The Montefiore Hospital

Updated 22 July 2021

The Montefiore Hospital provides a laboratory service to Montefiore House Limited, a private hospital, where the laboratory is co-located. They specialise in analysing blood samples (biochemistry and haematology). The laboratory was established in 2013 and is operated by Spire Healthcare Limited.

The service has had a registered manager in post since 2013 and is registered to provide the following regulated activities:

• Diagnostic and screening procedures.
• Management of supply of blood and blood derived products.

The service was last inspected in 2014 under a different methodology and met the standards of quality and safety with no breaches in regulation.

The laboratory is registered with the United Kingdom Accreditation Service (UKAS), which is the internationally recognised accreditation for medical laboratories. The most recent UKAS inspection took place on 15 October 2020. There were four actions which had all been completed.

The service processes a number of blood samples each day as well as triaging other samples, such as tissue, urine and sputum, to other hospitals for analysis. It is a small independent laboratory in one room within a private hospital. There is a biomedical scientist manager, two biomedical scientists, and one assistant biomedical scientist. Staff have the use of the facilities within the hospital such as the staff changing rooms, restaurant and toilets.

The laboratory does not have any direct contact with patients.

The laboratory is open from 8am to 6pm from Monday to Friday and from 9am to 1pm on Saturdays. There is a 24 hour on call system in place for more urgent requests.

We carried out an unannounced inspection on 25 May 2021 using our comprehensive inspection methodology.

Updated 22 July 2021

We did not rate this service. This is because CQC does not apply a rating to independent laboratory services.

We looked at four key questions: is the service safe, effective, responsive and well led. We did not inspect caring. This is because the service does not interact with patients.

• The service provided training in key skills to all staff and made sure everyone completed it. Staff had training on how to recognise and report abuse and they knew how to apply it. All areas within the laboratory were clean and had suitable furnishings. The design, maintenance and use of facilities, premises and equipment kept people safe. Staff completed and updated risk assessments to remove or minimise risks. The service had enough staff with the right qualifications, skills, training and experience. There was a system to report safety incidents and staff knew how to report incidents and near misses.
• The service provided care and treatment based on national guidance and evidence-based practice. The service made sure staff were competent for their roles. Staff worked together with the wider hospital team to benefit patients. The service was available six days a week with urgent cover available outside of normal hours and during busy times.
• The service was delivered in a way that met the needs of the hospital. Facilities and premises were appropriate for the services being delivered. There was an annual user feedback survey which staff at the hospital were invited to complete. Staff were encouraged to suggest improvements.
• Leaders had the skills and abilities to run the service and were visible and approachable. There was a clear leadership structure from service level to senior management level. Staff were aware of the overall vision and strategy and felt part of the vision for the hospital. Staff felt respected, supported and valued. The service had an open culture where staff could raise concerns. Leaders operated effective governance processes. Leaders and teams used systems to manage performance effectively. The service collected reliable data and analysed it. The information systems were integrated and secure. Leaders and staff engaged well with colleagues from the hospital and there were positive and collaborative relationships with external partners. Staff were committed to continually learning and improving services.

Updated 22 July 2021

We did not rate this service. This is because CQC does not apply a rating to independent laboratory services.