Wexham Park Hospital

Updated 28 August 2025

Date of assessment: 11 to 12 March 2025. Wexham Park Hospital provides a range of NHS hospital services. This assessment looked at urgent and emergency care and medical care including older people's care. We rated urgent and emergency services as good. We rated medical care as outstanding. The rating has been combined with ratings of the other services from the last inspections. See our previous reports to get a full picture of all other services at Wexham Park Hospital. The rating of Wexham Park Hospital improved to outstanding.

In our assessment of urgent and emergency care services we found there were processes to manage patient risk. There was a positive learning safety culture where events were investigated and learning was shared and embedded. The service planned and delivered people's care and treatment in line with legislation and current evidence-based good practice and standards. The service treated people with kindness, empathy and compassion, however people's privacy and dignity was sometimes compromised due to high capacity. The service made sure people were at the centre of their care and treatment choices. However, due to flow challenges, people did not always have access to care when they needed it. Leaders ran services effectively using best practice systems and supported staff to develop their skills.

In our assessment of medical care services we found the service had a proactive and positive culture of safety. Staff delivered good care and treatment following evidence-based practice and people had good outcomes. The service was exceptional at treating people with kindness, empathy and compassion and respected people's privacy and dignity. Staff treated colleagues from other organisations with respect. People could access care and treatment when they needed it. The leadership embodied the culture and values of their workforce and empowered staff to lead changes.

Updated 18 February 2025

On Tuesday 11 and Wednesday 12 March 2025 we carried out an inspection at Wexham Park Hospital. This inspection was part of our System Pressure Programme where we inspected Medical Care and the Emergency Department (ED). This report relates to the medical and older people's medicine directorates at Wexham Park Hospital. The directorates consist of around 26 wards and departments. We went to most of these areas. We spoke with 17 patients and two relatives/carers

We reviewed ten adult patient records. We spoke with more than 50 staff which included: consultants, resident doctors, nurses, senior leaders, healthcare assistants, administration staff, housekeeping staff and volunteers.

We assessed 24 quality statements across the safe, effective, caring, responsive and well-led key questions and we have combined the scores for these areas with scores from the last inspection to give the rating.

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. There were sufficient staff who listened to people's safety and individual needs. Systems and processes were in place to review the safety of care provided.

When the hospital was busy, leaders reviewed staffing levels to meet the needs of their patients. Staff delivered good care and treatment following evidence-based practice and people had good outcomes. The service monitored care outcomes and sought to improve, even when meeting national benchmarks.

The service was exceptional at treating people with kindness, empathy and compassion and in how they respected people's privacy and dignity. Staff always treated colleagues from other organisations with kindness and respect. The service was exceptional in how they listened to and understood people's needs, views and wishes. Staff responded to people's needs in the moment and acted to minimise any discomfort, concern or distress. The service always cared about and promoted the wellbeing of their staff and was exceptional at supporting and enabling staff to always deliver person-centred care.

People could access care and treatment when they needed it in a variety of ways. The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs. The service was aware of system pressures and sought to develop services that met the changing needs of patients.

The department and staff were well-led by strong leaders who embodied the cultures and values of their workforce. There was improved governance and risk management, and a positive culture. The service worked well with others in the Integrated Care Board to meet the needs of people. They empowered staff to lead change and improve the quality of service to patients.

Updated 18 February 2025

Date of assessment: 11 March - 12 March 2025

This inspection was part of the commissions system pathway pressure programme where we inspected medical care and urgent and emergency care (UEC) services.

The urgent and emergency service was outstanding at the last inspection, we assessed 24 quality statements across the safe, effective, caring, responsive and well-led key questions. We have combined the scores for these areas with scores from the last inspection to give the rating. We believe the quality of care has remained the same, meaning the rating has not changed.

At this assessment, we found that the urgent and emergency care service had a positive learning safety culture based on openness and honestly, where events were investigated, and learning was shared and embedded to promote good practice and continuous improvement. There were established safe systems of care in which safety was monitored and assured. There were processes to manage patient risk. Staff assessed risks to patients, acted on them and kept good care records. Staff had effective and embedded understanding in how to protect patients from abuse. The environment was safe and well maintained, equipment, facilities and technology supported the delivery of safe care. The service practiced high standards of infection prevention and control. There were enough qualified, skilled and experienced people, who received effective support, supervision and development. They worked together effectively to provide safe care. Medicine management was safe and met people's needs.

