Spire Cambridge Lea Hospital

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question good. At this assessment the rating has remained good.

We looked for evidence that people and communities had the best possible outcomes because their needs were assessed. We checked that people’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring people were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

We have not awarded this service a score for Effective.

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

Staff maximised the effectiveness of people’s care by assessing and reviewing their health, wellbeing and communication needs with them. All 7 care records we reviewed contained consistently completed health assessments in a timely manner.

Staff used an electronic preoperative assessment system to screen patients efficiently. The structured questionnaire and automated risk flags helped staff identify people who needed more detailed assessment. This system supported timely clinical decision making and ensured resources were used effectively.

Medical alerts were generated daily and shared with relevant teams, including pharmacy, to ensure continuity of information. Nurses carried out additional clinical reviews where required.

Staff responded quickly to issues through the Thursday rapid response meeting, where teams reviewed audit findings, discussed emerging themes and agreed next steps. Managers required evidence of completed actions so that improvements led to meaningful change.

Staff attended weekly Admissions and Assessment Meetings, which allowed teams to review the full plan for the week ahead. This helped identify staffing needs, consider any emerging clinical issues such as dizziness, new symptoms or recent medication changes, and ensure safe preparation for each patient.

Allergen information was clearly displayed throughout clinical areas to support safe decision making.

Staff supported communication needs well. Interpreter requirements were shared by email. Staff used a telephone interpreter service when a professional interpreter was required. Families could support general conversation but were not used for consent discussions.

A hearing loop was available, and staff said they were usually informed in advance when a patient with a learning disability attended.

Staff observed patients closely in waiting areas and raised concerns if communication needs appeared to affect safety or understanding.

The multidisciplinary team worked closely with local NHS trusts and independent hospitals to ensure patients received timely specialist input. Ear, Nose and Throat (ENT) and audiology specialists provided additional on‑site clinics, and a visiting professor carried out cochlear implant procedures to maintain continuity for patients receiving shared care.

Staff used the electronic pre‑operative assessment (EPOA) system to support collaborative risk review by nurses, anaesthetists and relevant clinical specialists. Daily medical alerts ensured pharmacy, therapy teams and allied health professionals remained aware of new or emerging issues affecting patient care.

Weekly Admission and Assessment Meetings brought together the wider multidisciplinary team to plan staffing, coordinate equipment and review any changes in patients’ needs, such as new symptoms or medication adjustments. This consistent communication ensured patients had timely access to the specialists required throughout their care journey. The hospital also functioned as a Centre of Excellence for Endometriosis, improving access to specialist services and helping reduce local waiting times.

The hospital offered robotic surgery for orthopaedics and leaders had introduced Da Vinci robotic surgery for General Surgery, Gynaecology and Urology on 17 January 2026. Governance arrangements were supported by consultants and robotic clinical leads to ensure safe practice.

Leaders recognised that implementing new clinical programmes safely required significant resources, time and training. They identified the need for experienced Surgical Care Practitioners to support surgeons during procedures, and while recruitment was necessary, the programme also enabled existing staff to develop and broaden their clinical skills.

Teams followed a structured audit programme to monitor compliance and support continuous improvement. Audit outliers were revisited to check validity and ensure results accurately reflected practice. Departments used an evidence‑based audit system, with actions and RAG ratings reviewed weekly at rapid response meetings.

Clinicians worked within clearly defined scopes of practice, which were reviewed every 6 months as part of a robust practising‑privileges process. This included performance monitoring, documentation checks and external oversight when required.

Staff engaged in clinical audit, benchmarking and quality improvement activity. Monthly audits covered medical device checks, point‑of‑care testing and national cleanliness standards. Quarterly audits assessed documentation, fire safety, health and safety, hand hygiene, infection control precautions, waste management and compliance with the surgical safety checklist.

Staff carried out an annual efficacy audit. From January 2025 to January 2026, most outpatient audits achieved over 95% compliance. A small number fell slightly below the required standard, including consultant documentation, fire safety, health and safety, sharps safety and infection control precautions. Action plans were developed to address these areas, such as clarifying documentation requirements and escalating audit questions for central review.

All 21 staff employed within outpatients received an annual appraisal, achieving 100% compliance. Staff competency compliance was also very high at 99%. Two newly recruited healthcare assistants were progressing through their competencies as expected, while a team member returning from maternity leave updated their competencies on return. Some part‑time staff said training could be challenging to complete within reduced hours, but they reported receiving appropriate support to remain compliant.

The Heads of Department led a daily 10:00am leadership huddle where staff discussed staffing, service pressures and any emerging risks. The safety huddle board gave a clear overview of staff allocation, supporting visibility and accountability. The organisation maintained strong relationships with local NHS trusts and other healthcare partners through Service Level Agreements, which also supported surrounding regions.

Teams used the weekly Admissions and Assessment Meeting to plan the week ahead, coordinate staffing, allocate equipment and discuss emerging issues such as new symptoms or medication changes. This supported consistent care for patients moving between services.

