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 outstanding. At this assessment the rating has changed to good. This meant patient’s outcomes were consistently good, and patient’s feedback confirmed this.

The service involved patients, carers and relatives in assessing their needs. Staff reviewed assessments and took account of each person’s physical, emotional, communication and personal care needs. The service-based care and treatment on the latest evidence and good practice, and patient outcomes met expectations. Staff identified pain quickly and managed it well.

The service did not always follow national guidance on consent, including guidance from the Royal College of Anaesthetists and the General Medical Council.

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 usually made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

The service made sure care and treatment were effective by assessing and reviewing people’s health, wellbeing and communication needs.

All surgical patients received a suitable pre‑operative assessment. These assessments reflected people’s physical health, the type and urgency of the procedure, and included health questionnaires. They also included patient information checklists and risk assessments, such as blood clot and infection risks. Staff recorded detailed medical histories and observations to support decisions about whether to proceed with surgery or to refer, delay or cancel where needed.

Staff considered people’s individual wishes where these could affect care and treatment. The provider shared evidence of a recorded discussion between a patient and a consultant surgeon about treatment options if complications were to arise during surgery. The records showed the patient shared their views about blood transfusion, and staff explained the limits of the service in managing this risk safely. The discussion showed staff involved the patient and explained why the service would not be able to provide surgery in this situation.

Staff shared key information to keep people safe during handovers. We observed structured handovers on site, and the provider shared evidence showing staff followed this process consistently. Senior staff discussed people’s wishes should their condition worsen, we witnessed these being discussed during the admissions assessment meeting.

Staff assessed and managed pain effectively. They used recognised assessment tools and provided pain relief in a timely way, in line with best practice. Patients received pain relief before leaving theatre, and people we spoke with told us staff managed their pain well. During our observations, patients appeared comfortable, and anaesthetic staff were available to support people with more complex pain needs.

Care plans reflected people’s assessed needs. These included clear arrangements for pain management. Patients told us they received pain relief when they needed it and felt involved in decisions about their care.

Staff assessed people’s nutrition and hydration needs appropriately. They used evidence‑based tools, and records showed staff consistently completed nutritional screening.

Staff assessed and met people’s communication needs. They used a range of tools to understand how people preferred to communicate, including written information to support people during their care. This helped staff deliver care that met individual needs.

Staff had completed mandatory training to support people with a learning disability, autistic people and people living with dementia. Staff we spoke with showed a good understanding of how to adapt their approach and provide appropriate support. We saw a recent example where the service provided a neurodiverse patient with quiet private room instead of day case bed

We spoke with 2 patients who told us staff saw them quickly when complications such as pain or swelling occurred. We also spoke with 3 patients who told us pain was well managed and recovery was progressing well.

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

Patients generally received care in line with national guidance, including guidance from the National Institute for Health and Care Excellence (NICE) and the Royal College of Surgeons (RCS). The service had up‑to‑date policies that reflected current national guidance and included review dates. Staff told us they used these policies to guide their practice.

The service received regular updates on changes to national guidance, safety alerts and policy updates from the corporate provider, which were shared with staff. The wider organisation monitored compliance with key NICE guidance, including NG45 (Pre‑operative tests), NG51 (Sepsis) and QS49 (Surgical site infection).

We reviewed 12 patient records and found care plans and risk assessments were fully completed. Patients were not kept nil by mouth longer than necessary. Staff completed nutrition and fluid balance charts accurately, and records showed consistent use of a nationally recognised malnutrition screening tool.

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 usually 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.

Staff across the service worked well together to support people’s care. Care appeared coordinated, and information about people’s needs was shared effectively when they moved between services, which reduced the risk of patients having to repeat information.

The service held multidisciplinary meetings to discuss risks identified during pre‑operative assessments. These meetings involved medical staff and supported shared decision‑making. There was effective daily communication between multidisciplinary teams working in pre‑operative assessment, wards, and theatres. This helped ensure care was coordinated and delivered safely.

Staff described holding daily safety huddles to share up‑to‑date information about patient risks and concerns, including clinical and safety issues. This supported consistent information sharing between teams.

Staff worked closely with consultants, resident medical officers (RMOs), pharmacy staff, and allied health professionals, including physiotherapists. We observed ward staff working collaboratively during patient assessments.

Staff also worked across healthcare disciplines and with external organisations when required. Ward staff liaised with GPs to support safe discharge planning and ongoing care arrangements.

The provider told us they sought feedback through an internal Patient Experience Group, and we reviewed minutes from these meetings. Patients told us physiotherapy input supported their recovery alongside nursing and medical care.

The evidence showed a good standard. 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.

