Mount Vernon 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

The surgical service at Mount Vernon Hospital demonstrated strengths in delivering evidence-based care, teamwork, and patient-centred consent processes. Initiatives such as the GIRFT programme, multidisciplinary collaboration, and the "joint school" programme for surgical patients showcased a commitment to quality and innovation. However, challenges were identified in communication consistency, accessibility to health promotion materials, and achieving RTT and cancer pathway targets.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service demonstrated a comprehensive, patient-centred approach to assessing and meeting the individual needs of patients, ensuring that each person received care tailored to their specific health, wellbeing, and communication requirements. Patients reported feeling well-informed and actively involved in decisions about their care. Clinicians took the time to explain available surgical options thoroughly and involved interpreters when required, enabling patients to make informed choices. This approach extended to instances where same-day surgeries were arranged, demonstrating the hospital's commitment to providing prompt, personalised, and high-quality care that responded directly to each patient’s individual needs.

The hospital run a "joint school" programme, with meetings held weekly in the physiotherapy department; it was designed to support patients preparing for joint surgeries. Patients who had completed their initial pre-operative assessments attended this programme, where they received additional information about their upcoming procedures. On arrival, they were booked in by a physiotherapy assistant and completed forms detailing their home environment, such as bed and chair heights, to ensure that post-operative care was adapted to their specific needs. This focus on tailoring care to the patient’s living situation supported a smoother, safer recovery.

The joint school was a multidisciplinary effort involving pre-operative staff, ward nurses, and occupational therapy professionals, each playing a role in delivering thorough care planning. Patients received clear information on what to expect throughout their recovery process, with physiotherapists providing detailed explanations of the recovery process and necessary steps to aid healing. Staff also discussed discharge medications and recovery timelines to ensure patients had a clear understanding of their treatment and self-care expectations post-discharge. It helped patients feel more confident and engaged in their own recovery, maximising the effectiveness of their treatment.

While feedback on the patient experience in surgical services was generally positive, there were isolated concerns regarding interactions with the pre-operative nursing team. A few patients expressed that they had encountered communication challenges, mentioning that some nurses did not appear fully informed, and 1 patient noted a nurse’s response was dismissive. Senior staff clarified that the pre-operative nursing team was primarily based at the Hillingdon Hospital site, with a smaller team stationed at Mount Vernon Hospital to support patients unable to travel. The trust reported no formal complaints about pre-operative communication; however, these concerns highlighted the importance of ensuring consistency in patient experience and communication standards across both sites.

Additionally, feedback from 1 patient indicated a need for improvement in post-operative care, as they had not been provided with pain relief following a prior surgery and had incorrectly been told their stitches were dissolvable.

The service demonstrated a strong commitment to evidence-based care and continuous improvement by implementing clinical practices aligned with national guidance and standards. Staff adhered to up-to-date policies and followed national best practice guidance. Systems were in place to check compliance with these policies, ensuring high-quality care that met current standards.

The service regularly reviewed outcomes and applied evidence-based practices to improve the quality and effectiveness of patient care. Central to this commitment was the incorporation of the "Getting It Right First Time" (GIRFT) initiative, which helped reduce unwarranted variations in care and supported the sharing of best practices within the NHS. In response to GIRFT recommendations, the surgical service introduced an enhanced screening protocol in February 2023. This protocol involved an early assessment of patients at the time of listing for surgery, allowing the service to identify and address any optimisation needs before patients underwent their procedures. The screening process covered several key areas, including anaemia, diabetes, and obstructive sleep apnoea, and provided referrals for patients who needed further management at a partnering local hospital. This patient-centred approach ensured that individuals were in optimal health for surgery, reducing the risk of complications and improving recovery outcomes. The peri-operative care was supported by the involvement of a lead anaesthetist, who provided recommendations for additional screenings that could benefit patient safety and recovery.

