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. There were procedures available for staff to follow when monitoring patients and for identifying and responding to deteriorating patients on the wards, in the operating theatre and recovery. People received treatment and care to reduce the risk of avoidable harm, such as pressure damage, blood clots or falls. There were safety processes in place before surgery with staff working together to ensure the right patient had the correct operation procedure as listed. Medicines were managed safely. Patients were safe from neglect, abuse and discrimination. Patients gave informed consent before procedures and where they were unable to consent, those close to them were involved in decisions made in their best interests.

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

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 positive culture of safety, based on openness and honesty. Staff and leaders listened to safety concerns, reported incidents and investigated safety events. Lessons were learned to continually identify and embed good practice. We saw examples of learning which had been shared with staff. For example, learning from incidents regarding incorrect clinical information for patients on booking forms. The learning was shared with theatre teams and consultants. Staff were reminded of the need to have the correct consent form signed for the correct surgical procedure.

The service managed patient safety incidents well. Staff who we spoke with recognised and reported safety incidents and near misses, using in-house IT systems. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. Managers acted on patient safety alerts and monitored progress against identified actions.

The service had a current incident reporting and reviewing policy, which reflected the provider and national guidance. The Incident Management Policy outlined the roles and responsibilities of all staff when they were required to complete incident reports, to ensure the incident was investigated and learned from to prevent the risk of reoccurrence. The policy used the Patient Safety Incident Response Framework (PSIRF) and the provider’s Patient Safety Incident Response Plan (PSIRP) to provide proportionate responses to incidents. The Patient Safety Incident Response Framework sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents, for the purpose of learning and improving patient safety. We saw evidence of this policy being used by staff to support improvements in patient care.

Staff raised concerns and reported incidents and near misses in line with provider policy. We saw evidence of incidents having been investigated, and sufficient action taken to reduce the risk of recurrence. We looked at the electronic system the service used for managing incidents. Recent examples of incidents included themes around clinical communication to patients, cancelled operations, readmission rates to the hospital and surgical complications. We saw evidence that the service had reviewed each incident and taken appropriate action to resolve any concerns identified. Most incidents reviewed resulted in low harm or no harm to patients. Where appropriate, the service stated details of lessons learned and each action for each incident. The quality and risk manager would oversee incident reporting and investigations.

There had been no reported serious incidents or never events in the preceding year. Never events are serious, preventable safety incidents which should not occur if the available preventative measures are followed. They include things like wrong site surgery or foreign objects left in a person’s body after an operation.

Staff we spoke with understood the duty of candour regulation. They gave us specific examples within the last 6 months of when they needed to apply the duty of candour with patients and their families. They were open and transparent and gave patients and families a full explanation if, and when things went wrong. Staff received feedback from investigation of incidents, both internal and external to the service.

There were processes for learning when things went wrong or when there was good practice, either locally or nationally. We were told about learning from the number of cancellations of surgical procedures and how the service was planning to reduce the overall number of cancellations. The service planned daily equipment checks to ensure equipment was clean and ready for use. Staff confirmed consumables were available at least 2 days before surgery. The service also offered tours to anxious and neurodivergent patients before their procedure. Staff and leaders were therefore committed to improving the patient experience.

The service worked with patients and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when responsibility for patient care moved between different areas of a service and between providers.

Safety was a priority throughout people’s care pathways. Patients were assessed before surgery and findings taken into account when planning care and treatment. This included cancelling or delaying the surgery in cases where an underlying condition was identified, or where further tests were required to ensure the patient was fit for surgery.

The service previously had a service level agreement with a local NHS hospital to support the transfer of critically ill patients. Although this agreement had expired in May 2026, staff told us they continued to follow the established transfer arrangements while the agreement was being renewed. Leaders confirmed they retained access to critical care services at the NHS hospital if required. However, the service told us they had not transferred any patients under the agreement since it was implemented in May 2023.

