Chelsea and Westminster 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 people 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.

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.

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, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The service’s shared vision, strategy and culture was aligned with the West London Children’s Healthcare (WLCH) strategic objectives. These focused on delivering high quality care and experience, increasing equality in health outcomes and reducing barriers to collaboration.

The strategy was developed in 2019 in collaboration with children, young people and their families who used the service, staff and external partners. Its aims included improving equality of access and outcomes, integrating and standardising services, developing a sustainable workforce and making effective use of technology.

Staff described a strong team spirit and supportive culture, with line managers who promoted learning and improvement. When things went wrong, staff were involved in investigating and understanding what had happened and identifying improvements. Incident investigation reports were shared with staff through emails, meetings, safety huddles and the Risky Business Newsletter publication to facilitate learning. Managers and clinical educators also shared weekly improvement themes through bite‑size lunch time teaching sessions, which covered new NICE guidelines, shared learning from incidents and other developments within the trust. This approach kept staff well‑informed, able to learn from incidents and equipped them to make ongoing improvements to the safety and quality of care delivery.

Leaders recognised areas for improvement, including communication, discharge processes and staffing. Which they had addressed through staff training and development.

Leaders supported staff development and progression. We saw examples of staff working towards advanced clinical and non-clinical roles. Staff we spoke with gave examples of teaching and learning programmes and conferences they had attended as part of their continuous professional development.

The service displayed patient feedback and staff spoke positively about this. They said patient feedback was encouraging and felt their hard work was recognised by parents and families of children and young people.

Patients and families told us they knew who to contact if they had concerns. Staff said they felt safe approaching managers with concerns. Leaders told us the service structure supported effective engagement with teams to deliver the shared vision. This approach had led to improved outcomes, including bespoke solutions for complex discharges, improved teamwork, reduced delays and helped families experience smoother, safer and better‑coordinated care.

Staff were aware of the trust’s values of “Putting patients first, Responsive to patients and staff, Open and honest, Unfailingly kind, Determined to develop”, known as PROUD. These values were visible within the service, and staff understood how they aligned with the WLCH vision and strategy.

Leaders at all levels were inclusive and understood the context in which care, treatment and support were delivered. They reflected the values of the organisation and the culture of their teams. Leaders had the right skills, knowledge and experience to carry out their roles effectively, and they led with integrity, openness and honesty.

The service was overseen by capable, compassionate and inclusive leaders who had clearly defined roles and responsibilities. They demonstrated the experience and capacity needed to deliver safe, sustainable care and to manage risk well. This leadership approach supported safe, well organised services and had led to improved staff confidence.

Leadership roles were clearly set out across the service and at hospital level. The managing director held overall responsibility for children’s services and reported to the trust’s chief executive. The medical director, director of nursing and head of operations held clinical governance accountability for the service. This approach promoted a service that was well‑led, responsive and consistently focused on the child, young person and their family’s needs.

The children and young people’s leadership team oversaw key areas including quality and safety, research, operational delivery, finance and workforce, education, projects and digital services. They reported to the managing director, who in turn reported to the chief executive. This structure supported a coordinated and consistent approach to managing CYP services.

Leaders we spoke with understood the priorities and challenges facing the service, including staffing pressures. Staff told us leaders were visible and approachable, and patients and families also gave positive feedback about leadership presence.

The service promoted a culture where staff felt able to speak up and were confident, they would be listened to. Systems and processes were in place to support staff in raising concerns.

Freedom to Speak Up (FTSU) was managed at a corporate level to maintain independence. Staff had access to an in‑date FTSU policy, which explained how to raise concerns and what to expect. The policy encouraged staff to raise concerns even if they were unsure and outlined routes for internal and external reporting.

The trust had FTSU guardians and a network of speaking‑up champions. Staff were aware of these roles and told us they felt able to raise concerns without fear of reprisal. Staff gave examples of concerns they had raised, which were handled sensitively and resolved appropriately. There were no particular theme identified from concerns raised in children and young people’s services.

Patients and carers also had opportunities to provide feedback in ways that reflected their individual needs such as staying with their children on the ward, taken time out to manage their own affairs whilst their child was in hospital.

Managers and staff accessed feedback from patients, carers and staff and used it to support improvement. This was reflected in governance meeting records we reviewed which showed carers feedback and comments were incorporated in the children’s services strategies.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff knew and had access to the trust wide equality, diversity and inclusion (EDI) policy, through the trust’s intranet. The policy was in date and had a review by date which was not due. Staff received regular updates and guidance about the services diversity and inclusion strategy through the trust’s inclusion and wellbeing communications.

Staff told us the service promoted inclusive practice and reflected EDI principles in service delivery. Support mechanisms were available for staff with protected characteristics, including flexible working arrangements. We heard examples of flexible working to support caring responsibilities and health needs of staff.

The service valued diversity within its workforce and promoted an inclusive and fair culture. The trust had an EDI steering group that met monthly to address equality and inclusion issues. Staff and patients voice were noted and considered during the development of the trust’s EDI strategy.

Staff had access to staff networks, which provided safe spaces for discussion, peer support and raising awareness. The trust also marked cultural events, such as South Asian Heritage Month and Black History Month, which staff said supported inclusion and belonging.

All new starters completed EDI induction training, which covered inclusive behaviours, the protected characteristics under the Equality Act and professional boundaries.

