SpaMedica Poole

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

This means we looked for evidence that people were protected from abuse and avoidable harm.

At our last inspection we rated this key question good. At this assessment the rating has remained good. This meant people were safe and protected from avoidable harm.

We have not awarded this service a score for Safe.

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

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had a strong reporting culture. During the 12 months prior to the assessment, 138 incidents were reported, no incidents were reported as moderate harm or above, with most recorded as no physical harm. Staff recognised and reported incidents and near misses in line with the service’s policy on the electronic system. Incidents were investigated using the SWARM approach, a structured rapid learning response that brings together relevant staff shortly after an incident to understand what happened, why it occurred, and identify immediate learning and actions to reduce the risk of recurrence. The provider had used key learning outcomes from investigations during the previous 12 months to inform their organisational patient safety and quality improvement strategy. Managers investigated incidents and shared lessons learned with the team and wider service. The hospital manager completed training in investigating patient safety incidents. Incidents were monitored at a national and local level. Staff were informed of incidents and learning through monthly team meetings.

Staff could access the duty of candour (DOC) policy on the service’s intranet site. The policy clearly outlined the roles of staff and their responsibilities regarding DOC. When something went wrong, patients received a sincere apology as soon as reasonable possibly following the incident. Patients were invited to attend a face-to-face meeting at a convenient location for them and informed of actions being taken to prevent the same reoccurrence.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service had an effective referral and admission process that ensured staff had access to all necessary information for patient care and treatment. This included information about patients’ communication needs, enabling the service to arrange interpreter support when required to ensure patients could access information and participate in their care.

The service had clear inclusion and exclusion criteria to determine which patients were suitable for treatment. Clinical staff completed health assessments and screening checks prior to surgery to ensure patients were appropriate for surgery at the location and well enough to proceed with treatment. Records included relevant information such as medical history, current medications and allergies. At the time of our assessment, most patients receiving treatment were NHS-funded. The service accepted referrals from optometrists and patients' own GPs.

Staff involved all necessary health and social care services to ensure patients had continuity of safe care. Following discharge, the service gave patients essential information and onward care details. There was a provider operated support line for patients to contact for advice post treatment. If a patient required emergency treatment there was a dedicated out of hours service that patients could attend.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The service shared concerns quickly and appropriately.

Staff were able to describe the signs of potential abuse, understood their role in safeguarding patients, and knew how to raise a safeguarding referral and report concerns through incident reporting and escalation to the safeguarding lead. Staff received both safeguarding adults and safeguarding children training at a level suitable for their role and in line with local guidance. We saw 100% of staff had completed their safeguarding training at the level required for their role. The service had a safeguarding adults and safeguarding children policy which staff could access. During the 12 months prior to inspection, the service made one safeguarding referral to protect a person from potential harm.

Staff understood the importance of supporting equality and diversity and ensured care and treatment was in accordance with the Act. Patients were supported to understand their rights, including human rights and rights under the Mental Capacity Act 2005.

Safety was promoted through defined recruitment procedures and employment checks. These included a disclosure and barring service (DBS) check, occupational health clearance, references, qualification and professional registration checks.

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

There was a strong awareness of the risks to patients across their care journeys. The approach to identifying and managing these risks was proactive and effective. We observed the pre-operative assessment process which ensured a comprehensive assessment of all risks to patients. When there were concerns, these were acted upon to ensure the patients wellbeing.

Patients had all treatment under local anaesthetic; the service did not use general anaesthesia. Staff worked closely with other clinicians, including opticians and GPs to ensure they understood the patient risks. Patients were informed about the risks and possible complications and how to keep themselves safe. Staff assessed risks in collaboration with patients.

The service took potential risks to patients seriously and ensured patients who had surgery were safe. Staff completed the World Health Organisation (WHO) safety checklist for surgery. The WHO checklist was a simple tool designed to improve team communication. We observed safety checks being carried out before and during surgery.

Staff responded promptly to any sudden deterioration in a patient’s health. There was a resuscitation and escalation policy directing staff to call 999 to transfer patients to an acute NHS hospital. Staff received paediatric and adult resuscitation training and compliance was 100%. A resuscitation trolley was available, and this was regularly checked by staff.

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service was aware of potential risks in the care environment and controlled them well. The service had facilities and equipment which met the needs of patients. Electronic equipment that was more than 1 year old was portable appliance tested (PAT) ensuring the equipment was safe to use. The service managed clinical waste and laundry safely. The domestic and clinical waste bins were clearly identified and emptied regularly in line with the service’s waste management policy. Waste was segregated and labelled in accordance with policy. The risk of sharps injuries was minimised by the safe management of sharp implements. Discarded syringes and needles were disposed of in approved clinical sharps bins. Hazardous cleaning products were stored in line with the Control of Substances Hazardous to Health (COSHH) Regulations 2002.

