Mount Vernon 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

The service had a proactive approach to ensuring patient safety, with strong processes for risk management, infection control, safeguarding, medicines optimisation, and maintaining a safe environment. The service fostered a culture of learning and transparency, actively encouraging staff to report incidents and share lessons learned. This culture was supported by visible mechanisms such as ward meetings, incident boards, and bitesize learning sessions, which promoted ongoing improvement in safety practices. The implementation of protocols like the WHO surgical checklist, "Stop Before You Block," and robust pre-operative and post-operative assessments underscored the service’s commitment to minimising risks throughout the patient care pathway.

The hospital maintained effective systems for managing clinical and operational risks, such as sepsis screening, accurate documentation of allergies, and daily checks of critical equipment. These measures, combined with safe staffing ratios and staff development programmes, supported the delivery of safe and effective care. The hospital had safe medicines management systems, with rigorous storage, disposal, and reconciliation processes in place to safeguard patients. Efforts to ensure cleanliness and compliance with infection prevention and control protocols, including regular audits and the use of personal protective equipment, further enhanced the safety of the environment.

This service scored 66 (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 fostered a culture of openness, transparency, and continuous improvement, ensuring patient safety through proactive incident reporting and collective learning. Staff expressed confidence and comfort in raising safety concerns, emphasising that their input was valued and taken seriously, contributing to a supportive and collaborative environment. This culture not only encouraged accountability but also promoted collective learning, which was evident across various practices within the service.

The department had established clear processes for incident reporting, organisational learning, and continuous improvement. Monthly ward meetings served as a platform where incidents were routinely discussed, ensuring that staff could review recent events and learn from them. Minutes from these meetings were made available to all staff, promoting transparency and enabling engagement. Additionally, the service employed visible methods to share learning outcomes; an information board within the ward displayed recent incidents and the lessons learned, ensuring that staff, regardless of their shift patterns, were kept informed of safety updates and procedural improvements.

A culture of daily learning and communication was ingrained in the service. Staff routinely discussed issues in real-time, facilitating immediate corrective actions and reinforcing the mindset of continuous improvement. The use of modern communication tools, such as a dedicated messenger group, allowed swift dissemination of information, ensuring quick responses and keeping all team members informed and engaged.

The surgical service also implemented “bitesize learning” initiatives, which were designed to address specific incidents and promote targeted improvements in clinical practice. One example observed during the inspection highlighted how the department responded to a 16-hour delay in identifying urine retention after a laparoscopic procedure, which led to a suspected bladder injury. The department introduced several measures aimed at enhancing patient safety and care quality, including enhanced monitoring where nursing staff were now required to ensure patients passed urine within 4 - 6 hours post-procedure, with further investigations mandated if they did not. Escalation protocols were put in place to address potential issues promptly, and there was an increased emphasis on accurate fluid balance documentation to ensure comprehensive monitoring. Staff were also reminded of the Trust’s Bladder Care protocol for Gynaecology Patients during the post-surgical period, reinforcing adherence to best practices. These bitesize learning sessions reflected a structured and proactive approach to embedding lessons learned into everyday clinical practice.

In alignment with its commitment to safety, the surgical service adhered to the principles of the Duty of Candour. This ensured that incidents were not only reported but were also communicated openly to the affected individuals and their families, reinforcing a sense of trust and accountability. The department’s approach to managing complaints was similarly effective. Staff reported that formal complaints were rare, as most concerns were resolved promptly and informally at the local level. This proactive resolution strategy minimised escalation while promoting a culture of accountability and learning.

The surgical service emphasised a collaborative approach to care, ensuring that patients, staff, and key partners were involved throughout the surgical pathway. Structured processes were in place for referrals, admissions, and discharges, enabling safe and seamless transitions at each stage of a patient’s journey. A local transfer policy was observed in action, detailing the escalation of patients from Mount Vernon Hospital to Hillingdon Hospital when a higher level of care or specialised treatment was required. This policy facilitated prompt and secure transfers, with well-defined communication channels between the 2 hospitals ensuring that patient progress was monitored closely throughout.