We found the service planned and delivered people's care and treatment in line with legislation and current evidence-based good practice and standards. The service worked effectively across teams and services to support people. Electronic systems were used successfully to share patient's assessment of needs when they moved between different services. People's care and treatment was routinely monitored to continuously improve it. The ensured outcomes were positive and consistent, and that they meet both clinical expectations and the expectations of people themselves. The service understood people's rights around consent and respected these when delivering person-centred care and treatment.

We found the service always treated people with kindness, empathy and compassion. However, people's privacy and dignity was sometimes compromised when demand out grew capacity of the department. People's needs were listened to and staff responded to minimise any discomfort, concern or distress. The service greatly cared about and promoted the wellbeing of staff. Staff were supported to enable them to always deliver safe and quality care for patients.

We found the service made sure people were at the centre of their care and treatment choices and decided, in partnership with them, how to respond to any relevant changes in their needs. The service provided appropriate, accurate and up-to-date information in formats tailored to individual needs. The service had systems and processes in place to make sure everyone could access the care, support and treatment they needed when they needed it. However, due to challenges with flow in the hospital patients did not always have access to care and treatment when they needed it and experienced long waits and overcrowding.

We found that leaders ran services effectively using best practice systems and supported staff to develop their skills. Staff understood the service's vision and values, and these were fully embedded in their working practices. Staff were motivated to provide the best care they could for their patients. There was a shared purpose on improving the quality and sustainability of care and people's experiences. Staff were proud to work at the service, there was strong collaborative team working and staff felt respected, supported and valued. Staff at all levels were clear about their roles and accountabilities. Leaders operated effective governance processes and used innovative approaches to drive and improve the delivery of high-quality person-centred care. The service engaged well with patients, staff and the local community to plan and manage services. Strategies and plans fully aligned with plans for the wider health economy and leaders demonstrated commitment to system-wide collaboration.

Updated 2 February 2016

Overall we rated services for children and young people at Wexham Park Hospital 'Good' because:

The treatment and care needs of children and infants were assessed and planned from referral to discharge, taking into account their individual needs. The health and wellbeing of children, young people and infants was monitored using recognised assessment tools. Arrangements were in place for looking after vulnerable children. Staff responded compassionately when children and young people needed help and supported them to meet their basic personal needs as and when required.

Children said that the staff were kind and caring and that they received information that helped them understand what treatment and care they were receiving. Staff helped children and young people and those close to them to cope emotionally with their care and treatment. Comprehensive safeguarding policies and procedures were in place. This included referral pathways for children’s safeguarding. The service had systems in place to ensure that incidents were reported and investigated appropriately.

Children and young people’s services were well-led by a very enthusiastic and committed staff team. The leadership, governance and culture promoted the delivery of high quality child-centred care. There was a clear statement of vision and values, driven by quality and safety, with defined objectives. Staff were aware of best practice guidance for the safe and effective care of children and infants. The service had experienced nursing staff shortages, but were actively recruiting nurses by advertising the vacancies.

Updated 2 February 2016

Overall we rated the critical care unit (CCU) at Wexham Park Hospital as 'Outstanding' this was because:

We found significant areas of good practice through our review of clinical audits, staff training, patient notes, clinical outcomes and other indicators such as an exemplary programme to promote independence and person-centred care. Leadership in the unit was coherent, robust and respected by staff. This leadership contributed to a team that continually challenged existing practice to identify new and improved ways of working. Innovation was very much part of the culture in the unit and staff spoke positively about the development opportunities available to them as a result.

