Chelsea and Westminster Hospital

Updated 7 August 2026

On 28 and 29 April 2026 we carried out an announced inspection at Chelsea and Westminster Hospital. This assessment looked at urgent and emergency care which we rated as outstanding, children and young people’s and end of life services which we rated as good. The ratings for these services has been combined with the ratings of the other services from our previous inspections. See our previous reports to get a full picture of all the other services at Chelsea and Westminster Hospital.

In our assessment of Urgent and Emergency Care, we found.

Staff had a strong and open safety culture. They reported and investigated incidents and used them to improve practice. Learning from incidents was shared through governance systems. This led to changes, including improvements to medication safety, escalation processes and communication. Safeguarding systems were effective, training compliance was high, and staff worked well with local partners to protect vulnerable people. Staffing levels were generally maintained. Environments were safe, and infection prevention and control processes were well embedded.

Care and treatment were delivered in line with national guidance and evidence-based practice. This was supported by a structured audit and quality improvement programme. Staff participated in national audits and used benchmarking data to improve services, including mental health care, frailty and time-critical medicines. Multidisciplinary working was strong. Staff worked effectively across teams and with specialty services, which supported positive outcomes.
Staff monitored outcomes using clinical data. Re-attendance rates were stable, and there was evidence of continuous improvement.

Staff treated people with kindness, compassion and respect. People reported positive experiences of care. People were involved in decisions about their treatment and were supported to understand their care and next steps. Staff adapted communication to meet individual needs and considered cultural, social and emotional factors. Staff focused on maintaining dignity and supporting vulnerable groups, including people with mental health needs.

Care was organised to meet the needs of the local population. Pathways supported different groups of people and helped maintain flow. Staff delivered personalised care through holistic assessment. They worked closely with other services to ensure coordinated care and timely discharge. People were able to provide feedback, which the service used to improve care. This included changes to communication, waiting time information and flow processes.

Systems supported equitable access to care, including reasonable adjustments and timely access to senior clinical review.

Leaders had a clear and shared vision. There was a positive and inclusive culture that promoted high-quality, person-centred care. Governance systems were well established. Leaders had clear oversight of risks, performance and quality through regular meetings and structured reporting. Staff were engaged, supported and encouraged to take part in quality improvement, learning and innovation. There was strong partnership working with system partners, and feedback from staff and people who used the service was used to drive improvement.

In our assessment of end of life services we found;

The service had a positive culture of safety based on openness and honesty. Staff investigated incidents and shared learning to promote good practice and continuous improvement. People were cared for in a safe environment and protected from avoidable harm.

Staff were qualified, skilled and experienced and had received relevant training in end of life care. People’s care and treatment were routinely monitored to continuously improve it. The service worked effectively across teams and services to support people and ensure continuity of care. The service understood people's rights around consent and respected these when delivering person-centred care and treatment.

Staff treated people with kindness, empathy and compassion. The service made reasonable adjustments for people with additional needs, including those with learning disabilities or communication needs.

The service made sure people were at the centre of their care and treatment choices. People could access care in ways that met their personal circumstances and protected equality characteristics.

Leaders were experienced, skilled and knowledgeable. They were inclusive and embodied the culture and values of their workforce and organisation. Leaders maintained oversight of risks and performance through established governance processes.

In our assessment of children and young people we found;

The service had appropriate staffing levels, and a suitable skill mix to deliver safe, high‑quality care. This was supported by extensive specialist input from NHS clinicians.

The service worked closely with patients and partners to maintain safe systems and ensure continuity of care. Staff understood how to report incidents, felt confident to raise concerns and described an open, no‑blame culture.

The service supported people to understand and manage risks in a holistic way. Equipment and technology were well maintained, and infection risks were consistently assessed, managed and controlled. Medicines and treatments were managed safely and were aligned with people’s needs and preferences.

