Chelsea and Westminster Hospital

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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 evidence showed that service leadership, management and governance assured ensured 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 changed to outstanding. This meant service leadership was exceptional and distinctive. Leaders and the service culture they created drove and improved 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 evidence showed an exceptional standard. The service had a very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities.

Leaders had developed and communicated a clear and coherent strategic vision for the emergency department that aligned with the wider emergency and integrated care (EIC) divisional strategy. Staff consistently understood the provider’s vision and values and described how these underpinned day-to-day practice and decision making.

The service operated using a structured strategic framework that set out clear priorities across four key ambition areas: prevention, quality, accessible care and recovery. These ambitions were supported by defined goals, key aims and measurable outcomes, which gave staff clarity on how high-quality, safe and effective care was delivered in practice.

The senior leadership team communicated the vision and strategic direction to frontline staff through a programme of engagement, communication and implementation activity. Staff reported that the strategy was developed through engagement and feedback and responded to emerging pressures such as increasing complexity, demand and health inequalities. This meant staff at all levels understood the purpose of the strategy, the challenges facing the service and the actions required.

Leaders had engaged with a range of partners, such as local groups and mental health partners, on specific elements of the strategy and utilised their feedback to ensure the vision and strategy met the needs of the local population and emerging pressures. For example, through the monthly meetings with the local ambulance service how any changes to services would impact on their partner and ensured that the 2 organisation’s strategy were aligned were necessary. The department had also worked with the urgent community response team to avoid admissions for patients wherever possible under an agreed standard operating procedure. This ensured services were delivered by the most appropriate team in the most appropriate environment for the patient.

During the design of the children’s waiting room and when the department are considering improvements to the service provided to children, they actively engaged with children and young people, who were key members of the design group. Ensuring the facilities and services meet their needs. The team have also engaged via community events with children and young people to obtain their experience of care, promote careers in health and also get their participation in research and health promotion.

The department not only engaged with local providers and patient groups to inform its vision and strategy, but they also employed patients with lived experience in the department. These individuals have helped design the mental health rooms, advised on the mental health pathway and conducted experience surveys with mental health patients who were receiving or had received care in the department. This feedback was used to inform practice and staff training.

Leaders established clear delivery frameworks and monitoring arrangements, including defined measures of success such as reductions in unplanned attendances and admissions, improved outcomes and enhanced experience for people using the service.

Staff had opportunities to contribute to the development and implementation of the service strategy, particularly during periods of change. Evidence showed that the divisional strategy was shaped through staff engagement and supported by ongoing initiatives such as division-wide engagement sessions, shared learning opportunities and structured planning cycles. The approach supported a culture of inclusion and collective ownership of the service’s direction. Staff were encouraged to and were involved in providing feedback and participate in quality improvement and service redesign.

Staff clearly explained how they delivered high-quality care in line with the provider’s vision and strategic ambitions. Staff described how they contributed to prevention by supporting initiatives such as GP redirect pathways, Pharmacy First and targeted programmes for people at risk of frequent attendance. They also showed how they supported integrated, multidisciplinary care through collaboration with community services and system partners.
Staff understood the importance of delivering accessible, person-centred care and promoting safe and timely discharge and linked their roles to wider organisational goals such as improving outcomes, reducing health inequalities and enhancing system flow. This showed the provider’s strategy was embedded in operational practice and applied consistently across the service.

The evidence showed an exceptional standard. The service had exceptionally 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 the skills, knowledge, experience and credibility to lead effectively. They always did so with integrity, openness and honesty.

Leaders in the service had the appropriate skills, knowledge and experience to perform their roles and provide effective oversight of the emergency department. They understood the operational and clinical challenges facing urgent and emergency care, including increasing demand, complexity and system pressures.

Leaders explained how services were structured and governed and how multidisciplinary teams worked together to deliver safe, high-quality care. This was supported by a comprehensive governance framework, including divisional and departmental governance meetings, clinical governance forums and mortality and morbidity reviews, which enabled leaders to maintain oversight of performance, quality and safety.

Leaders understood the services they managed and clearly described how teams delivered high-quality care aligned to organisational priorities. They explained how governance structures and regular multidisciplinary meetings supported quality improvement, shared learning and continuous service development.
For example, staff engagement in departmental clinical governance meetings, patient safety meetings and improvement forums supported the review of performance, monitoring of outcomes and improvement in care delivery.

