The Montefiore Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. The service provided care in an environment that was safe, clean and well equipped.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

The service kept patients safe and provided good quality care. The service followed safe systems of work and ensured staff responded appropriately when patients became unwell. The service had enough staff with the right skills, experience and qualifications to meet patients’ needs. The service maintained a clean environment, and facilities and equipment were well maintained and suitable for care. The service managed medicines safely and took action to reduce risks.

However, the service did not always maintain a strong learning culture. The service did not always identify and embed learning from incidents, and investigations did not always record the correct level of harm. The service protected patients from harm, but it did not always ensure staff fully understood local safeguarding arrangements.

We have not awarded this service a score for Safe.

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

The evidence showed some shortfalls. The service did not always have a proactive and positive culture of safety based on openness and honesty. Lessons were not always learnt to continually identify and embed good practice. They did not always listen to concerns about safety. However, the service always investigated and reported safety events.

Staff gave mixed feedback about incident reporting and learning. While some staff said they received feedback and felt supported after an incident, others said this did not always happen. The service shared information about incidents on staff noticeboards, but the information did not include the dates of these incidents. This meant the service could not be assured the information was up to date or still relevant.

Between 1 February 2025 and 31 January 2026, the service reported 739 incidents and near misses. Of these, 179 related to patient discharge. However, the service had not yet reviewed discharge processes to help identify opportunities for improvement.

We reviewed 5 patient safety investigation reports. Managers investigated all incidents at the right level. When we checked these reports against the provider's guidance, we found that staff had recorded the level of harm incorrectly in two reports. Staff recorded the harm as low or no harm, even though the information showed it was more serious.

The service shared learning from incidents with staff in different ways including ‘feedback Friday’, staff meetings, daily huddles and consultants’ digest. We asked staff who confirmed these were held and notes shared about learning from incidents across different departments. However, it did not always explain clearly what actions it would take to make improvements. There was limited evidence of follow-up, so it was not always clear whether changes had been made or whether learning had led to improvements in patient care over time.

The service had policies to support staff to report and investigate incidents. Staff told us they knew how to report incidents and near misses, and the service used an electronic reporting system. However, agency staff could not access this system, which meant not everyone was able to report incidents in the same way.

Staff understood their responsibility to be open and honest with patients when things went wrong and followed the service’s Duty of Candour policy when needed. When staff identified an immediate risk of harm to patients or others, they felt confident to take action straight away to prevent harm.

The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service had systems in place to keep patients safe during their surgical care. There were clear admission criteria which set out the patients the service could safely admit and treat, as well as the conditions it could and could not manage on site As a Level 0 hospital, the service only admitted patients who were medically stable and could be safely cared for on a standard ward without needing additional support.

The ward included beds for patients who needed closer monitoring. Staff had access to policies for admission, pre‑operative assessment, consent and discharge. Staff described how they used these policies to guide their day‑to‑day practice.

Staff assessed patients before surgery and used the information gathered to plan care and treatment. The service had an established pre‑operative assessment process. Audit data showed staff completed pre‑operative assessments in 99% of cases, which showed strong compliance with the service’s standards.

Patients told us they felt prepared for surgery and understood what to expect. Consultants held regular multidisciplinary meetings to agree surgical plans. The service held Admission Assessment Meetings (AAM) to review patients’ suitability for surgery and identify any additional support needs. We observed an AAM during our assessment and saw staff discussing patients in detail to support planning and risk management.

The service used clear admission criteria. This made sure the service only admitted patients whose care needs could be safely met. Staff said the criteria supported safe decision-making. Staff gave examples of postponing, cancelling or declining procedures when a patient was not suitable for treatment within the service. Records we reviewed showed staff applied this approach appropriately and acted in patients’ best interests.

Staff identified patients with additional needs and made reasonable adjustments to support their care. For example, we saw a patient with neurodiverse needs was allocated a quieter side room to ensure care was delivered in an appropriate and supportive environment.

