The Care Quality Commission
  • Hospital
  • Independent hospital

Spire Cambridge Lea Hospital

Overall: Good read more about inspection ratings

30 New Road, Impington, Cambridge, Cambridgeshire, CB24 9EL (01223) 266900

Provided and run by:
Spire Healthcare Limited

All Inspections

During an assessment of Diagnostic imaging

Safe:

Diagnostic imaging services provided at this location included: x-ray, CT scan, magnetic resonance imaging (MRI) for adults and children between the ages of 4 and 17 years. The service provides a wide range of magnetic resonance imaging (MRI) examinations and serves the host NHS hospital. The service accepted referrals from private patients and NHS patients referred from the NHS through the integrated care board (ICB) contracts and GP referrals.

The service had a good learning culture and staff and patients could raise concerns. Managers investigated incidents thoroughly. Patients were protected and kept safe because staff understood local safeguarding arrangements. There were enough staff with the right skills, qualifications and experience in the departments to ensure high quality care and treatment.

Managers made sure staff received training and had regular appraisals to maintain high-quality care. Staff managed medicines safely. Staff identified and reacted to unexpected deterioration in a patient’s condition. Staff understood and managed risks from the environment. The facilities and equipment met the needs of patient, were clean and well-maintained and any risks were mitigated.

Effective:

Patients, and where appropriate those close to them, were involved in assessments of their needs. Staff reviewed assessments taking account of patient’s physical emotional, communication and personal care needs. Care and treatment was based on latest evidence and good practice guidance. Patient outcomes met expectations, and harm free care was the norm. Patient’s comfort was observed throughout the procedures

Where necessary staff assessed and managed patients nutritional and hydration needs. Staff made sure patients understood their care and treatment to enable them to give informed consent.

Caring:

Patients were treated with kindness and compassion. Staff protected their privacy and dignity. They treated patients as individuals and supported their preferences. Staff responded to patients in a timely way. Patients had the opportunity to ask questions from allied health professionals.

Responsive:

Patients, or their representatives, were involved in decisions about their care and treatment. The service provided information which patients could understand. Patients were invited to give feedback, knew who to speak with if they had concerns and were confident the service took their concerns seriously. The service monitored and worked to improve access. The environment was adjusted to meet the needs of people with conditions which could create a barrier to access. The service worked to reduce health and care inequalities through service planning, quality monitoring, staff training and feedback. Patients were involved in making decisions about their care and understood the need for the recommended diagnostic procedures. The service supported staff wellbeing.

Well-led:

Leaders and staff knew the service’s local vision, aims and objectives and understood how their service aligned with this. There was a culture based on speaking up, listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Leaders had sound oversight of the quality of service being delivered through effective governance and risk management systems. Staff with protected characteristics felt supported. There was a culture of continuous improvement with staff able to contribute ideas through a quality improvement programme.

During an assessment of Outpatients

The assessment took place on 11 February 2026. It was a fully comprehensive assessment, carried out because the service’s previous rating was aged. The last inspection had been completed in December 2016. This assessment was required to ensure the current quality and safety of the service were accurately reflected.

We rated the service as good because staff continued to provide care that was safe, effective, caring, responsive and well-led. People received support from staff who understood their needs and delivered care in a consistent and person‑centred way. Staff treated people with kindness and respected their dignity, and feedback from those using the service was generally positive about the quality of care provided. Systems and processes were in place to help protect people from harm, and staff understood their safeguarding responsibilities. Care was delivered in line with good practice guidance, and people were supported to maintain their health and wellbeing.

Staff had the skills and knowledge they needed, and there was evidence of effective teamwork and communication. People’s care plans were up to date and reflected their current needs, enabling staff to provide coordinated and personalised support. The service responded well to people’s concerns and worked in partnership with other agencies when needed. Leaders promoted an open and inclusive culture and maintained oversight of the service through regular checks and audits. Staff felt supported and able to raise issues.

However, staff reported that some consultants still saw patients without formal referrals and that they did not always receive essential information.

During an assessment of Surgery

Spire Cambridge Lea Hospital is an independent hospital located in Impington, north of Cambridge. It primarily serves the communities of Cambridge, Suffolk and Peterborough, while also accepting patients from further afield through private medical insurance, self‑pay arrangements and NHS contracts.

