised personnel entered the main hospital. Staff gained access to clinical areas with electronic swipe cards and patients gained access after authorisation by administrative staff in the reception area.

The environment was visibly clean and clutter free with furnishings in a good state of repair. The service had completed the appropriate environment risk assessments, these included but were not limited to control of substances hazardous to health (COSHH), fire safety and general clinical activities.

Fire exits and doors were observed to be free from obstruction, clearly marked, and staff knew the correct procedures to follow in an emergency. The fire drills were conducted on a weekly basis, and there were designated fire marshals within the department.

Staff could access appropriate equipment, including emergency equipment as needed. We saw that resuscitation trollies were secure and positioned in an easily accessible area of the departments. Checks were recorded electronically and compliance was monitored by management. Resuscitation equipment we reviewed onsite were checked daily and all items were present and in date.

The maintenance and use of equipment kept patients safe. Electrical appliances and equipment we checked during the assessment had been tested and serviced to ensure they were safe to use and had stickers with appropriate dates to show that this had taken place.

Staff managed clinical waste well. Waste management was handled appropriately with separate colour coded arrangements for general and clinical waste. Sharps, such as needles, were disposed of correctly in line with national guidance. We observed cleaning equipment stored securely in locked cupboards.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Medical and nursing staffing met planned numbers on both days of the assessment. Staff could refer to the hospital’s safe staffing framework to identify staffing red flags in each clinical area and the escalation process. Staffing red flags were events that prompt an immediate response by the registered health professional in charge of the department.

The service planned and regularly reviewed staffing levels and skill mix to ensure people received safe care and treatment. Rotas were prepared by the clinical service manager and shared with staff 1 month in advance. However, the clinical service manager was on long term sick leave at the time of assessment, so rotas were drafted by the outpatient department team and reviewed by the director of clinical services in the interim.

The service had low vacancy rates, data showed that the overall vacancy rate was 2.4% in May and June 2026. Staff reported that the service regularly used bank staff to cover nursing and physiotherapist staffing shortages. Staffing shortages in the physiotherapy department were due to maternity leave however; the service assured us that bank usage would reduce in August 2026 as permanent staff would be returning. To mitigate the risk associated with temporary staffing, the service booked bank staff who were familiar with the service, local processes and had completed the required induction and mandatory training.

All staff we spoke with told us they enjoyed working at the service. The overall staff turnover rate was 20% in March, 19% in April and 18% in May 2026. The service had low and reducing sickness rates. The overall sickness rate was 5.7% in April, 5.9% in May and 5.6% in June 2026. The provider did not have set targets for vacancy, turnover or sickness rates.

Staff had received and were up to date with appropriate mandatory training. Mandatory training included topics such as basic life support, conflict resolution, equality and diversity and moving and handling. Mandatory training compliance for all staff was 98% which exceeded the provider target of 90% and was an improvement from the last assessment.

All consultants working at the hospital had practicing privileges, disclosure and barring services (DBS) checks, indemnity cover and are registered with the information commissioner’s office (ICO).

All staff we spoke with told us they received yearly appraisals. Hospital wide appraisal compliance was 87% which exceeded the provider target of 80%.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Clinical areas were visibly clean and had suitable furnishings which were clean and well-maintained. The general décor of the unit was also well maintained; this was an improvement from the last assessment.

Daily cleaning was performed by domestic staff who had a daily cleaning schedule to follow and sign after completion. Cleaning records were up to date and demonstrated that the ward areas were cleaned regularly.

Staff had clear roles and responsibilities around infection prevention and control. We observed staff following infection control principles, including the use of personal protective equipment (PPE) and hand hygiene. Hand washing stations and alcohol rub was available throughout the service and each consultation room had a handwashing station. This was also an improvement from the last assessment.

The service performed well for infection, prevention and control (IPC) principles and standards. The outpatient department had 100% compliance with aseptic non- touch technique and hand hygiene between March and May 2026. Staff cleaned equipment after patient contact and labelled equipment with green ‘I am clean’ stickers to show when it was last cleaned. The service met the control of substances hazardous to health (COSHH) standards.

The hospital audited healthcare associated infections and reported on this quarterly. This audit included data on surgical site infections, bacteraemia and Clostridioides difficile (C. Diff). Audit data showed 2 episodes of surgical site infections and 0 bacteraemia and C.Diff cases between March and May 2026.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

Staff followed comprehensive medicines policies and guidance, including those relating to controlled drugs. The hospital's medicine policies were in date, regularly reviewed and aligned to national guidelines. In the outpatient department prescription of medication was completed by consultants during the consultation, via a FP10 NHS prescription form or private prescription form. FP10 and private prescription pads were stored securely and there was a clear audit record.

Medicines were stored in secure storage areas with access restricted to authorised staff. The service did not store controlled drugs within the outpatient department. All medicines we reviewed were in date and the hospital pharmacy team performed regular stock audits.

The service also had a hypoglycaemia kit to rapidly treat dangerously low blood sugar. The kit had the appropriate contents which were all in date. Including medication stored in the fridge.

Staff monitored fridge and ambient room temperatures daily to confirm temperatures were within the range and we saw these were recorded.

The hospital conducted a monthly medicines audit, this was a comprehensive audit that included but was not limited to; appropriate storage of medication, daily monitoring of fridge and ambient temperatures and documentation of medicine administration. Information on medication issues such as incidents, audits and learning was actioned and discussed at monthly meetings.