To manage risks effectively, the hospital integrated a sepsis screening tool within both the preoperative and postoperative stages. This tool was crucial in identifying early signs of sepsis, a potentially life-threatening condition, allowing for timely intervention and improving patient outcomes. The inclusion of this tool demonstrated the hospital’s proactive approach to managing risks associated with surgical care.

Risk assessments were thorough across all stages of surgical care. The inspection highlighted the use of the surgical WHO checklist, which was followed by surgeons. This checklist served as a vital safety mechanism, ensuring that all necessary precautions were taken before, during, and after surgery. Such practices reduced the likelihood of errors, contributing to a safer surgical environment for patients.

However, the inspection noted an ongoing issue with the readability of patient ID wristbands, raised by both patients and anaesthetic staff. This problem had been previously identified but remained unresolved, posing a risk to the accuracy of patient identification. Addressing this concern was critical, as accurate identification is essential in preventing errors during surgical procedures.

In promoting safety, the hospital also implemented the "Stop Before You Block" initiative, which involved displaying posters in each theatre. These reminders encouraged anaesthetic staff to pause and verify the procedure and site before administering regional anaesthesia. This initiative was part of a broader strategy aimed at reducing the risk of wrong-site surgery and enhancing safety throughout the surgical care episode.

Partnership working was central to the hospital’s approach, ensuring that stakeholders involved in a patient’s care were well-informed and engaged. Regular feedback was solicited from patients, staff, and partners, enabling the hospital to refine and aimed at improving its services continuously.

The hospital had a comprehensive safeguarding framework supported by a specialised and well-resourced team. This team included key roles such as the Head of Safeguarding for Families, the named nurse for safeguarding adults, the lead nurse for mental health, and a clinical nurse specialist for the Mental Capacity Act (MCA), Deprivation of Liberty Safeguards (DoLS), and adult safeguarding. Administrative support was also in place, providing crucial assistance to the team by managing documentation and referrals efficiently.

The inspection highlighted variability in staff understanding of what constitutes abuse, particularly among nursing staff. This inconsistency indicated a need for continuous training and education to ensure that all staff had a consistent, thorough understanding of safeguarding protocols and the different forms of abuse. Despite this variability, most staff displayed a strong awareness of how to escalate safeguarding concerns, demonstrating a generally supportive culture within the hospital. Staff were well-informed about the hospital’s safeguarding procedures, including when and how to escalate concerns, which was a critical component of the safeguarding framework.

The hospital utilised an electronic patients record system to document and flag safeguarding needs. This electronic system enabled safeguarding concerns to be reviewed promptly by the safeguarding team, ensuring efficient communication and a clear audit trail of actions taken. It was used for maintaining a swift response and providing assurance that safeguarding concerns were managed systematically.

During the inspection, only a small number of patients were identified with safeguarding needs. Those identified were referred promptly to the safeguarding team, demonstrating the effectiveness of the hospital’s procedures for detecting and addressing safeguarding concerns. The safeguarding team reviewed these cases and provided necessary support and interventions, ensuring that patient needs were met appropriately and in a timely manner.

The hospital also had a robust process for managing Deprivation of Liberty Safeguards (DoLS). This process was multi-disciplinary, involving a collaborative approach that ensured comprehensive assessment and decision-making. When a patient was identified as potentially lacking mental capacity, a two-stage mental capacity test was conducted in line with the Mental Capacity Act. The multi-disciplinary team, consisting of medical and nursing staff, worked together to assess the patient’s capacity and determine the appropriateness of implementing DoLS measures. This collaborative approach ensured that all decisions were made in the patient’s best interest, aligning with legislative requirements and upholding the patients' rights and autonomy.

The hospital's processes facilitated the early identification and management of safeguarding issues and ensured that when intervention was required, it was executed promptly and collaboratively, with the patient's best interests as the priority.

surgical service at Mount Vernon Hospital demonstrated a robust approach to managing risks, underpinned by comprehensive risk assessment protocols and patient safety practices. This included the consistent use of the National Early Warning Score (NEWS) and Venous Thromboembolism (VTE) assessments, which played a crucial role in identifying early signs of patient deterioration and minimising the risk of blood clots. Clear documentation of allergies in patient records was also prioritised, ensuring that all relevant information was accessible to clinical staff and that potential risks were mitigated effectively.