Staff followed recognised safety processes in theatres. Audit data showed 100% compliance with the World Health Organization (WHO) Surgical Safety Checklist between February 2025 and January 2026. Audit data also showed 100% compliance with the ‘Stop Before You Block’ safety check. During our observations, we saw staff complete patient identity checks and follow theatre safety processes in line with national guidance.

We observed staff completing patient identity checks and following theatre safety processes in line with national guidance.

The service had clear policies in place to help staff recognise and escalate concerns about deteriorating patients. Staff used the National Early Warning Score (NEWS2) to monitor patients and used a structured communication tool to escalate concerns appropriately. A registered doctor was on site 24 hours a day, 7 days a week to review patients whose condition deteriorated.

The service had a policy that allowed patients and their families to request an independent review of care through “Ask to Escalate”. This was a patient safety initiative to support the early detection of deterioration by ensuring the concerns of patients, families, carers and staff are listened to and acted upon.

Consultants responded promptly when staff requested support. Staff told us they felt confident to escalate concerns at any time.

Transfers between theatres, recovery and the ward were carried out safely. The anaesthetist remained responsible for patients while they were in recovery. Staff described clear communication between teams. Ward staff told us handovers from recovery were smooth and consistent.

Although discharge-related incidents had been reported, the service followed a structured discharge process. Staff assessed patients to make sure they were medically fit for discharge. They provided patients with written and verbal information about their recovery, including who to contact if they had any concerns. We reviewed discharge records and found staff completed them appropriately. Staff shared discharge summaries with GPs and other relevant services to support continuity of care.

The service had an escalation agreement in place for deteriorating patients and followed an established transfer policy for patients who required urgent care at a local NHS trust. Between February 2025 and January 2026, the service recorded 10 patient transfers to local NHS providers for higher‑level care. Staff told us these transfers were carried out safely and described the use of a closed‑loop transfer process. The closed‑loop process had been completed for 9 of the 10 transfers. In one example, the service had not obtained a follow-up update on the patient's outcome after transfer

Staff worked collaboratively with external providers to support patient care. Physiotherapy staff described effective working relationships with a local authority equipment provider, which enabled mobility equipment to be sourced promptly. This supported safe mobilisation for patients and helped reduce pressure on NHS services.

Patient records were a mixture of electronic, and paper based and were kept securely. The IT connectivity was consistently available across the service to meet the needs of staff completing the records.

A patient told us their transfer from the NHS to the hospital was straightforward and communication had been “brilliant”.

The evidence showed some shortfalls. The service did not always work well with patients and healthcare partners to understand what being safe meant to them and how to achieve that. They did not always concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. They did not always share concerns quickly and appropriately.

Not all staff had completed mandatory safeguarding training relevant to their role. The service set a target of 95% for safeguarding training by end of March each year. At the time of our assessment, compliance levels varied across departments. Compliance on the wards ranged between 72.7% and 77.3%, and pre‑operative assessment ranged from 75% to 100%, with overall compliance of 87.5%. Pharmacy had the lowest compliance at 50%. However, theatres, including endoscopy, achieved high compliance at 98.4%, while physiotherapy achieved 100% compliance across all required modules. Plans were in place to ensure compliance by March 2026.

The service could not be assured that staff consistently understood their safeguarding responsibilities. Staff we spoke with were unable to give examples of how they safeguarded patients at risk of, or experiencing, harm. When we looked at safeguarding incident records, it was not always clear whether the service had taken all reasonable steps to safeguard people beyond addressing their immediate safety needs. This meant opportunities to identify wider safeguarding concerns and support ongoing protection may not always have been fully considered.

The hospital director held overall responsibility for safeguarding. The deputy director of clinical services acted as the safeguarding lead and had completed level 4 safeguarding training. Staff described the safeguarding lead as supportive, visible, and easily accessible for advice.

The service had an up‑to‑date safeguarding policy and pathway aligned with national guidance. Staff could easily access this information through the intranet, and the service displayed safeguarding posters in pre‑operative assessment, theatre, and ward areas. Staff knew how to access safeguarding procedures and how to escalate concerns. They demonstrated an understanding of how to protect patients from abuse and how to work with partner agencies when required.

