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

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

Patients, or their representatives, were involved in decisions about their care and treatment. The service provided information which patients could understand. Patients were invited to give feedback, knew who to speak with if they had concerns and were confident the service took their concerns seriously.

The service monitored and worked to improve access. The environment was adjusted to meet the needs of people with conditions which could create a barrier to access.

The service worked to reduce health and care inequalities through service planning, quality monitoring, staff training and feedback. Patients were involved in planning their care and understood options around choosing to withdraw or not receive care.

The service supported staff wellbeing.

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 made sure patients could access communication support when they needed it. This included access to interpreters, hearing loops and sign‑language services. Staff knew how to arrange these services, and care records showed they used communication support to help patients understand their care and take part in decisions.

The service had a clear approach to supporting people living with dementia. Staff used a hospital passport during pre-assessment instead of a standard questionnaire. This helped them understand the person’s needs, preferences and what mattered to them, with input from those who knew them well.

Senior clinical leaders reviewed completed passports to check whether the service could safely meet people’s needs, plan the timing of procedures and identify any additional support required. Dementia champions were available to advise and support staff and help ensure people with dementia received person‑centred care.

Patients were offered a choice of food and drink that reflected personal, cultural and religious preferences. A faith room was available for anyone who wanted a quiet space for prayer or reflection.

However, we saw one example where there was a delay in providing communication support. A surgical patient waited over an hour for a remote interpreter, and a relative was used to interpret instead, which was not in line with the service’s policy.

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. Patients who were responsible for paying all or part of the costs of their care or treatment were provided with a statement setting out the terms and conditions of the services to be provided. This included details of the fees payable and the method of payment. Where possible this was always provided in writing prior to the commencement of the services.

The evidence showed a good standard. 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 pathways. Staff shared discharge information promptly with patients’ GPs and, where appropriate, relevant NHS trusts to support ongoing follow‑up and continuity of treatment. However, we saw a quarter of incidents related to discharge between 1 February 2025 and 31 January 2026, with no current action plan in place to address this.

The service monitored readmissions and transfers to other providers or NHS trusts and reviewed these to identify learning and maintain continuity of care. We saw clear evidence of effective communication with NHS trusts, including accurate and timely discharge summaries.

The service worked with internal teams and external partners to support responsive and joined‑up care. Staff coordinated with consultants, the patient support centre and admissions teams to plan care and manage changes to treatment schedules. The service used multidisciplinary meetings to review patients’ readiness for admission and ensure information was shared between teams, supporting continuity of care and reducing delays where possible.

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

Patients told us they received clear information about their treatment and understood their care plans, procedures and recovery. Information was available in different languages and formats, and the service met the Accessible Information Standard. Spire Healthcare also provided online pre‑operative information, including a hip replacement video, to help patients prepare for surgery.

Information leaflets were available across patient areas, and staff could arrange information in alternative languages or formats when needed. This helped patients and those close to them understand their care and make informed decisions.

Staff had timely access to the information they needed to deliver care. Clinical policies were available on the intranet, and staff used paper‑based patient record booklets to capture each stage of the patient pathway in a single, integrated record. This supported continuity and coordination of care.

Information governance systems protected the confidentiality and security of patient records. The service recorded and investigated any data breaches, with learning identified and shared to reduce the risk of repeated incidents. We saw evidence that staff logged and reviewed data breaches in line with policy.

The service provided information to help patients understand their rights, available services and how to raise concerns or complaints. This information was displayed throughout the hospital.

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

The service used patient surveys and questionnaires to collect feedback and look for ways to improve care. Learning and actions identified were shared with staff through the service’s complaints learning reports to support continuous improvement.

There were 25 complaints and concerns raised (24 complaints and 1 concern) at Spire Montefiore between 1 Feb 2025 and 31 Jan 2026 (these were not specific to surgery). Of these none were escalated to stage 3 independent adjudication (ISCAS).

Patients, relatives and carers knew how to raise concerns or make a complaint. The service offered several ways to do this, including speaking to staff, using the telephone, email or letter, or scanning a QR code. Patients and relatives could also use the website to submit a complaint. Once submitted the email was sent to a shared inbox managed by the patient experience lead.

