Chelsea and Westminster Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

At our last assessment we rated this key question good. At this assessment the rating has changed to outstanding. This meant people’s outcomes were consistently better than expected compared to similar services. People’s feedback described it as exceptional and distinctive.

We looked for evidence that people and communities had the best possible outcomes because their needs were assessed. We checked that people’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring people were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

We did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

The evidence showed an exceptional standard. The service always planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation. They worked to develop evidence-based good practice and standards.

People's physical, mental health and social needs were holistically assessed, and their care and treatment was delivered in line with legislation and evidence-based guidance, such as NICE to achieve effective outcome. All policies we reviewed reflected national guidance and evidence-based practice and were in date. All staff we spoke with knew could show us how to access the policies and reported that they had issues accessing these. We noted there was a process in place for considering new national guidance and where appropriate incorporating this into policies and guidance to ensure they reflected the most up to date information.

Staff took part in a structured programme of clinical audit, benchmarking and quality improvement initiatives, including national royal college of emergency medicine (RCEM) quality improvement programmes and locally led audits. The service had an established and structured audit programme with clear governance arrangements. Audit topics were based on local risk and national priorities, and findings drove improvement. We were provided with several examples including care of older people and provision of mental health care in the ED audits that had resulted in improvement opportunities being identified and implemented to provide the quality of care provided to these groups of patients.

Audit outcomes were reviewed through formal clinical governance and audit meetings, and actions were tracked through a quality improvement programme tracker to embed and sustain learning. The tracker contained detailed interventions, outcomes and plans for how they monitor improvement.

Staff took part in national benchmarking, including RCEM audits on time critical medications, care of older people and mental health care. This enabled comparison with national performance and helped identify gaps and target improvement actions. There was evidence of sustained quality improvement activity. For example: audit and quality improvement work to improve the management of time critical medications showed sustained improvement over time, with improved identification of people and increased staff awareness supported by prompts, teaching and system changes. There was evidence the trust consistently remained a top performer nationally, successfully meeting the operational goal of admitting, transferring, or discharging patients within 4 hours. Performance reports showed compliance rates of 78% to 81.8%, making it one of the few trusts to achieve full-year regional national targets

The mental health quality improvement programme demonstrated performance above national averages for timely triage and parallel assessment, with continued work to improve documentation and risk assessment. The care of older people programme monitored frailty screening, delirium assessment and safety rounds. Staff used targeted actions such as electronic prompts, teaching and pathway redesign to improve compliance.

The service worked collaboratively with specialist staff to meet people’s needs. The multidisciplinary team included doctors and nurses, with access to pharmacy teams. Emergency department staff and pharmacy teams worked together to support safer medicines management, including improving the management of time-critical medicines.

Staff also worked with mental health practitioners to provide parallel assessment for people presenting with mental health needs, ensuring timely specialist input alongside emergency care. This ensured people presenting with mental health need were seen, triaged and treatment commenced in a timely manner.

Collaborative working extended to other specialties and services, including frailty services and specialty teams. Staff used pathways to support holistic assessment and management of vulnerable groups, including older people.

Staff were experienced, qualified and had the appropriate skills and knowledge to meet the needs of the people they served. There was a strong focus on education and training to support evidence-based care. Staff received regular teaching aligned to audit findings and national guidance.

Managers supported staff development through induction, ongoing education and access to training programmes. Staff received a structured induction. Teaching formed part of induction and ongoing departmental education, including daily training sessions to ensure competence in key clinical areas.

Staff were supported to maintain and develop their skills through quality improvement activity, teaching sessions and participation in audit cycles. For example, teaching and clinical guidance were introduced following audit findings in areas such as imaging practice, falls risk assessment and emergency care pathways which improved consistency and compliance with evidence-based standards.

Managers provided staff with opportunities for supervision and professional development. Staff had access to regular clinical governance meetings, audit meetings and multidisciplinary forums to reflect on practice, review outcomes and share learning.

Managers monitored staff performance through structured governance processes and acted on findings from audits and feedback to improve practice. Where areas for development were identified, managers provided targeted teaching, supervision and system changes to address gaps in knowledge or performance.

Managers ensured that staff had access to regular team meetings and governance forums. These provided opportunities to discuss audit outcomes, share learning and review progress against improvement plans, supporting continuous professional development and service improvement.

