Charing Cross Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last assessment we rated this key question requires improvement. At this assessment, the rating remained requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed. The service was in breach of legal regulation in relation to safe care and treatment.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had a positive culture of safety and learning. There was a no blame approach which empowered staff to report any issues without fear of negative consequences. Staff understood their responsibilities to raise and record safety incidents, concerns and near misses, and were encouraged to do so by senior leaders.

Staff reported incidents through an electronic system which could be accessed by all staff, including bank and agency staff. The service had reported 7 serious incidents for the previous 12 months . We saw all had been investigated, or were being investigated at the time of the assessment.

The service ensured that lessons were learned, and improvement was made when things went wrong. The service had a Patient Safety Incident Response Plan (PSIRP) in place, and Patient Safety Incident Investigations (PSII) were carried out according to the plan.

Staff received feedback on incidents they reported, and learning was shared through handovers, emails, and safety huddles. Learning from incidents was also part of the regular agenda at team meetings. We saw examples of how the service had implemented changes as a result of incidents. For example, we saw the introduction of additional teaching sessions for medical and nursing staff on unusual stroke symptoms following a serious incident. All staff we spoke with could articulate the complaints and compliments process and would proactively share this information with people. There were posters on the wards advising people how they could make a complaint if needed. The service had an up-to-date complaints policy in place. Patients and their families knew how they could raise a formal complaint if needed, all patients we spoke with told us they would not need to raise a formal complaint as any issues were resolved by the ward staff.

Staff understood the duty of candour. They were open and transparent and gave people and families a full explanation if and when things went wrong. The service had an up-to- date duty of candour policy in place and we saw formal duty of candour was provided when required.

The trust had a freedom to speak up guardian and policy in place, however only 1 of the 20 members of staff we spoke with knew what freedom to speak up was, or how to access the freedom to speak up guardian.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The trust had processes and policies to support staff to manage the discharge of patients safely. Plans and progress for patient discharges were discussed by the multidisciplinary staff teams (medical staff, nursing staff, therapists, and discharge coordinators) at board rounds, and these were clearly documented in patient’s electronic notes.

The hospital had a team of registered and unregistered staff who facilitated discharge pathways for patients with complex needs, including those requiring fast-track discharges, such as individuals at the end of life wishing to return home.

Trust-wide, there was a policy in place to support staff in safely managing patient flow through the hospital. Due to ongoing challenges with patient flow, staff reported that additional patients were sometimes cared for in areas designed to accommodate fewer patients. Although there were no additional patients on the wards at the time of the assessment, we saw these areas did not always have call bells available. Staff told us that when an additional patient was present, a member of staff remained within the patient area at all times to ensure patients could call for assistance if required.

Staff reported that the use of additional beds (“boarding”) only occurred between 9am and 3pm. We did not see any patients boarding on the wards visited during the time of our assessment. We saw that risk assessments were carried out for any patients who may require boarding to ensure their safety was maintained.

The trust had a standard operating procedure for boarding patients, which included strict exclusion criteria to ensure only appropriate patients were boarded, as well as the maximum number of additional patients a ward could safely care for. Staff reported these criteria were adhered to. We saw that privacy screens were available for any additional patients being cared for on the wards visited.

The service used an electronic patient notes system that was used across the wider trust. This meant staff could access a person’s previous notes when assessing a person and also allowed the service to instantly share notes with other services, such as a specialist department if requiring a specialist service review.

Electronic discharge summaries were provided to patient’s General Practitioners and care providers on discharge to inform them of the patient’s admission to hospital, medications, and any follow up care that may be required. Appropriate referrals to other specialities such as the fall’s clinic were completed prior to patients being discharged, and these were documented on the discharge summary. Patients were given a copy of their discharge summary and could also access this through the patient’s own individual access to their electronic record.

The computer system had an effective flagging system. We saw people with dementia, learning disabilities, autism, mental health conditions, and Parkinson’s disease flagged on the system. This alerted staff that these people may require additional support while in hospital and could be referred to the speciality team, such as the learning disabilities team or mental health outreach team. We saw patients had been appropriately referred to speciality teams such as the mental health team.

We scored the service as 1. The evidence showed significant shortfalls. The service did not always have adequate systems and processes in place to understand what being safe meant to people and healthcare partners. They did not always have appropriate training on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They did not always have adequate training or up to date policies to know when to appropriately share concerns.

Mechanisms to ensure systems, processes and practices to protect people from abuse and neglect were not always effective.

The trust had a Safeguarding Adults policy and a Safeguarding Children, Young People and unborn policy in place, and both policies were due for review March 2026. Both safeguarding policies outlined training requirements for staff, however the Safeguarding Adults policy referenced out of date guidance and had not been reviewed in line with updated 2024 intercollegiate guidance for Safeguarding Adults training. This meant that not all staff were trained to the level expected for their role in line with best practice.

Safeguarding adults and safeguarding children were included in the trust’s mandatory training programme; however, safeguarding adults training did not align with current guidelines. Staff groups that should have been trained to Level 3 in line with best practice had only been trained to Level 2.

