Hendon Hospital

On this page

• 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 patients and communities had the best possible outcomes because their needs were assessed. We checked that patient’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring patients 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 rated this key question good. At this assessment the rating has remained good. This meant patients’ outcomes were consistently good, and patient’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 patients’ care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Staff shared key information to keep patients safe when handing over their care to others. Shift changes and handovers included all necessary key information to keep patients safe. The pre-assessment consultation patients had was led by nursing staff which would take place a minimum of 2 weeks before the patient’s surgery. Staff told us the nurse would escalate concerns to the consultant and anaesthetist where needed.

There was an elective surgical care admission criterion for both private and NHS patients, which included an initial assessment to decide if surgery was needed. This was followed by a pre-operative assessment. Patients requiring tests and investigations were given enough information to enable them to understand the procedure. Patients were involved in their care planning, and their families and those close to them were able to attend consultations and treatments with them.

We saw evidence of risk assessments for patients' pre-procedures having been carried out. Risks considered included of developing blood clots, assessments for delirium and cognitive impairment, clinical frailty scores, malnutrition screening tools and falls risk assessments.

Staff with appropriate seniority had discussions about the patients’ preferences and wishes if their condition deteriorated. Decisions about care were made with consideration of wishes of the patient and/or their family.

Staff assessed patients’ pain and used recognised tools to do so. Staff gave pain relief in line with individual needs and best practice and assessed how effective this was. Patients’ pain was addressed before they left the operating theatre or recovery.

The service usually planned and delivered patient’s care and treatment with them, including what was important and mattered to them. Staff 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 according to best practice and national guidance. All policies we looked at contained a date of issue and review date, and clear references to current national guidelines including guidance from the National Institute for Health and Care and Excellence (NICE). There were systems to communicate changes in guidance through meetings and management newsletters. We saw notice boards displaying up-to-date guidance to staff.

Elective orthopaedic and other surgical pathways followed recognised standards and guidance.

We reviewed 9 patients’ care records for evidence of completion of care plans and risks assessment of patients and found staff had completed care records sufficiently. The level of detail included in these records helped staff to provide safe and effective care, in accordance with their needs, and for continuity of care during the patient’s stay. We saw evidence that staff fully completed WHO surgical safety checklists, which staff signed and dated. Medicine charts were fully completed, as were admission checklists, NEWS observation charts, falls risk assessments and IPC risk assessments. We also saw evidence of staff completing post-operative care and recovery notes for patients.

Patients waiting to have surgery were not left nil by mouth for longer than necessary. Intravenous fluids were used to ensure pre-operative optimisation for emergency surgery, when necessary. Staff fully and accurately completed patients’ fluid and nutrition charts where needed. The information was used to inform care planning and delivery.

Staff used a nationally recognised screening tool to monitor patients at risk of malnutrition and used this to inform care planning and delivery. Patients requiring special diets for clinical reasons, were assessed and advice given.

The service reported information to the Private Healthcare Information Network (PHIN). Intelligence reports were reviewed by service leaders. These reports contained data on PHIN’s existing performance measures, including; patient activity volumes, length of stay, never events, Patient Reported Outcome Measures (PROMs), infections and also data submission levels. For example, in relation to overall patient satisfaction by inpatients, 98% of 583 people said that their overall experience in this hospital was very good or good.

The service usually worked well across teams and services to support patients. Staff made sure the patient only needed to tell their story once by sharing their assessment of needs when the patient moved between different services.

Doctors, nurses, and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care.

Staff reported healthy working relations across staff groups including between medical and nursing teams. We saw and heard examples of effective team working which was based on mutual respect and trust. For example, we observed morning and afternoon staff huddle meetings in the wards and in the theatre. These meetings were attended by clinical staff at different levels, including the director of clinical services, consultants, nurses, anaesthetists and HCAs. Staff discussed patients’ surgical procedures scheduled for the day, the type of anaesthesia being administered for the patient and the number of patients on the wards and theatres to determine sufficient staff levels and acuity.

Plans for discharge considered people’s individual needs, circumstances, ongoing care arrangements and expected outcomes. Discharges were planned at an early stage to ensure they were safe and appropriate for the person’s needs.

Information was shared between teams and services to ensure continuity of care.

Staff worked across health care disciplines and with other agencies when required to care for patients. For example, the service would write a letter to the patient’s GP summarising the procedure undertaken at the clinic and any medication the patient needed as part of discharge planning.

Peoples’ records showed there was input from a range of clinicians and that they shared information to ensure a consistent approach to care and treatment pathways.

Staff held regular and effective multidisciplinary meetings where required, to discuss treatment options for individual patients and improve their care. We reviewed clinical governance meeting minutes, which provided evidence of multidisciplinary discussions about patient care and agreed treatment options based on the individual medical needs of the patient.

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

Staff gave patients information on the importance of eating, drinking and fasting before their procedures. The service emphasised to patients the importance of the body needing to repair itself after surgery, and eating a healthy, balanced diet in the days and weeks before and after surgery. The service also advised patients to speak to their GP if they had any problems or concerns managing their food.