However, despite the proactive approach, the service noted that not all patients attended pre-operative assessments due to various constraints. To mitigate this challenge, the hospital is working with the wider North West London Acute Provider Collaborative to develop a digital design solution for pre-operative assessments across the sector. This initiative aims to enhance accessibility and allow patients to participate in assessments remotely.

Patients reported feeling well-supported and noted that clinicians provided clear, understandable explanations of their care options and the rationale behind each intervention. This transparency ensured patients were involved in the planning of their care and had a solid understanding of how recommendations applied to their treatment plans.

The service prioritised timeliness in care delivery, with the breast unit meeting faster diagnosis standards to ensure that patients received prompt, relevant care. Additionally, staff referred to the psychological and emotional needs of patients during handover meetings, demonstrating an integrated approach to patient wellbeing.

During the assessment we observed staff, teams, and services collaborated effectively to deliver coordinated, patient-centred care. The multidisciplinary team (MDT) approach ensured that patient care was well-integrated across different departments, and relevant information was shared to support informed decision-making and continuity of care.

Patients expressed confidence in the hospital’s teamwork, citing clear communication and a proactive approach to discharge planning. For example, 1 patient reported that additional carers were arranged upon discharge to support them at home, highlighting the hospital’s commitment to tailoring care transitions to individual needs. This emphasis on coordinated discharge planning demonstrated how the hospital’s staff worked collectively to support each patient throughout their hospital stay and beyond, with teams working together to ensure continuity and a smooth transition into community care.

Staff across various specialities and roles, including doctors, nurses, and allied health professionals told us they felt supported by their colleagues. This mutual support contributed to a positive working environment and facilitated quality patient care. Regular and effective MDT meetings enabled staff to discuss patient cases in depth, allowing each professional to contribute their expertise to enhance patient outcomes.

Staff demonstrated effective communication and coordination for patients moving between services, ensuring that all necessary information followed the patient throughout their care journey. This approach allowed patients to ‘tell their story only once’, with seamless information sharing ensuring that each team had a full understanding of the patient’s history and ongoing needs.

The surgical service demonstrated a clear focus on patient education and preventive health practices, empowering patients to take an active role in their recovery and future health. The patient-centred approach, combined with individualised advice from clinical staff, underscored the service’s dedication to promoting long-term health and supporting patients’ independence and well-being.

Patients consistently reported feeling empowered by the practical guidance provided by the clinical staff, who encouraged them to make healthy lifestyle choices to support recovery and maintain their overall health. Staff provided practical advice tailored to each patient’s needs, including guidance on post-operative care and lifestyle adjustments. For example, health promotion materials were readily available, for example, on topics such as breast self-examinations, or enabling patients to actively monitor their health. Nurses also offered specific interventions for patients identified as smokers, encouraging smoking reduction and providing nicotine patches as part of a supportive approach to smoking cessation.

Although the service typically provided health promotion information electronically—covering areas such as alcohol consumption, smoking cessation, and healthy diets—printed resources were not routinely available in clinical areas. However, staff were able to print information on request, including in a patient's preferred language, which allowed for personalised, up-to-date materials tailored to individual needs.

The service demonstrated a strong commitment to monitoring and improving patient outcomes through adherence to national standards, accreditation, and continuous quality improvement initiatives. As 1 of only 40 trusts in the UK awarded surgical hub accreditation, the hospital's surgical services were recognised for excellence in surgical care, consistently applying best practices and standards to ensure safe, effective, and reliable treatment for patients. The service also implemented a programme of regular audits across clinical areas, which assessed the quality and effectiveness of care and treatment provided. These audits served as a tool to evaluate compliance with evidence-based clinical guidelines and identify areas for improvement. Findings from these audits were reviewed at both departmental and organisational levels, with managers and clinical teams collaborating to implement improvements where required.