The service had reported 4 unplanned transfers of inpatients to another hospital in the last 12 months, which included transfers to the nearest NHS hospital. These transfers were required for patients who had suffered clinical deterioration and needed to receive a higher level of care. We saw evidence of handover by the resident medical officer (RMO) to the ambulance crew who transported the patients to the NHS hospital. We also saw evidence of immediate actions taken and staff contacting the affected patients and their families to follow up on the progress of the patient’s condition. The service had a policy regarding care of the deteriorating patient, which emphasised the roles and responsibilities of all staff including consultants and RMOs to manage deteriorating patients, and this included guidance around the National Early Warning Score (NEWS2) to detect and monitor patients who were acutely ill or at risk of physical deterioration.

The service had a policy regarding ‘Non-Critical Transfer of Patients to other Circle Sites’. This policy applied where a consultant decided that should a patient be assessed not to be clinically fit for discharge following surgery, they could be safely transferred, where possible, to another Circle hospital within an acceptable distance, for ongoing care. All patient handover information was required to accompany the patient, including photocopies of the complete set of patient records and a transfer of care letter. This also included the involvement of key stakeholders in the process of the transfer pathway, including the receiving hospitals, private ambulance transfer, or the NHS ambulance service, and the next of kin for the person being transferred. Consultants who had practicing privileges took over the patient’s care when planned transfers took place to another Circle hospital. Practicing privileges define the scope of work a healthcare professional can perform within a particular hospital beyond their general professional registration. Practising privileges define the procedures and treatments consultants are authorised to provide within a hospital.

Care and support were planned and organised with patients, together with partners and communities in ways which ensured continuity. We reviewed 3 patient discharge letters, where the service contacted the patient’s GP summarising the procedure undertaken at the service and any medicines the patient needed as part of discharge planning. The letters also provided contact details of the ward and the RMO if the patient had any concerns, as well as advising the patient to visit their nearest accident and emergency department in case of an emergency.

There were safety-based systems and processes to ensure the correct patients were treated throughout the patient journey. We tracked patient care from admission to the ward and the operating theatre. We observed handover of patient information including all related identification checking processes. Once in theatre, the World Health Organisation (WHO) surgical safety checklist was used to avoid harm. We observed staff completion of the process.

The transfer of patients from the operating theatre to the recovery was managed safely, with the anaesthetist retaining responsibility for determining the readiness for transfer. Suitably skilled and qualified staff accompanied patients in all areas.

The service had an Operating Theatres Operational Policy, which included 3 defined pathways for management of deteriorating patients. This included the option of the patient returning to the theatre following clinical review, or patients requiring continued inpatient care who could not be safely discharged home but did not require critical care being transferred to another Circle Health Group (CHG) site where the consultant held practising privileges. The policy included arrangements for emergency transfers if a patient’s condition deteriorated and they needed critical care. It stated that transfers to a nearby NHS trust should follow the NHS Critical Care Standard Operating Procedure.

Patient records were a mixture of electronic and paper based and were kept securely. Records we reviewed were completed appropriately by nursing and medical staff.

The service worked with patients and healthcare partners where required, to understand how best to keep people safe, what it meant for individuals and the best way to achieve that. Staff concentrated on protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. All clinical staff received adult and children's safeguarding training and received Level 3 Safeguarding training, while all non-clinical staff received Level 2 Safeguarding training. Training modules included topics such as Female Genital Mutilation (FGM). Data showed staff achieving an overall safeguarding training completion rate of 98%.

The current safeguarding policies we looked at were in date, and reflected the national guidance for adults and children, including visitors.

Staff in the ward and theatres knew how to make a safeguarding referral and who to inform if they had concerns. The director of clinical services was the dedicated clinical safeguarding lead for the service and they had oversight of safeguarding within the service. The director of clinical service had received Safeguarding Level 4 training and was responsible for making safeguarding referrals. The director of clinical services shared learning from safeguarding incidents with other staff members and teams. There were monthly drop-in learning sessions which staff at all levels and roles were invited to attend. The registered manager also received Level 4 Safeguarding training. We saw information on display at the service regarding the name and contact details of the provider’s national safeguarding lead and the Integrated Care Board (ICB) safeguarding lead, in addition to the name and contact details of the site lead for safeguarding.

There were clear processes on display for staff to follow when making a safeguarding referral. Safeguarding concerns were considered when an incident occurred and a referral or further advice sought, when necessary. There were links to external agencies, including the local authority safeguarding team and on call duty social workers to make an urgent referral and the police. Although the service did not treat patients under the age of 18, there were protocols on display for staff to follow if they had concerns about a child or young person’s welfare. This included referrals to multi-agency safeguarding hubs and emergency services.