The hospital provides a range of surgical services for adults. Facilities include 19 day‑case beds, and a 44 private room bedded inpatient ward. There are six operating theatres, three of which have laminar flow and an endoscopy suite.

The service had enough staff to care for people and keep them safe. Staff had training in key skills and managed infection risks well. They assessed risks to people and acted on them. Premises, facilities and equipment were clean and well-maintained, medicines were managed well and incidents were investigated in a timely manner with focus on learning and improvement.

Staff assessed people’s health needs and provided good care and treatment with positive care outcomes. They monitored people’s nutritional needs and managed pain relief. Staff worked well together and with service partners for the benefit of patients. Staff monitored the effectiveness of care and treatment and used the findings to make improvements and achieved good outcomes for patients.

Staff treated people with compassion and kindness, respected their privacy and dignity and took account of their individual needs and choices. Staff were alert and responsive to people’s needs and provided emotional support to patients to avoid any preventable discomfort, concern or distress. The service had systems in place to support staff with their wellbeing, safe working and emotional support. Staff spoke positively about the support they had received from managers.

During an assessment of the hospital overall

We assessed Spire Cambridge Lea Hospital on 11 February 2026. This was a fully comprehensive assessment carried out because the service's previous rating was aged. The last inspection had taken place in December 2016. The assessment was required to ensure the current quality and safety of the service were accurately reflected.

Spire Cambridge Lea Hospital is registered with CQC to carry out the regulated activities of treatment of disease, disorder and injury, diagnostic and screening procedures, family planning, services in slimming clinics and surgical procedures. The service had a Registered Manager and a Controlled Drugs Accountable Officer.

At this assessment, we assessed 3 service areas: surgery, diagnostics and imaging, and outpatients.

We visited the following areas as part of our assessment: surgical wards, theatres, recovery, outpatients, and diagnostics and imaging. We rated this location as Good.

6 June 2016

During a routine inspection

Spire Cambridge Lea Hospital is part of Spire Healthcare Limited. Spire Cambridge Lea offers comprehensive services to patients from Cambridge, Suffolk and Peterborough. The hospital is located in the village of Impington, just north of Cambridge and is accessible from the A14 and the M11, as well as being 30 minutes from London Stansted airport.

Healthcare is provided to patients with private medical insurance, those who self-pay and patients referred through NHS contracts. Hospital facilities include an outpatient service, diagnostic imaging service, 15 day-case beds and a 46 bedded inpatient ward. Theatre provision includes five theatres, three of which have laminar flow and an in house sterile services department. From January 2015 to December 2015 there were 7,539 visits to theatre.

We inspected this hospital as part of our independent hospital inspection programme. The inspection was conducted using the Care Quality Commission’s comprehensive inspection methodology.

We carried out an announced inspection of Spire Cambridge Lea on 6 June 2016, Following this inspection we also undertook an unannounced inspection on the 20 June 2016, to follow up on some additional information.

The inspection team inspected the following core services:

  • Surgery
  • Outpatients and diagnostics

All services at this hospital were inspected during our visit.

We rated Spire Cambridge Lea as good overall,with caring as outstanding. Core services achieved good overall in surgery and outpatient and diagnostics.

Our key finding were as follows :

Are services safe at this hospital/service

  • Staff were aware of the incident reporting system. There were good examples of incident investigations and root cause analysis (RCA). Learning from incidents was shared with staff and there was evidence of recommendations to improve the service.

  • The hospital completed a ‘Deep Dive’ into all reported patient deep vein thrombosis. Should there be any cause for concern or learning, an RCA would be performed. The report is submitted to the central clinical governance team. This information is logged and analysed quarterly for trends and learning.

  • Staff were aware of duty of candour, and we saw evidence of when duty of candour had been applied in conjunction with incidents.

  • The hospital collected data to support the safe running of the service on the clinical scorecard. The scorecard was predominantly positive. However, seven out of the 35 clinical outcomes were not consistently met in 2015, but improvements had been made in 2016 in four of these measures, which improved patient safety. The remaining three measures which were not met in 2016 related to the Net Promoter Score measure for patient satisfaction/feedback. Action plans were in place to monitor improvement.

