Orpington Endoscopy Centre

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• 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

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has remained good.

This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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 clear vision and strategy, and leaders had communicated this effectively to most staff. Staff understood the service priorities and could describe how their work contributed to delivering safe, high-quality care.

The provider’s strategy focused on developing the standalone endoscopy service while maintaining quality standards, improving patient experience, increasing activity and strengthening referral routes. Priorities included operational improvement, governance, consultant engagement and digital development.

We observed that staff across different roles were able to describe the key priorities for the service and how these aligned with organisational objectives. Administrative staff told us the main priorities were patient safety, providing excellent care and maintaining key performance indicators. Clinical leaders identified priorities including ensuring staff competency, supporting staff wellbeing, maintaining regulatory compliance and continuing quality improvement activities. Frontline staff also recognised activity growth and staffing as current service priorities.
Leaders communicated the organisation’s vision and priorities through quarterly strategy meetings, board updates and bi-monthly network meetings. Staff could contribute to discussions about service development through these forums and local meetings.

The 2026 staff survey showed the Orpington service group scored 6.30 for understanding the organisation’s vision and values, compared with the organisational average of 5.98.

Although staff generally understood local priorities and how their work supported service objectives, not all staff were able to clearly articulate the wider organisational vision when asked. However, this did not affect staff's understanding of their role in delivering safe, effective and patient-centred care, and we observed staff consistently demonstrating behaviours that aligned with the provider's values and priorities.

Leaders had the knowledge and experience required for their roles and understood the service’s operational risks, workforce challenges, governance requirements and development priorities.

Leaders described priorities relating to staffing, activity, staff competence, patient safety, regulatory compliance and quality improvement. Governance meetings, audits, incident reporting and competency frameworks were used to monitor quality and safety.

Leaders used competency assessments, quality dashboards, after-action reviews and training programmes to oversee service delivery. They were also monitoring digital pre-assessment pathways, patient experience improvements and preparations for Joint Advisory Group accreditation.

Staff described managers as visible, approachable and available to respond to concerns. Leadership arrangements included daily presence in the service, 1-to-1 meetings, an open-door approach and staff meetings covering performance, governance, workforce issues, patient feedback, training and service developments.

Staff said managers listened to them, supported wellbeing and encouraged involvement in service improvement. They could access development opportunities and speaking-up arrangements and reported that they could raise concerns without fear of repercussions.

The 2026 staff survey showed higher scores for the Orpington service group than the organisational average for line-manager support, at 9.04 compared with 7.66; valuing staff opinions, at 9.04 compared with 7.48; regular feedback, at 8.39 compared with 6.75; and open and honest discussions, at 9.00 compared with 7.38.

The provider offered accredited Institute of Leadership programmes at levels 3 and 5 for junior, middle and senior managers. The programmes covered leadership, coaching, strategy, organisational culture, equality, diversity and inclusion, change management and business improvement, and required participants to complete workplace improvement projects.Succession planning included leadership training and internal progression opportunities, with examples of staff moving into new roles and undertaking leadership development.

Leaders monitored competencies, protected time for assessments, mandatory training and role-specific development. Training compliance was reported at 98%, and workforce development needs were reviewed through staff meetings.

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

Staff said they felt able to raise concerns and challenge poor practice. They described managers as accessible and reported that concerns were taken seriously without fear of repercussions.

The provider’s whistleblowing policy set out escalation routes, access to the Freedom to Speak Up (FTSU) Guardian and protections against victimisation or detriment.

FTSU arrangements included 1 Guardian and 6 champions across the organisation. Guardians also contributed to staff induction to raise awareness of speaking-up routes.

Data provided by the provider showed since July 2025, 12 issues had been raised and staff had been supported to resolve concerns.

The service work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The provider had an Equality, Diversity and Inclusion (EDI) Committee, supported by a network of champions. Policies and training addressed EDI and discrimination. Staff could also raise related concerns through EDI Champions or FTSU arrangements.

Staff could request flexible working and reasonable adjustments. Managers described supporting individual needs relating to appointments, professional development and personal circumstances. The equality and diversity policy set out arrangements for discussing and implementing workplace adjustments for staff with disabilities.

The provider used workforce equality data and staff survey findings within its governance arrangements to identify inclusion priorities and inform action plans. However, they did not provide workforce EDI data showing the percentage representation of staff groups. We therefore could not assess workforce diversity or identify whether any groups were under-represented.

