Hendon Hospital

On this page

• 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 patients 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 good. At this assessment the rating has remained good. This meant patients’ needs were met through good organisation and delivery.

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 and strategy, supported by a culture based on transparency, equality, inclusion and engagement.

The service had a vision for what it wanted to achieve. The vision was sustainable growth through clinical excellence, operational resilience, and patient trust. The vision was centred on transitioning into a facility undertaking more complex procedures, including hip and knee replacements, with an expansion of the gynaecological service offerings. This vision reflected the overarching provider aims and objectives.

Leaders told us the strategy was in the process of being redeveloped, which aimed to focus on high quality, safe and compassionate care to patients. Leaders told us they had held patient participation groups, to involve patients in helping co-design the strategy. The service also held various engagement events with staff and community services to co-design the strategy, including GPs.

Staff were focused on the needs of patients receiving care. The service had an open culture where patients, their families and carers as well as staff could raise concerns without fear.

Staff felt respected, supported and valued. Staff reported that the leadership culture was inclusive and how they felt valued and respected. Relationships between staff of all grades were positive, with strong teamwork and collaboration. Staff felt motivated about the future and planned changes for the service.

The service had leaders 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 and understood the impact their behaviours and leadership had on patient outcomes and experience.

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 a range of experience, skills and abilities to run the service, and they understood and managed the priorities and issues the service faced. Leaders were visible and approachable in the service for patients and staff. Staff at all levels felt the leaders supported them to develop their skills and competencies and take on more senior roles. This was achieved by having in place a structured induction and shadowing programme for staff, and this enabled staff competencies to be signed off.

Leaders had taken incidents seriously and knew how to deal with concerns when raised, which promoted a positive culture in the service. Leaders attend the wards and departments to assess for themselves how the service was running.

Staff achievement and success was recognised and celebrated. Staff were thanked for their work by patients and colleagues, in the form of patient satisfaction surveys and online reviews used for both positive and constructive feedback.

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

Staff and leaders acted with openness, honesty and transparency. Staff were encouraged to raise concerns and offer ideas; the culture allowed staff to be confident their voices were heard. For example, leaders and managers encouraged staff to raise concerns in 1:1 meetings. Staff told us when they had raised valid concerns or felt they would be able to, were or would be supported, without fear of detriment.

The service had a dedicated Freedom to Speak Up Guardian and whistleblowing lead who staff could contact if they had any concerns they needed to raise. Staff we spoke with in theatres and wards were aware of who the Freedom to Speak Up lead was at the service, and we saw on display on staff noticeboards details of the Freedom to Speak Up Guardian and how staff could contact them.

The service had an up-to-date Freedom to Speak Up policy. This policy applied to all individuals working at the service and outlined some of the concerns that staff could raise, in addition to the escalation process for staff to raise concerns. This included an external escalation process, if staff who raised concerns felt these were not being appropriately addressed within the service. The policy included details of timescales and feedback from the investigation of concerns, while also reaffirming protection for staff speaking up and being treated fairly and without prejudice.

Patients, their families and carers were provided with information to explain how they could raise a concern and how this would be investigated. Senior staff on ward areas were encouraged to respond to immediate concerns or complaints with a view to resolution. There were policies to support the complaints process. Staff had regular meetings to discuss feedback from patients and identified learning and actions from feedback received.

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

The service promoted equality and diversity in daily work and provided opportunities for career development. Leaders acted to improve where there were any disparities in the experience of staff with protected equality characteristics. Leaders took steps to remove bias from practices to ensure equality of opportunity and experience for the workforce within their place of work, and throughout their employment. The service had a diverse workforce, and the workforce was representative of the local population.

Staff told us they had opportunities to apply for project work, new roles and to undertake external studies. Staff were given opportunities to enrol for apprenticeships, so they could develop new skills, gain valuable qualifications and grow their careers with CHG. We saw this information displayed on staff noticeboards, with details of further information on how staff could enrol for the apprenticeships. Leaders told us that approximately 15-16% of staff carried out apprenticeships, for their learning and development.

The service acted to prevent and address bullying and harassment at all levels and for all staff. Staff felt everyone was treated fairly and that they would be able to report behaviour or attitudes which were negative in style.

The service had clear responsibilities, roles, systems of accountability and good governance. Staff used these to manage and deliver good quality, sustainable care, treatment and support. Staff responded to information about risk, performance and outcomes, and shared this with others when appropriate.

Staff at all levels were clear about their roles and accountabilities. Staff had job descriptions, and these set out expectations and responsibilities. Where senior staff had designated tasks related to audit and monitoring quality of services, they understood what was required of them. Staff could find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements. The information systems were integrated and secure.

The service had plans to cope with unexpected events and had a business continuity plan, which included major incident plans. The service had not reported any data breaches and systems were secure. Patient identifiable information was handled correctly.

We reviewed several service level and provider policies and found these were up to date and readily available to staff. There was leadership oversight of the accuracy and validity of each policy.