Clinical practice was benchmarked against national guidance from organisations such as the National Institute for Health and Care Excellence (NICE), the Royal College of Physicians and the Intensive Care Society (ICS). Such guidance was embedded into the work culture and staff used it to evaluate and improve their practice. For example, an extensive programme of audits was used to update policies and procedures. Staff contributed to national audits compiled by the Intensive Care National Audit and Research Centre (ICNARC). They then used the national audit results alongside local studies to inform the planning of staff study days. The CCU team had access to multidisciplinary specialists who contributed to decision-making and ward rounds to ensure best care for patients. An established critical care outreach team supported patients across the hospital and provided bereavement and emotional support.

The CCU appeared clean, hygienic and well maintained. Staff demonstrated good infection control practices but there was room for improvement in some areas of housekeeping. Equipment was serviced regularly and staff were competent in its use with regular training updates. We found one area of non-compliance with the trust’s medication management policy but there were safeguards in place to ensure that this would not affect patient safety.

A robust incident reporting system was in place that staff confidently used to investigate incidents and errors. There was evidence that learning from investigations had taken place consistently with an effective system in place to ensure all staff were aware of updates to practice. These measures contributed to an environment in which safety was prioritised and patients received individualised care.

We observed numerous instances of significant commitment to personalised care. Staff were competent, passionate and driven, and their efforts included supporting a patient to return home safely to their garden during an extended CCU stay and a programme to promote independence in patients' in the middle of their recovery. Staff were active in clinical research and were supported in this by a senior team of nurses and doctors who understood the need for continued innovation in care and treatment. One relative told us, “I am overwhelmed by the attention of all of the people looking after [relative].”

Staffing levels were reviewed continually using an established nursing acuity tool and there were enough staff to provide care and treatment in accordance with Royal College of Nursing (RCN) guidance. The use of agency staff was consistently below the maximum acceptable level set by the trust and temporary staff underwent stringent induction and background checks before working on the unit. Without exception staff told us they were supported and valued by the senior team and they felt proud to work in the unit.

At our last inspection of Wexham Park Hospital, we found critical care services for responsiveness to require improvement. This was because admissions and discharges were often delayed and patients were sometimes transferred out of hours because of a lack of capacity elsewhere in the hospital. At this inspection we found a significant and sustained improvement in these areas, with an acute commitment from the senior team to improve the unit's responsiveness to patient needs that had been highly successful. In areas we previously found to be good, staff had worked hard to build on their existing practice and explore innovation in patient care and treatment.

Updated 2 February 2016

Overall we rated the EOLC services at Wexham Park Hospital as 'Good' this was because:

National guidance determines precisely what end of life care (EOLC) should look like for adults diagnosed with a life limiting condition in all care settings. EOLC is defined as a patient with less than 12 months to live no matter what the diagnosis.

Overall we found the EOLC service provided by Wexham Park Hospital was good. The duty of the inspection was to determine if the hospital had policies, guidelines and training in place to ensure that all staff delivered suitable care and treatment for a patient in the last year of their life. The hospital provided mandatory EOLC training for staff which was attended, a current End of Life Care Policy was evident and a steering group met regularly to ensure that a multidisciplinary approach was maintained.

Staff at Wexham Park Hospital provided focused care for dying and deceased patients and their relatives. Facilities were provided for relatives of patients and patient's cultural, religious and spiritual needs were respected. Further supplies of syringe drivers were purchased to enable a dying patient to receive prompt, adequate and appropriate medication.

The palliative care team had a high level of evidence based specialist knowledge. They worked well with the local hospice and other departments involved in providing EOLC. The team were well thought of throughout the hospital. They supported, trained and gave advice to other staff.

There was evidence that systems were in place for the referral of patients to the palliative care team for assessment and review to ensure patients received appropriate care and support. Through education and acknowledgement of national guidance the number of referrals to the palliative care team had increased since the last inspection and these referrals were seen and acted upon within 24 hours.

At our last inspection of Wexham Park Hospital we found the EOLC service to require improvement. This was because the service relied on the drive and vision of the EOLC team and not through any trust wide strategy. EOLC did not appear to be a priority for the trust.

Since the hospital's acquisition by Frimley Health  NHS Foundation Trust the service had board representation and a dedicated clinical lead. This had resulted in a well led trust wide service that had a clear vision and strategy.