Managers identified the learning needs of staff and provided opportunities to develop skills and knowledge. This included targeted teaching sessions, development of clinical guidelines, prompts within electronic systems and ongoing quality improvement programmes.

Managers addressed areas of poor performance through structured audit and governance processes, ensuring that improvement actions were implemented and monitored over time. The service took a proactive and sustained approach to improving staff performance and clinical practice through ongoing review, feedback and re-audit. However, staff did not always assess and meet people’s needs for food and drink well, including those requiring specialist nutrition and hydration. People did not usually stay in the department for long periods, food and hot drinks were available, the department did not have a dedicated staff member to provide food and drinks, and nurses did not always have time to offer food and drinks.

The evidence showed an exceptional standard. The service always worked well across teams and services to support people. They shared thorough assessments of people’s needs when they moved between different services, so people only needed to tell their story once.

Staff, teams and services worked effectively together to deliver coordinated care and treatment. There were effective board rounds, safety huddles and interactions between emergency department (ED) and specialty teams, which demonstrated collaborative decision-making.

Clear pathways supported joint working between the ED and specialty teams. Staff understood their roles and responsibilities when caring for people awaiting review or transfer. The ED retained clinical oversight until responsibility was formally transferred, so people were monitored and deterioration was identified and acted on promptly.

Referral processes were supported by clear documentation, established escalation routes and the use of electronic systems. This enabled timely specialty input and reduced delays in care.

Multidisciplinary team working was embedded across the department. Staff worked collaboratively across medical, nursing and allied health professionals, as well as in-reach services including mental health and frailty. Staff described working relationships as positive and constructive, with shared accountability for outcomes.

Specialty teams assessed people promptly in line with local expectations, and there were agreed processes to manage disputes, clarify responsibilities and escalate concerns. This supported consistent decision-making and ensured people received timely and appropriate care.

There were effective systems to support communication and coordination within the department and across the wider health and care system.

Staff demonstrated awareness of system pressures, including demand and capacity across acute and community services, and understood how to escalate concerns through operational processes.

Board rounds, safety huddles and multidisciplinary discussions were used to review flow and coordinate care, Supporting effective prioritisation and timely decision-making. Pathways such as acute frailty services were used appropriately to avoid unnecessary admissions and support flow.

Electronic patient records showed that responsibility for care was clearly documented, including timely specialty review, escalation and handover processes. Discharge and transfer processes were well managed, with arrangements in place to ensure continuity of care. Discharge summaries were generally completed in a timely way and included clear information for people and primary care services to support ongoing management. However, some discharge summaries were completed at the end of shifts. This was raised with the service, who provided assurance that work had been completed to improve timeliness. The impact this could have on patients would be if they represented to the department again before they had been discharged from the system from their first attendance. This would delay them being triaged and admitted to the system again.

Staff shared relevant clinical information when people were transferred between services or organisations. This supported safe and coordinated transitions between services.

People using the service said care felt coordinated and that they understood their care pathway and discharge arrangements.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

The service had effective systems to monitor and improve outcomes. There was a clear quality improvement approach, supported by the routine use of performance metrics, audit findings and clinical outcome data to identify areas for improvement and track progress over time.

Re-attendance rates within seven days were monitored as a key indicator of quality and effectiveness across urgent and emergency care pathways. Data showed that overall emergency department re-attendance rates remained stable, consistently ranging between approximately 10% and 11% over the reporting period, with a cumulative rate of around 10.6%. This showed consistent performance with no significant unexplained variation and indicated that people generally received effective initial assessment and treatment.

Leaders used outcome data to understand variations between groups of people and to inform improvement work. For example, paediatric re-attendance rates were consistently higher than adult rates, averaging approximately 13.9% compared with 9.9% for adults. Staff were aware of this variation and used this information alongside wider quality intelligence, including incidents, complaints and people’s feedback, to identify themes and implement targeted improvements. For example staff developed alternative care pathways and community-based models to support ongoing care and reduce avoidable re-attendances.

Monitoring across both the emergency department and the wider urgent and emergency care system showed alignment in re-attendance rates, demonstrating a coordinated system-wide approach to improving outcomes.

