SpaMedica Southampton

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• 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

At our last assessment 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 learned to continually identify and embed good practice.

Staff knew what incidents to report and how to report them, this included near misses. They did this using an online incident reporting system which automatically notified leaders. There was a clear policy for staff to follow when reporting an incident and all staff at the service had completed training on reporting them.

The service had no serious incidents in the 12 months prior to inspection. A serious incident is a harmful, potentially harmful, or traumatic event which requires a heightened response due to the risk of significant harm, loss, damage, or disruption to individuals or the organisation itself. Although the service had not had any serious incidents, leaders told us there was a provider level policy to ensure staff were debriefed and received support after a serious incident. The service had reported 81 incidents in the past 12 months, 78 of these incidents were graded as no physical harm, 2 were low clinical harm, and 1 was moderate harm. We reviewed these incidents and saw they had been correctly categorised. We saw how the number of incidents reported was proportionate to the service activity and in line with organisational reporting averages.

The service operated within the network of a large provider with multiple locations within the UK. Staff received feedback from investigation of incidents, both internal and external to the service. These were shared with staff electronically in weekly bulletins. Staff met to discuss that feedback. Leaders sent out emails to staff to review these for learning and to ensure changes in practice were implemented.

Safety bulletins from national safety organisations, such as the Medicines and Healthcare products Regulatory Agency (MHRA) were shared with all staff within the wider organisation. This was done through electronic safety updates and there was also a flash bulletin folder within the medicines area for staff to review. The purpose of a flash bulletin is to provide healthcare professionals and organisations with a centralised, monthly summary of all safety-critical updates and alerts.

There was a provider level Duty of Candour (DOC) policy, and this could be accessed by all staff. This was reviewed 3 yearly and in date. Staff described how the policy clearly outlined the responsibilities for all staff, dependent on their role. They were open and transparent and gave patients and families a full explanation if things went wrong. We saw evidence of staff complying with DOC. This included apologising and letting the patient know how they would investigate and take actions to prevent repeated incidents. All staff had completed mandatory training course ‘Handling Complaints’. Managers undertook complaints training specific to their role and evidence showed they had completed this training.

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 a referral and admission process that ensured all essential information about the patient was received to determine if the patient’s needs could safely be met. At the time of our assessment, the majority of patients receiving treatment were NHS funded. The service received referrals from a range of Ophthalmic providers and patients’ own GPs. Bookings for the service were centrally managed bookings by the provider. This ensured consistency and gave patients a choice of locations to suit their needs. When a new patient booking was received, staff at the service prepared patient notes which gave details of any additional requirements.

Staff involved the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. Following discharge, the service gave patients their own copy of essential information and onward care details. These were also sent electronically, or in some cases by post, to the referring clinician and patients GP.

Patients could contact a provider operated support line if they had additional questions or post treatment. This was available 24 hours a day and advice was provided by ophthalmic clinicians. The service provided an out of hours service for emergency treatment following surgery such as raised ocular pressure. Raised ocular pressure most frequently occurs around 3-7 hours after surgery. Patients from other provider locations, who did not provide emergency provision, would also be directed to the service. The service had provided emergency treatment for 24 patients in the 6 months before inspection. Of these patients 14 has surgery at the service and 10 came from other provider locations. Staff told us they worked on call as an additional service to ensure patients could access treatment easily and in good time.

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. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm, and neglect. The service shared concerns quickly and appropriately.

Staff received training specific for their role on how to recognise and report abuse. Records showed 100% of staff had completed their required safeguarding training. Staff received mandatory safeguarding children and adults training. All staff, including non-clinical staff, were trained to level 2 safeguarding adults and children. There was 1 staff member on site who was level 3 safeguarding adults and children trained. The safeguarding lead for the service was trained to level 4 and supported staff in escalating concerns and supported referral processes to the relevant local authorities.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. We spoke with staff who were able to give examples of the kinds of abuse that patients with protected characterises may experience.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. There was a safeguarding policy which was readily available on a centrally managed system. This gave clear guidance for staff to follow. There was also safeguarding pathways on display in all areas clearly instructing staff on how to raise safeguarding concerns.

Staff followed safe procedures for children visiting the service. The service did not provide treatment for patients under the age of 18 years. If a patient attended an outpatient’s appointment with a child, they were advised to bring a second adult to accompany and supervise the child while diagnostic tests were completed. Children were not able to attend when a patient received surgical services.

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.

Staff worked closely with other clinicians, including opticians and GPs to ensure they understood the patient risks.

Patients were given clear information about their appointment for treatment by reception staff. Staff undertook dynamic risk assessments on patients’ health and wellbeing from the point of arrival. Patients were risk assessed for falls, mobility issues, dementia, and to check they could tolerate lying flat during surgical procedures. Patient feedback said reception and clinical staff checked on patients and this was welcome.