In December 2025, the service appointed a patient engagement lead, who met with patients. We were told if concerns were raised, these were promptly resolved. The service held patient engagement meetings twice a year to seek feedback and involve people in service development; however, there were no patient representatives present at the most recent meeting. Leaders were aware of this and acknowledged the need to strengthen patient involvement to ensure views and experiences were better represented.

The service had an up‑to‑date complaints policy, which explained how staff should listen to concerns, respond appropriately and meet legal and regulatory requirements. Staff understood the complaints process and knew how to support patients and escalate concerns when needed. Patients could take any unresolved complaints to a third-party organisation or to the parliamentary ombudsman, if an NHS patient.

The evidence showed a good standard. The service made sure that people could access the care, support and treatment they needed when they needed it.

People could access the service when they needed to and received the right care promptly. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were in line with national standards (NHS patients via the choose and book). Where there were large waiting lists, these were monitored and reduced over time.

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.

Referral to Treatment (RTT) measures the time from referral to treatment. The service monitored RTT performance through regular theatre utilisation meetings, action planning and daily tracking of breaches and long waiters. Data showed improved control of the longest waits. In orthopaedics, confirmed 65‑week breaches reduced from 29 in January 2025 to 0 by November 2025 and remained at 0 in January 2026, while 52‑week breaches reduced from 32 to 7 over the same period. In general surgery, 65‑week breaches reduced from 36 in January 2025 to 0 by October 2025 and remained at 0 in January 2026, and 52‑week breaches reduced from 15 to 0. Although confirmed 18‑week breaches remained, particularly in orthopaedics, numbers reduced from 413 in April 2025 to 260 in January 2026.

Data showed ongoing breaches of the 18-week standard, particularly in orthopaedics, where higher numbers of patients waited longer for treatment. However, there was improvement over time, with a general reduction in long waits over 52 and 65 weeks.

The service worked with consultants, medical secretaries and the patient support centre to manage RTT performance. The theatre manager, NHS capacity manager and theatre coordinator met regularly to plan capacity, review admissions and prioritise long‑waiting patients. This work linked with the weekly multidisciplinary Admissions Assessment Meeting and used information shared with the Integrated Care Board through weekly RTT forecasting and reporting.

The hospital staff managed the bed occupancy and patient flow well. 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.

Staff made reasonable adjustments to help people access care. This included supporting people with disabilities, communication needs or dementia. Staff listened to patients and those close to them and supported them to share their views and experiences. Staff also gave examples of how they supported people who were neurodiverse, such as arranging a private room for day‑case treatment when this was needed.

People were able to access the service when they needed it and received care in line with national standards. The service held weekly multidisciplinary clinical meetings to review cases referred for medical care. A lead clinician and staff from relevant departments attended these meetings, which helped ensure decisions were made together and care was planned and delivered in a timely and coordinated way.

The service uses average length of stay, which shows how long patients stay in hospital after surgery. This helps show whether people were able to recover and go home without unnecessary delays. For hip and knee replacements, patients go home quicker than the UK average, which shows the service is working well and patients are getting timely care. However, we saw evidence that some hysterectomy patients were staying longer than expected.

The evidence showed a good standard. 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 completed equality impact assessments for its policies and procedures. These assessments aimed to ensure policies did not disadvantage people in vulnerable circumstances or those with protected characteristics.

The service met equality and human rights legislation and made reasonable adjustments to support equitable access, experience and outcomes for patients. For example, the service shared evidence showing staff supported neurodivergent patients to visit the service before treatment. Staff adapted care to meet individual sensory needs, such as adjusting appointment times and making changes to lighting and noise levels, to help reduce anxiety and support people to feel more comfortable.

People who did not speak English as their first language could access the service. Staff had access to interpreting services by telephone.

The evidence showed a good standard People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future.

Staff supported patients to make decisions about their care and treatment and created personalised care plans to account for their needs, wishes and feelings.

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.