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

Where relevant, staff checked that people claiming Lasting Power of Attorney had the appropriate documents to support this. Discharge and follow up arrangements were organised safely. Patients knew what to expect and when they would be next seen by a nurse or doctor.

Staff followed safe procedures for visitors visiting the ward and patients we spoke to told us they felt safe.

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

We saw evidence that nurses carried out all necessary risk assessments for patients' pre-procedures. Pre-admission assessments were carried out face-to-face or via telephone depending on the type of surgery being performed. Where anaesthesia and anaesthesia-led sedation was required, staff required patients to complete a full health questionnaire. This included previous medical and surgical history and any risks related to allergies to medicines or food, whether the patient was a smoker, had a medical history of heart attacks, strokes or diabetes, for example. Risk assessments about care were person-centred, and the pre-assessment team would flag any reported risks to the consultant surgeon or anaesthetist before the patient’s surgery.

The service had confirmed there were no venous thromboembolism (VTE) or pulmonary embolism incidents over the last 12 months. VTE is a condition that occurs when a blood clot forms in a vein. The risk of developing VTE is highest after major surgery, major injury, or during periods of infection and inflammation.

Staff teams on the ward contributed to the initial part of the World Health Organisation (WHO) 5 steps to safer surgery checklists. The WHO safer surgery checklist is designed to reduce surgical errors, prevent avoidable harm and improve team communication before, during and after surgery, ensuring comprehensive care from preparation to recovery. The operating teams would then complete the remaining sections of the WHO checklist. The service also carried out audits on a quarterly basis for the WHO checklists ranging in audits for surgical specialities including cataract surgery and endoscopy, of which at least 97-98% compliance rates were achieved. The service identified specific actions required from the audits to increase compliance or reduce any gaps identified.

We spoke to 3 patients during our assessment who told us they felt listened to, risks had been explained, and they were involved in decisions about their care and treatment. For example, 1 patient told us their pre-assessment telephone consultation was straightforward, and staff had explained the procedure clearly to them. They felt staff were well trained and had given them an opportunity to ask questions about their care and treatment.

The service detected and controlled potential risks in the care environment. Leaders and staff took steps to make sure equipment, facilities and technology supported the delivery of safe care. Leaders identified environmental risks and planned actions to reduce them.

Staff were trained to use equipment and to manage different types of waste safely. We saw electrical equipment was serviced and had been safety tested.

The environment of the wards and other areas used for patient care reduced the risk of patient harm, and included, for example, safe flooring, handrails and window restrictors.

Fire safety equipment was available and had been serviced. Fire exits were clear and free from obstruction.

There was suitable equipment provided and used correctly, such as for patients who were at increased risk of pressure damage or a blood clot developing. Staff carried out daily safety checks of specialist equipment. There was ready access to resuscitation equipment on the ward and in theatres, where we saw that staff completed daily checks of the resuscitation equipment. Specialist equipment in the operating theatres was used in accordance with national guidance and regulatory requirements.

Leaders maintained oversight of equipment to ensure it was safe and ready to use. Equipment audits were completed and outcomes shared with staff. Staff told us they had enough equipment to carry out their work safely and to support the treatment and care needs of patients. There were effective means of ensuring repair or replacement of broken or missing equipment. This was on the service’s risk register.

The operating theatres were clean and tidy, free from clutter and had suitable furnishings which were clean and well-maintained. There were separate sharps and clinical waste bins, and these were clearly labelled and waste was disposed of securely.

Specialist equipment used in the operating theatres was used in accordance with national guidance and regulatory requirements. The theatre environment followed national guidance, with separate areas to enable flow from clean storage, preparation through to an area for dirty equipment and waste management. There was storage for equipment including sterile packs, uniforms and linen. There was sufficient space for laying up theatre trolleys under a ventilation canopy, if required.

Surgical instrumentation was managed off site under a service level agreement, which involved the processing of items, delivery of these and collection after use for cleaning and sterilising.

Patients could reach the call bells, which were positioned by patient beds. Staff showed patients how to use them to summon help. We saw call bells were responded to swiftly and the noise level from unanswered call bells was minimal.

