SpaMedica Sittingbourne

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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

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

Staff understood safeguarding responsibilities, managed medicines safely, and followed processes to reduce risks before procedures. Patients were involved in decisions about their care, understood the risks of treatment, and gave informed consent. The service provided a clean and well-maintained environment, had enough suitably trained staff, and ensured patients received safe and coordinated care through appropriate referrals and clear care pathways.

This is the first assessment for this service. This key question has been rated as 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.

The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. Staff and leaders listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Learning was shared with staff.

Staff told us they felt confident to speak up and raise concerns about safety, and survey results supported this. In the most recent staff survey the response rate was 100%, 92% of staff felt confident to raise patient safety concerns and believed they would be listened to. All staff reported the service supported learning and improvement from incidents, complaints and feedback.

The service managed patient safety incidents well. Staff understood how to report incidents and near misses using an electronic system and said leaders encouraged them to do so. Staff were able to give examples of learning from incidents. For example, after a patient fall, changes were made to seating areas, including adding clear hazard markings to reduce trip risks for patients with visual impairments.

Over a 12-month period, the service reported 30 incidents. Most incidents resulted in no harm, and none resulted in moderate harm or above. Action plans were put in place for all incidents to support learning and improve safety. Incidents were reviewed, and learning was shared through team meetings, safety huddles and governance processes, including across other locations.

The service had an up-to-date incident reporting policy and followed the Patient Safety Incident Response Framework (PSIRF). The Patient Safety Incident Response Framework (PSIRF) is the NHS approach to responding to patient safety incidents, focusing on learning, improvement, and reducing the risk of future harm rather than assigning blame. All incidents were reported to the national Learning from Patient Safety Events system to support wider learning.

There had been no reported never events in the previous year. Never events are serious, preventable safety incidents which should not occur if the available preventative measures are followed. They include things like wrong site surgery or foreign objects left in a person’s body after an operation. However, we reviewed an example from another location, which showed clear action plans, named leads, timescales and measures of success.

Staff understood duty of candour. Staff were open and honest with patients when things went wrong. They gave apologies and support in line with the duty of candour. Between 1 April 2025 to 31 March 2026, 30 incidents were reported under duty of candour. Data showed the number of incidents were higher than average for proportion of activity at 1.32% where the organisational average is less than 1%. Leaders felt this was due to a positive reporting culture from staff.

Leaders shared learning from patient safety events meeting every week. Staff could describe changes made following incidents, showing t learning was put into practice. The service also used swarm huddles. Swam huddles are quick team meetings held after an incident to understand what happened and decide what actions are needed. We saw this being used to support learning and improve safety.

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. The service worked closely with patients and other healthcare providers to make sure care was safe and joined up at every stage. Staff had access to clear referral guidance, including NHS trust contact details and referral letter templates, helping ensure timely referrals and appropriate sharing of patient information with other services.

Staff supported the transfer and discharge of patients between services. Records reviewed showed transfer and discharge processes were followed, helping to ensure continuity of care and patient safety.

There was an admission criterion for both private and NHS patients. The criteria helped to ensure people received safe care by admitting only those whose needs could be safely met by the service. This included cancelling or delaying the surgery in cases where an underlying condition was identified. Records showed these checks were carried out consistently. For example, people with high risk of needing additional support such as, patients with multiple medical concerns.

Staff gave patients clear information about tests and procedures so they knew what to expect and could feel confident about their care. We saw staff explain things in a simple and easy-to-understand way, helping patients to be involved in decisions.

Patient records were managed securely in line with national standards. Records were well organised and easy for staff to access when needed. Paper records were stored safely, and the service also used an electronic record system.

We observed the patient journey and tracked patient care from admission to wards and on to the operating theatre. We saw that it ran smoothly and efficiently. Staff worked well together and followed safety checks to make sure procedures were carried out correctly. We saw checks were completed at each stage from admission to discharge.

Safety processes in theatre were in place to help prevent harm. Staff used the World Health Organisation (WHO) surgical safety checklist, and records reviewed showed these were generally completed. We observed safety checks being carried out during procedures and staff described how procedures would be stopped if concerns were identified.