The service provided care and treatment based on national guidance and evidence of effectiveness. National Institute for Health and Care Excellence (NICE) guidance was routinely discussed and reviewed at clinical governance and team meetings. Leaders told us NICE guidance was followed during pre‑assessment and throughout the care pathway. Staff used up‑to‑date policies to plan and deliver high‑quality care in line with best practice. The trust had a policy in place for implementing NICE guidance and quality standards.

Children, young people and their families were actively involved in pre‑operative assessments. Staff communicated clearly about risks, treatment options and expected outcomes. Assessment processes supported staff to identify and respond to individual health, wellbeing and communication needs. Families were encouraged and supported to be involved in their child’s care.

Leaders supported joined‑up team working. The service used clinical outcomes, audit findings and performance data to identify areas for improvement and develop action plans.

Children and young people were treated with kindness and compassion, and their privacy and dignity were respected. Staff understood that how children and young people were treated and supported was important. Children and young people were treated as individuals and given choice and control wherever possible.

The hospital took a comprehensive approach to supporting CYP staff wellbeing across all clinical areas. A range of staff initiatives were in place to support emotional resilience, boost morale, and reduce workplace stress. This included a monthly presentation shared across all sites, called the ‘Monthly Team Brief’, which provided updates on quality, safety and performance, while also celebrating successes. Most staff we spoke with felt that the team brief, along with governance awareness half days study sessions, supported staff to contribute to setting strategic priorities and shaping the service’s annual work plan.

Children, young people and their families were at the centre of decisions about care and treatment. Staff worked in partnership with families to respond to changing needs and ensure care was coordinated and person‑centred.

Leaders and staff demonstrated an understanding of the diverse needs of the local population. They used this information to identify and address inequalities and to deliver care that was joined up, flexible and responsive. Children and young people were also supported to plan for important life transitions, enabling informed decision‑making about their future care.

Leadership, management and governance arrangements supported the delivery of high-quality, person-centred care. The service was well managed and well led. Leaders promoted an open and fair culture that supported learning and innovation. Governance processes were effective in maintaining quality and safety.

The service followed the trust’s values of “Putting patients first”. Leaders encouraged staff to place children, young people and families at the centre of their practice. The service vision was “Healthier futures for all children and young people in North West London”. Leaders had the skills, knowledge and experience required to manage the service and deliver this vision. They valued diversity, encouraged innovation and worked closely with local communities.

Leaders contributed positively to people’s experiences of care through a clear vision and values. They demonstrated the ability to manage risk while supporting continuous improvement.

Leaders promoted an open and inclusive culture. Staff were encouraged to provide feedback and raise concerns. Regular team meetings, safety huddles, reflections and debriefs supported learning and improvement. The service had a quality assurance framework that supported policy compliance, audit activity and accreditation, helping to identify areas for development and maintain standards.

Updated 9 March 2026

The Chelsea and Westminster NHS Foundation Trust provides end of life care across two locations including Chelsea and Westminster Hospital. End of life care encompasses all care given to patients who are approaching the end of their life. It may be given on any ward or within any service in the trust.

The specialist palliative care team (SPCT) is responsible for overseeing the delivery and quality of end of life care services across the hospital. The team provides expert clinical leadership, and guidance for pain and symptom management. The SPCT included a palliative care consultant, 1 lead nurse, 4.45 whole time equivalent (WTE) specialist palliative care (SPC) clinical nurse specialist (CNS), 1 SPC speciality registrar and 1 foundation year 2 doctor. The team received SPC therapy support from oncology therapists.

We carried out an assessment of end-of-life care at Chelsea and Westminster Hospital on 28 and 29 April 2026 because the service had not been inspected since 2018.

Overall, we rated the service as good. We assessed all quality statements across the safe, effective, caring, responsive and well-led key questions. We rated all key questions as good.

We looked at 7 sets of patient clinical records; we spoke to 3 people using the service and relatives, and 22 members of staff. We visited wards where people were being cared for at the end of life.