Leaders also showed services were supported through structured teaching programmes and regular team meetings, which reinforced clinical standards and enabled staff to maintain and develop their skills.

Leaders were visible and approachable across the service. Staff reported that senior leaders, including the executive team, engaged with frontline teams through walkabouts, staff events and recognition initiatives. Leaders promoted open and inclusive communication through regular engagement activities, providing opportunities for staff to raise concerns, ask questions and contribute to service improvement.
This supported a positive culture where staff felt listened to and valued and where leaders understood day-to-day challenges within the service.

Leadership development opportunities were well established and accessible to staff at all levels, supporting the development of a sustainable and inclusive leadership pipeline. The provider offered a comprehensive range of programmes, including emerging leader development, management training, coaching and mentoring, and leadership apprenticeships at multiple levels.

There were also bespoke development opportunities for clinical leaders, including ward manager and matron development programmes, as well as targeted initiatives to support leaders from under-represented groups and promote cultural inclusion.
Staff were supported to access national leadership programmes and benefited from multidisciplinary learning opportunities, which strengthened leadership capability across the service.

Staff survey results reflected these approaches and showed sustained improvement in compassionate leadership, team working and line management over a five-year period, with scores consistently above the acute trust average. This showed leadership development, visibility and engagement had a positive impact on staff experience and the overall culture within the service.

The ED team worked collaborative with other teams in the trust to facilitate patient flow and share improvements. They attend and contribute to a range of cross site meetings including bed meetings and safety huddles, which provide an overview of the site’s activity, any specific issues that require senior decision-making input or areas that require additional support. The ED leadership team met regularly with the local ambulance service to review handover performance and areas they support each other to improve patient experience.

Staff from the department had worked with the trust’s HIV, Sexual Health and genitourinary medicine (GUM) team on blood borne virus testing. The department had implemented with the support of this team, an opt out of blood borne virus testing. This meant all patients were tested for blood borne virus unless they opted out. The evaluation of this initiative demonstrated positive results for patients who had not previously known their status. The team had worked closely with the HIV, Sexual Health and GUM team with engagement for the communities, providing appropriate follow up and support for these patients.

Following the department’s successful implementation of a cost improvement initiative aimed at reducing overall pathology expenditure, by reducing the number of coagulation tests performed through clearly defining when this should be completed, this had been rolled out in other parts of the trust. We saw the initiative had been implemented across acute medicine, ambulatory emergency care (AEC), and inpatient medical wards to support wider adoption of this cost-saving approach. Whilst this was a cost saving, it also supported green initiatives through the avoidance of unnecessary tests and consumables, minimised any impact on patients and reduced delays of waiting for unnecessary tests.

To address issues with violence and aggression to wards staff, a known issue in many EDs, the team have taken a proactive approach reviewing all incidents. They held weekly multi-disciplinary meeting with medical, nursing, mental health, a drug and alcohol worker and representatives from safeguarding to review all incidents submitted with violence and aggression to ensure appropriate action was taken post the incident. Each incident was assessed with the MDT team input reviewing physical and mental health needs and recreational substance use. The incident was assessed against the acceptable behaviour standards policy to establish if a behavioural letter should be sent to the patient or relative. The group also considered if further actions should be taken such as referral to the Police or safeguarding. Feedback was provided to staff post the incident highlighting the actions taken. This approach promoted a safer working and care environment. As a result of the success of this approach in the ED, this has now been rolled out to the medical wards in the hospital.

We saw evidence that learning from incidents, complaints, after action reviews (AARs) and patient safety investigations was routinely shared across specialties, divisions and with external partners to drive improvement at both departmental and organisational level. We saw that the review of recent AARs demonstrated a clear pattern of multidisciplinary working, shared ownership of safety issues, and the development of cross-divisional improvement actions. We saw several examples of learning flowing both from ED into the wider organisation and from other specialties into ED practice, creating a mutually reinforcing system of organisational learning. For example, shared organisational learning relating to procedural sedation. Following a significant medication incident involving the administration of high-strength ketamine within ED, the multidisciplinary AAR involved representatives from a range of teams including intensive care, pharmacy, anaesthetics, nursing leadership and clinical governance. The review identified wider organisational risks related to procedural sedation, medication preparation, communication and patient monitoring. The learning resulted in actions with trust-wide implications, including: the development of revised sedation guidance, development and implementation of sedation checklists, shared learning sessions involving medical and nursing staff and simulation training around medication handover. This demonstrated that ED learning was shared with the wider organisation, informed trust policy and practice through the trust’s governance structures. It also highlighted that the team considered a range of professional perspectives rather than just the departments views.