Patients undergoing elective operations had access to information about their condition, their treatment and how best to prepare for surgery. Staff spoke with them about how best to optimise their outcomes after surgery and how to modify their choices to ensure better health. Staff encouraged patients to keep hydrated and drink enough water and where possible sugary drinks before their procedure, to aim to reduce patients’ hunger and thirst and help them recover more quickly.

Staff encouraged patients to become mobile and able to move around the ward area, toilets and bathroom. Physiotherapists provided exercise routines to patients when needed and supported patients to learn new ways of moving, so they could be up out of bed as soon as possible.

The service monitored patients’ care and treatment to continuously improve it. Staff ensured outcomes were positive and consistent, and they met both clinical expectations and the expectations of patient themselves.

Staff monitored the effectiveness of care and treatment through continuous monitoring and auditing of patient records. For example, the service participated in notes audits, where patient records were checked for completeness, such as information related to pre-operative assessments, inpatient care and risk assessments, amongst other areas. Audit data we reviewed showed that compliance was over 95% for the last 12 months. The service used the findings to measure compliance and achieve good outcomes for patients.

The service had an audit tracker for all relevant provider led clinical audits they participated in, which outlined the frequency of the audits and when these were scheduled to take place. For example, we saw evidence the service took part in pain management and falls risk assessment audits. Audit data we reviewed showed pain management compliance was at 95% or above for the last 12 months, with no recommendations identified from the audits. Similarly, audit data we reviewed for falls risk assessments showed that compliance was above 95% for the last 12 months, and the service regularly ensured audit compliance as part of ongoing monitoring.

The service had a low number of readmissions for patients having elective care. Data we reviewed showed there were 5 readmission rates in the last 12 months. There was only 1 case of an unplanned return to theatre rate in the same reporting period. All patients were treated and discharged home.

The service had reported 3 surgical site infections for all surgery performed over the last 12 months. We saw evidence the service had recorded the details of each surgical site infection, which had resulted in low harm and the service had taken appropriate action to resolve these incidents.

The service recently reintroduced complex joint surgery work and was planning to submit its orthopaedic outcomes to the National Joint Registry (NJR), in the near future and in line with the rest of the CHG. The NJR is the largest national orthopaedic registry in the world and collects information on hip, knee, ankle, elbow and shoulder joint replacement surgery. The NJR monitors, analyses and reports on the performance of joint replacement surgery procedures, the hospitals where these are performed and the surgeons who perform the surgery.

The service collected PROMs data and produced monthly reports to monitor compliance, deterioration and outcomes. PROMs assess the quality of care delivered from the patient perspective and are standardised questionnaires completed by patients to assess their own health status. Over the last 12 months, cataract surgery was the largest surgical procedure the service carried out, followed by carpal tunnel surgery and knee replacement surgery. The service benchmarked outcomes internally against individual hospitals, regions or CHG as a whole entity, to monitor patient improvement over time.

The service participated in Patient-Led Assessments of the Care Environment (PLACE) audits. The results of the latest PLACE audits from 2024 and 2025 showed patients had a very good experience of using the service overall. The service scored above 90% for patient satisfaction rates in almost all areas, including cleanliness, food, privacy and dignity and also in specific areas including dementia and disability.

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

Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. Staff knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health.

Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. Staff followed the service’s policies related to consent, mental capacity, deprivation of liberty and restrictive practice, as relevant. We saw information on display in the wards regarding the principles of the Mental Capacity Act.

Where possible, staff gained consent from patients for their care and treatment in line with legislation and guidance. We observed patient consent processes for surgery in the wards and in theatre, where consent was sought by the most appropriate doctor and included discussion with the patient about the benefits, potential complications, the risks and alternative options including conscious sedation. Patient consent was checked at various points before they went to the operating room and immediately before surgery.

Patients said they were involved in decision making about their care and treatment. They were given the opportunity to ask questions and could describe the risks and benefits they were told about before surgery. Relatives said they were kept informed about the care and treatment of their family member when they lacked capacity to consent to surgery.

There were consent audits completed and outcomes shared with staff in departmental meetings, and the audit results were also discussed at the hospital clinical governance committee and where necessary at the corporate clinical governance committee. These audits checked that all sections of the consent form were completed for the patient, including discussion on known risks, intended benefits and alternative options being documented. The service achieved 100% compliance with the audit results for the ward and consulting rooms from the last 12 months.

The service had an up-to-date chaperone policy, and chaperones were provided if requested. We saw information on display in the wards regarding the option for patients to have a chaperone for consultations, examinations and procedures, which was also written in languages spoken by patients in the community. This information was on display in community languages such as Arabic, Polish and Portuguese.

Interpreters were used to support patients to give informed consent, including for British sign language (BSL) and face-to-face interpreting when necessary.

Staff sought permission before sharing patient information with family or friends.