However, not all staff consistently participated in all elements of the safety checking process, including the 'stop' check. The 'stop' check is a final team check carried out immediately before a procedure to confirm the correct patient, procedure and treatment site. During our assessment, we observed that this process was not always fully completed by all staff present. We raised this with the provider at the time. The provider subsequently submitted evidence showing staff had been reminded of the importance of completing the process. The information provided did not demonstrate how ongoing compliance would be monitored.

The service had clear processes to respond if a patient’s condition changed. Patients could contact the service easily, with access to follow-up calls and emergency on-call support if needed.

The evidence showed a good standard. The service worked with patients and healthcare partners where required, to understand how best to keep people safe, what it meant for individuals and the best way to achieve that. Staff concentrated on protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

The service worked well with patients and other organisations to keep people safe from harm, abuse and discrimination. Staff understood their responsibilities and acted quickly when concerns were identified. They were able to recognise signs of abuse or neglect, and we saw clear safeguarding information displayed on site alongside up-to-date guidance.

Staff received safeguarding training appropriate to their role on recognising and reporting abuse. Staff completed mandatory safeguarding training for both adults and children, with training records showing 100% compliance. All staff, including non-clinical staff, had completed safeguarding adults and children training to level 2.

The registered manager and safeguarding lead had higher-level training, making sure staff had access to expert advice when needed. The registered manager was trained to level 3 training, and the provider and regional safeguarding leads were level 4 safeguarding trained.

trained. The safeguarding lead supported staff with raising concerns and making referrals to local authorities, and staff worked with external agencies when required to protect patients.

Staff knew how to raise concerns and access support. Guidance was clear, and safeguarding leads were available for advice. There were current safeguarding policies, and these were detailed, reflected the national guidance for adults and children, including visitors and contained website hyperlinks for further information. Staff knew who to report concerns to and felt confident that these would be taken seriously and acted on.

Staff were able to give examples of how they kept patients safe. For example, concerns were raised when a patient appeared unwell or was not caring for themselves, and in another case when a patient was struggling to manage their medication.

Staff understood how to protect patients from discrimination and harassment, including those with protected characteristics. Patients were given information to help them understand risks and stay safe. Leaders kept oversight of safeguarding through regular reviews and made sure concerns were managed appropriately.

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.

The service worked with patients to understand and manage risks in a holistic and personalised way. Patients were assessed to make sure treatment was safe and suitable, including whether they could tolerate cataract surgery and position themselves safely during the procedure. For example, we saw a lying flat assessment being completed. This helped make sure patients could tolerate the required position for the procedure and remain comfortable and safe throughout treatment. By identifying any difficulties in advance, staff could take appropriate action to reduce risks and support the patient's individual needs.

Staff worked together to identify and manage risks to patients. We observed a daily safety huddle where staff discussed patient needs and risks, including mobility concerns and any patients requiring additional support. The team also reviewed staffing levels and arrangements for emergencies, including resuscitation, first aid and fire safety, ensuring staff understood their roles and responsibilities.

The service had clear support in place after discharge. Patients could access a 24-hour emergency helpline, supported by an on-call optometrist and senior staff. Patients were given clear written and verbal information about their care, including when and how to seek help, so they could recognise and respond to any concerns.

Staff considered patients’ day-to-day needs. For example, they discussed how advice not to bend after treatment and how this might affect daily activities, helping patients understand and manage any risks during their recovery.

Patients told us they felt listened to, understood the risks, and were involved in decisions about their care. We saw consultations where clinicians explained conditions and treatment options clearly, checked understanding, and agreed care plans with patients. Patients told us they left with a clear understanding of next steps and how to manage their care safely.

Risk assessments were personalised, proportionate and regularly reviewed with patients. All patients had a pre-operative assessment and were given a risk rating based on their health and eye condition. Risk assessments were updated if patients’ needs changed, and staff worked with other healthcare professionals, including opticians and GPs, to ensure risks were fully understood and managed.