The service had clear roles, responsibilities, accountability and governance arrangements. These supported the delivery of good-quality, sustainable care and the effective management of risk, performance and outcomes. Relevant information was shared securely with appropriate partners.

Although Orpington Endoscopy Solutions Limited was the registered provider for this location, a number of policies, leadership functions and governance arrangements were provided through corporate and organisational support from a hospital and its satellite sites. Local governance information from Orpington Endoscopy Centre was escalated through these wider organisational structures, including satellite governance, quality and governance committee, and Medical Advisory Committee (MAC) meetings.

The service had a governance framework at local and organisational levels. Endoscopy user group, satellite governance, quality and governance committee, and MAC meetings reviewed incidents, complaints, audits, risks, training compliance, patient experience, quality indicators and regulatory updates. Information was routinely monitored and shared to support patient safety and improvement.

The MAC provided quarterly oversight of the Orpington Endoscopy Service and satellite sites. It reviewed information from specialty groups, governance committees and service leads, including incidents, complaints, transfers, consultant performance, quality indicators and learning. Membership included senior leaders, registered managers, specialty leads and a patient representative.

Incidents, complaints and transfers were reviewed through established governance structures, with learning shared and actions monitored. Improvements included changes to communication, patient administration systems and clinical pathways. Complaints involving consultants were reviewed through the MAC and specialty meetings.
The audit programme included consent, medicines management, infection prevention and control, clinical documentation, hand hygiene, WHO checklist compliance and consultant performance using NED data. Findings were reviewed through governance meetings and informed improvement activity.

The service worked with pathology providers, local NHS trusts, governance teams, the MAC and specialist partners. Governance arrangements supported referral pathways, escalation and collaborative working.

The service maintained an active risk register, covering staffing, infrastructure, environmental and operational risks. Staff understood escalation processes, and actions were monitored through local and organisational governance arrangements.

Consultant performance and practising privileges were overseen through specialty lead and MAC review, annual appraisal and performance monitoring. Where concerns arose, actions could include enhanced oversight, mentoring, retraining, restrictions or removal of practising privileges.

Leaders used quality dashboards, governance reports and risk management systems to monitor performance, staffing, patient experience, incidents, complaints and training compliance. Provider data showed high compliance across key quality indicators.

Emergency and business continuity arrangements covered deteriorating patients, emergency transfers, disaster recovery and service continuity. Sustainability, activity and workforce risks were monitored through governance processes. We found no evidence that cost improvement measures had adversely affected patient care.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The service engaged with a range of external stakeholders, including local GP practices, consultants, NHS organisations and health insurers. Leaders described ongoing work to strengthen referral pathways, promote local services and develop relationships across primary and secondary care. Community engagement activities included attendance at local events and engagement with GP practices to increase awareness of available services.

The service had a formal partnership with a local gut clinic, which supported local access to specialist gastroenterology services. Clear governance arrangements were in place, including practising privileges agreements, regulatory requirements and defined responsibilities to support safe and effective care delivery.

Patients and staff had opportunities to provide feedback through organisational forums, staff engagement meetings and service feedback mechanisms. Leaders described bi-monthly network meetings where staff could share ideas and contribute to service developments, and patient feedback was used to inform improvements to care and patient experience.

The service had a culture of continuous learning and improvement. Staff were supported to participate in quality improvement initiatives, learning from audits and accreditation processes was embedded into practice, and innovation was being used to improve patient experience and service delivery.

Staff participated in quality improvement through governance groups, audits and service development projects. The service also contributed to the Patient Safety Incident Response Framework Safe Surgery Project, which examined incidents and risks and shared learning across clinical services.

Audit findings informed improvements to consent processes, patient information and documentation. Actions included reviewing information leaflets, peer review, observational audits and competency assessments. Provider data showed high compliance with two-stage consent, provision of patient information and recording of risks and benefits.

The service introduced a digital pre-assessment platform that enabled patients to complete questionnaires remotely and supported clinical review before procedures. Assisted digital support was available for patients who needed help to use the system.

Staff accessed professional development and national learning opportunities, including the British Society of Gastroenterology annual conference.

The service participated in endoscopy accreditation and was working towards Joint Advisory Group (JAG) re-accreditation at the time of this assessment. Audits, competency assessments, quality indicators and governance reviews supported accreditation requirements and informed practice. Learning was shared through governance and quality improvement processes.

Although there was no evidence of formal participation in clinical research studies, staff were actively involved in quality improvement, service redesign and innovation projects that contributed to improvements in patient care and operational effectiveness.