The hospital’s compliance with cancer treatment standards showed strong performance in some areas, particularly in relation to the faster diagnosis standard (FDS), where breast, children/CTYA, and skin pathways achieved high compliance rates, ensuring timely access to initial consultations for these patients. However, compliance in gynaecology, colorectal, and urology pathways was below the expected standard, with rates as low as 64%, indicating the need for targeted improvements to ensure timely initial assessments and follow-up care for patients on these pathways. Variability was also evident in the 62-day standard, though the hospital showed generally strong compliance with the 31-day cancer pathway. Low patient volumes in certain specialties and frequent referrals to other facilities made it difficult to assess specific performance levels across individual specialties. Nevertheless, the hospital demonstrated an improvement in cancer performance, related to the FDS, when compared to 2022 and 2023.

In elective care, the hospital met or exceeded its planned activity levels in several categories from April to June 2024, with elective inpatient and day case procedures exceeding planned levels of episodes of care. The activity reached between 103% and 154% of planned levels in certain months, reflecting the hospital's capacity to manage and even surpass its targeted volumes, thereby improving timely access to care for many patients.

The service had established time-bound targets to reduce waiting times and improve patient flow across its services. A key objective was to eliminate 52-week waits across all specialties (except in high-demand areas such as ENT and Trauma Orthopaedics) by September 2024. In addition, the Trust aimed for a 10% reduction in 0-17 week waits across all specialties by March 2025. For cancer care, the Trust set ambitious targets to achieve a 70% treatment rate within the 62-day cancer wait standard and a 77% compliance rate with the FDS by March 2025.

Despite these efforts, the referral to treatment (RTT) dashboard indicated ongoing challenges, with long wait times exceeding trajectory targets. The number of patients waiting 52 weeks or longer remained static or showed only slight declines, reflecting difficulty in achieving the planned reduction in long waits (April to July 2024). Although the total number of patients waiting over 52 weeks in 2024 (up to August 2024) was lower than in 2022 and 2023, substantial wait times persisted across categories like 40, 27, 18, and 16 weeks, particularly in the 27 and 40-week categories, highlighting ongoing difficulties in reducing wait times to clinically acceptable thresholds. Data suggested challenges in meeting RTT recovery plans.

Patient outcomes, including readmission rates, were routinely monitored and compared with national benchmarks, allowing the hospital to assess its performance relative to broader standards. Managers and staff regularly reviewed audit results to inform practice changes, making data accessible to all staff members to keep them informed of performance metrics and areas requiring focus. This culture of shared knowledge and accountability fostered improvement within the surgical department.

The hospital’s surgical services demonstrated a thorough and patient-centred approach to obtaining consent, which was underpinned by adherence to national legislation and guidance. Patients consistently reported satisfaction with the consent process, highlighting that their views, wishes, and concerns were actively considered during the planning of their care. The service ensured that patients were provided with sufficient time and clear information to enable informed decision-making, promoting a sense of confidence and autonomy. Healthcare professionals routinely sought consent prior to delivering care and treatment, and observations during the inspection confirmed a diligent and respectful approach. Comprehensive consent forms, which included structured statements to clarify patients’ understanding, further enhanced this process. These forms also allowed patients to withdraw consent at any stage, reinforcing their right to maintain control over their care decisions.

Staff demonstrated a solid understanding of the Mental Capacity Act (MCA) 2005 ensuring that patients who lacked capacity were supported appropriately. Where patients could not provide consent, decisions were made in their best interest, considering their cultural background, traditions, and known preferences. This was supported by accurate and detailed documentation in patient records.

Staff brought our attention to an incident involving a missing consent form, which delayed a scheduled surgical procedure, highlighted the importance of robust consent processes. Following this event, an after-action review was conducted, leading to reinforced guidance for staff to verify the accuracy and completeness of consent documentation prior to surgery. This proactive learning culture ensured that the incident was used to drive improvements. Staff received regular training in the MCA and Deprivation of Liberty Safeguards, and managers monitored compliance with relevant legislation to ensure high standards of practice were maintained.