Leaders told us that a senior clinical member of staff trained to Level 3 was available on site 24 hours a day to provide advice and support to staff, however training records showed that only 38% of eligible staff had received level 3 training. This meant that 62% of staff identified as being able to advise others were not trained to the level required.

96% of staff had completed Safeguarding Children’s training appropriate for their role, which was above the trust target of 90%.

All staff we spoke with were able to describe and explain how to recognise and report safeguarding concerns. The trust had a safeguarding team in place, and staff knew how to contact them for advice and support. Safeguarding referrals were completed appropriately, and potential safeguarding concerns were discussed during the daily ward board rounds.

The trust did not routinely offer dementia training to all staff. The trust had a dementia strategy in place, however it was due for renewal in 2024. The trust were working with an external body to develop a new strategy; however, the trust told us this would not be in place until 2026 and did not provide evidence to support this.

All staff were aware of how to recognise people with learning disabilities and autism and encouraged the use of individual care passports. These passports helped staff understand each person’s specific needs and how best to support them while in hospital. Staff were aware of the Equality Act and knew how to make a referral to the trust’s learning disability and autism team. Learning Disability and Autism training was part of mandatory training. 86% of all staff had completed the training, which was below the trust target of 90%. Leaders told us this was due to junior doctors starting at the beginning of August 2025 who had not yet completed the training.

The service had access to a Mental Health Outreach Team (MHOT) which was based at Charing Cross Hospital, who staff could contact for advice and support when caring for patients under the Mental Health Act or those requiring enhanced supervision to keep them safe. All staff we spoke with, including leaders and ward staff, knew who the MHOT were and how to contact them for support. The MHOT office was located on ward 8N, and staff told us they could access the team easily and received support whenever needed. They also reported that the MHOT provided bespoke training when required.

The service had an enhanced supervision policy in place. Enhanced supervision risk assessments were appropriately completed for all patients receiving enhanced supervision during the assessment. The MHOT would provide enhanced supervision. On occasion when this could not be provided due to staffing or the number of requests, ward staff were supported by the MHOT to ensure they had guidance and support to enable them to provide the enhanced supervision at times of gaps. Staff reported they found the guidance helpful and felt supported with providing enhanced care.

The trust reported they did not offer mental health act training as part of the mandatory training as staff had 24 hour support available from either the MHOT, or the clinical site practitioners. However only 71% of clinical site practitioners had received training on the Mental Health Act meaning not all staff available to provide advice and support had received the necessary training. All staff in the MHOT received mental health act training as part of their induction.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was supportive and enabled people to do the things that mattered to them.

Staff had access to policies and procedures to support them with assessing risk of harm and deterioration of patient’s conditions. Treatment escalation plans were used by staff to record and communicate patients personalised and realistic goals for treatment, particularly when their condition may deteriorate.

Staff used a nationally recognised tool to identify deteriorating patients and escalate their conditions to medical staff. The National Early Warning Score (NEWS2) was used in the service to identify patients at risk of deterioration. Our review of documents showed staff completed scores correctly. When a concerning score was calculated, the patient was escalated for medical review. Staff demonstrated a good understanding about the use of NEWS2 and when and how to escalate a deteriorating patient to medical staff.

Systems were in place for patients and their families, friends, or carers to escalate concerns about their conditions. The service had implemented ‘Martha’s rule’ of detecting deterioration enabled patients and their friends, family, or carers to contact the critical care outreach team if they felt their condition was getting worse and was not being addressed by the staff on the ward. Posters advertising this service were visible on the wards.

Staff completed risk assessments for each patient on admission using nationally recognised tools. This included a range of risk assessments, for example, falls, pressure areas, sepsis, nutrition, and venous thromboembolism (VTE). When actions or plans were required to reduce the level of risk, patient records showed these had been completed.

Staff communicated with patients and their families so that they understood their care and treatment, including finding effective ways to communicate with people with communication difficulties. For example, we saw posters for an available translation service for those people whose first language was not English, as well as hearing loop availability. All patients and families we spoke with told us they were involved with the decision making about their treatment. Patients and their families said the staff on the wards had been very helpful and explained things well.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The environment on 2 of the 3 wards visited was old and in need of refurbishment. For example, we saw 1 bathroom door had a missing vent, leaving a hole in the bottom of the door. On 2 of the wards, the bedspaces were cluttered when patients needed a lot of equipment alongside their personal belongings. This created a trip hazard and made it difficult for staff to access patients in case of emergency.

The trust had an ongoing refurbishment plan, and we saw 1 ward had recently been refurbished to a high standard, resulting in a fresh, spacious and welcoming environment. There were plans in place for the refurbishment of the 2 remaining wards

Staff had access to equipment and consumables they needed, however there was insufficient storage space for equipment and consumables, and expired consumables were found on all 3 wards.

Ward areas looked visibly clean, and we saw cleaning staff on all 3 wards visited during the assessment. Housekeeping staff had a daily and weekly rota of items to clean, and this was completed on the wards we saw.

Planned preventive maintenance and electrical appliance tests were completed annually and recorded centrally. We checked equipment and most had undergone electrical safety checks within the last 12 months.