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

Leaders had clear roles, responsibilities and systems of accountability that supported effective governance across the service. These arrangements ensured there was a structured and coordinated approach to overseeing safety, quality and operational performance. Leaders understood their individual and collective responsibilities, and the governance systems in place enabled them to monitor risks, review performance information and act where improvements were required. The clear lines of leadership accountability and responsibilities meant staff knew who was responsible for decision‑making, escalation and oversight, which strengthened the service’s ability to manage risk proactively and maintain high standards of care. This ensured leadership and governance supported consistent oversight, timely action on emerging issues and sustained improvements in the safety and quality of care delivery.

Staff at all levels understood their roles and had opportunities to review service performance through meetings and governance processes. The matron and clinical services leads were responsible for governance within the service, they reported to the managing director, who in turn reported to the chief executive of the trust. This reflected a clear and established line of accountability within the service’s governance structure.

A range of clinical audits monitored care quality and safety. Audits were completed in line with the audit schedule and documented appropriately. Leaders used audit outcomes, such as the hand hygiene, medication and personal protective equipment (PPE) to identify risks and areas for improvement.

Governance meetings covered key topics including staffing, infection control, health and safety, mandatory training and patient experience. The service had a clear governance framework that was supported by a structured programme of meetings, which provided effective oversight of safety, quality and operational performance. Minutes of governance meetings demonstrated that meetings were well attended and followed consistent agendas that covered key areas such as quality, safety, incidents, policy updates and changes in clinical practice. Leaders ensured that information from these meetings was disseminated to staff through established channels, including team meetings, email briefings and daily safety huddles. Safety huddles were used to identify and manage immediate risks and to ensure staff were aware of any emerging concerns. These governance arrangements provided leaders with a reliable oversight of risks, performance and quality, enabling timely action, consistent learning and safer, more effective care for children, young people and their families.

The trust had a risk management system and risk register. Risks were dated, tracked and monitored, with mitigating actions identified. Staff we spoke with were able to identify the main risks within the service and understood how these were being mitigated. The risk register was reviewed regularly, with clear ownership and actions allocated to responsible staff. Escalation plans were in place for specific risks or significant events, and staff understood how and when to escalate concerns. Leaders used clear performance measures to monitor and analyse service performance, and this informed decision‑making and improvement activity. These arrangements ensured risks were clearly understood, actively managed and escalated appropriately, enabling leaders and staff to maintain safe practice, respond quickly to emerging concerns and drive continuous improvements in the quality of care.

There were appropriate arrangements in place to ensure the availability, integrity and confidentiality of data. Records and data management systems supported accurate reporting, effective oversight and safe clinical practice.

The CYP service understood its responsibility to work in partnership with other organisations to support joined‑up care. Leaders shared information and learning with partners to improve services and strengthen collaborative working.

The CYP used the “15 Steps methodology” and peer‑review processes to gather feedback and shared learning across the service and with other local trusts. The service also hosted engagement events with partner organisations to involve children, young people and communities in shaping services. This strengthened understanding of lived experience and ensured service improvements reflected what mattered most to children, young people and families.

WLCH had established strong multi‑agency partnerships across Northwest London, including with acute providers, CAMHS, safeguarding teams and local authorities. These partnerships supported children and young people who did not fit into traditional service pathways by enabling joint work with local stakeholders to provide tailored and responsive support.

The service developed a multi‑agency pathway for children and young people under 18 who presented in crisis with mental health and/or social care needs. This pathway supported coordinated care and improved outcomes. This had a positive impact by ensuring timely, joined‑up responses across agencies, reducing delays in assessment and intervention, and improving the safety and experience of children and young people in crisis.

The CYP service supported children, young people and families to manage their health and wellbeing, maximise independence and make informed choices about their lives. The service aimed to reduce future healthcare needs through prevention, early intervention and education. This was demonstrated through active engagement in community initiatives, including a project at Chelsea Football Stadium attended by more than 250 children and their families. These initiatives promoted health awareness, strengthened community relationships and increased opportunities for early support.

The CYP service demonstrated a strong focus on continuous learning, innovation and improvement across the organisation and wider system. Leaders encouraged creative approaches to delivering equality of experience, outcomes and quality of life for children, young people and families. Staff were supported to reflect on both incidents and examples of good practice, and learning was used constructively to improve care rather than assign blame.

Staff were actively involved in research and innovation projects at local and national level. The service worked with external partners to support service development and embed evidence‑based practice. This collaborative approach strengthened the quality, safety and effectiveness of care. The CYP service had a joint patient‑experience lead working in partnership with the Mohn Centre. Their work was focused on understanding the lived experience of children and young people in an urban environment. The partnership strengthened the service’s insight into local needs and ensured that improvement activity was informed by the real experiences of children, young people and families.

The CYP service held a monthly “Team Brief”, an online forum attended by around 100 participants, which provided a structured platform for shared learning from incidents and communicated key updates. The service also delivered “Clinical Governance Half‑Day Study Days” on five occasions each year, these sessions brought together more than 100 CYP staff to review incident learning, hear about service improvements, and present audit findings within a coordinated governance framework.

The Children and Young People (CYP) service at Chelsea and Westminster Hospital was one of the first trusts to introduce Martha’s Rule. They set up Martha’s Rule escalation pathway that made sure all North West London (NWL) hospital sites could access paediatric intensive care (PICU) expertise for a second opinion. This was achieved by working differently and collaborating with other providers and local partners to deliver this service at no additional cost.