Mount Gould 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

We looked for evidence that people had the best possible outcomes because their needs were assessed. We checked that people’s care, support and treatment reflected these needs ensuring people were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

This key question has been rated good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

We have not awarded this service a score for Effective.

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

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

People using the service told us it was accessible and met their needs.

The service had processes to assess people’s needs. Staff carried out pregnancy checks in line with legislation and was trialling a more inclusive processes to support all patients attending appointments. There were processes to support people who had a learning disability to attend appointments. Staff from the Learning Disability Team could be contacted to support people to attend their appointments if they needed this support. People’s needs were reviewed at booking, and where appropriate extended appointment times were offered to allow more time for staff to respond to and meet people’s needs.

Staff told us they had enough time to attend to people’s needs during appointments.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. Staff did this in line with legislation and current evidence-based good practice and standards.

During the assessment we observed staff following safety protocols. Checks included confirming people’s identity and selecting ionising radiation exposure to be as low as reasonably practicable (ALARP).

There were processes to deliver care in line with legislation and best practice. The service carried out audits to monitor the quality and safety of care provided. The service had up-to-date employer’s procedures. However, folders containing printed versions of the local rules retained an out-of-date document alongside current. This meant there was a risk staff may refer to our-of-date information. Staff could identify where to find current guidance. During our onsite assessment, staff removed out-of-date printed guidance.

Staff told us they would check they were referring to current guidance by looking at the document review dates.

The service worked well across teams and services to support people.

Referrals for X-ray were only allowed from authorised professionals. The service had a named radiation protection supervisor and access to radiation protection advice. The service did not report on images onsite. Reporting was completed by a third-party provider or reporting radiographers and radiologists at the trust’s other location, Derriford Hospital. The service monitored and reviewed performance of clearly defined service level agreements with the third-party provider.

Staff told us they felt they could access support, advice and raise concerns as needed.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control.

During the assessment of the service, we saw leaflets in waiting area that provided information to support patients to live healthier lives.

Staff ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

The service monitored people’s feedback to understand how people using the service were satisfied with care provided.

The service monitored staff exposure to ionising radiation. We observed staff wearing dose badges that recorded an individual’s exposure levels. At the time of the assessment there were no national targets for plain film X-ray. However, leaders told us they were developing targets to help plan and monitor the service.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Feedback collected by the service showed 94% of people using the service said they received adequate information about their X-ray.

During the assessment of the service, we saw staff gaining consent from people to perform the X-ray. Staff understood the importance of consent and whether a person had the capacity to make a decision about their care. They would raise concern to the referrer about a person’s capacity to consent but had not had need to do this. There was a formal consent policy for the service.