We also saw examples of the ED working not only with other specialities but with external providers to address complex patient safety issues. For example, the AAR relating to the transfer of a patient with an acute aortic dissection, a life-threatening medical emergency that occurs when a tear develops in the innermost layer of the aorta (the body's main artery). The review included representation not only from the department but from intensive care, anaesthetics, clinical governance, the cardiothoracic network and the regional transfer service. The review highlighted issues with inter-hospital transfer arrangements, escalation pathways, out of hours support and responsibilities for escorting patients. In response to the review a Northwest London referral pathway was developed and implemented, an ED aortic dissection guideline has been developed, there is now a joint ED and anaesthetic standard operating procedure and provision of increased transfer opportunity training for staff. This approach improved patient care and outcomes but also by working with external partners it supported learning beyond the trust contriving to safe, more integrated patient care across the wider healthcare system.

We noted from the examples provided that improvement actions were developed and delivered through shared ownership arrangements, reflecting patient care pathways. We saw that action plans often involved multiple specialties and services, and there were clear accountability and collective responsibility for the implementation and sustainability for improvements. This approach facilitated learning that resulted in change and strengthened the Trust's culture of patient safety, continuous learning and quality improvement.

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

The service promoted a culture where people, carers and staff were encouraged and supported to speak up and provide feedback. People and carers had opportunities to share their views on the care they received through a range of mechanisms, including formal feedback channels and routine engagement processes. These arrangements reflected an inclusive approach and enabled feedback to be provided in ways that met individual needs.

The FTSU policy outlined clear processes for capturing concerns, reviewing themes and identifying areas for action. Feedback was recognised as a key source of information to support improvement and was actively used to shape service delivery and people’s experience. Evidence from the freedom to speak up (FTSU) arrangements showed the organisation actively sought feedback and valued contributions from people, carers and staff to identify areas for improvement. Managers and staff had access to feedback from people, carers and staff and used this information to make improvements to the service.

Established mechanisms for monitoring and analysing feedback included regular reviews of data, themes and hotspots. This enabled the service to identify trends and take timely action. Learning from feedback was shared across teams and embedded into service improvement activity. There was a clear expectation that speaking up led to changes in practice and improved outcomes for people. Staff described how feedback, including concerns raised through speaking up processes, was used to shape improvements, with actions taken to address identified issues and prevent recurrence. This supported a culture of co-production, where the views and experiences of people and carers contributed to service design and quality improvement.

The provider had established clear and accessible routes for people, carers and staff to raise concerns and provide feedback directly to senior leaders and those with oversight responsibilities. The FTSU policy described multiple internal and external routes for speaking up, including escalation to senior leaders, non-executive oversight and external bodies where required. Staff spoke up through line management, specialist teams or directly to the FTSU Guardian and were supported to do so confidentially or anonymously if preferred.

Senior leaders received regular thematic reports on speaking up activity, with oversight by the executive board and designated non-executive leads. This ensured concerns were visible at the highest level of the organisation and appropriate action was taken.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

The evidence showed a good standard. 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 act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Leaders had established a clear and comprehensive governance framework that ensured essential information was routinely discussed at service, team and directorate level. Evidence from the governance meeting minutes reviewed, including the ED sub directorate meeting, the ED patient safety governance meeting and senior meeting minutes, showed standing agenda items included incidents, complaints, audit activity, feedback, workforce, performance and risk. This ensured learning from incidents, mortality reviews and complaints was consistently shared and discussed across multidisciplinary forums.

Formal terms of reference for the emergency department performance and improvement meetings supported that essential information was routinely discussed and defined standing agenda items such as performance, improvement plans and action tracking, ensured consistency and oversight across governance structures.

Staff showed they implemented recommendations from reviews of deaths, incidents and complaints. Patient safety and governance meeting records showed incidents were routinely reviewed, with identified themes such as pressure ulcers, access to care and medication errors discussed and actions progressed.