Staff also demonstrated an understanding of the Mental Capacity Act (2005) and Deprivation of Liberty Safeguards and had completed relevant training. We saw an example of how staff supported a person who lacked capacity during the pre‑operative assessment process.

The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The service had clear systems in place to assess and manage risks to patients throughout their surgical journey. Staff assessed risks before and after surgery and used this information to plan care that met each patient’s individual needs.

We reviewed 12 patient records and found that staff had completed and recorded risk assessments appropriately. These included assessments for blood clots (VTE), risk of falls and nutrition. Staff used this information to support safe care and make appropriate clinical decisions.

Staff used nationally recognised tools to monitor patients’ health and spot early signs of deterioration. They recorded National Early Warning Score (NEWS2) observations correctly and said they understood when and how to escalate concerns if a patient’s condition changed. Staff told us they felt confident and supported to raise concerns with senior colleagues when needed. Audit data showed that 97% of NEWS2 observations were completed correctly.

The service held regular multidisciplinary team meetings to review patients and plan their care. Senior clinicians attended these meetings. Staff discussed patients’ individual risks, support needs and whether surgery was appropriate, helping to ensure care was safe and well planned.

Patients we spoke with told us they understood the risks and benefits of their surgery. They said staff discussed consent with them and completed it before their procedure. Patients felt involved in decisions about their care. One patient on the ward told us they were pain free following surgery and that staff had met their care needs.

Staff told us they held daily safety huddles. Records showed these meetings were used to share important safety information, including risks such as falls. This helped ensure information was shared clearly and consistently between teams.

Staff followed recognised safety procedures in theatre, including using the World Health Organization (WHO) surgical safety checklist. Staff understood their roles in keeping patients safe and told us they would stop a procedure if they had concerns about patient safety. The service also made reasonable adjustments for patients with additional needs. For example, we saw staff adapt their communication and involve a patient with learning difficulties directly in discussions so they could understand what would happen.

We observed physiotherapy staff supporting patients to walk safely after surgery. They encouraged patients to wear non-slip socks and used simple measures to reduce the risk of falls. We spoke with 4 patients who told us staff explained risks before treatment and checked they understood before proceeding.

The evidence showed a good standard. The service detected and controlled potential risks in the care environment. Leaders and staff made sure equipment, facilities and technology supported the delivery of safe care. Where they were unable to do so, they mitigated the risks.

The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use equipment and to manage different types of waste safely.

The design of the environment followed national guidance around the built environment. Where required, areas were secure and protected patients.

Access to theatre areas was appropriately restricted through swipe‑card entry controls. However, access to the ward was unrestricted. Members of the public could enter directly through the main entrance without challenge or access control measures. This meant the service could not be assured that only authorised individuals were accessing the ward at all times, which posed a potential risk to patient safety and security. Leaders told us they used closed‑circuit television (CCTV) to help lessen this risk.

The environment of the wards and other areas used for patient care reduced the risk of patient harm, and included, for example, safe flooring, handrails and window restrictors.

Leaders maintained oversight of equipment to ensure it was safe and ready to use. Equipment audits were completed and outcomes shared with staff. Staff told us they had enough equipment to carry out their work safely and to support the treatment and care needs of patients. There were effective means of ensuring repair of replacement of broken or missing equipment.

Fire safety equipment was available and had been serviced. Fire exits were clear and free from obstruction.

The service had effective systems in place to make sure the environment supported safe care. Clinical areas, including pre-operative assessment rooms, the ward, theatres and equipment storage areas, were visibly clean, orderly and free from clutter. Staff showed us clearly labelled clean and dirty utility rooms, which they used correctly to keep clean equipment separate from used items and waste. Furniture was in good condition and suitable for patient use. It was made from wipeable materials, which supported effective cleaning.

