Source · CQC inspection

Chelsea and Westminster Hospital

Type NHS Healthcare Organisation Region London Last inspected 24 May 2023

Overall rating: Outstanding View full CQC report

Domain ratings

Five CQC key questions

Safe

Good

Effective

Good

Caring

Outstanding

Responsive

Outstanding

Well-led

Good

Earlier inspection findings

pre-2024 framework · 3 must-do 6 should-do

Must-do actions (3)

Legal requirements based on regulation breaches identified during inspection.

Must-do action 1 of 3

Must do

Safe

The service must ensure that all daily safety checks are completed, and all equipment is in date, clean and ready for use.

Regulation: Regulation 12

⚠ Daily checks on equipment were not always completed, with some emergency trolleys not checked daily. In the Kensington private wing, daily checking compliance for resuscitaires was consistently below target (42–64%), and on the day of inspection, some equipment was dusty, out of date, and daily checks had not been taking …

Must-do action 2 of 3

Must do

Safe

The service must ensure that compliance with appropriate PPE in the maternity inpatients department improves.

Regulation: Regulation 12

⚠ PPE compliance was below the trust target rate in the maternity inpatients department, which consistently failed PPE audits with compliance results between 60-80%.

Must-do action 3 of 3

Must do

Safe

The service must ensure that all staff have the level of safeguarding training appropriate to their role, including doctors, and compliance with mandatory training targets improves.

Regulation: Regulation 12

⚠ Some specialist midwives were overdue their safeguarding training. Medical staff had lower rates of compliance with safeguarding training (50% for level 3 adult safeguarding, 81% for level 2 child safeguarding). Some modules of mandatory training, particularly basic life support, fire, and moving and handling, had lower compliance rates below the …

Should-do actions (6)

Recommended improvements to enhance service quality.

Should-do action 1 of 6

Should do

Well-led

The service should ensure all records within the maternity pathway are completed contemporaneously in line with professional standards, in particular: telephone consultations in the triage area. The service should ensure that antenatal documentation is completed including, but not limited to risk assessment and fetal wellbeing.

Regulation: Regulation 17.2

Should-do action 2 of 6

Should do

Safe

The service should ensure compliance with MEOWS chart completion improves.

Regulation: Regulation 17.2

Should-do action 3 of 6

Should do

Safe

The service should ensure recording and monitoring of maternity staffing ‘red flag’ events takes place.

Regulation: Regulation 12

Should-do action 4 of 6

Should do

Well-led

The service should ensure that incidents are harm-rated appropriately.

Regulation: Regulation 17.2; 20

Should-do action 5 of 6

Should do

Safe

The service should maintain safe storage of medicine in all areas including, but not limited to ensuring medicine is in date, medicine is stored at the recommended temperature and risk assessments are reviewed regularly.

Should-do action 6 of 6

Should do

Well-led

The service should take measures to provide all staff with an annual appraisal.