Mount Vernon Hospital

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

The leadership had a unified vision, and prioritised equity, inclusion, and collaboration. Leaders were visible and approachable, fostering a positive environment where staff felt valued and supported. The service fostered partnerships and community engagement, enhancing integrated care delivery.

Effective governance processes facilitated risk management and quality assurance, though the service experienced challenges in addressing long waiting times and referral to treatment standards. While learning and innovation were evident in specific initiatives, there was an opportunity to develop a more comprehensive strategy to embed these practices consistently. Similarly, environmental sustainability required greater focus to align with national healthcare goals.

This service scored 71 (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 commitment to fostering a shared direction and culture built on transparency, equity, and inclusion. The Trust's overarching vision to be an outstanding healthcare provider, combined with Theatres’ mission of continuous improvement and fostering a learning-focused, blameless culture, was effectively embedded into the service. Staff at all levels were aligned with this vision and values, creating a unified approach to delivering high-quality, patient-centred care.

The development of this vision was underpinned by a structured planning process, incorporating input from patients, staff, and external stakeholders. This inclusive approach ensured that the strategy was reflective of the needs and priorities of the community and workforce. Leaders and staff exhibited a culture of compassion, collaboration, and openness, which fostered trust and a positive working environment. There was a clear focus on promoting equality, diversity, and human rights, with staff demonstrating an understanding of these principles in their daily practice. The service actively identified and addressed barriers to inclusivity, ensuring that workforce inequality was tackled, and equitable opportunities were provided to all. Regular monitoring of risks and progress against strategic goals further ensured the sustainability of the vision and its alignment with local and organisational priorities.

The service had capable, compassionate, and inclusive leaders who embodied the organisation’s culture and values. Leaders demonstrated the skills, knowledge, and experience required to manage the complexities of the service while addressing its priorities. Succession planning was implemented, enabling the service to identify and support talent within the workforce, ensuring a pipeline of skilled individuals ready to take on leadership roles.

Leaders were visible and approachable, fostering a culture of openness and collaboration. Staff and patients consistently reported feeling supported and valued, with leaders modelling behaviours that promoted respect and trust across the organisation. Leaders were quick to identify and address issues of poor culture, ensuring they did not impact the quality of care or staff wellbeing. Through regular engagement with staff and development opportunities, leaders sustained a high standard of care, and empowered staff to develop their skills and take on greater responsibilities within the service.

The service fostered a positive culture where staff felt empowered to speak up, confident that their voices would be heard and valued. Leaders actively promoted the importance of raising concerns, emphasising that doing so was integral to improving the quality of care and maintaining a safe working environment. A Freedom to Speak Up (FTSU) Guardian was in place to support staff in voicing their concerns, providing an avenue for raising issues. Additionally, staff had access to multiple reporting channels, including their direct line managers, senior leadership, and a confidential email and phone line. This comprehensive system ensured that staff felt supported and had a range of accessible options for speaking up.

When concerns were raised, leaders handled them with sensitivity and confidentiality, fostering trust within the organisation. Investigations into concerns were conducted thoroughly, with lessons learned shared transparently across the team to encourage collective improvement. In instances where mistakes occurred, patients and their families received a sincere and timely apology, as well as clear explanations of the actions being taken to prevent recurrence.

The service was committed to fostering an inclusive and equitable workplace, valuing diversity across its workforce. Leaders reviewed, and sought to improve, the organisational culture with a focus on equality, diversity, and inclusion (EDI). The Trust employed an EDI lead and implemented a comprehensive action plan aimed at enhancing career progression, promotion, and development opportunities for staff from black and minority ethnic (BME) backgrounds and other protected groups under the Equality Act. This proactive approach reflected a dedication to addressing disparities and creating equitable opportunities for all staff.

The trust supported several staff networks, including groups for disability, LGBTQ+ and allies, multicultural communities, international nurses, and women, which provided safe spaces for staff to connect, share experiences, and advocate for meaningful change. Staff reported high morale within the service, citing a strong sense of teamwork and collaboration across roles and departments. Leaders also prioritised flexible working arrangements and reasonable adjustments for disabled staff, ensuring that all employees were supported to perform their roles effectively.