Staff described strong communication across departments and said they felt confident raising concerns. Leaders responded quickly to issues, including equipment faults, delays with blood tests and concerns about poor practice such as missed hand hygiene, which supported safe teamwork.

Staff observed patients closely in shared areas and escalated concerns when someone appeared unsafe or unable to consent. One example involved a patient with dementia, where staff initiated a discussion about best interests and safeguards to ensure appropriate decision‑making.

Chaperones were routinely provided, and staff followed standard safety practices such as knocking before entering rooms and maintaining privacy. Environmental risks linked to the relocation of part of the building were recorded on the risk register, and weekly rapid‑response updates ensured staff across the service were kept informed.

Staff described working in a fast‑paced outpatient environment. Workload could be heavy, but managers were supportive when staff needed help or a short break. Teams used paper rotas on clinic trolleys to coordinate activity and maintain patient flow throughout the day. Shift rotas allocated staff to specific consultants to ensure clinics were safely staffed. Although rotas were sometimes issued late, staff adapted and worked flexibly across early and late shifts to maintain coverage.

Staff suggested improvements to support coordination, including more computer screens and digital displays to show room allocation and daily schedules. They felt this would reduce reliance on paper and improve real‑time visibility of workloads across the department.

Teams worked well together during emergencies. Staff followed clear escalation processes, and Advanced Life Support trained staff and porters responded quickly to alarms. Daily equipment checks supported preparedness. An ENT emergency involving a burst blood vessel demonstrated effective coordination: staff called 999, alerted the local hospital and stabilised the patient until transfer.

Staff also attended virtual meetings with regional partners to review transfer processes. Quarterly governance meeting minutes were due to be requested to support ongoing learning.

The hospital identified a gap in specialist intensivist support, particularly for managing frail or clinically complex patients. Adding an intensivist was considered an important step to strengthen clinical decision‑making, improve escalation pathways and increase resilience in the management of high‑risk patients.

Staff supported patients to live healthier lives. Staff would refer on to NHS services when people were interested in smoking cessation or mental health support.

Staff monitored waiting times closely and tracked the first available appointment for each consultant and specialty. When any wait went beyond 4 weeks, leaders arranged additional clinics to reduce delays. At the time of inspection, almost all specialties had waits of less than a week, with spinal surgery and rheumatology around 2 weeks.

On clinic days, outpatient nurses monitored delays in real time, kept patients updated and recorded significant waits on the incident system. Persistent late starts or overrunning clinics were escalated to the Director of Clinical Services. Appointment lengths or clinic schedules were adjusted to improve flow and prevent repeated delays.

Leaders routinely monitored safety and performance data to identify trends and improve outcomes. For example, staff reported 7 falls in one quarter, most resulting in minor or no injury. Each incident was reviewed and no urgent themes were identified.

Teams revisited audit outliers to confirm the findings accurately reflected practice and to identify where targeted actions were needed. Departments used an evidence‑based audit system to complete all mandated audits, and weekly rapid‑response meetings were used to review actions and RAG ratings. Most outpatient audits between January 2025 and January 2026 achieved compliance above 95%. Where results were slightly below expectations, such as documentation or infection control, action plans were implemented to support sustained improvement.

Diagnostic processes were monitored to ensure efficiency. The phlebotomy team operated a main blood‑taking room and an overflow room. The team booked appointments and accepted same‑day requests from consultants, which supported good turnaround times. Across all clinics, the service saw an average of 300 to 350 patients daily and completed 15 to 20 minor procedures each day, demonstrating effective throughput and consistent delivery of care.

Staff used daily medical alerts to remain aware of new or emerging patient risks, enabling pharmacy, therapy teams and allied health professionals to adjust care plans promptly. Risks were also reviewed collaboratively through the electronic pre‑operative assessment system, allowing pre‑operative nurses, anaesthetists and specialist clinicians to identify concerns early and plan safely.

Clinicians worked within clearly defined scopes of practice, reviewed every six months through the practising‑privileges process, which included performance monitoring and documentation checks to ensure care remained consistent and aligned with clinical expectations.

All joint‑replacement patients received follow‑up assessments due to the complexity of their procedures, enabling ongoing monitoring of recovery and early management of any concerns.

Staff had access to policies designed to protect patients, including a Deprivation of Liberty Safeguards policy which explained how to keep people safe when they were unable to make decisions for themselves and required necessary restrictions for their care. A consent policy was in place to ensure patients were given appropriate information and were able to give informed consent, and all policies were in date and aligned with national guidance, including recommendations from the National Institute for Health and Care Excellence.

Staff followed chaperone guidelines to make sure patients had the option of a trained chaperone during examinations. Chaperone posters were displayed in public areas, clinics had allocated chaperones, and all patients were verbally offered a chaperone. We reviewed 7 care records and found that consent had been clearly recorded in every case.