  • The mandatory training target of 95% had been achieved for 2015.

  • Safeguarding training had met the hospital’s target of 25% per quarter. Knowledge of safeguarding was good, and staff who required level three safeguarding children, for example consultants and matron, had completed the training. The hospital had recently updated the safeguarding training to include female genital mutilation (FGM) and radicalisation.

  • Monitoring of hand hygiene was carried out by measuring hand sanitisation usage, which lacked credibility. The infection control lead nurse had been undertaking local observation hand hygiene audits on a quarterly basis since January 2016 as part of the ‘Saving Lives Care Bundle’ audit. Spire Healthcare were implementing a national observational hand hygiene audit within the clinical scorecard measures from July 2016.

  • Nurse staffing levels across the hospital were planned, met consistently and sufficient.

  • A single patient record was not held on site, and we found patient records containing loose notes. The hospital had taken steps to address this and had commenced a pilot of a single patient record at the time of our inspection.

  • The World Health Organization (WHO) Five Steps to Safer Surgery checklist was in use at the hospital. However, we observed the completion of a WHO checklist prior to the commencement of a surgical procedure and noted poor practice. On our unannounced inspection the hospital had introduced a new WHO checklist which mirrored the one used in the NHS trust. This had been well received by staff. We observed the checklist being completed appropriately and there was evidence of regular auditing to ensure that the new document became embedded.

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Are services effective at this hospital/service

  • Hospital policies were evidence based and we saw examples of where policies had been revised in line with best practice guidance.

  • There was a good level of local auditing across the hospital, and good examples of participation in national audits in surgery, for example the Health Protection England surgical site infection surveillance.

  • The annual compliance score with pre-operative fasting guidelines for 2015 was 41%, but had increased to 55% in the first three months of 2016. However,

  • Patient Reported Outcome Measures (PROMS) data was collected for groin hernia surgery, total knee and hip replacements. All results for this hospital were above the England average for NHS patients.

  • Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards training compliance was low at 17%. However, this had increased to 70% at end of May 2016, following additional face to face training provided. Staff were knowledgeable about MCA and Deprivation of Liberty Safeguards. There were good processes in place to obtain consent from patients.

  • There was evidence of good multidisciplinary team working, between teams and specialists.

Are services caring at this hospital/service

  • Friends and Family Test results (July 2015 to December 2015) were consistently above average, scoring between 97 and 100% of people recommending the hospital.

  • Patient feedback at the time of inspection was positive, with patients speaking highly of the care and treatment received. Patients and relatives felt involved in decision making.

  • A chaperone service was available to support patients undergoing intimate examinations.

Are services responsive at this hospital/service

  • Referral to treatment times (RTT) for NHS patients undergoing surgery was within the national expected timescale of 18 weeks for all patients.

  • Services were available for patients with additional needs, for example translation services, hearing loops and the ability for relatives to stay with patients who require additional support.

  • The hospital provided formal dementia training and this had met the hospital quarterly trajectory for staff attendance.

  • Consultant medical cover was available 24 hours per day, seven days per week via clinics, daily inpatient review, the on call system and resident medical officer (RMO). There was a senior nurse on call rota which provided additional support if there were staffing issues on the ward or patients required to be transferred out into an NHS acute hospital.

  • There was a robust system for dealing with, and learning from complaints. We saw examples of where the hospital had worked directly with the complainant to improve services. Outcomes and learning from complaints were shared with staff.

Are services well-led at this hospital/service

  • The hospital had a clear vision and strategy underpinned by a set of core values for staff to follow. Staff were aware of the vision and strategy.

  • Governance processes were well established, including incident management, audit, policy management and learning from complaints. Information flows between committees were well documented. However, review dates on the hospital risk register were not always recorded. This meant we could not be assured risk management and mitigation was being reviewed regularly.

  • The hospital had a consultant dashboard, which included the monitoring of practising privileges. Processes were in place with local NHS trusts to ensure communication in relation to consultants’ practice.

  • There was an open and transparent attitude to serious incidents which involved duty of candour.