At this assessment we found the service had a positive culture of safety based on openness and honesty. Staff investigated incidents and shared learning to promote good practice and continuous improvement. People were cared for in a safe environment and protected from avoidable harm.

Staff were qualified, skilled and experienced and had received relevant training in end of life care. People’s care and treatment were routinely monitored to continuously improve it. The service worked effectively across teams and services to support people and ensure continuity of care. The service understood people's rights around consent and respected these when delivering person-centred care and treatment.

Staff treated people with kindness, empathy and compassion. The service made reasonable adjustments for people with additional needs, including those with learning disabilities or communication needs.

The service made sure people were at the centre of their care and treatment choices. People could access care in ways that met their personal circumstances and protected equality characteristics.

Leaders were experienced, skilled and knowledgeable. They were inclusive and embodied the culture and values of their workforce and organisation. Leaders maintained oversight of risks and performance through established governance processes.

Updated 9 March 2026

Chelsea and Westminster Hospital children’s services are part of West London Children’s Healthcare (WLCH). WLCH provided services for children and young people at Chelsea and Westminster Hospital NHS Foundation Trust with the aim to improve patient experience, reduce health inequalities and improve outcomes for children and young people.

Chelsea and Westminster Hospital provided an extensive range of paediatric services, including specialist paediatric and neonatal surgery; a breadth of tertiary paediatric surgical and medical specialties including burns care; and specialist dental services focused on children and young people with additional needs such as autism.

WLCH also works with other acute NHS providers through the North West London Acute Provider Collaborative to develop shared service models, strengthen clinical networks and improve outcomes for children and young people across the region.

The hospital hosts many specialist services serving children and young people from across North West London, such as the regional endocrinology service which hosts the new Complications from Excess Weight (CEW) service, videofluoroscopy services and the Providing Assessment and Treatment for Children at Home (PATCH) service, which delivers specialist care in the community across North West London in partnership with the Acute Provider Collaborative.

The service demonstrated system leadership supporting multiple improvement projects including implementation of Martha’s Rule and NPEWs and a new torsion pathway that improved care for children and young people beyond its own organisation.

Children and young people were cared for across several wards. Neptune ward focused on oncology and adolescent care, alongside general paediatrics, and included safe spaces for children and young people with mental health needs. Mercury ward provided surgical and gastroenterological care. Apollo ward delivered high‑dependency unit care, and Mars ward provided level 2 HDU burns care. Saturn ward had a surgical lounge and recovery suite. The service also had a Paediatric Ambulatory Care Unit, which provided day‑case services and outpatient care.

Updated 9 March 2026

We undertook a comprehensive assessment of the urgent and emergency care service on 28 and 29 April 2026. The assessment was undertaken using our winter pressures assessment framework and we assessed 25 quality statements.

We rated the service as outstanding.

Staff had a strong and open safety culture. They reported and investigated incidents and used them to improve practice. Learning from incidents was shared through governance systems. This led to changes, including improvements to medication safety, escalation processes and communication. Safeguarding systems were effective, training compliance was high, and staff worked well with local partners to protect vulnerable people. Staffing levels were generally maintained. Environments were safe, and infection prevention and control processes were well embedded.

Care and treatment were delivered in line with national guidance and evidence-based practice. This was supported by a structured audit and quality improvement programme. Staff participated in national audits and used benchmarking data to improve services, including mental health care, frailty and time-critical medicines. Multidisciplinary working was strong. Staff worked effectively across teams and with specialty services, which supported positive outcomes.
Staff monitored outcomes using clinical data. Re-attendance rates were stable, and there was evidence of continuous improvement.

Staff treated people with kindness, compassion and respect. People reported positive experiences of care. People were involved in decisions about their treatment and were supported to understand their care and next steps. Staff adapted communication to meet individual needs and considered cultural, social and emotional factors. Staff focused on maintaining dignity and supporting vulnerable groups, including people with mental health needs.