A key aspect of the service’s safety approach involved thorough pre-operative assessments. Nurses confirmed that pre-operative assessment information conducted at Hillingdon Hospital was accessible and integrated into their systems, which facilitated continuity of care. The surgical service also conducted additional "on the day" pre-operative assessments to capture any recent changes in a patient’s condition, including falls, alterations in mental health status, and mobility issues. These updates were promptly recorded in the electronic patient records system, ensuring any emerging risks were communicated to the surgical team before the procedure. This practice highlighted the service’s commitment to maintaining accurate and up-to-date information, enabling effective risk management on the day of surgery.

The hospital implemented specific measures for emergency preparedness within the surgical department. An action card specific to theatre settings outlined the procedures to be followed in the event of a fire or major incident. This card provided clear, step-by-step instructions, detailing responsibilities at various levels, including departmental, floor, building, and site-wide actions. Such guidelines demonstrated the hospital's proactive approach to risk management, ensuring staff were prepared to respond effectively in crisis situations and maintain the safety of both patients and staff.

The hospital’s management of equipment, facilities, and technology in its surgical services demonstrated a commitment to maintaining a safe, organised, and efficient environment. This approach ensured that staff could deliver safe and effective care, while the use of reciprocal agreements and external support effectively safeguarded the availability of critical surgical resources.

At the time of the inspection we observed a well-maintained environment, designed and managed in accordance with national safety guidelines to meet patient and staff needs effectively. The hospital's surgical facilities, including theatres, wards, and recovery areas, were observed to be in good condition, promoting a safe and efficient care environment that supported high-quality care delivery.

The hospital’s theatre suite consisted of 4 theatres, each equipped with an anaesthetic room, a setup area, and a scrub-up area. These areas were bright, clean, and orderly, with no outstanding repair issues noted for staff attention. The theatres themselves were spacious and well-lit, creating a safe and comfortable working environment for the surgical teams. This setup supported various multi-speciality day case procedures, demonstrating the hospital’s flexibility and readiness to manage diverse surgical needs.

The anaesthetic rooms adjacent to each theatre were similarly well-maintained, offering a safe and efficient space for anaesthesia preparation and administration. Equipment within the theatre suites was found to be up-to-date and well-maintained, with the in-house electro-biomedical engineering (EBME) department handling most of the servicing. Equipment checks were current, with the most recent servicing logged in April 2024, underscoring the hospital’s commitment to maintaining reliable and safe surgical tools.

The hospital employed a dedicated staff member responsible for managing theatre packs, stored in a temperature-controlled room to preserve their integrity. This staff member also oversaw the theatre sterile supply unit (TSSU) packs, ensuring stock was rotated and supplies were kept in optimal condition. Adequate storage was observed throughout the theatre areas, which remained uncluttered, supporting a safe and organised working environment for staff.

Specialised equipment, such as the difficult intubation trolley and the cardiac arrest trolley, were checked and secured following national guidance and local policies, guaranteeing its readiness for immediate use in emergencies.

The recovery area within the theatre suite provided 8 beds for post-operative care. A one-way system was implemented with separate entrances and exits to minimise cross-contamination risks and enhance overall patient safety. Two of the recovery bays were designated for storage, clearly marked to maintain order and minimise the risk of confusion or obstruction in the recovery space.

The hospital managed sterile supplies through a reliable outsourcing arrangement, as the hospital did not have an in-house central sterile services department. An external company provided a 24-hour turnaround for the sterilisation of surgical instruments, ensuring that surgical teams had access to properly sterilised equipment promptly. To further strengthen its sterile supply chain, the hospital had reciprocal agreements with other facilities located on the same site. These agreements provided an additional safety net, enabling quick sourcing of sterile supplies if needed at short notice.

During the inspection, it was observed the service maintained well-structured staffing arrangements that supported the delivery of safe and effective care, though certain challenges were identified in specific areas.