Learning from incident investigations and after-action reviews was documented, including changes such as adjustments to medication processes and escalation of concerns to senior forums. Actions were tracked through governance meetings and escalated to senior and sub-directorate meetings where required, which demonstrated learning informed service improvement and operational decision making.

Staff undertook local clinical audits and quality improvement activity, which provided assurance on the quality of care delivered. Audit activity included ongoing programmes such as sepsis, time critical medications, head injury and mental health care, as well as targeted audits linked to clinical priorities and emerging risks. Audit findings were regularly reviewed in governance meetings, and actions were taken to address identified gaps, such as development of new pathways and guidelines. Audit programmes were embedded into routine practice, with responsibilities allocated to medical staff and progress monitored through governance structures, which showed a systematic approach to continuous improvement.

Staff understood the arrangements for working with other teams both within the provider and externally to meet the needs of people using the service. Meeting records showed close working between emergency department teams, mental health services, community partners and system stakeholders. For example, escalation processes were in place for delays in mental health bed availability, and multidisciplinary approaches were used to support people with complex needs, including involvement of specialist teams and external providers. There was also evidence of collaborative working with system partners such as ambulance services to improve flow and reduce administrative burden, supporting more timely and coordinated care.

There were effective systems in place for the management of risk, issues and performance. The service maintained a comprehensive risk register, which clearly described key risks including demand pressures, violence and aggression, staffing levels and flow challenges. Risks were assigned ratings, reviewed regularly and supported by defined mitigation actions and governance oversight. Staff were aware of the key risks affecting the service and were able to escalate concerns through established governance forums.
Evidence from meeting minutes showed that risks discussed at department and team level, such as triage delays, staffing concerns and service capacity, were reflected on the risk register, which showed alignment between frontline concerns and organisational risk management processes.

The service had arrangements in place to respond to emergencies and operational pressures, including demand surges and seasonal variation. Risk register entries and governance discussions showed planning for increased demand, workforce pressures and system-wide challenges, supported by mitigation plans such as workforce planning, escalation processes and performance monitoring.

Financial oversight was also evident, with cost pressures and efficiency programmes regularly reviewed at sub-directorate level. No evidence showed cost improvement measures compromised care or patient safety. Decisions were made within governance frameworks that considered quality and safety alongside financial sustainability.

The service used systems to collect and review data from across the department to support performance management and improvement. Performance information, including operational metrics such as waiting times and flow, were routinely reviewed in senior meetings and performance forums.

Data was used to monitor trends, identify areas for improvement and inform service planning. Initiatives to improve digital integration, such as the transfer of ambulance data directly into the electronic patient record, showed efforts to reduce administrative burden and support more efficient working. These systems enabled staff to access timely and relevant data without unnecessary burden on frontline teams.

Staff had access to the equipment and information technology required to carry out their roles, and systems were in place to support information governance and confidentiality. The risk register included ongoing improvements to digital systems, including integration of point-of-care testing and electronic records, with appropriate controls in place to ensure clinical information was recorded, reviewed and stored securely.

Governance arrangements ensured information governance was maintained. Staff used electronic systems such as the electronic patient record system to support clinical decision making and continuity of care.

Managers had access to information to support them in their roles, including data on performance, staffing and quality of care. Governance meetings provided regular updates on key performance indicators, workforce metrics and service pressures, enabling leaders to make informed decisions.

Information was presented in a structured and accessible format, including dashboards and performance reports, and was used to identify areas for improvement and monitor progress. This supported effective oversight and ensured leaders had the information required to manage the service safely, effectively and sustainably.

The evidence showed an exceptional standard. The service clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for people. They always share information and learning with partners and collaborate for improvement.

Leaders in the service actively engaged with a wide range of external stakeholders to support the delivery of safe, effective and integrated urgent and emergency care services. The service worked collaboratively within the wider system through participation in the regional integrated care board’s urgent and emergency care delivery board, which provided a formal structure for partnership working across acute providers, commissioners, local authorities, mental health, community services and ambulance providers. This forum enabled joint oversight of system performance, shared decision making and coordinated responses to operational pressures.

The delivery board had a clear focus on collaboration across partners to identify priorities, reduce delays and improve outcomes, which showed strong engagement with system partners and commissioners at place and system level.