Care was organised to meet the needs of the local population. Pathways supported different groups of people and helped maintain flow. Staff delivered personalised care through holistic assessment. They worked closely with other services to ensure coordinated care and timely discharge. People were able to provide feedback, which the service used to improve care. This included changes to communication, waiting time information and flow processes.

Systems supported equitable access to care, including reasonable adjustments and timely access to senior clinical review.

Leaders had a clear and shared vision. There was a positive and inclusive culture that promoted high-quality, person-centred care. Governance systems were well established. Leaders had clear oversight of risks, performance and quality through regular meetings and structured reporting. Staff were engaged, supported and encouraged to take part in quality improvement, learning and innovation. There was strong partnership working with system partners, and feedback from staff and people who used the service was used to drive improvement.

While the service did not meet the royal college of emergency medicine’s (RCEM) recommendation for a minimum ratio of emergency department (ED) whole-time equivalent (WTE) consultants per 4,000 attendances, ratios had improved since our last inspection. .

Updated 10 April 2018

Our rating of this service improved. We rated it it as good because:

• The Hospital made improvements in most of the areas above that we told them they must improve following the inspection in 2014.
• There had been a review of staffing requirements for level two patients in AAU, the call bell system had been refurbished, there was evidence of sharing of learning from incidents, and there was regular review of the risk register with appropriate mitigating actions being indicated.
• Overall, medicines were managed and stored appropriately across medical wards.
• Staff demonstrated knowledge of safeguarding processes and were able to effectively escalate safeguarding concerns.
• The senior divisional team used a ward accreditation scheme to monitor quality and safety performance in each inpatient ward. The results were used to identify areas of good practice and areas for improvement.
• Although staff vacancies remained a challenge for the service, ward managers and senior nurses actively addressed recruitment and retention using various initiatives.
• The work of the Hospital at night team mitigated the risk related to low junior doctor cover on medical wards at night.
• Staff provided care and treatment in line with national guidance and good practice. The service monitored the effectiveness of care and treatment through continuous local and national audits.
• Staff competencies were monitored by practice development nurses (PDNs) working within medical services who we found to be passionate and keen to improve the service.
• There was effective multidisciplinary team (MDT) working, which was embedded into practice in all the areas we inspected.
• Staff were knowledgeable about and demonstrated a good awareness of consent, mental capacity and the Mental Capacity Act (2005). This was evidenced in our conversations and from looking at patient records.
• Staff treated patients and their relatives with kindness, compassion, respect and dignity.
• Between September 2016 and August 2017, five of eight medical specialties performed better than the national average for referral to treatment within 18 weeks.
• There was a clear vision and strategy for the service and senior staff understood their responsibilities in carrying out the strategy.
• There had been an improvement in relation to staff engagement by senior teams. In 2014, we told the Hospital staff engagement needed to improve.
• Leadership and governance processes had been simplified and were clearly structured and this encouraged effective governance from board level to ward level.
• Risks identified on the risk register had appropriate actions to mitigate them and had been reviewed regularly. This meant the service had taken action in response to our 2014 recommendations.
• There had also been an improvement in relation to service leading being aware of the risk faced by staff and patients on the wards.

However:

• Similar to the findings in 2014, not all agency staff had access to the electronic patient records.
• Due to staff shortages, ambulatory emergency care (AEC) staff were not always able to follow up patients requiring urgent investigation or ongoing support following discharge from AAU.
• There was variable completion of mandatory training. For medical staff, the trust target of 90% was met in one out of eight training modules. For nursing staff the target was met in four out of nine modules.
• There was poor overall compliance with annual staff appraisals with only 64% of staff having been appraised from August 2016 to July 2017.
• From July 2016 to June 2017, the average length of stay for both medical elective and medical non-elective patients at Chelsea and Westminster Hospital was higher than the England average.
• From August 2016 to August 2017, the Hospital had 91 complaints which took an average of 49 days to investigate and close. This was not in line with their complaints policy, which states complaints should be closed within 25 working days. Eighteen complaints remained open at the time of the trust’s submission.
• Between September 2016 and August 2017 three of eight medical specialties performed worse than the national average for referral to treatment within 18 weeks.
• On some medical areas, staff said they did not feel they were part of the service, for example the diagnostic centre.
• Although the working culture was generally positive, some individuals said they did not feel supported by colleagues or senior staff on the wards.

