The Montefiore Hospital

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that people and communities had the best possible outcomes because their needs were assessed. We checked that people’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring people were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

People were involved in assessments of their needs. Staff reviewed assessments taking account of people's communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with patients to support healthy living. Staff made sure people understood their care and treatment to enable them to give informed consent.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

The evidence showed a good standard. The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

We reviewed 18 care records during the assessment. Staff completed a comprehensive health assessment of the patient prior to receiving treatment. Risk assessments were completed, for example falls, moving and handling and pressure damage and allergies were documented. Staff gave patients information packs during pre-assessment appointments and again after chemotherapy treatment or endoscopy procedures. The packs included contact details for the oncology service, their consultant and the names of the nursing staff. Patients were also given alert cards to carry, which explained that they were at high risk of sepsis, which is a potentially life-threatening condition. The card contained advice for healthcare professionals and the contact details for the service.

Patients undergoing endoscopy procedures were monitored appropriately for signs of clinical deterioration. We saw evidence that heart rate, oxygen saturation and blood pressure were monitored frequently and documented. Patients were provided with information about fasting before colonoscopy procedures that detailed dietary requirements and how long patients should do this for. Procedures would not be carried out if preparation procedures had not been followed for example bowel screening preparation. Staff considered patients’ individual needs where food or drinks were necessary following the procedure.

Oncology nurses assessed patients’ nutrition and hydration status as part of the modified toxicity grading in the care pathway. An oncology dietitian was available to support this. The service had access to cancer‑specific information, specialist health professionals, and out‑of‑hours telephone support from oncology nurses who were on call 24 hours a day. Patients and family members could contact the service for advice.

Translation services were available and individual communication needs were documented in patient records. We saw posters with translation service details and two patient records where a translator was required. Staff told us they could access the translation service as required.

The evidence showed a good standard. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Care, treatment and support were delivered in line with legislation, standards and evidence-based guidance. The service used policies, care and treatment pathways, clinical protocols and standard operating procedures. The endoscopy unit was JAG accredited in 2023 and achieved annual renewal in July 2025. This meant the team had demonstrated and maintained consistent care, quality and safety in line with national standards.

Staff assessed and met patients’ needs for food and drink and for specialist nutrition and hydration. The oncology service had a varied menu to support individual choice and needs when receiving chemotherapy and access to an oncology dietician.

The oncology service participated in clinical audit, benchmarking and quality improvement initiatives. Staff told us about a trial to reduce extravasation injury to evaluate the effectiveness of the infusion site surveillance technology to improve outcomes. This was based on research published in the British Journal of Nursing which found a reduction in infiltration and extravasation injures which can improve patient safety and have a positive financial impact.

The oncology team included cancer nurses, consultant oncologists and cancer pharmacists and patients had access to a specialist NHS oncology Multidisciplinary Team (MDT). Cancer patients also had access to charitable organisations who provided holistic care and advice such as talking therapies, hair loss, reflexology and acupuncture.

Staff followed up-to-date policies to plan and deliver high quality care according to best practice and national guidance. Policies were stored on an online system which all staff had access to. We reviewed 10 policies and found all were within the review date. Updates to policies and tracking of policy review dates, were carried out at corporate level and cascaded to the hospital for implementation. Policies were current and based on professional guidelines, for example, National Institute for Health and Care Excellence (NICE) and Royal College guidelines. The hospital completed a range of audits as part of the organisation’s annual programme to ensure healthcare was provided in line with their policies, national guidance and standards. Audit results were collated and used to benchmark against the other hospitals in the Spire Healthcare Limited group.

Managers identified staff learning needs and provided opportunities for them to develop their skills and knowledge. Staff told us that a pharmacy technician had received oncology training to support the pharmacist. This ensured the service maintained oncology expertise when the pharmacist was on leave.

The service reported information to the Private Healthcare Information Network (PHIN). Intelligence reports were reviewed by service leaders. These reports contained data on PHIN’s existing performance measures, including; patient activity volumes, length of stay, never events, Patient Reported Outcome Measures (PROMs), infections and data submission levels. In addition, it also includes complaints data that we receive from private insurers.

The evidence showed a good standard. The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

The service held a daily multidisciplinary meeting which we observed during our assessment. This took place every morning and was attended by the senior management team and a representative from each department including estates and hospitality. All staff contributed to provide an overview of the hospital’s activity, identify risks or staffing issues. Any relevant information was taken back to each department and cascaded to the team through the safety huddle. Staff discussed staffing levels and moved staff to cover areas as required.

There were processes to ensure members of the multidisciplinary team (MDT) worked together to ensure the needs of the patients were met. Key governance meetings were attended by members of the MDT which demonstrated an effective and cohesive service. Minutes from various governance and quality meetings were attended by members of the MDT. Key messages were displayed on notice boards throughout the hospital to share information with staff.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

Staff supported patients to live healthier lives for example, the oncology service offered smoking cessation schemes and reducing alcohol consumption. The service had relevant information promoting healthy lifestyles, access to a specialist oncology dietician and a range of therapies to support wellbeing for example, acupuncture. Staff assessed each patient’s health when they attended and provided support for any individual to live a healthier lifestyle. The service offered patients an ‘Eating Well’ booklet which provided information on balanced diet and how diet can affect and improve symptoms during and after bowel cancer treatment.

The service routinely monitored patient’s care and treatment to continuously improve it. Staff made sure outcomes were positive and consistent, and they met both clinical expectations and the expectations of patients themselves.

Staff used recognised tools to improve the detection and response to clinical deterioration in patients as a key element of patient safety and improving patient outcomes.

Managers used information from audits to improve care and treatment. For example, we saw actions had been taken following the endoscopy service infection prevention and control (IPC) audit. These actions included replacing equipment to address identified issues and reduce potential risks to patients.

There were regular audits being conducted which included patient reported outcomes. Improvement was checked and monitored. The service participated in quality improvement initiatives such as local and national clinical audits, benchmarking, accreditation schemes, and research. For example, the endoscopy service had achieved JAG accreditation.

The service told patients about their rights around consent and respected these when delivering person-centered care and treatment.

We observed staff seeking verbal consent before providing care or treatment. People were involved in decision making at all levels. Housekeeping staff asked patients what they wanted to eat and drink. Where specific requests had been made by patients, for a same sex health care professional this was discussed and provided whenever possible.

Chaperones were provided if requested. Interpreters were used to support patients to give informed consent, including for BSL and face to face interpreting when necessary. We saw evidence of staff delaying consent until an interpreter was available to ensure consent was informed and meaningful.

Staff sought permission before sharing patient information with family or friends.

Staff completed the two‑stage consent process for care and treatment, making sure patients made informed decisions. They made sure patients consented to treatment based on all available information, and they checked and confirmed consent before any procedure. Staff understood how to assess a patient’s capacity to make decisions. Each patient record contained a consent form showing that staff had discussed the risks and benefits of treatment with patients before procedures took place. Staff clearly recorded consent in patients’ records.

Staff received Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards training. They understood relevant consent and decision-making requirements. Staff knew how to access policies and advice on these topics. We saw evidence that best interest meetings were held when people may have lacked capacity to consent. These meetings ensured appropriate advocacy was in place and that information was presented in a way that supported patients’ understanding of the proposed procedures.

The oncology service used a digital chemotherapy prescribing system that incorporated consent recording. Audit data covering the period from 1 August 2025 to 31 January 2026 demonstrated 100% compliance with consent requirements.