The hospital's 4 theatres were supported by 2 recovery bays per theatre, each staffed on a 1-to-1 basis, ensuring that every patient in recovery had a dedicated staff member monitoring their progress. This ratio was a critical measure for maintaining patient safety, allowing for immediate intervention if complications arose during the post-surgical recovery period.

The hospital operated a flexible staffing model, adjusting shifts in alignment with theatre activity and patient needs. Shifts were structured based on patient theatre schedules, enabling the hospital to adapt staffing levels dynamically. Both Trinity Daycare and Trinity inpatient ward were typically staffed with 5 registered nurses (RNs) and 2 healthcare assistants (HCAs) on a long day shift. During the night shifts, 2 RNs and 1 HCA were allocated, maintaining safe staffing levels throughout different times. For shorter day shifts of 7 hours, staffing was similarly adjusted to match patient needs.

According to national guidelines, the recommended nurse-to-patient ratio is 1 qualified nurse to 6 patients during the day and 1 to ten at night. The trust informed us that it uses the safer nursing care tool to determine staffing levels, which takes into account the dependency and acuity of patients rather than applying a fixed staffing ratio. The hospital generally met these standards, with the theatre manager and nursing staff confirming that staffing was effectively managed. Additional staff could be arranged through the matron when required and supplemented with bank staff, ensuring that adequate staffing levels were consistently maintained.

While theatre staffing was generally stable, there were occurrences of long-term sick leave, which prompted the hospital to utilise bank staff to cover these gaps. Furthermore, the hospital implemented additional weekend surgery lists to address the backlog created by the COVID-19 pandemic, highlighting its proactive response in managing resources to meet patient needs. The hospital’s strategy of investing in staff development was evident, with several team members enrolled in operating department practitioner (ODP) courses. This initiative aimed to ensure a steady flow of skilled professionals, supporting the hospital’s long-term staffing resilience.

Medical staffing arrangements were also robust, ensuring comprehensive cover for all surgical specialities. The hospital maintained an emergency resident medical officer (RMO) specifically for orthopaedic cases, with anaesthetic cover also available on-site. Additionally, a clinical site practitioner was present 24/7 to provide immediate support, demonstrating the hospital’s commitment to ensuring continuous care availability.

The hospital’s day-to-day medical staffing consisted of 5 orthopaedic speciality doctors, operating on a 1 in 5 weekend rotation to provide round-the-clock coverage. Alongside these doctors, consultants from various specialities, including urology, pain management, breast surgery, general surgery, and ophthalmology, brought their teams to theatres for procedures. This approach ensured each surgical case had a skilled, specialised team available, enhancing the quality and safety of care provided. Occasionally, the hospital employed locum doctors to cover absences, ensuring the continuity of patient care.

In the pre-operative department, the hospital faced difficulties recruiting a band 7 nurse, with challenges stemming from a lack of candidates with sufficient experience and a limited number of applicants. The absence of a senior nurse required the current theatre and pre-operative matron to allocate significant time to service development, pre-operative activities, and matron responsibilities. The post was advertised following the inspection and the trust told us recruitment was in progress. This proactive approach indicated the hospital's focus on staff development and continuity of leadership. Despite the recruitment challenge, the pre-operative department maintained a stable workforce. Two new nurses joined the team, filling vacancies left by retirees and a relocated staff member. This consistent staffing support ensured that pre-operative services continued without significant disruption.

The service implemented robust infection prevention and control (IPC) measures, aligned with national guidelines, ensuring a safe environment for both patients and staff across all surgical areas. The hospital had a well-documented cleaning regime throughout theatres, recovery bays, and surgical wards, which adhered to national standards and ensured high levels of cleanliness.

The service maintained a structured approach to cleaning, with documented protocols accessible in each theatre. A yellow booklet in every theatre outlined daily, weekly, and monthly cleaning tasks, ensuring consistency and adherence to the hygiene standards. To provide visible assurance of cleanliness, green "I am clean" stickers were used on equipment following each cleaning session.