The service supported people to manage their health and wellbeing so they could maximise their independence, choice and control. Staff encouraged early mobilisation to support recovery and provided clear guidance on how to manage pain safely at home, including when to seek help.

Patients were given information about their condition, treatment and how best to prepare for surgery, and staff discussed how they could optimise their outcomes through lifestyle choices and post‑operative exercises.

Physiotherapy staff further supported recovery by providing rehabilitation guides with written and visual exercises, pre‑operative preparedness information such as the “Call Don’t Fall” safety message, and practical advice on safe movement, personal care, household activities, and gradually resuming daily routines.

The service also worked with the local authority’s equipment contractor to ensure patients had timely access to appropriate mobility aids for safe and independent recovery.

People we spoke to said they received enough information about their care and treatment. We spoke with 3 patients who confirmed they received written information and advice before surgery to help them prepare.

The evidence showed a good standard The service monitored people’s care and treatment to continuously improve it. Staff ensured that outcomes were positive and consistent, and they met both clinical expectations and the expectations of people themselves.

Leaders monitored clinical outcomes to check the quality and safety of the service. They reviewed performance data, audit findings, patient feedback and incidents to identify where improvements were needed.

The service collected outcome data for all key procedures. Teams recorded results in a central database and used this information to monitor trends over time. Leaders compared performance against national standards and similar services to understand how well the service was performing and where further improvement was required.

The service took part in national audits to support quality monitoring and improve patient outcomes. These included the National Joint Registry (NJR), the Breast and Cosmetic Implant Registry, the National Patient Reported Outcome Measures (PROMs) Programme for hip and knee replacement surgery, and the British Spine Registry.

The service’s consent rate for the NJR remained above 95% over the previous six months. This meant that more than 95% of joint replacement procedures could be tracked, supporting effective monitoring of implant performance and patient outcomes.

The NJR data showed that hip revision rates were within the expected national range. However, knee revision rates were slightly higher than the England average, meaning more patients required further surgery than expected. Leaders reviewed these results and told us they had implemented a targeted action plan to address this.

The PROMs data for the previous 12 months showed outcomes following hip replacement surgery were better than the England average. All patients reported an improvement following hip replacement, and post‑operative Oxford hip scores and health gain scores were higher than national benchmarks.

For knee replacement surgery, 89.8% of patients reported an improvement overall, which was in line with the England average. Outcomes for NHS patients were above the national average, while outcomes for private patients were slightly below the national average. Overall, most patients experienced improved outcomes following knee replacement surgery.

The service had processes in place to monitor outcomes and post‑operative infections. Staff completed audits and carried out surveillance of surgical site infections to identify and reduce risk.

Leaders monitored unplanned returns to theatre, readmissions and patient transfers. They reviewed each case to check that the clinical response had been appropriate. Leaders analysed themes, discussed findings at governance meetings and identified areas for improvement where needed.

The service used a structured audit programme covering areas such as sepsis management, early warning scores, clinical documentation and post‑operative monitoring. Leaders reviewed audit results. However, it was not always clear how actions were identified when compliance did not meet expected standards, or how responsibility for improvements was assigned and followed up to confirm changes had been completed and sustained.

We spoke with 3 patients about their outcomes, and they told us their condition had improved following treatment.

The evidence showed some shortfalls. The service did not always tell people about their rights around consent and did not always respect their rights when delivering care and treatment.

We reviewed 12 patient records. We saw examples where staff did not follow the correct consent process. Staff asked patients to sign consent forms in the anaesthetic room. National guidance from the Royal College of Surgeons states that staff should not take consent in the anaesthetic room because patients may feel under pressure and may not have enough time to make fully informed decisions. The wider organisation monitored compliance with national guidance; however, the Montefiore Hospital was not specifically included in group‑wide compliance evidence.

Although the service recorded these incidents, it was not always clear how learning had been used to drive improvement actions. The incident records did not show how staff were reminded of correct consent procedures, how leaders monitored practice, or how the service would prevent similar incidents from happening again. This limited assurance that consent was always obtained safely and consistently.

However, the service had clear consent policies. Staff usually allowed enough time for patients to make decisions about their care and followed required “cooling‑off” periods, including a minimum of 14 days for cosmetic procedures. Audit results from August 2025 to January 2026 showed 100% compliance with consent documentation.

Patients told us staff explained the risks, benefits, and alternatives to treatment in a clear way. They said staff gave them enough time to ask questions and did not make them feel rushed when making decisions about their care.

Staff followed processes to check consent before procedures. They reviewed consent on the day of treatment and reconfirmed consent if care plans changed. Staff understood the importance of gaining consent in line with national guidance.

Staff also considered people’s mental capacity to consent. They knew how to support patients who needed extra help to understand information and involved family members or carers where appropriate, with the patient’s consent.