Staff stored equipment safely and kept it well organised and ready for use. They told us they had access to enough appropriate equipment to carry out their roles effectively. One consultant gave an example of specialist equipment they felt was of a particularly high standard and helped them deliver high quality care.

The service used tracking systems for surgical instrument trays, which allowed staff to trace instruments from decontamination through to use. Staff stored substances covered by Control of Substances Hazardous to Health (COSHH) regulations securely in locked cupboards within staff-only areas.

Resuscitation trolleys were available in clinical areas. Staff knew where they were located and how to use them. The service sealed the trolleys with tamper-evident tags so staff could clearly see if equipment had been accessed. Staff completed daily and monthly checks, and we found no gaps in records. The quarterly resuscitation trolley audit was 100%.

The design and layout of the hospital supported care for Level 0 patients, who require routine ward-based care. The ward had three high-observation beds for patients who needed closer monitoring. Bedroom doors were solid and did not have observation panels, which reduced visibility into rooms. Staff managed this risk by carrying out more frequent observations, ensuring call bells were always within reach, and placing patients who needed closer monitoring near the nurses’ station. Staff clearly documented individual risks and used this information to guide decisions about patient placement and monitoring.

Staff told us the hospital had a designated latex-free theatre to keep patients and staff with latex sensitivities safe. Theatre environments were clean, well maintained and appropriately equipped, with equipment stored safely and ready for use.

However, during our assessment we identified that some electrical plug sockets in the pre-operative assessment area were overloaded, which posed a potential safety risk.

The evidence showed a good standard of care. The service made sure there were enough qualified, skilled and experienced staff, who received support, supervision and development. Staff worked well together to provide safe care that met people’s individual needs.

The service made sure there were enough qualified, skilled and experienced staff to provide safe care and treatment. Leaders planned staffing levels and skill mix to meet patient needs. The service had a safe staffing policy for departments and used a recognised staffing tool to calculate staffing requirements. Leaders managed staffing using an 80:20 mix of 80% permanent staff and 20% temporary bank or agency staff. Leaders told us this supported continuity of care while allowing flexibility during busier periods.

At the time of the assessment, there was one vacancy for a deputy nursing manager. The director of clinical services had been appointed and was due to start in May 2026. Leaders told us they managed these vacancies safely within existing staffing levels and received additional support from colleagues at other Spire Healthcare locations.

There was adequate 24-hour medical cover provided by 5 Responsible Medical Officers (RMO). RMOs were employed jointly with the local NHS trust and undertook a twelve-month placement whilst completing Post Graduate teaching certificate.

Sickness levels were low in the three months before the assessment. Rates were 2.9% in theatres, 1.9% on the wards and 0.2% among medical staff.

All new staff completed a 12-week induction programme and recorded progress in individual skills and learning passport and a personal learning checklist. All staff had an appraisal known as “Enabling Excellence Review” which set individual objectives and monitored progress throughout the year.

Staff confirmed they received appropriate induction and support. This included a structured induction programme, clinical supervision and a personal induction checklist for new starters. The service provided on-site induction for bank staff. Staff told us they had the skills and experience needed to carry out their roles and described supportive local leadership. However, staff also told us that when departments were busy, providing local induction for bank or agency staff placed additional pressure on permanent staff.

Consultants were not directly employed but had practising privileges at the hospital and would make arrangements individually to review their patients when they were on the ward. The service had governance arrangements for medical staff working under practising privileges. These practising privileges (PPs) were outlined in the practicing privileges and appraisal policy. This policy and other related policies documented eligibility for privileges, roles and responsibilities, scope of practice and how their work was reviewed. Consultants received a handbook which set out expectations and responsibilities. Consultants we spoke with told us their main employment was within NHS organisations, where they completed their appraisal and professional supervision.

Advisory Committee (MAC) authorised the formal granting of practicing privileges, and this was documented in staff files. The MAC committee also reviewed PPs in terms of scope of practice and competence.

