Mount Gould Hospital

Updated 27 May 2025

Date of assessment: 26 February to 18 March 2025. Mount Gould Hospital provides a range of NHS hospital services. This assessment looked at diagnostic imaging services, which we rated as good. The rating from diagnostic imaging has been combined with ratings of the other services from the last inspections. See our previous reports to get a full picture of all other services at Mount Gould Hospital. The rating of Mount Gould Hospital remains requires improvement. In our assessment of diagnostic imaging services, we found people were kept safe and protected from avoidable harm. There were effective processes to monitor the quality and safety of the service and ensure people could access the service. The service had a positive culture with capable leaders. Governance processes were robust, and leaders mitigated risks

Updated 25 November 2016

• Some staff were still not receiving feedback from incidents.

• Staff incident reporting was the only safety indicator used by some senior managers.

• Cleaning audits carried out by Livewell were not shared with staff.

• Some diagnostic imaging protocols were out of date and referred to out of date practice.

• Staff were unsure how information about patients additional needs was gathered.

• A backlog of typing in some specialties was having a knock on effect to other specialties.

• The pain management service sometimes had more patients booked than it had capacity.

• Some specialties still had DNA rates above the England average.

However:

• Senior staff provided guidance and support to junior staff to help them report safety incidents.

• Regular hand hygiene audits in pain management fed results directly back to monthly governance meetings.

• The number of temporary notes had reduced, and audits were being carried out.

• A new system of monitoring FP10 had been introduced.

• A pharmacy review of medicines had removed unused medicines from the pain management outpatients, and regular pharmacy visits had increased their visibility to staff and strengthened relationships.

• Diagnostic reference levels had been implemented.

• Patient outcome audit results had been presented nationally, and a senior nurse sat on the NICE board.

• External organisations had been approached to help develop new policy documents.

• Pain management planned some of its treatment to suit the needs of the patients.

• Large notice boards displayed patient centered information.

• A new reporting structure in the bookings team had helped develop a live clinic booking system, and work was being done to maximise the clinic use through overbookings.

• Overall, the DNA rate in outpatients and pain management had improved, and less than 1% of diagnostic imaging patients DNA.

• Pain management and ENT collected friends and family test data to continually improve services for patients.

• There was strong leadership in the pain management service and good working relationships in the bookings team.

• Staff fed and understood how audits fed into the overall governance framework.

• One central equipment register in diagnostic imaging helped plan the future capital replacement program.