Patients were informed about any risks that treatment posed and advised how to keep themselves safe. All patients were automatically risk graded with a percentage following a pre-operative assessment and were classified according to this risk. This was based on their ocular history and their co-morbidities. Patients were allocated to operating lists that reflected their risk rating. For example, a patient at higher risk of complications would be allocated a more senior surgeon and increased time for their procedure. The service did not use general anaesthesia. All patients had their treatment under local anaesthetic.

We saw risk assessments had been completed by staff to highlight concerns and record health information such as blood pressure, past medical history and allergies. This information was also recorded within electronic records to ensure easy access for staff to relevant medical information.

The staff completed a daily team brief with all the staff at the beginning of each shift followed by an additional and safety huddle for theatres. We observed a team huddle; this followed a clear agenda and discussed each patient and relevant safety considerations and clinical information. Meeting notes from the past weeks team briefs and safety huddles contained relevant information such as procedural changes, surgical lists and any safety notes such as allergies or communication restrictions to manage individual patient risks.

Staff told us knew how responded promptly to any sudden deterioration in a patient’s health but had not had to do so. There were crash trolleys in the outpatient and theatre areas and these were monitored daily. There was an escalation policy directing staff to call 999 to transfer patients to an acute NHS hospital.

There was a dedicated emergency patient helpline which was available 24 hours a day, 7 days a week. It was supported by both an optometrist on-call and senior management on-call service.

The service took potential risks to patients seriously and ensured patients who had surgery were safe. We reviewed patient journey information from admission to discharge and saw safety checks were completed diligently and at multiple stages. Staff completed the World Health Organisation (WHO) safety checklist for surgery that had been adapted and improved following learning from incidents in the organisation. The WHO checklist was a simple tool designed to improve team communication. We observed safety checks being carried out before and during surgery.

The service undertook audits to monitor compliance to NatSIPPS2 8 steps to safer surgery and WHO compliance, and these were effective in identifying improvement. NatSSIPs 2 is a set of national safety rules used in the UK to prevent mistakes during "invasive procedures. Compliance in surgical safety checklists were above target at 99% for the past 12 months. Evidence showed that in the period June-August 2025 the audit for theatre brief and debrief had highlighted a lack of compliance and this was below target at 66%. The service developed an action plan for improvement, and the subsequent 3 audits (September-November 2025) showed this had increased to 100%.

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.

Facilities, premises and equipment supported meet the needs of patients who used the service. The building was modern, and the service was located on the ground floor. The admission area, theatres and ward area were designed to allow a smooth flow. We saw an annual buildings inspection had been undertaken by an external maintenance agency in December 2025, this monitored aspects such as health and safety, fire zones, equipment, and maintenance. The inspection had noted some areas for improvement such as scuff marks on doors and a ceiling tile to be replaced. We were advised these works had been scheduled for repair.

There were separate bays within the ward where patients were seated. Staff regularly monitored each patient and carried out comfort checks with patients waiting in the ward area prior to surgery. Patients had access to a call buzzer and staff were present in clinical areas to ensure they could respond if needed. There was CCTV in all waiting areas of the service which sent a livestream to dedicated monitors in managers and reception areas.

The service monitored potential risks in the care environment took actions to minimise them. Staff made sure equipment, facilities and technology supported the delivery of safe care. There was a clear in date service level policy for the management of pathology specimens which ensure compliance with the Carriage of Dangerous Goods and Use of Transportable Pressure Equipment Regulations 2009.

A contracted Laser Protection Adviser (LPA) had completed a statutory risk assessment around the risks associated with using a laser or intense light source at a workplace. This ensured the service complied with regulations like the Control of Artificial Optical Radiation at Work Regulations (AOR) 2010.

The operating theatre had clear signage for laser surgery above all entry points. Staff could describe the safety precautions used for managing safe use of lasers. There was a provider level laser safety policy, and this had been reviewed in August 2025. The service had an in-date copy of local rules for laser safety, and all relevant staff had reviewed these and signed to say they had done so.

The service was fully compliant with laser safety checks including protective equipment availability, access security and usage reports for each laser unit. All records completed demonstrated staff had performed these checks well, with clear records to show when any additional action had been undertaken. Laser safety audits were undertaken monthly which were above provider target for compliance.

Staff carried out safety checks of specialist equipment prior to treatment taking place. We checked a sample of electrical equipment and confirmed all items had evidence of a recent portable appliance testing (PAT) safety test.