Our findings reflect improvements in most of the areas we told the Hospital they must improve following the inspection in 2014. Although we found instances where staff had not managed or stored medicines safely or in line with the trust policy, overall there was appropriate medicines management across the medical service. Although we found that not all agency staff had access to electronic patient records, overall, our findings in relation to the safe domain were positive.

During our inspection, we spoke with 76 members of staff including health care assistants, doctors, nurses, allied health professionals and ancillary staff. Staff represented a range of roles and grades across all specialties and medical departments. We also spoke with the directorate leadership team, 34 patients and 15 relatives. We reviewed 23 electronic patient records, multiple paper records including bedside patient notes, 23 electronic prescription charts and various pieces of equipment. We also reviewed evidence sent to us before and after the inspection including minutes of meetings and audit results.

Updated 31 January 2020

Our rating of this service improved. We rated it as outstanding because:

• Staff understood the impact of patients’ care, treatment or condition to their wellbeing and those close to them. Patients we spoke to told us they felt staff were concerned not just about their clinical condition but also about their emotional, and social needs. Staff facilitated special activities and events for patient’s emotional well-being such as; weddings in the unit and taking patients to the on-site cinema. The service provided dedicated psychologist support to patients on the unit. Patients and those close to them were treated as active partners in the planning and delivering of their care and treatment. Patients and their families were given appropriate information and were encouraged to make decisions about their care and treatment. Staff understood the importance of family input and conducted regular feedback surveys for relatives. They used the findings to improve patient care and improve the service provided to patients’ families. Patients were treated and cared for with compassion, respect, and dignity. The service achieved high satisfaction rates from patients. We observed that staff had built a good rapport with patients and their families. Staff promoted patient dignity and privacy.
• There was a fully embedded and systematic approach to improvement, which made consistent use of improvement methodology. Improvement was the way to deal with performance and for the organisation to learn. Staff were empowered to lead and deliver change in care. There was a strong record of sharing work locally, nationally and internationally. Safe innovation was celebrated. There was a clear, systematic and proactive approach to seeking out and embedding new and more sustainable models of care.
• Managers across the service promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. The culture was positive with a primary focus on patient care and experience. The service had a vision for what it wanted to achieve and workable plans to turn it into action. Managers at all levels in the trust had the right skills and abilities to run the service. The department collected and used information well to support all its activities. The department engaged well with patients, staff, the public and local organisations. The service had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. The trust used a systematic approach to continually improve the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish.
• The service had enough nursing staff on duty to meet the needs of the patients. Staff had the right qualifications, skills, training, and experience to keep people safe from avoidable harm and to provide the right care and treatment. Staff understood how to protect patients from abuse. Staff adhered to infection prevention and control practices and they kept equipment and the premises clean. Staff completed and updated risk assessments for patients. Records were clear, up-to-date, and easily available to all staff providing care. The service followed best practice when prescribing, administering, and recording medicines. The service managed patient safety incidents well.
• The service provided care and treatment based on national guidance and was able to provide evidence of its effectiveness. Staff had access to up-to-date, accurate and comprehensive information on patients’ care and treatment. Staff gave patients enough food and drink to meet their needs and improve their health. Staff assessed and monitored patients regularly to see if they were in pain. Managers monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them. The service made sure staff were competent for their roles. Staff of different kinds worked together as a team to benefit patients. Staff understood their roles and responsibilities under the Mental Capacity Act 2005.
• The service planned and delivered care in a way that reflected the needs of the population of patients who accessed the service to ensure continuity of care. The needs and preferences of patients were considered when delivering and coordinating services, including those who were in vulnerable circumstances or had complex needs. People could access the service when they needed, and the service was committed to continual improvements regarding this.  Arrangements to admit, treat and discharge patients were in line with good practice. There were processes in place to ensure complaints were dealt with effectively.