The department’s fire safety equipment and emergency systems, such as call bells, were tested and maintained appropriately. There were systems in place to check emergency equipment daily; however, we saw that on some days these checks had not been completed. This meant that, in an emergency, equipment may not have been available or may have expired. Medical gases were stored securely.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service planned and regularly reviewed staffing levels and skill mix to ensure people received safe care and treatment. Leaders used recognised staffing tools to ensure that there was enough staff to deliver care and treatment and staffing was reviewed yearly.

Staffing charts were clearly displayed on all wards, showing both the planned and actual staffing levels. Overall, wards had the planned number of staff on the day of our assessment, however on 1 ward, an untrained member of staff was unexpectedly absent on the day of our visit. Managers acted appropriately when unanticipated absences occurred, transferring staff from other areas where necessary. We saw that where a staff absence had occurred another member of staff was moved to the ward to ensure all patients requiring one-to-one supervision had appropriate support in place.

The service had a medical staff vacancy rate of 8.5%, and a nursing staff vacancy rate of 6%, which was below the trust target of 10%. Leaders told us they used regular bank and agency staff to fill the staffing gaps while recruitment was being undertaken. This was evidence by a 91% shift fill rate meaning that the service was very rarely short staffed.

All staff we spoke with told us they enjoyed working at the service. The service had a low staff turnover rate of 5.7% which was below the trust target of 12%. The service had low sickness rates of 2.3% among medical staff, and 4.1% among nursing staff, which was in line with the trust target of 4%.

Bank and agency staff received induction to the service and told us they regularly worked at the service as their preferred temporary employer.

Staff had received and were up to date with appropriate mandatory training. Staff received training in conflict resolution; equality and diversity; fire safety; health and safety; infection prevention and control; information governance; moving and handling; learning disability and autism; safeguarding children and adults; and various levels of life support specific to their role.

We saw 93.8% of administrative staff, 94.9% of qualified nursing staff, and 94.8% of unqualified nursing staff completed mandatory training, which was above the trust target of 90%. 94.9% of consultants, and 100% of career grade doctors had completed mandatory training, however only 74.5% of training grade doctors had undertaken mandatory training. Leaders told us this was due to the training grade doctors only starting employment in August 2025, and that all training grade doctors had been booked on future training days. Agency staff received mandatory training through their agencies and told us their agency prevented them booking shifts if any training had not been completed.

All staff we spoke with told us they received yearly appraisals and found these valuable. Appraisal compliance for medical staff was 94.5%, and nursing staff was 100%, meeting the trust target of 95%.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

We observed most staff following infection, prevention and control (IPC) principles, including the use of personal protective equipment, effective handwashing and being bare below the elbows.

Patients who required to be cared for in isolation were able to have single rooms, however staff did not always manage infection control practices safely. We saw 4 doors to single rooms that should have been closed for isolation reasons left open, potentially exposing staff, patients and the public to risk of infection.

Staff had relevant training in infection prevention and control. Training compliance for all staff groups was above the trust target of 90%, except for the training grade doctors whose compliance rate was 67.6%. Leaders told us that this was due to their recent employment at the service, and that all training grade doctors had been booked on future training sessions. The trust had a designated infection, prevention and control lead and team that staff could contact for advice and support if required.

The service had daily equipment and cleaning checklists in place, but these were not consistently completed. However all equipment we saw was visibly clean, and ‘I am clean’ stickers were in use to show that equipment had been cleaned and was ready for use. We saw all equipment had been cleaned on the day of the visit.

Hand hygiene signage was displayed throughout wards. The service regularly audited hand hygiene and environmental cleanliness. The average hand hygiene audit score for the 12 months prior to the assessment was 68%, which was below the trust target of 75%. The worst performing month was November 2024 where the audit result was 47%. Following this result the service introduced an improvement programme, led by the IPC doctor, which led to continuous improvement, with the highest result being 83% in August 2025, and these high levels have since been maintained.

All waste was observed to have been segregated and managed appropriately

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

The service used an electronic prescribing system. Medicines were stored safely and appropriate records kept, including for controlled drugs, medicines requiring refrigeration and emergency medicines. Ward staff were able to access medicines from other wards if needed to reduce delays in administration. There was suitable storage and processes to enable patients to self-medicate where this was appropriate.

The pharmacy teams were available on the wards for clinical and medicines management support. Nurses were aware of time critical medicines and used the electronic patient record (EPR) system to flag patients with specific needs.

Medicines were stored securely within a locked treatment room. We saw that medicines trolleys in medical wards were kept locked when they were not in use. Patients told us they received their medicines regularly and received additional painkillers when or if they needed it.

We saw that people’s allergy status and weights were accurately documented on patient’s notes.

Trust policies for safe administration of medications were current and up to date. There was a supportive culture regarding reporting and learning lessons from medicines incidents. Regular audits supported safe care, for example on the administration of time critical medicines and improvements were made as a result of poor results. For example, earlier audits identified that fridge temperatures were not always recorded. Following targeted spot checks and ongoing audits, compliance improved significantly. During this assessment, all observed fridge temperature records were completed accurately.