Staff used recognised clinical tools to improve the detection and response to deterioration, supporting safety and improving outcomes. Standardised early warning systems, such as the national early warning score (NEWS) and paediatric early warning tools (PEWS), were embedded in practice to support consistent assessment and escalation of deteriorating people to support consistent assessment and escalation.

Staff monitored observations regularly and used these tools to inform timely escalation and clinical decision-making. This ensured that deterioration was identified promptly and people received appropriate interventions, contributing to improved clinical outcomes. However, we did raise a concern with the service regarding oversight of people who might deteriorate whilst waiting in the waiting room, there were areas of the waiting room where people could not be seen easily, and no clinical staff were based in the waiting room observing people waiting.

Technology was used effectively to support monitoring of outcomes and delivery of care. Staff had timely access to diagnostic systems, including electronic reporting of blood test results and imaging, enabling prompt clinical decision-making and reducing delays in treatment.

Digital systems also supported the monitoring of key performance indicators, enabling teams to review trends in people’s outcomes, including re-attendance rates, flow metrics and clinical indicators. This enabled leaders and staff to respond proactively to emerging risks and improve the quality and effectiveness of the service.

The evidence showed an exceptional standard. The service always carefully explained to people what their rights around consent were, making sure they fully understood them and always fully respected these when delivering person-centred care and treatment.

The service went out of its way to ensure that people were meaningfully involved in decisions about their care and treatment. Resulting in people feeling listened to, valued and fully involved.

Staff followed clear processes to ensure that people were supported to make their own decisions about care and treatment wherever possible. The service had a comprehensive, organisation-wide consent framework which stated that all people had a fundamental legal right to determine what happened to their own bodies and that valid consent must be obtained for all care, from routine interventions to complex procedures. Staff we spoke with were all knowledgeable about the framework and told us they used it consistently.

We observed consent being assessed with compassion and respect. Staff understood that consent was an ongoing process rather than a one-off event and ensured people were given sufficient, clear and timely information about proposed treatments, including risks, benefits and alternatives. Staff provided information in appropriate formats and encouraged people to ask questions and express what mattered to them. Staff responded to questions in an open manner and provided honest, personalised explanations about all aspects of their care.

Staff understood that people could withdraw consent at any time and ensured this was respected and documented. Staff took all possible steps to enable people to make their own decisions in line with the Mental Capacity Act 2005.

People received information that is fully tailored to their individual needs, cultures and presented in a way that they could fully understand and engage with. People were presumed to have capacity unless assessed otherwise, and clinicians provided all appropriate support to enable decision-making, including adjusting communication methods and allowing sufficient time for consideration.

Staff recognised that making an unwise decision did not indicate a lack of capacity and ensured that people’s autonomy was respected. This supported individualised care and shared decision-making, with people at the centre of decisions about their treatment.

For people who might have impaired mental capacity, staff assessed and recorded capacity to consent appropriately. Capacity assessments were completed using a structured, two-stage approach and were undertaken at the time the decision was required.

Staff understood that capacity was both decision-specific and time-specific, and they assessed each significant decision individually. The service required that assessments considered the person’s ability to understand, retain, weigh information and communicate their decision. All assessments and outcomes were documented in line with national guidance and service policy, ensuring transparency and legal compliance.

Where people lacked capacity, staff made decisions in the person’s best interests. Staff followed the principles of the Mental Capacity Act 2005 and considered the least restrictive option. Best interest decisions included consultation with people important to the person, such as family members, carers or those with legal authority, including a lasting power of attorney or court-appointed deputy.

We noted staff took a culturally sensitive approach to obtaining consent that enabled people, their families and carers to fully understand their rights and play an active, empowered role in decisions about their care. Staff considered the person’s wishes, feelings, beliefs and values, including any previously expressed preferences or advance decisions. Decisions and the rationale were clearly documented, including any differing views. This ensured care was person-centred and ethically sound.

Staff were fully invested in supporting people to make informed and proactive decisions about their care, including on advance care planning. The service had robust systems to support complex decision-making in relation to life-sustaining treatment. Policies relating to cardiopulmonary resuscitation and treatment escalation planning required staff to involve people in decisions wherever they had capacity, and to consult appropriately where they did not. Staff documented discussions and reviewed decisions regularly. This demonstrated that decisions about consent, including those at the end of life, were made in a transparent, lawful and person-centred way.