Leaders also showed effective partnership working with local authorities, public health teams and third-sector organisations to support population health and address wider determinants of health. For example, the service worked collaboratively through initiatives such as the hospital alcohol liaison service, which brought together hospital teams, local authority partners and community providers to deliver joined-up care and support continuity between hospital and community services.

Stakeholders from across health and social care organisations were involved in regular meetings to support service development, shared learning and coordinated care pathways. This showed a proactive approach to partnership working to improve outcomes and reduce avoidable attendance and admissions.

The service worked closely with local authority and community partners to deliver prevention-focused initiatives, including smokeless and tobacco dependency programmes. These arrangements included collaboration with integrated care system groups, local authority partnerships and community-based services to ensure people were supported beyond the hospital setting. There was evidence of strong system integration, with onward referral pathways into community services and alignment with local authority programmes.
This supported continuity of care and improved access to preventive interventions and showed effective engagement with external stakeholders and system partners.

People and staff had opportunities to engage directly with senior leaders and system partners to provide feedback and influence service development. Feedback mechanisms included structured patient experience programmes, where people’s feedback was collected, reviewed and shared with clinical and operational teams to inform improvement.
This ensured people’s voices were central to service development and learning was shared across internal and external partners.

In addition, the service participated in system-level forums and partnership boards, providing opportunities for staff and stakeholders to engage with senior leaders and commissioners, contribute to discussions on service delivery and influence decision making at organisational and system level.

The evidence showed an exceptional standard. The service had a strong focus on continuous learning, innovation and improvement across the organisation and local system. They always encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

Leaders had created an environment where staff were supported to develop and implement improvement ideas and innovation in practice. Staff were actively encouraged to lead quality improvement projects and participate in service development initiatives, with dedicated forums such as clinical governance days and quality improvement presentations enabling them to share learning and progress.

Evidence showed that staff-led improvement work, including projects focused on mental health pathways, care of older people and asthma management, had led to changes in care delivery, such as the introduction of new clinical proformas, pathway redesign and improved assessment processes. This showed staff were supported with time, structure and leadership to develop and embed improvements that enhanced care and safety.

Staff had opportunities to participate in research and innovation activity within the service. The service was engaged in innovation programmes, including the development and evaluation of new technologies such as artificial intelligence (AI) supported diagnostic pathways. For example, the introduction of an AI guided ultrasound pathway for suspected deep vein thrombosis (DVT) aimed to reduce unnecessary scanning, improve flow and minimise delays in care. This project included structured evaluation through audit and data collection, which showed research and innovation activity was embedded in clinical practice and aligned with improving outcomes and efficiency.

Innovation took place across the service, with a clear focus on improving pathways, experience and operational efficiency. Projects such as the AI-supported ultrasound pathway showed a forward-looking approach to service delivery, with potential to reduce unnecessary admissions, improve waiting times and deliver cost-effective care.
In addition, collaborative initiatives such as joint working with ambulance services through observership programmes supported shared learning and system-wide improvement.
These initiatives enabled staff to understand pathways across the system and develop solutions to improve coordination and outcomes.

Staff understood quality improvement methodology and how to apply it in practice. Quality improvement programmes were structured around recognised approaches, including data collection, benchmarking against standards and iterative testing of changes.
Staff participated in multiple quality improvement projects aligned to national programmes, such as those delivered through the royal college of emergency medicine (RCEM). These projects used defined standards, regular data submission and ongoing cycles of review to measure performance and drive improvement. This showed quality improvement was embedded within the service and staff had the skills and knowledge to apply these methods effectively.

Staff participated in national audits relevant to the service and used the findings to improve care. Evidence showed engagement in national quality improvement programmes, including audits on mental health care, care of older people and time critical medications. These audits enabled benchmarking against national standards and identified areas for improvement. For example, audit findings highlighted areas such as timeliness of assessment and documentation of risk assessments, which informed targeted interventions including new clinical tools, teaching and pathway redesign. This showed the service used national data to drive continuous improvement and improve outcomes.

Clinical areas within the service participated in structured clinical pathways and governance processes that supported continuous learning and improvement. Locally developed guidelines, such as those for the management of people with multiple rib fractures, were regularly reviewed and updated in line with emerging evidence and changes in practice. These guidelines were supported by audit and monitoring arrangements, including data sharing at regional peer review meetings. This enabled the service to benchmark performance and identify opportunities for improvement. This showed a commitment to maintaining high standards of care through continuous learning, audit and collaboration.