The Montefiore Hospital

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We looked for evidence that patients and communities were always at the centre of how care was planned and delivered. We checked that the health and care needs of patients and communities were understood, and they were actively involved in planning care that met these needs. We also looked for evidence that patient could access care in ways that met their personal circumstances and protected equality characteristics.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant patient’s needs were met through good organisation and delivery.

We have not awarded this service a score for Responsive.

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

The evidence showed a good standard. The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Managers ensured that patients, carers and staff had access to appropriate communication support, including interpreters, hearing loops and sign language services when required. Information on how to access interpreting services was readily available, and we saw clear evidence in patient records that these services were used appropriately.

The service had a dementia care framework which outlined expected standards of care across the patient pathway. A hospital passport was used at pre‑assessment for people living with dementia instead of a standard medical questionnaire. This approach actively involved the patient and the person who knew them best, helping staff to understand individual needs, preferences and behaviours.

The passport was reviewed by the director of clinical services and the clinical team to assess whether the service could safely meet the patient’s needs, plan the timing of procedures and identify any additional support required. Dementia champions were available within the service to provide advice and support to staff and help ensure patients with dementia received person‑centred care.

Patients were offered a choice of food and drink which took account of cultural, religious and personal preferences. The oncology menu offered lighter meal options to accommodate reduced appetite commonly associated with chemotherapy treatment. Menus included clear nutritional information and highlighted allergens and other dietary requirements to help patients make informed choices and support safe care. A faith room was available and accessible for anyone who required a quiet space for prayer or reflection.

We found examples of chemotherapy treatment being planned in partnership with patients, taking account of individual circumstances and family needs. For example, patients with young children were invited to visit the cancer suite in advance to familiarise themselves with the environment, which helped to reduce anxiety and support emotional wellbeing.

Private or self-pay patients were told about and knew all the planned and possible costs, including the costs of future care and treatment and dealing with possible complications. When a patient was responsible for paying the costs of their care or treatment (either in full or partially), they were provided with a statement specifying the terms and conditions in respect of the services to be provided, including as to the amount and method of payment of fees. Where possible this was always provided in writing prior to the commencement of the services.

Score 3

The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.

There was effective continuity of care across medical care pathways. Staff explained how discharge information was shared promptly with patients’ GPs and, where appropriate, relevant NHS trusts to support ongoing follow‑up and continuity of treatment. Any readmissions or transfers to other providers or NHS trusts were monitored and reviewed to ensure learning and continuity of care. We saw clear evidence of effective communication with NHS trusts, including documented discharge summaries.

We also found strong evidence of continuity of care within the oncology service. UK Oncology Nursing (UKON) triage assessments were used to appropriately signpost patients to attend the Emergency Department (ED) at their local NHS trust when required. Nursing staff pre‑alerted the receiving trust so that staff were expecting the patient and had access to relevant clinical information about their diagnosis and treatment, supporting safe and coordinated care.

The service usually supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Patients told us they were well informed about their treatment, understanding their care plans, procedures and recovery process. Treatment pathway information was available in multiple languages and formats, and the service complied with the Accessible Information Standard. The endoscopy service had produced a video available online to inform patients on what to expect when attending for a procedure.

Information leaflets were available throughout patient areas and were available in alternative languages and formats on request. Display boards signposted patients to a range of services and information such as the chaperone service and types of cancer.

Staff had timely access to information required to deliver effective care. Policies were available via the intranet. Paper-based patient record booklets were used to ensure all stages of the pathway were contained within a single integrated record.

Information governance systems ensured the confidentiality and security of patient records. Any data breaches were recorded, investigated, and appropriate actions taken, with learning identified and shared to reduce the risk of recurrence. We saw evidence that data breaches were routinely logged, reviewed and managed in line with policy.

Staff ensured that patients could obtain information on treatments, local services, patients’ rights, how to complain and this was supported by display boards throughout the hospital.

The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. Staff involved patients and their families in decisions about their care and told them what had changed as a result.

Patients, relatives and carers knew how to raise concerns or make a complaint. The service provided several accessible routes to do this, including verbally, by telephone, via email or letter, and by scanning a QR code. In December 2025, the service appointed a patient engagement lead who visited patients attending the service and aimed to resolve concerns promptly, often at the point they were raised.

The service had an up‑to‑date complaints management policy which clearly set out responsibilities for listening to concerns, responding appropriately and meeting regulatory requirements. Staff were familiar with the complaints policy and understood how to support patients and escalate concerns when necessary. Patients could take any unresolved complaints to a third-party organisation or to the parliamentary ombudsman, if an NHS patient.

The service used patient surveys and questionnaires to gather feedback and inform service improvement. Between 1 February 2025 and 31 January 2026, the service received one complaint relating to medical care. This was escalated to tier two, investigated thoroughly and was not upheld. Learning and actions identified were shared with staff through the service’s complaints learning reports to support continuous improvement.

The endoscopy and oncology service recognised that response rates from patients about their care were sometimes low. The service held patient engagement meetings twice a year to seek feedback and involve people in service development; however, patient representatives were not always able to attend meetings. Leaders were aware of this and acknowledged the need to strengthen patient involvement to ensure views and experiences were better represented.

People could access the service when they needed to and received the right care promptly.

Managers monitored waiting times, where this was necessary and made sure patients could access services when needed and received treatment within agreed timeframes and national targets. For example, oncology patients booked appointments directly with the oncology service to ensure they received timely care and treatment regimen.

Managers worked to keep the number of cancellations to a minimum. When patients had their appointments or procedures cancelled at the last minute, managers made sure they were rearranged as soon as possible and within national targets and guidance.

The service made sure that patients could access the care, support and treatment they needed when they needed it.

Staff made reasonable adjustments for patients to ensure inclusive access to care. This included supporting people with disabilities or communication difficulties. Patients and those close to them were listened to and supported to share their experiences and views about their care. Staff told us about supporting people with a learning disability to access the endoscopy service at a time that suited them with support from a carer.

The service held weekly multidisciplinary clinical meetings to discuss all cases referred for medical care. These meetings were attended by a lead clinician and representatives from relevant departments, supporting collaborative decision‑making and timely, coordinated care.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

The provider had undertaken equality impact assessments of their policies and procedures to ensure they did not place vulnerable people or people with protected characteristics at a disadvantage.

The service complied with equality and human rights legislation and made reasonable adjustments to promote equitable access, experience and outcomes for patients. For example, neurodivergent patients were supported to visit the service in advance of treatment, and care was adapted to meet individual sensory needs. This included tailoring appointment times and adjusting lighting and noise levels to support desensitisation and reduce anxiety.

People who did not speak English as their first language could access the service. Staff had access to interpreter services by telephone and planned for this ahead of treatment. This was recorded in patient notes and planned for in advance.

Staff received training in equality, diversity, inclusion and human rights to support inclusive, respectful and equitable care for all patients.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Staff supported patients to make decisions about their care and treatment and created personalised care plans to account for their needs, wishes and feelings. For example, the oncology service held discussions with patients about palliative care, end of life and healthier living with cancer.

Patients were kept informed about future appointments and care planning. Staff worked well together as an effective multidisciplinary team throughout the patient journey. Records were updated following appointments to document discussions and agreed actions.

Discharge summaries were given to the patient to take home and for their GP and follow up appointments were made before discharge for endoscopy patients.