The evidence showed a good standard. The service detected and controlled potential risks in the care environment. Leaders and staff took steps to make sure equipment, facilities and technology supported the delivery of safe care. Where they were unable to do so, they mitigated the risks.

The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use equipment and to manage different types of waste safely.

The design of the environment followed national guidance. Where required, areas were secure and protected patients, for example, access to high-risk areas was restricted. Monthly health and safety checks were completed. These covered fire safety, electrical equipment, environmental risks such as trip hazards, and the safe storage of hazardous materials. The most recent audit showed full compliance with these checks.

Leaders and staff made sure equipment, facilities and technology supported safe care. Where faults or breakdowns were identified, action was taken promptly to reduce risks to patients. For example, we saw that when a door failed the day before the inspection, it had been reported and repaired promptly, showing that issues were identified and resolved quickly.

The service made sure specialist equipment was used safely and in line with national guidance. We saw annual service checks in place for 2 machines ophthalmic surgeons may use. The service used regular Portable Appliance Testing (PAT) for more generic electrical equipment such as power adapters and power cables.

Leaders maintained oversight of equipment to ensure it was safe and ready to use. Regular audits were completed and findings were shared with staff. Equipment was repaired or replaced quickly when required. We saw a calibration register and systems to monitor safety. Staff told us they had access to the equipment they needed to provide safe care.

Staff followed local safety procedures for using equipment. Only staff who were trained and authorised used equipment, with appropriate supervision where required. The service maintained an asset register to monitor and manage equipment. Staff carried out daily safety checks of specialist equipment.

There was easy access to resuscitation equipment on the ward and in theatres. Emergency equipment, including a defibrillator, was regularly checked and maintained. Staff had received training in its use.

Call bells were positioned by patient beds, and staff showed patients how to use them to summon help.

The service had suitable facilities to meet the needs of patients’ families when necessary.

Staff managed clinical waste safely, with correct separation, labelling and disposal, including sharps. There was also a service agreement in place for waste management. Fire safety equipment servicing had been completed within the last 12 months, and fire systems were checked regularly.

Hazardous substances were stored securely in line with Control of Substances Hazardous to Health (COSHH) regulations, with restricted access and clear guidance for staff on safe handling.

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 qualified, skilled and experienced staff to keep patients safe from avoidable harm and to provide the right care and treatment. Staff members included a hospital manager, registered nurses, healthcare technicians, patient coordinators, and optometrists.

A standard operating procedure was in place for staffing, based on Association for Perioperative Practice (AfPP) guidance. During our assessment, staffing levels reflected this and were appropriate for the activity being carried out. Managers regularly reviewed staffing levels and adjusted them where needed. Staff worked well together, understood their roles, and we saw this reflected inpatient care and interactions.

There were safe recruitment practices to make sure all staff were suitably experienced, competent and able to carry out their role. We reviewed 5 staff records across a range of roles and found all required recruitment checks had been completed. This included up-to-date Disclosure and Barring Service (DBS) checks, training and appropriate references.

The service had enough medical staff to keep patients safe. Surgeons worked under practising privileges. Managers monitored compliance with their practising privileges policy and through the medical advisory committee. Surgeons were granted practicing privileges following a trial period and graded by a senior SpaMedica surgeon. We saw practising privileges documentation for consultants, which was securely held.

Clinical and surgical care was delivered by appropriately skilled and experienced clinicians, and patients were clear about who was responsible for their care. Managers planned and limited the number of operations to reduce the risk of staff fatigue and ensure safe care. There were cross-cover arrangements in place for theatre staff to always maintain safe staffing levels.

Staff training records were complete and up to date, and competencies were monitored by the registered manager. Staff were reminded when training or competencies were due to expire. Access to staff records was appropriately restricted depending on role, ensuring confidentiality and information governance requirements were met.

New staff completed a structured induction programme relevant to their role before starting work. Managers supported staff through regular appraisals and ongoing oversight to maintain standards. Data on appraisals showed 15 staff had received their appraisals. There was no data for surgeons on appraisal completion.