The service had suitable facilities to meet the needs of patients’ families when necessary.

Staff disposed of clinical waste safely, both inside and outside the building. Waste was segregated and labelled in accordance with the service’s policy. The risk of sharps injuries was minimised because of the safe management of sharp implements.

Hazardous substances were stored safely and information about products was available to staff.

However, there was no controlled access in ward areas and patients could use the lift to access the different floors of the ward. This meant that patients could access areas they were not authorised to access. This in turn could have impacted the safety and security of other patients, their relatives and staff members. We raised this concern with the provider during our assessment, where this was on the service’s risk register and they understood the impact of this risk. The service was planning to install a swipe card access system at ward entry/exit points to mitigate this risk.

The pantry area was excessively warm, with temperatures recorded above 27°C. Leaders had not identified alternative controls to reduce temperatures in this area.

The service made sure there were adequate numbers of qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care, which met patient’s individual needs.

The service had enough clinical staff including nursing and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Staff received their rotas in advance and could request changes where required.

Managers reviewed the number and grade of clinical staff, healthcare assistants and other key roles, needed for each shift in accordance with national guidance. Managers could adjust staffing levels daily according to the needs of patients. Theatre and recovery staffing was planned, based on activity and the skills needed for everyday and emergency work, including out of hours cover arrangements.

The service had low vacancy rates. At the time of our assessment, there were currently 2.6% clinical vacancies and 2.1% non-clinical vacancies. The service did not report turnover rates and therefore could not demonstrate trends in staff retention. The service did not have specific targets for sickness, but aimed to maintain vacancy and sickness rates as low as possible. The sickness rates were 4.2% for clinical staff, 5.2% for non-clinical staff and an overall rate of 4.7% for staff.

Managers limited their use of bank and agency staff and requested staff familiar with the service.

We saw patients were attended to in a kind and supportive way. Patients appeared comfortable and were engaged in conversations because there were sufficient staff.

Managers made sure staff attended team meetings or had access to the information shared, when they could not attend. We saw notes from team meetings and other general information was shared on noticeboards.

Managers supported staff to develop through constructive recorded, annual appraisals of their work and regular clinical supervision. If poor staff performance was identified, this was managed in a supportive way, with a view to improvement.

The service had formal arrangements for a resident medical officer to be on-site when patients were receiving treatment and care.

Consultant surgeons and anaesthetists were subject to a full assessment through the practice privilege process. They were required to provide evidence of appraisal and re-validation.

Surgical procedures and clinical decisions were carried out by doctors with appropriate seniority and speciality training. Patients were clear who the doctors involved in their treatment were.

The overnight and weekend provision was adequate, with patients having access to the admitting consultant for advice or to attend, if necessary. The admitting consultant reviewed their patient/s regularly, including at weekends.

Although staffing levels were sufficient to maintain safe care, some staff reported working extended shifts, which leaders were reviewing through workforce planning arrangements.. While the ward manager outlined some mitigation measures in place, further consideration was needed to support nursing staff in maintaining a sustainable work-life balance and managing workload effectively.

The service provided mandatory training in key skills to all staff. Mandatory training modules included topics such as health and safety awareness, infection prevention and control, information governance, fire safety awareness and equality and diversity. There were also role-specific mandatory training modules which staff needed to complete. This included Display Screen Equipment (DSE), Control of Substances Hazardous to Health (COSHH) and Venous thromboembolism (VTE) Prevention. Managers monitored mandatory training and alerted staff when they needed to complete updates.

Medical and nursing staff received and kept up to date with their mandatory training. The data showed an overall staff completion rate of 98%, which included both clinical and non-clinical staff.

Clinical staff completed training on recognising and responding to patients with, for example, learning disabilities and dementia. Staff completed the mandatory training on learning disability and autism, and had dementia awareness training too.

New staff completed a full induction tailored to their role before they started work. Managers supported staff to develop through constructive recorded, annual appraisals and constructive clinical supervision of their work. Temporary bank and agency workers had a local induction to the area in which they were working.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading by following policies. Infection and prevention and control data was collected and reviewed. Where required, actions were taken to improve shortcomings.