Updated 13 September 2023

Updated 2 February 2016

Overall we rated the outpatients and diagnostic imaging departments at Wexham Park Hospital as 'Good' this was because:

The hospital consistently met waiting and treatment times in line with national standards. Professional staff treated patients with kindness, dignity and respect. The outpatient and radiology departments followed best practise guidelines and there were regular audits taking place to maintain quality.

The booking centres had processes to ensure patients received appointments within the appropriate timeframe. There were fail-safes in place and medical staff assisted management if required. Medical record management enabled clinicians in outpatients to have access to patients’ records more than 99% of the time. The radiology department had worked to reduce waiting times in the past year.

Staff were competent , professional and treated patients with dignity and respect. The outpatient and diagnostic imaging department appeared clean and well maintained. Staff demonstrated good infection control practices . Equipment was serviced and maintained regularly.

Every member of every team contributed positively to patient care. All staff shared the vision and values of the hospital and good leadership was visible at all levels. Staff worked hard to deliver improvements in their departments. They were proud of their achievements and had the vision and energy to continue with improvements and develop services further.

Updated 13 March 2019

Our rating of this service stayed the same. We rated it as good because:

• Security of theatre had improved; all areas had been secured and access was restricted. Checking of the blood fridge had improved and was consistently completed and recorded.
• The service had improved on how it carried out the safe surgery checklist and undertook audit to ensure compliance. Further development of the debriefing process was underway to ensure the process remained robust.
• The service provided mandatory training in key skills to all staff. Mangers made sure staff had the right skills to perform their role. There were practice development nurses in all areas and departments who supported staff training within a positive learning environment.
• Staff understood how to protect patients from abuse. staff had training on how to recognise and report abuse and they knew how to apply it.
• The service controlled infection risk well and had suitable premises and equipment and looked after them well.
• Staff completed and updated risk assessments for each patient. Patient safety information was collected and safety monitoring results were used to drive improvements in practice.
• The service managed patient safety incidents well. Staff knew what incidents to report, how to report, investigate and lessons learnt were shared. They identified any themes and monitored improvements in practice.
• The service provided care and treatment based on national guidance and evidence of effectiveness. Patient outcomes were monitored and staff used findings to improve them. They compared local results with those of other services to learn from them.
• Doctors, nurses, other healthcare professionals and all other staff worked together to benefit patients and supported each other to provide good care.
• A consultant-led seven days a week service was in place. It was being further developed in a two-year plan to provide full service delivery in line with National Health Service Improvements (NHSI), seven-day service in the NHS.
• Staff understood their roles in gaining valid consent. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
• Staff cared for patients with compassion, treating them with dignity and respect. Staff were passionate about delivering high standards of care and took account of patient feedback. Patient feedback was overwhelmingly positive and confirmed that staff were helpful and positive and treated patients with kindness.
• The service planned and provided services in a way that met the needs of local people. They could generally access the service when they needed it. Patients’ individual needs were taken into account. There were specialist nursing and medical practitioners available to support patients and staff.
• The service treated concerns and complaints seriously, investigated them and learned lessons from the results and shared these with staff. Managers had the skills, knowledge and experience to manage the service. Managers demonstrated the ability to understand the challenges they faced and developed plans to deal with these challenges. Governance and performance management arrangements are proactively reviewed and reflect best practice.
• There were high levels of staff satisfaction across all staff groups. Staff were proud of the organisation as a place to work, and they spoke highly of the culture.

However:

• The service did not currently achieve its target of 85% of all staff to complete mandatory training.
• There was a lack of consistency in how the change of the theatre list was managed on two consecutive days. Practice should be consistent to protect the safety of the patient.
• Feedback from junior doctors was that rotas were not always planned in a timely way and there was no guardian of safe working hours in post, as there was a gap between retirement of the post holder and another taking up the post.
• Fridge and room temperatures where medicines were stored were recorded daily but we were not sure that staff always took appropriate action when temperatures were outside the required range.
• The corridor to pre-assessment had a fire door open to give ventilation to the area. This should be addressed to maintain safety.
• The service did not currently achieve its target of 85% of all staff to receive an appraisal.
• Complaints were not always responded to in a timely way; the service did not achieve the target of 25 days for a response to complaints.