Staff disposed of clinical waste safely and used appropriate systems for the management of sharps. The service used service level agreements to manage waste streaming, including the storage and disposal of hazardous waste, in line with national standards. Processes were compliant with DHSC health technical memorandum (HTM) 07/01 in relation to the safe management and disposal of healthcare waste.

Staff managed clinical waste in accordance with the provider policy. There was an in-date provider level waste clinical waste policy that all staff could access. There were clean and dirty sluice areas, and these were well maintained and secure. Employers are legally required to assess risks from sharps injuries and put appropriate control measures in place. All sharps’ bins and sharps’ practice we observed were complaint with Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.

Cleaning and disinfection arrangements for the surgical theatre included continuous air filtration using specialist equipment. Staff used single-use equipment for minor surgery. They documented serial numbers in patient records, which meant items were fully traceable in line with national guidance. The provider had a service level agreement for the sterilisation of reusable equipment.

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, patient coordinators, and optometrists. The service employed permanent staff who moved between other SpaMedica services in the region to support safe staffing levels. This meant when other locations within the network had higher levels of patient activity, staff were required to work elsewhere. Staff told us they understood this was a necessary requirement to maintain patient safety and were happy to do this.

There was a standard operating policy to support leaders in ensuring staffing levels. We reviewed this policy and saw that it outlined clear staffing levels for a range of clinical patient scenarios and treatment areas and complied with best practice guidance from relevant bodies such as the Association for Perioperative Practice (AfPP) and Royal College of Ophthalmologist standards (RCO). We reviewed staffing levels for the 2 months prior to inspection and saw there were appropriate staffing levels and skill mix to make sure patients received consistently safe, good quality care that met their needs. These records showed the service planned staffing levels based on patient activity to allocate shifts. We heard how leaders held meetings to assess and plan staffing in line with activity.

There were robust and safe recruitment practices to make sure all staff were suitably experienced, competent and able to carry out their role. Staff received training appropriate and relevant to their role. All staff had an induction, and staff were provided with supervision as standard. We saw that there was an employee handbook available containing relevant information such as company values and learning and development.

All clinical staff competencies were aligned with the system which allocated staff to clinics based on their competency, these were renewed every 3 years. There were training and development competencies for staff to complete before being able to undertake procedures such as, sedation, eye drop administration, and anaesthetics safety. There were also role specific competencies such as scrub practitioner for Cataract surgery. Staff were not allocated to work in areas that they had not completed competencies and leaders supported all staff to complete these.

The provider offered a range of apprenticeship programmes to allow staff to gain external accredited qualifications to further their development. These included courses such as customer service specialist, coaching and mentoring, team leader supervisor and business administration.

All staff received yearly appraisals with a 6-month interim review. Staff appraisals included conversations about career development and how it could be supported. We heard how staff were supported to develop in their careers. Administrative staff told us how they had undergone training appropriate to their role which enabled them to support patients and each other. We saw data that demonstrated all staff had received an annual appraisal and 6-month interim review. All staff had also undertaken training in improving individual performance through appraisals.

Leaders told us they monitored mandatory training and were provided with weekly updates of staff compliance so that these could be addressed with staff. Mandatory training for staff was appropriate and aligned with clinical roles. The training was appropriate for the patient group using the service. Initial evidence provided by the service showed overall compliance with mandatory training for the service was just below the 95% target at 91%. We spoke with leaders at the service who evidenced that this included some staff who were on long term leave, or staff who worked on flexible contracts and had not worked at the service recently. We reviewed additional evidence which demonstrated that all staff currently based at the service had completed training.

The training lead supported new optometrists with their competencies and conducted appraisals and 6-month interim reviews. The service was a designated teaching location for the provider and provided experience for pre-registration optometrists.

The hospital had a defined recruitment pathway and procedures to help ensure relevant recruitment checks had been completed for all staff. These included a disclosure and barring service (DBS) check, occupational health clearance, references and qualification and professional registration checks.

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 and shared concerns with appropriate agencies promptly.

All areas within the service were visibly clean, had furnishings that were well-maintained and easy to clean. We saw that there was a provider level infection prevention and control (IPC) policy which had been reviewed in July 2025, and this gave clear guidance to all staff for a wide range of IPC scenarios including sharps, food hygiene and linens.

Staff completed daily cleaning check lists to record compliance with cleaning schedules and standards. Cleaning records were up to date and demonstrated that all areas were cleaned regularly. I am ‘clean’ stickers were visible and in date. Deep cleaning of surgical areas was undertaken regularly, and this was audited for compliance. Records showed full compliance with monthly deep cleaning for the past 6 months. Ad-hoc deep cleans could be requested when required for example after a blood or body fluid spillage. We saw that the service had performed routine water testing in November 2025 for bacteria such as legionella and pseudomonas in line with health and safety guidance for high-risk areas, such as theatres. This showed there was no evidence of these bacteria in these areas.