  • We reviewed minutes from the medical advisory committee and clinical governance meetings which showed a good level of scrutiny and challenge from a senior level.

  • There were examples of innovation and sustainability, such as plans to extend the hospital provision of their Enhanced Recovery Area (ERA) to provide increased capacity to care for level one patients (patients requiring additional monitoring or clinical interventions), with completed staffing competency in place for the end of 2016.

We saw several areas of outstanding practice including:

  • There was a system in place which recorded and monitored consultants’ competencies, mandatory training, continued professional development, indemnity and revalidation. This information was part of a rolling programme within the medical advisory committee (MAC) meetings, before being signed off by the hospital director and matron in order to re-establish consulting practising privileges.

  • The hospital director, matron and MAC chair had clear oversight on the running of the hospital. The director had worked hard to improve staff engagement since coming into post, and had increased the senior management team to improve visibility and to ensure all areas of the hospital were represented at senior level. Staff had nothing but praise for the management team, with exceptional feedback given for the new matron.

  • The hospital responded promptly to all areas of concern raised during our inspection, with changes noted on our unannounced visit. However, changes need to be monitored and embedded.

However, there were also areas of where the provider needs to make improvements.

The provider should:

  • Ensure that within the theatre department, improvements made concerning equipment and the World Health Organisation (WHO) Five Steps to Safer Surgery checklist are sustainable.
  • Review the Royal College of Surgeons professional standards on consultation for cosmetic surgery and ensure it is working in line with these standards.
  • Consider the adequacy of the low compliance target for the percentage of patients being correctly fasted prior to surgery.
  • Consider the effectiveness of action planning and follow up to demonstrate improvements.
  • Hospital wide and departmental risk registers should be reviewed to ensure that they correlate, and should have a method for capturing review dates, recommendations, actions, responsible individuals, deadlines and dates of completion of actions.

Professor Sir Mike Richards

Chief Inspector of Hospitals

3 December 2013

During a routine inspection

We spoke with six people and one relative during our inspection on 03 December 2013 and found that people were very positive about their experience at the hospital. One person told us: 'Staff have been very friendly and respectful, I can't fault them', and another told us: 'It's been great. I was shown straight to my bed and staff explained everything that was going on. The doctor was very good and really took his time and made sure I understood everything they were going to do'.

During our inspection we looked at people's medical notes and found that their consent to their treatment had been recorded and that people's care and support needs were well documented.

We saw that people were cared for in a safe and caring environment. Staff communicated people's care needs effectively to ensure continuity of care. We saw that appropriate guidance was followed and people had person centred care plans and risk assessments. There was emergency equipment in place to deal with foreseeable emergencies.

The provider had a recruitment procedure in place to ensure that staff employed were suitable to work with vulnerable people.

The provider had processes and procedures in place to monitor the quality of service that people received.

29 October 2012

During a routine inspection

During our inspection we spoke with four people who had received, or were receiving, treatment at the hospital. We also spoke with seven members of staff including nurses and a consultant. We spent time in the ward and in the out patient's department.

People told us that they were happy with the treatment and care that they had received and they said that they felt that they had received good information about their treatment options. They told us that the staff, including reception, domestic and clinical staff, had all been kind and respectful.

The care records provided clear evidence that assessments had been carried out and that these resulted in care plans which provided information for staff about the treatment and care needed by individuals. Regular monitoring of the care records took place with action taken to make improvements where these were identified.

Staff told us that there was good team work within the hospital and that they received regular supervision and support. They also told us about the range of training opportunities that were available to them.

2 February 2012

During a routine inspection

People confirmed that procedures and processes had been clearly explained to them and that they had been given opportunities to ask questions. They stated that they had signed consent to treatment forms and these had also been explained in detail. Two people we spoke with stated that care and nursing staff had discussed with them how they were going to provide their care and had asked them if they had any preferences how this was carried out.

People said that staff were kind and polite, and that staff had attended to their requests immediately. One person confirmed they were able to choose alternative pain relief following surgery, that better suited their needs.

People we spoke with confirmed that they had no concerns about their care and treatment. They stated they knew who to speak to if they were not happy with any aspect of their care but that they had not needed to do this.