The service had a risk register, which had risks assigned to staff from different roles to action and which had clearly stated the owners of each risk and the likelihood and impact of each risk, along with actions taken to keep oversight and manage mitigations. Staff contributed to decision-making to help improve sustainability and improve quality of care. The risk register included the dates the risks were added to the register, the dates the risks were last reviewed, and the target dates for completion of each risk. The top 3 risks identified were the risk of delayed emergency responses resulting from patient call bells not working due to an inoperative nurse/emergency call bell system, video laryngoscopes used in theatres being at the end of the life cycle (equipment used for intubation and placing a breathing tube for airway assessment), and risk of fire spread due to lack of fire compartmentation. Leaders we spoke to told us they were taking action to address the risks, including patient call bells being replaced with a new system due to come into effect imminently, new equipment for video laryngoscopes being replaced soon, and current controls in place to manage risk of fire occurring, such as all fire pagers being tested daily to ensure that they are in good working order and departmental daily checks of fire exits.

The service had a provider-wide governance and assurance framework, which was in date. The framework contained the terms of reference for various committees including the audit and risk committee which met at least 3 times a year, the Clinical Governance Committee which met monthly, and other committees such as the Financial Governance and Health and Safety Committees. We reviewed Clinical Governance Committee meeting minutes and saw performance data was reported into the clinical governance committee and displayed on hospital performance boards. This included incident reporting data such as patient falls and surgical complications. The data was analysed and compared within the provider organisation and where improvements were needed at the location level, action plans were developed to make this happen. The service reviewed all complaints, feedback and compliments monthly in the Clinical Governance Committees. This information was analysed for trends and learning, and used to improve patient safety, experience, and service quality. This ensured that learning was derived and improvements were made from each complaint. The service therefore operated effective governance processes through various committees and on-site activities. Governance processes provided leaders with oversight of service performance, risks and actions required to improve quality.

There was a Medical Advisory Committee led by a chair and supported by the service leadership, which included approval of applications from doctors who applied to work at the service under practicing privileges and review of clinical outcomes of individual doctors. Leaders told us there was an interview process which these applicants had to undertake, and the necessary Disclosure and Barring Service (DBS) and indemnity checks were carried out. If there were any concerns with performance, there were processes to follow and if necessary, information would be shared with other professional bodies as required.

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.

Staff and leaders at the service collaborated with relevant external stakeholders and agencies to improve care and treatment for patients using the service. For example, the service had regular meetings with the Integrated Care Board (ICB) and covered topics such as service quality updates and performance. This included an overview of rescheduled and cancelled operations due to clinical issues on the day and learning from incidents at all the CHG sites located within the ICB. Staff and leaders were open and transparent with all relevant external stakeholders and agencies.

The service had an engagement team called the ‘Heart Hendon engagement and response team’. This team met monthly rotating between different departments, and they gathered patient feedback looking at themes and complaints. Current work being done included plans to make the wards more dementia-friendly, where the service liaised with other organisations to make improvements to the wards for patients who had dementia.

Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. We saw evidence of this through patient feedback systems, online reviews, surveys, and discussions recorded in clinical governance meetings. We reviewed clinical governance meeting minutes, which included discussions on positive and negative feedback from patients and consideration given to improvements that could be made. The minutes contained a section dedicated specifically to patient experience and feedback. The leadership team viewed all patient feedback as a way of driving forward improvement within the service.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of delivering equality of experience, outcome and quality of life for patient. Staff actively contribute to safe, effective practice and research.

Staff were committed to continually learning and improving services. There was a provider-wide quality improvement (QI) programme to enhance patient clinical outcomes, reduce adverse events, achieve financial efficiencies, and enhance organisational performance. Leaders had a system in place to drive QI at a service level via the clinical teams, using staff development and a system to capture, record and report improvement initiatives. Leaders planned to develop the QI skills of staff to support a culture of improvement by implementing in-house introductory training available for all staff in basic QI methodology and use of tools (e-learning and workshops). Advanced training was available to staff via access to external courses for identified individuals, for example quality and risk managers, QI ambassadors and governance and improvement team members. The service had opportunities for networking via regular forums, annual conferences and national improvement awards.

At a local level, the service was in the process of completing the Quality, Service Improvement and Redesign Virtual Course (scheduled for completion in September 2026). This was an online programme which built health and care staff’s skills in quality and service improvement. At the time of our assessment, the team was working through the full qualification, demonstrating strong engagement with structured QI methodology and continuous improvement principles. There was a dedicated local QI team, where there was capability to lead, support, and sustain improvement initiatives both locally and in alignment with national priorities. Local QI projects included improving patient satisfaction to 90% and a reduction in cancelled operations, where both of these projects were in progress. Staff were therefore supported to have the time to develop their skills around improvement and innovation and to pursue areas of interest in the service. Leaders encouraged innovation and participation in research.