Chartwell 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

Leaders did not always demonstrate the skills and abilities to run the service. Leaders did not operate effective processes for governance, information management and the management of risk, issues and performance. Policies were generic and did not reflect up-to-date national guidance. The service did not have external relationships to support any innovation or service improvements. However, leaders had made improvements to the environment to ensure it was safe for patient use.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service did not have a clear vision for what it wanted to achieve. In the senior leadership team interview we asked what the vision and strategy was and we were told they wanted to improve the building structure following the flooding a few years ago and they were in discussions about becoming a clinical development centre. The clinical service manager told us they wanted to expand the endoscopy service to a two-treatment room and to get CT scanning started. However, the registered manager had no clear strategy in how to achieve this. Following the inspection the service provided a strategy document which was created after the inspection. Therefore, there were discrepancies in what we were told by the senior leadership team and what we saw on paper after the inspection. We could not be assured the values and strategy have been developed through a structured planning process in collaboration with people who use the service, staff and external partners. Staff were unaware of any vision or strategy. Therefore, could not understand how their role helps in achieving vision or strategy. Some of the staff members we spoke with did not speak positively about the culture of the service. We were told the leaders did not listen to feedback and when feedback was given it would take a long period of time to implement any change. Staff had concerns about the focus of leaders to learn and improve. The senior leaders told us the service could be better with two way communication as many informal conversations took place.

Service leaders were approachable and had appraisals and staff meetings, particularly for the endoscopy and reception teams, contributed to this supportive environment. In the 2024 staff survey for the whole hospital, 57% of staff agreed that they had regular meetings to discuss unit matters and other issues, 92% felt well-supported by the management team. Staff feedback included positive comments such as, "The clinical manager is very helpful," though one comment noted that the "Hospital manager sometimes needs to be more understanding." According to the 2024 staff survey, 85% of staff felt they received adequate support while working in their specialised area.

The management team reported that they have an open door policy and they engage with staff daily to monitor their well-being, which helps staff recognise and become familiar with the leadership team.

Staff knew who their speak up champion was and how to contact them if they wanted to raise concerns. Staff felt comfortable raising concerns if they needed to. However, staff we spoke with were not confident their voices would be heard. We did not see how staff were encouraged to raise their concerns. This was not physically promoted in the service. For example, we did not see any posters on the walls or in the staff areas.

The service is supported by a Speak Up champion, who fosters a culture of openness and transparency through an open-door policy. In the latest staff survey of the whole service 93% of staff said they were able to speak to their managers. 71% said their line manager listened and felt that staff suggestions, comments and ideas were welcomed and acted upon.

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.

During our inspection the senior leadership team (SLT) told us they used a risk database to update their risks onto the risk register. Staff were not clear about their roles and accountabilities as not all staff members would report and log concerns onto the risk register. The SLT told us it was not always at the forefront of staff members mind to prioritise entering the risk database. All staff spoke highly of the senior leaders and spoke of good teamwork. They commented on the friendliness and visibility of the senior leaders and that they felt able to approach them. However, we were told leaders did not always support staff to develop their skills and take on new roles. Staff told us the service did not undertake routine clinical and governance audits, which would allow the service to benchmark against other similar providers, and to identify changes that would improve the service based on information. The leadership team understood some of the issues, challenges and priorities faced by the service. For example, the building and clinical areas had been made safe by the service following a flood in April 2021. The service had made the necessary changes and had an action plan in place for the rest of the restoration work to take place. The registered manager was supported by the clinical manager and the executive assistant. The service had a risk register, but it was unclear if this was reviewed regularly as we did not see the risks mentioned within minutes of team meetings, action points and any improvement. Staff told us they did not see senior leaders such as the board of directors and owner, so they were unsure if their voices or feedback was heard at that level.

The service had a structured meeting schedule, including bi-monthly endoscopy meetings, quarterly meetings for the reception team, and semi-annual meetings for the Medical Advisory Committee (MAC). We were informed that many governance meetings had the same attendees, so the service consolidated these into a single Endoscopy User Group (EUG) meeting. We reviewed the senior management team meeting minutes from the past 12 months, which showed that the team met frequently. And leaders also maintained an incident and accident log in line with the hospital's adverse incident policy. However, there was no indication that incidents, new or emerging risks, or risks on the risk register were consistently reviewed, outcomes of audits were not discussed; raising concerns about the service’s oversight on risk and lack of accountability. According to the staff survey, 57% of employees indicated that regular staff meetings were held, providing a forum for staff to discuss unit matters and other issues. The board comprised five directors (including the owner and chief operating officer) and three non-executive directors. It met monthly to review minutes from the MAC and governance meetings, as well as the senior leadership team meetings and the hospital dashboard. Due to a service closure in 2021, attendance had reportedly been challenging. Attendees typically included the registered manager, the service owner, and finance representatives, with discussions covering staffing and estate issues, and a dedicated agenda item for risk management. Previously, the service was Joint Advisory Group (JAG) accredited; however, they were unable to provide evidence to maintain the accreditation standards. The service indicated their intent to reapply for JAG accreditation in 2024.

Leaders did not consistently collaborate with external stakeholders or agencies. While they worked with the Integrated Care Board (ICB) in 2023 to ensure safe conditions for lifting their suspension and resuming patient care, they did not partner with other key organizations to support service development. The service reported participating in local intelligence meetings and, following the inspection, provided minutes from the Controlled Drugs Local Intelligence Network meeting for Hertfordshire, West Essex, and Mid and South Essex in November 2023. However, the attendance list indicated that the service had not participated in this meeting, and they did not clarify why they shared these minutes or their relevance to the service.

The service did not have any collaborative working between any other organisations.

The service did not have any processes in place to collaborate or work in partnership with any external stakeholders or agencies.

Leaders did not have a good understanding of how to make improvements happen. Staff were not supported to develop their skills around improvement and innovation. Staff and leaders did not engage with external work, for example any participation in research or embedding evidence-based practice in the service.

The service did not have processes in place to ensure learning happens when things went wrong. Leaders did not encourage reflection or collective problem-solving.