There was a comprehensive system to proactively manage the safety, maintenance and repair of facilities, premises and equipment. There was clear signage about what to do in the event of fire. Fire extinguishers were available and maintained. Staff were required to complete fire training as part of statutory and mandatory training. We saw 100% of staff had completed their training. Whilst we found a keypad for a door near to the theatre area was not functioning properly, this did not pose a risk to patients. We also identified inconsistencies in the equipment stored within the resuscitation trolleys and the service checklists; however this was quickly resolved by the service.

Facilities, premises and equipment were purpose-built and met the needs of all patients who used the service. The building was modern and well designed to support safe patient care. The admissions area, theatres, and recovery area were arranged to enable safe and efficient transfer between departments.

The building was bright, spacious and clean with ventilation and heating that met the requirements of the service. Daily room and fridge temperature monitoring showed the environment had been well maintained for equipment and medicines requiring consistent storage conditions.

Spill kits were available to enable staff to safely clean fluids from floors and work tops.

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service had enough staff to keep patients safe. Staff members included a hospital manager, registered nurses, healthcare technicians, scrub nurses, patient coordinators, and optometrists. The service employed permanent staff who moved between other SpaMedica services in the region to support safe staffing levels. Staff told us they understood this was a requirement to maintain patient safety, and this was part of their contract. We found 4.8% of the team at Poole had covered activity at other locations over the last 12 months. The service had more staff in post than it currently needed based on its level of activity. May 2026 staffing data indicated that 5 administration duties were recorded as unfilled which totalled 47.5 hours. The service told us this reflected an administrative vacancy and confirmed that the associated responsibilities were covered by suitably skilled staff until the vacancy was recruit to.

The service provided a range of mandatory training to all staff in line with provider policy, designed to support the needs of patients. Leaders monitored mandatory training completion rates and compliance was 97.5%. Leaders told us they were provided with regular updates of staff compliance with mandatory training, so any gaps in compliance could be addressed with staff. Staff received regular 1:1s and yearly appraisals with a 6-month midpoint review. Staff appraisals included conversations about career development and how they could be supported. Staff confirmed they were supported to develop in their careers. We saw evidence that all staff had an appraisal in the last 12 months.

Patients we spoke with were all very positive about the staff and service they received.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading.

All areas of the hospital were clean to a high standard and had suitable furnishings which were clean and well maintained. We saw there was a provider level infection prevention and control (IPC) policy, and this gave clear guidance to all staff for a range of IPC scenarios including sharps, food hygiene and linens.

The service managed and controlled infection risks effectively. The premises and equipment were clean. Staff cleaned equipment after patient contact and recorded when it was last cleaned. Wall mounted cleaning logs were present in all rooms. The housekeeping team were on duty throughout the day and a deep clean completed each evening. Records showed the service managed the risk of legionella. The service identified bacteria in the water system during the 12 months prior to our assessment, which was resolved following disinfection of the system. Leaders ensured annual water microbial tests were only undertaken by accredited companies.

Staff used records to identify how well the service prevented infections. Infection prevention and control (IPC) audits were conducted quarterly and hand hygiene audits completed monthly. The last IPC audit was performed in June 2026, the service scored 97%. The provider completed a yearly IPC report which looked at key achievements from April 2025 to March 2026 ensuring that effective prevention and control of healthcare associated infections (HCAIs) was embedded into everyday practice. The report looked at key areas such as cleaning, water, ventilation, laundry, waste and included the aims for 2026/27.

Staff followed infection control principles including the use of personal protective equipment (PPE). Hand-washing and antimicrobial hand-rub dispensers were available at strategic points for staff and visitors. We observed staff undertaking effective hand hygiene in line with best practice.

Staff worked effectively to prevent, identify and treat surgical site infections. From January 2025 to June 2026, there was 1 incidence of endophthalmitis. The 2025 NOD audit results showed a postoperative endophthalmitis rate of 0.05 which was better than the national average. Endophthalmitis is an inflammation of the internal eye tissues, most commonly caused by an infection, that is an ophthalmic emergency.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

Staff followed good practice in medicines management in line with national guidance. The service made sure medicines and treatments were safe and met patients’ needs and preferences. Staff followed systems and processes to prescribe and administer medicines safely. Medicines were prescribed, supplied and administered in line with the relevant legislation, current national guidance or best available evidence. A medicines management audit undertaken in June 2026 showed 100% compliance. Compliance with medicines management mandatory training was 92%.

Patients were involved with assessments and reviews about the level of support they needed to manage their medicines safely and to make sure their preferences were considered. Allergies were clearly recorded in the patients’ records.

Medication was securely stored with controlled access. Temperatures were recorded to ensure medicines were stored within the required temperature range according to local policy. Temperatures were monitored daily. There were arrangements for the safe management, use and oversight of controlled drugs. Controlled drug accountable officers completed routine audits of controlled drugs, the outcome of the last review at Poole raised no concerns or actions.