SpaMedica Exeter

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This means we looked for evidence service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first assessment for this service. This key question has been rated good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

We have not awarded this service a score for Well-led.

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

The evidence showed a good standard. The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider had 3 main objectives: patient safety, excellent care and patient satisfaction. They were centred around ensuring every patient had the best possible experience of their services, and the best possible outcome every time. The organisation’s values of safety, integrity, kindness and transparency encouraged staff to achieve the objectives. They had made a Team Charter and made a pledge of what would be achieved for the year. Staff focused on the needs of patients receiving care and worked well together to ensure they achieved good outcomes for patients. Staff were passionate about the care they provided for patients.

The provider had commissioned a ‘Great Place to Work Survey’ which was completed in October 2025. Improvement was shown from in results from 2024. Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. Overall staff were positive about working there but reported to us the requirement to travel and work at other SpaMedica locations was impacting on the culture at the service and on them. The senior leadership stated they were aware of the impact of supporting other locations and further recruitment would help reduce travel.

The provider showed a good standard. The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had the experience, capacity, capability and integrity to ensure the organisational vision could be delivered, and risks were managed. The southwest structure has an allocated hospital director and an area manager along with a hospital manager who is the registered manager. The registered manager is the person who was registered with CQC and was legally responsible person to oversee the daily operation.

Leaders were visible and approachable to staff, staff overall felt well supported and would confidently raise concerns to the hospital manager. Staff we spoke to were overall complimentary around the leadership team, they felt well supported and able to escalate if they had any concerns or needed help. As the current hospital manager was leaving there was some apprehension raised to us from staff about the impact of this change.

We spoke with leaders of the service including the hospital manager. They had an excellent understanding of the service they managed. They could explain clearly how the teams were working to provide high quality care. They also understood the difficulties staff were experiencing, and this was partly due to changes in workstreams. Changes were necessary to ensure business continuity.

All staff said there were regular team meetings and information shared by the hospital manager. We looked at previous minutes from team meetings. We reviewed weekly updates and these included information about updated procedures and documents, peer review, inclusion events, safety alerts and lots of supportive information updating staff. In their staff survey key improvements and high scores were that management was approachable, competent and delivered on their promises.

There were leadership opportunities available including a managerial apprenticeship. The hospital manager had completed a management course to further support the development of their leadership skills.

The evidence showed a good standard. The provider fostered a positive culture where patients felt they could speak up and their voice would be heard.

Staff we spoke with felt they could speak up and be listened to. There were ‘Freedom to speak up’ posters with links to staff could go to if needed. There was a policy regarding Freedom to Speak Up (Whistleblowing). This encouraged staff to speak with their line manager first, though they were offered alternatives if not appropriate.

Staff were actively encouraged to speak up and raise concerns. Some staff we spoke with said they felt they could raise concerns easily and they would be investigated.

When something went wrong, patients received a sincere and timely apology and were told about any actions being taken to prevent the same happening again.

The evidence showed a good standard. The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had recently launched an equality, diversity and inclusion strategy. This was a 3-year plan to create an inclusive environment where everyone feels safe, valued and respected. Equality, diversity and human rights training was part of the mandatory training programme. All current staff were up to date with training regarding this. Leaders acted to continually review and improve the culture of the organisation in the context of equality, diversity and inclusion.

The leadership spoke of reasonable adjustments and individualised support plans to support individual staff members. Overall staff felt supported to do their role.

The evidence showed a good standard. The provider had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

There were clear and effective governance, management and accountability arrangements. Staff understood their role and responsibilities. Managers could account for the actions, behaviours and performance of staff. There was a well-led and effective clinical governance structure with clear systems and processes. Each region had a governance lead who supported the hospital manager with compliance.

The service had effective systems, such as audits and risk assessments, to monitor the quality and safety of the service. There was a comprehensive audit schedule of clinical and non-clinical audits set by the corporate team. Leaders took additional steps to ensure good governance and compliance and had their own monthly audits.

As well as a corporate risk register, the service had a risk register specific to the location. This included risks such as staffing issues and equipment failure; it had last been recently reviewed. It was clear who the responsible person was to monitor the risk and when the level of risk was next to be reviewed. The risk register was an agenda item on the monthly team meeting.

Staff understood and actively contributed to the risk management strategy. Patient outcome data was submitted to the National Ophthalmology Database Audit to benchmark their performance against other service providers. Quarterly meetings were held with the ICB where key performance indicators were reviewed as well as referral to treatment times, incidents and complaints were monitored.

An operations balanced scorecard was available for each location, this included monitoring of patient’s quality and safety, this was reviewed by the hospital manager on a fortnightly basis. Surgical staff performance was regularly monitored for all the surgeons.

There were suitable arrangements for the availability, integrity and confidentiality of data, records and data management systems. Information was used effectively to monitor and improve the quality of care.

Policies and procedures were developed and reviewed nationally. Staff were sent a weekly update email which included new policies and any tasks needing to be actioned. These were also discussed at monthly team meetings.

The service conducts peer review audits, where a manager from another site would conduct an audit. We reviewed a peer report from mid-2025 for Exeter. Overall, this was positive with some areas in the safe domain for action like weekly checks not being completed, these were actioned as a result.

The service had an up-to-date business continuity plan should a major event interrupt the provision of care and treatment.

The evidence showed a good standard. The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

The local ICB confirmed that they had worked closely with the provider and undertaken a quality review following a patient complaint. Actions had been taken and the review was now closed.

The provider had links with local ophthalmic and NHS providers. As a result of the recent quality review, they now had quarterly meeting with their local NHS Trust and clear referral pathways. Further community collaboration has been demonstrated with Devon Insight Team being invited to walk through the patient’s journey from the perspective of someone living with sight loss.

SpaMedica had community champions across their hospital sites. These roles were a key enabler to maximise fundraising. Some specific events for Exeter include ‘Dogs for Good’ which promotes independence and inclusion for people living with sight loss, Macular Society, ‘Make a wish’ foundation and Insight Charity. SpaMedica supports the Macular Society to support not only raising funds and signposting but by improving information for patient with Age-related Macular Degeneration.

The evidence showed a good standard. The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Leaders demonstrated a commitment to improvement. Performance was used to promote learning and learning was shared across the organisation. The senior leadership team and staff shared a wide range of innovation and research across all locations.

The hospital manager spoke how the provider has developed their staff and some staff have progressed into management.

Staff spoke with us about areas where they have made quality improvements, they were well supported to provide feedback on what could be improved and solutions to be able to do this. The hospital manager advised of recent changes to stock checks following a suggestion by a staff member.