However;

• There were not enough consultants within critical care areas during times of maximum capacity to meet the national standards which came into effect in June 2019. Night time resident cover did not meet national standards. Medical staff overall had the right qualifications, skills, training, and experience to keep people safe from avoidable harm and provide the right care and treatment.
• Health promotion information on the intensive care unit was limited
• The outreach team governance was not meeting best practice recommendations.

Updated 24 May 2023

Updated 10 April 2018

We rated it as good because:

• The department had improved how they managed incidents; there were clear processes in place for reporting and investigating incidents.
• Staff had a good awareness of safeguarding and knew how to protect patients from abuse. Staff understood how to escalate safeguarding concerns and report incidents. Learning was shared effectively about safeguarding.
• There was protection and support in place for women and children who had undergone female genital mutilation (FGM) or were considered to be at risk.
• There were clear infection control procedures and an infection prevention and control lead. Staff were aware of their responsibilities around preventing infection.
• There were clear protocols and procedures in place for assessing and responding to patients who became unwell in the department.
• The department was visibly clean and there were cleaning schedules in use which were fully completed.
• Medicines were managed safely and the Hospital audited their compliance with medicines procedures. Patients received the right medications at the right time.
• Staff had a good understanding of mental capacity, deprivation of liberty safeguards and consent.
• Patients we spoke with were universally positive about the care and treatment they received in the department.
• The department met patients’ needs through a wide range of services; there were plans in place to improve patient access to the service.
• Staff we spoke with were positive about the support they received from their managers and colleagues and there was good multidisciplinary team working.
• There was a positive working culture in the department, staff we observed were friendly and helpful and proud to work at the Hospital.
• We observed staff treating patients with kindness and compassion and there was emotional support in place.

However:

• Managers in the department felt that incidents were underreported by staff. Incidents were not reported promptly and we were not assured that learning was shared.
• There was limited auditing of the performance of the department.
• Failure to mitigate staffing shortages in ophthalmology had resulted in poor patient outcomes for patients undergoing injections for wet macular degeneration.
• The department was not compliant with all referral to treatment targets across the reporting period.
• There was limited evidence that people’s views and experiences were gathered and used to shape improvements to the department.

Updated 28 October 2014

There were effective procedures to support a safe and effective service for patients. Clinical standards were adhered to and patients were appropriately involved in research and drug trials. The environment at clinics was clean and uncluttered. The clinics at 56 Dean Street and Dean Street Express were trendy, modern and bright. One patient representative told us the team had brought “sexual health and HIV services into the 21 century”. Patients described the service offered at each of the clinics as “exceptional”, “caring”, “confidential” and “quick”. Staff were highly trained and were compassionate and caring. They treated patients with dignity and respect and “normalised” conversations about sexual health. Staff worked in a multidisciplinary way to centre care around the patient.

Each location had identified the demographic of the people using their service and provided speciality clinics, outreach, community engagement and counsellors suited to the people using the service. The team constantly explored new and innovative ways to deliver the service. National guidelines were being used and most patients could access services at one of the locations within 48 hours. The service reviewed its performance through patient surveys and the patient champions. There was clear governance and strong leadership and staff at all levels felt involved in decisions and ideas that could help the division and individual locations run well. The service was well-recognised at local and national levels.