Clinical waste management within the surgical services was compliant with both national and local policies. Waste disposal areas were secured with keypad access, restricting entry to authorised personnel and reducing contamination risks. Within these areas, clearly labelled yellow clinical waste containers and sharps disposal bins ensured that hazardous materials were handled and disposed of safely. The waste removal process was well-organised, with waste bags transferred from theatres through the dirty utility room to the clinical waste area, effectively segregating clean and dirty workflows to minimise cross-contamination risks.

In compliance with the Control of Substances Hazardous to Health (COSHH) regulations, each dirty utility room was equipped with secure, locked cupboards designated for storing hazardous substances. This policy was adhered to, prioritising the safe storage of chemicals and other potentially harmful materials to prevent unauthorised access and safeguard staff and patients.

The hospital’s proactive approach extended to environmental maintenance, including the regular management of curtains in patient areas. Curtains were scheduled for replacement every 6 months, aligning with the broader IPC strategy to prevent the accumulation of pathogens. This regular replacement schedule helped in maintaining a clean environment and minimising infection risks throughout patient areas.

The hospital’s infection control measures extended beyond environmental and equipment hygiene. Staff adhered to infection control principles, including the appropriate use of personal protective equipment (PPE). They worked effectively to prevent, identify, and manage surgical site infections, employing systems that monitored infection risks and outcomes. The service’s good performance in cleanliness was reflected in high Patient-Led Assessments of the Care Environment (PLACE) scores.

Mount Vernon Hospital's surgical service demonstrated a structured approach to medicines management, aligned with national guidelines. Staff, including agency personnel, received training on medicines management and were assessed for competency, ensuring that they were well-prepared to provide safe and effective support for patients' needs. Staff were knowledgeable about accessing local medicines policies, procedures, and guidelines, enabling them to maintain good standards of practice consistently.

The service used established systems and processes to safely prescribe, administer, record, and store medicines. Patients’ medicines were reviewed regularly, with staff providing relevant advice to both patients and carers about their medications to support understanding and safe usage. During transitions or changes in levels of care, staff ensured that accurate, up-to-date information on medicines was readily available.

Pharmacists played an integral role in supporting the surgical wards, providing timely assistance with medicine-related queries. An on-call pharmacist service was available outside regular working hours, ensuring continuous support. Medication incidents were discussed in departmental meetings, with learning shared across the trust by the medication safety officers and technicians. This approach fostered a positive safety culture and encouraged the reporting, investigation, and learning from medication-related incidents, contributing to overall safety in medicines management.

Medicines were securely stored in line with national guidelines. Emergency medications were readily available on the wards, with daily audits conducted to check the contents of emergency trays, ensuring their readiness. To further support timely discharge, the surgical day case unit prepared "to take away" (TTA) medicines packs, which helped avoid discharge delays by ensuring patients received their medications promptly before leaving the hospital.

The service maintained efficient processes for the handling and disposal of controlled drugs, in line with legislation, and local policies. Medicines, including controlled substances, were disposed of safely when no longer needed, with all actions carefully documented. Medical gas cylinders, such as oxygen, were securely stored, with empty cylinders segregated to prevent confusion and maintain readiness for patient care.

To promote hygiene and prevent contamination, medicines dispensing areas and equipment, including tablet crushers and cutters, were regularly cleaned. Staff adhered to infection control principles, consistently using personal protective equipment (PPE) when handling medications. Medicines records were completed accurately and kept up to date, ensuring that documentation reflected current patient care and was accessible when needed.

Audits demonstrated safe management of medicines within the hospital. These covered essential areas, such as medicines reconciliation, missed or delayed doses, and compliance with patient safety alerts. Upon admission, medicines were carefully reconciled and recorded, ensuring accurate treatment from the outset. Patient allergy statuses were clearly highlighted on the electronic prescribing and medicines administration system, with patients wearing red wristbands to indicate allergies, minimising the risk of adverse reactions. Venous thromboembolism (VTE) risk assessments were also documented, with appropriate actions taken to manage identified risks effectively.

Lessons from safety alerts and incidents were integrated into practice to enhance patient safety, reflecting a commitment to continuous learning and improvement. Additionally, "when required" medicines use was regularly reviewed to assess its effectiveness, and clear guidance and outcomes were documented, ensuring that medication use remained appropriate and aligned with patient needs.