The service managed infection risks well. The service used systems to identify and prevent surgical site infections. Staff used equipment and control measures to protect patients, themselves, and others from infection. They kept equipment and the premises visibly clean. Staff cleaned equipment after patient contact and labelled equipment to show when it was last cleaned. Equipment was labelled to show when it had been cleaned for equipment used at the service.

Theatre practice minimised the risk of cross infection and we saw staff following best practise regarding the treatment and care of their patients.

The management of clean and used surgical equipment and the flow through theatre reduced the risk of cross contamination. Staff checked the condition of sterile packs before they were opened and before use.

There was appropriate testing of water outlets and air exchange systems in theatres.

Staff understood the process for managing spillage of body fluids both on the wards and in theatres. There was a spillage kit located in the COSHH cupboard, and staff received training on how to deal with spillages.

The service used the provider’s infection and control manual, which contained policies and procedures (for example, bare below the elbow guidelines for staff undertaking patient care related activities or entering a clinical area). The manual was consolidated into one document to ensure the policies and procedures were user-friendly and readily accessible to staff. The provider’s guidelines reflected national Infection Prevention Control (IPC) guidance from Public Health England (PHE), and the Royal College of Surgeons. Staff had access to expertise in infection control as needed. Nursing staff were required to complete an IPC risk assessment tool for all inpatient and day case admissions, as per the provider’s IPC manual.

The service had a hospital infection prevention and control committee (HIPCC), which met quarterly covering areas such as IPC audit reports, compliance and action plans. The hospital had an IPC lead, who attended the HIPCC meetings and monitored compliance with IPC.

The service performed well in local IPC audits. In the most recent audits, the scores showed compliance with IPC measures in all clinical areas. There was a programme of regular IPC audits including for example, the theatres and ward. Data of the IPC audits we reviewed showed the service achieved at least 95% compliance in the different areas. There were specific actions in place to increase compliance and reduce gaps that had been identified. For example, replacing damaged or worn window blinds in patients’ rooms.

There were processes to enable staff to respond to IPC risks, such as a sepsis screening tool.

We saw staff were following infection control principles including compliant handwashing and the use of personal protective equipment (PPE) as outlined in the service’s PPE standard operating procedure. We saw posters on display in the ward regarding hand hygiene guidelines that staff needed to comply with.

Staff supported infection prevention and control measures by following the uniform policy. Nail varnish and jewellery was not worn, and staff in clinical areas were bare below their elbows to allow for full hand decontamination.

The service carried out up-to-date COSHH risk assessments for staff in the wards and theatres who were responsible for the handling, storage, dispensing and transportation of chemicals within the hospital. This included e-learning for all staff handling hazardous substances and provision and use of appropriate PPE as required and identified in COSHH assessments (for example, wearing protective gloves), and adhering to any safety instructions on packages.

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

Patients received their medicines safely and as prescribed. The service used a paper-based prescription chart to support safe prescribing and administration, and we observed medicines being administered safely.

Medicines, including controlled drugs (CDs), were stored securely. CD management was in line with legal requirements. However, pill cutters stored within the medicines trolley contained visible residue, increasing the risk of cross-contamination between medicines.

The service received pharmacy support. Pharmacy staff issued stock medication, carried out medicines reconciliation (the process to accurately record a patient’s medicines when moving between services), discharge screening, and provided discharge medicine counselling. Patients were supported with QR code-linked video resources to assist with further understanding of their medicines after discharge.

We saw VTE risk assessments were completed before patients were sent for surgery, and where required people were prescribed appropriate preventative treatment. Clinical records had allergies status clearly documented, as well as regular post-operative pain reviews. Discharge letters communicated the surgery and post-operative plan clearly with GPs. We saw evidence the staff carried out post-operative phone call reviews 48 hours after discharge. These calls allowed staff to check how well the patients were and to identify and advise on any issues relating to their recovery.

Staff monitored medicine storage temperatures, but did not always take action when readings fell outside recommended ranges. This meant the service could not be fully assured medicines were consistently stored within safe temperature limits. The guidance on acceptable ambient temperatures was unclear, with conflicting information on the medicine policy and temperature record form. This was important as medicines stored outside recommended temperatures may have become ineffective or unsafe to use.