Updated 10 April 2018

Our rating of this service improved. We rated it it as good because:

• The overall completion rate for mandatory training for nursing staff at the Hospital had improved since the last inspection from 72% to 87%. Work was ongoing to raise this to the trust target of 90%. Electronic (E) learning was used for the majority of mandatory training.
• Staff in the operating theatres and Treatment Centre followed the World Health Organisation (WHO) surgical safety checklist and five steps to safer surgery, and monitored this to make sure this was completed accurately.
• Observations and a review of documents confirmed a minimum of four hourly national early warning scores (NEWS) were carried out and recorded recording for all patients.
• Vacancy rates for nursing staff had improved. The Hospital reported an overall vacancy rate among nursing staff in surgery of 7% from August 2016 to July 2017. This was an improvement from the last inspection where the vacancy rate was 15%.
• Junior surgical doctors reported no current gaps in the on-call rota and they said that they were supported well by their senior colleagues.
• We saw improvements which showed that medicines were being stored securely. We also saw that tamper evident seals were in use for emergency medicines to ensure that they were readily available when needed and fit for use.
• Patients and staff now had access to safety thermometer information, as it was presented on the patient safety and staffing boards in each ward.
• The Practice Development Nurse (PDN) was heavily involved and engaged in developing new staff, and was particularly keen to impart high standards of documentation and care delivery. We saw that newly qualified staff were well supported by this process.
• Multi-disciplinary (MDT) working was evident, such as collaboration between occupational therapists, physiotherapists and pharmacists. Staff working in Decontamination Services showed outstanding MDT working with the surgical teams.
• We observed patients were looked after in a caring and professional manner. Most patients that we spoke with during this inspection were very complimentary about the level of care they had received.
• Psychological support was provided to patients where needed. For example the Burns Unit had five psychologists who were able to provide support to patients who had experienced a burns injury. This service also included their relatives.
• Patients scheduled for surgery had all been through pre-assessment and assessed by the anaesthetists to be fit for surgery.
• From July 2016 to June 2017 the average length of stay for all elective patients at Chelsea and Westminster Hospital was 3.1 days, which is better than the England average of 3.3 days.
• There were quiet facilities in the Hospital, which patients, relatives and staff could use in their personal time and space for reflection.
• Staff at ward level were able to corroborate senior management’s accounts of being regularly present and involved at ward level and we were told by a senior manager that the Chief Operating Officer was very visible both on and off the rota for working clinically.
• There were no individual strategies for each of the surgical specialities. However, we saw that the strategy for the surgical division was broadly linked to the trust’s three corporate strategies.
• There were ongoing plans to increase private patient working within the NHS framework, with a potential increase in the operating capacity.
• There was a transparent and open culture where staff escalated concerns, reported incidents and sought support from peers and seniors.

However,

• Access to mandatory training for nursing staff varied across wards and clinical areas with some staff having dedicated time to complete training whilst others having to undertake their training in their own time.
• We looked at a total of 11 patient records. There were a number of different ways in which staff were recording medical data at the time of our inspection. This had the potential to cause confusion, given the combination of written notes and online notes.
• We found issues with the monitoring of fridge and room temperature readings where medicines were being stored. Staff took minimum, current and maximum temperature readings each day however, we did not find evidence of action taken by staff when temperatures were found to be outside of the recommended range.
• The service did not meet national standards for care and treatment in key areas, such as length of Hospital stay and perioperative assessments.
• There remained some overlap in understanding of differences between mental capacity and mental health and this was mainly amongst junior nurses, though they were clearly aware of when and how to escalate to senior nurses.
• The service had not achieved its referral to treatment (RTT) target for general surgery, oral surgery, trauma and orthopaedics and urology. However, it was meeting the target for: ENT, ophthalmology, plastic surgery and cardiothoracic surgery.
• From August 2016 to August 2017 there were 160 complaints about surgery. The trust took an average of 57 working days to investigate and close complaints. This was not in line with the trust’s complaints policy, which states complaints should be completed within 25 working days. As of August 2017, there were 22 complaints still open and yet to be completed.