The surgical service had established comprehensive governance structures and systems of accountability. Regular governance meetings were held and attended by divisional directors, nursing management, and clinical leads, ensuring multidisciplinary input in decision-making processes. These meetings were documented, with minutes reflecting discussions on performance, risk management, and quality assurance. Regular discussions during governance meetings focused on surgical site infections (SSIs), policy reviews, and improvements in vascular care, underscoring the service’s commitment to adhering to national standards. The matron also met with the divisional head nurse monthly to discuss key themes such as patient feedback, documentation, and communication.

A risk register was maintained to monitor key risks, each assigned a score and a responsible lead. These risks were reviewed and updated routinely during governance meetings to ensure continuous oversight of potential issues impacting care quality. Theatre’s related risks, such as battery-operated call bells, were being addressed in collaboration with external companies. The service ensured that call bells, anaesthetist machines, fridge temperatures, and drug rooms were checked daily to manage risks effectively.

Governance processes integrated the review of incidents, patient safety alerts, and clinical audit outcomes, with information used to update the risk register and inform quality improvement initiatives. For example, specific risks identified within surgical specialities, such as urology, were monitored, and assigned actions were followed up by designated staff. Incidents were categorised and escalated, when necessary, with learning points shared among teams.

Data and notifications were consistently submitted to external organisations as required, and information management systems ensured the confidentiality and availability of records. These systems were used to monitor the quality of care and support continuous improvement. Leaders implemented recognised quality frameworks and best practices, including GIRFT (Getting It Right First Time) meetings, to improve outcomes and address inequalities. Additionally, the service worked closely with external partners to ensure smooth patient transfers and the digitisation of screening questionnaires, contributing to improved service efficiency and patient care.

Clinical audit programmes were a core component of the governance structure, aligned with national quality frameworks and incorporating lessons from prior incidents and safety data. Staff responsible for these audits were clearly identified, and the programmes included speciality-specific elements.

While the governance framework effectively monitored and addressed most risks, challenges remained in areas such as capacity and access, especially consistent improvement of the referral to treatment times.

The service demonstrated a strong understanding of its responsibility to collaborate and work in partnership with other services, communities, and stakeholders to provide seamless care. The service actively engaged with local health and social care partners, as well as other relevant agencies, to enhance service delivery and share learning. Regular meetings and communication with external partners reflected a commitment to integrated care and collaboration aimed at improving patient outcomes.

Leaders and staff engaged openly with a range of stakeholders, including patients, equality groups, the public, and local organisations, to plan and manage services effectively. These engagements facilitated the sharing of best practices and learning, contributing to continuous improvements within the service. For instance, the governance meetings included discussions on collaborations with external bodies such as social care partners, emphasising a collaborative approach that aimed to ensure joined-up care for patients.

This commitment to partnership working supported the hospital's efforts to deliver integrated services that addressed the diverse needs of its patient population. By maintaining transparent and open communication with key organisations, the surgery service was able to implement new initiatives and explore ideas, contributing to ongoing improvements in service delivery and patient care.

The service was committed to continuous learning, innovation, and improvement by driving initiatives that directly measured outcomes and assessed their impact. Staff and leaders reflected on both successes and challenges, fostering a culture of collective problem-solving. Patients, families, and carers played an integral role in shaping improvement initiatives, ensuring that changes were aligned with community needs and focused on patient-centred care. The service prioritised staff involvement, encouraging contributions to improvement projects and allocating time and resources to help staff develop their skills in innovation and quality enhancement.

The service lead on several impactful innovations. For example, the lead anaesthetist championed a programme to screen patients for obstructive sleep apnoea, referring them to specialist hospitals for tailored management. This initiative, which improved patient outcomes, was presented at national conferences. The team also completed audits to support critical business cases, including the recruitment of additional surgical geriatricians to run frailty assessment clinics. Furthermore, the service implemented preoperative iron deficiency anaemia screening for patients undergoing major surgery. By treating anaemia, the service reduced hospital stays and improved postoperative outcomes, with these findings also presented nationally.