The service supported the learning and development needs of staff and made sure staff received any specialist training for their role. Managers helped staff to identify any training needs and gave them the time and opportunity to develop their skills and knowledge. For example, staff completed training on recognising and responding to patients with learning disabilities and dementia, with completions rates at 100%

Staff spoke positively about working for the service and told us they felt supported in their roles. They confirmed they were able to take appropriate breaks during shifts, supporting their wellbeing and ability to provide safe care.

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.

The service managed infection risks well. Risks of infection were assessed and managed through clear policies, regular checks and monitoring. Staff used the right equipment and followed procedures to protect patients, themselves and others.

Staff followed infection control principles including the use of personal protective equipment (PPE). People and staff had access to facilities to maintain good hand hygiene. We saw staff undertaking effective hand hygiene in line with best practice guidance. Staff were ‘bare below the elbow’.

Staff ensured equipment in the operating room was kept clean, well maintained and dust free. Staff cleaned equipment between patients.

Theatre staff followed protocol to manage infection prevention and control. 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. Staff had access to an up-to-date infection and prevention and control policy and supporting guidance that was accessible to staff.

There was local guidance for managing infection outbreaks, including a procedure for conditions such as endophthalmitis. Endophthalmitis is a serious and painful inflammation of the inside of the eye. It affects the fluids and tissues inside the eyeball and is usually caused by a bacterial or fungal infection.

There was a programme of infection and prevention and control audits. Audit results from the period October 2025 to March 2026 showed good compliance ranging from 98% to 100% across key areas, including hand hygiene and aseptic non-touch technique (ANTT). Aseptic Non-Touch Technique (ANTT) is a globally standardised clinical framework designed to prevent infections during invasive procedures. We observed ANTT being followed in theatre. The service monitored any audits that fell below 95% compliance. Staff used audit findings to ensure infection risks were effectively managed.

There were systems in place to maintain a safe environment, including water safety testing.

Surgical instrumentation was managed off site under a service level agreement. This included the processing of items, delivery of these and collection after use for cleaning and sterilising. Where staff used single-use equipment for minor surgery, they documented serial numbers in patient records. This meant items were fully traceable in line with national guidance.

All staff received infection prevention and control training. Information to support good practice, including hand hygiene posters, was clearly displayed in staff areas and toilets.

The evidence showed a good standard. The service made sure that medicines and treatments were safe and met patient’s needs, capacities and preferences. Staff involved patient in planning, including when changes happened.

The service made sure medicines and treatments were safe and met patients’ needs. Staff involved patients in planning their care and explained any changes to treatment. Patients told us they understood their medicines and felt involved in decisions.

There were systems in place to safely prescribe, administer, record and store medicines. The medicines management policy was up to date, specific to the service and aligned with national guidance. Regular audits were carried out to monitor safe practice.

We reviewed prescription records and found they were clear, complete and up to date. Staff reviewed each patient’s medicines as part of ongoing care and provided advice to patients and carers where needed.

The service had clear guidance to support safe medicines use in specialist areas. This included procedures for the use of off-label medicines in ophthalmic surgery, antimicrobial guidance to support appropriate antibiotic use, and standard operating procedures (SOPs) for the safe administration of topical medicines by non-registered staff. We saw staff had completed competency assessments and were appropriately supervised.

Medicines were stored securely, with access restricted. Stock checks were carried out regularly, and medicines and prescribing documents were managed safely.

Controlled drugs were stored securely and checked regularly, with records showing they were appropriately monitored. Recently the service received a report from the CDAO (controlled drugs accountable officer) reminding staff to stock check-controlled drugs in accordance with guidance. The report also praised staff for keeping the registers in good condition and up to date. Medicines requiring refrigeration were stored safely, and fridge temperatures were checked daily and maintained within the required range.

Staff followed national guidance to ensure patients received the correct medicines when moving between services. Medical records were completed accurately and kept up to date.

Leaders monitored national patient safety alerts relating to medicines and acted where required. Staff learned from safety alerts and incidents to improve practice.