Mandatory training compliance varied and did not always meet the 95% overall mandatory training target across all learning areas. Overall figures showed compliance as 87% for ward staff, 69% for staff in pre-operative assessment and physiotherapy staff compliance was 91%. Staff in the theatre department did meet the target with 97% compliance. Plans were in place to ensure compliance by March 2026.

The hospital had a defined recruitment pathway and procedures to ensure that the relevant recruitment checks had been completed for all staff. These included a disclosure and barring service (DBS) check, occupational health clearance, references and qualification and professional registration checks.

The evidence showed a good standard. The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading, by following policies. but they did not always share concerns with appropriate agencies promptly.

The service maintained a clean and safe environment. All areas we inspected were visibly clean, tidy and free from clutter, and furniture was well maintained and suitable for use. Cleaning records showed staff completed daily and weekly cleaning tasks as required. Staff followed national decontamination guidance, and spill kits were available.

Staff segregated clinical waste appropriately, sharps bins were assembled correctly and not overfilled, and staff reported sharps incidents in line with policy. Equipment was clearly labelled with “I am clean” stickers to indicate it was ready for use.

The service promoted good hand hygiene. Alcohol hand gel was available in all clinical areas and at department entrances. We observed staff cleaning their hands appropriately, and a patient confirmed their nurse washed their hands before providing care. Staff followed a bare-below-the-elbows approach. Personal protective equipment was readily available and staff used it appropriately. In theatres, staff followed aseptic non-touch technique in line with national guidance.

The service had an up-to-date infection prevention and control (IPC) policy, which staff could access via the intranet. A named IPC lead was in post. The service held quarterly IPC and antimicrobial stewardship meetings, and records showed these took place. During these meetings, staff discussed appropriate microbiological sampling, antimicrobial prescribing, and the recognition of infection and sepsis, which supported oversight of infection-related risks.

Data showed low surgical site infection (SSI) rates. From February 2025 to January 2026 figures showed for hip arthroplasty an infection rate of 0.18% and for knee arthroplasty 0.56%. There were no spinal SSIs reported. The service also recorded miscellaneous SSIs reported for procedures not included in UKHSA Surgical Site Infection surveillance programme.

The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities, and preferences. Staff involved people in planning, including when changes happen.

The service managed medicines safely and had effective systems in place to support safe practice. The service had appropriate policies and procedures, and staff had access to current local prescribing guidance. This included antimicrobial guidance and information to support venous thromboembolism (VTE) prophylaxis. Medicines were stored securely in all areas we visited. Staff managed controlled drugs appropriately, with accurate records and correct balance checks. Staff monitored fridge and room temperatures consistently.

We reviewed 12 medicine records. Staff completed them correctly and recorded allergies. We found no missing doses without a clear reason.

Medicines reconciliation audits showed 90% compliance over the previous 6 months. We observed staff administering medicines safely. They completed recognised safety checks, including confirming the right patient, medicine, dose, route and time, and checked patients’ understanding. Patients told us their pain was well controlled after surgery.

Staff had access to pharmacy support. On-site pharmacy services were available Monday to Friday between 9am and 5pm, and staff could access pharmacist advice at all times. Medicines cupboards were available on wards when the pharmacy was closed. Audit data showed high levels of compliance. Controlled drug audits over the previous 12 months showed compliance rates between 96% and 99%. Compliance with VTE prophylaxis was above 95%. The service was registered with the Home Office controlled drugs register.

Medicines governance processes supported learning from incidents. Leaders reviewed medicines-related incidents and shared learning through safety alerts, monthly bulletins and medicines management meetings. In the six months before the assessment, staff reported 22 medicines-related incidents, all of which resulted in no harm. Most themes focused on reinforcing expected safe practice rather than requiring significant changes to systems.

The service had an antimicrobial stewardship policy and access to microbiology advice. A policy was also in place to support patient self-administration of medicines where appropriate. Staff shared discharge information, including any changes to medicines, with GPs and other relevant services.

One patient told us collecting medication from the pharmacy was easy and instructions were clear.