There were adequate supplies of (PPE) and scrubs available. Staff were observed wiping down equipment after patient contact and between patients. There were multiple large pieces of equipment in the operating room, and these were kept clean, well maintained and dust free.

Theatre staff followed protocol to manage infection prevention and control. We observed surgical procedures and saw that staff followed policy at all times. Staff followed protocols to avoid the incidence of surgical site infections. Staff checked equipment sterilisation records before surgery took place, and the provider maintained end-to-end tracking for surgical instruments sent off site for sterilisation. This enabled tracing to take place in the event of a suspected infection.

There was an infection prevention and control (IPC) link staff member at the hospital. They also had an IPC regional support nurse who visited the hospital monthly. There was an online forum for the IPC link nurses across the company to ask questions and offer each other support.

Patients were protected from infection risks as the premises and equipment were kept clean and hygienic throughout. There was a systematic approach to assessing and managing the risk of infection, which was in line with current relevant national guidance. The service performed well for cleanliness audits. The service was consistently above 95% compliance for theatre infection prevention and control audits with the most recent audit demonstrating 100% compliance.

Information about the risk of infection was shared appropriately with relevant partners, including agencies and patients using the service and visitors. The service had no confirmed endophthalmitis cases in the 12 months prior to inspection. Endophthalmitis is a severe, sight-threatening inflammation of the inner eye fluids caused by bacterial or fungal infection. It most commonly occurs following intraocular surgery (e.g., cataract surgery) or trauma, requiring urgent antibiotics and sometimes surgery to save vision.

We saw staff following infection control principles including the use of personal protective equipment (PPE). There were clear roles and responsibilities around infection prevention and control. Hand-washing and sanitising facilities were available for staff and visitors throughout. We observed staff undertaking effective hand hygiene in line with best practice guidance. Staff were observed to be ‘bare below the elbow’ and following best practice guidelines for hand washing. We reviewed hand hygiene audits completed by the service and saw that these showed compliance above target for the past 3 audits. Staff completed IPC and handwashing training. Relevant staff also undertook additional manufacturer training in how to clean specific clinical equipment.

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 best practice in medicines management, in line with national guidance. The service made sure medicines and treatments were safe and met patients’ needs, capacities and preferences.

Staff followed systems and processes to prescribe and administer medicines safely. Patients’ medicines were appropriately prescribed, supplied and administered in line with the relevant legislation, current national guidance or best available evidence. There was guidance to support the use of off-Label and unlicensed formulations which included patient discussion. This is used in clinical situations when the use of unlicensed medicines or use of medicines outside the terms of the licence (i.e., ‘off-label’) may be judged by the prescriber to be in the best interest of the patient on the basis of available evidence. Such practice is particularly common in certain areas of medicine such as ophthalmology.

The provider had a medicines management committee who met quarterly. They had a fixed agenda which included the governance report, medicine risks, new policies, training compliance and new relevant national guidance. The provider had an in-date medicines management policy that outlined relevant areas such as exclusion, duties and responsibilities.

Medicine management audits showed good compliance. The service conducted quarterly medicine audits. We saw this showed compliance was consistently above service target of 95%. The most recent audits in December 2025 had compliance of 98% for departmental medicine management, and 100% in patient medicine management.

Patients were appropriately involved in decisions about their medicines. 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.

The service actively sought ways to make aftercare easier for patients. For example, patients who may struggle to administer eye drops, were given eye drop’s following their outpatient’s preoperative assessment so they could practice administering at home. This was to enable them to practice before surgery and get them used to this.

Access to areas where medicines were stored was restricted to only relevant and appropriate staff. We saw that staff stored and managed all medicines and prescribing documents safely in their medicines store. Within the medicines areas there were dedicated refrigeration, and ambient medicines storage areas. All fridges were securely accessed with keys these were all monitored to ensure the temperature was safe for the medicines stored within.

Medical gases were stored safely and securely. Empty and full oxygen cylinders were stored separately, ensuring these would not be easily mixed up.

There were appropriate arrangements for the safe management, use and oversight of controlled drugs (CDs). CDs are drugs that are subject to high levels of regulation as a result of government decisions about those drugs that are especially addictive and harmful. CDs were securely accessed within the medicines area via a dedicated lock box which held the access keys to a secure wall mounted safe. Only staff who had completed competencies in the management of medicines dispensed and administered medicines to patients.

Medicines competencies included medicines management, awareness, disposal, and storage. All relevant staff had completed medicines disposal and storage, medicines management training and medicines prescribing.