Spire Cambridge Lea Hospital

On this page

• 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.

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 found that the service had robust systems and processes in place to keep patients and staff safe. The environment was safe, clean and well-maintained, and the staff had the required qualifications, training and skills. Risks were assessed and managed, and there were good processes in place to report and learn from incidents.

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.

Staff reported 257 incidents between 1 February 2025 and 31 January 2026. Most involved documentation or patient information issues. Followed by pathology sample problems, medication incidents, and slips, trips or falls. Smaller numbers related to treatment issues, theatre concerns, appointment delays or cancellations, and patient deterioration. All incidents resulted in no harm or low harm, and none met the threshold for a CQC notifiable safety incident.

Staff recorded isolated incidents such as equipment issues, communication problems at discharge. Each category contributed only a small number of reports.

The governance team investigated 3 outpatient incidents between November 2025 and January 2026, including a Venous Thromboembolism (VTE) case, a triage incident and a review incident. In the VTE case, pre‑operative assessment staff completed an incorrect risk assessment, ward staff corrected it, the discharge nurse provided guidance, and the outpatient nurse escalated suspected DVT promptly. The governance manager carried out and quality‑assured a review under the patient safety framework. The governance team reviewed the remaining incidents in the same way and monitored all actions through a single action summary process.

Staff understood the duty of candour. They were open and transparent and gave patients and families full explanations when things went wrong.

Staff received feedback from internal and external incident investigations. Leaders shared learning widely across hospitals so changes could be implemented quickly and consistently.

Staff said they felt able to speak up when something was wrong. They raised concerns about backlogs of blood tests, delays in training access, broken equipment and poor clinical practice. A new Health Care Assistant reported that a consultant had not washed their hands after examining a patient. The team welcomed and acted on this report. Staff said they trusted that action would follow when concerns were raised.

Teams escalated learning from unexpected incidents. When a medication contained an unrecognised allergen, staff shared the learning across all hospitals to prevent recurrence. When teams identified patterns, such as incorrect sharps disposal, they reinforced training.

Staff were debriefed and supported after serious incidents. Staff provided examples such as escalating a case where a patient had attended their outpatient appointment and later died. The team referred this to the coroner and reviewed the incident to identify learning and ensured staff support.

Staff carried out an After-Action Review following the first activation of the major haemorrhage protocol. The incident was managed safely with good outcomes, and the review demonstrated effective emergency preparedness and reflective learning.

Staff said the new Hospital Director created a positive, safety‑focused culture. They said the senior leadership team was visible and took quick action following walkarounds.

Leaders shared a weekly rapid‑response update so staff could quickly learn from new risks or incidents.

Leaders distributed monthly colleague safety bulletins summarising policy updates and implementation dates. The December 2025 bulletin included major revisions to the safeguarding adult’s policy and minor updates across medicines management, privacy and dignity, carbon reduction and diagnostic imaging guidance.

Leaders reviewed statutory and regulatory requirements. There were no incidents that required duty of candour in Quarter 1 and no incidents meeting the threshold for Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) reporting.

Staff submitted excellence reports, for example, we saw 38 submitted in Quarter 1. Staff recognised good practice through these excellence reports across theatres, radiology, wards, pre‑operative assessment, pharmacy and therapy services.

Staff identified concerns that required further learning and review. Staff raised concerns about delays in accessing training, broken equipment and poor clinical practice. Staff also identified incomplete documentation in the Venous Thromboembolism (VTE) case, including an incorrect risk assessment and missing recovery‑pathway timings. Leaders reviewed a small number of moderate‑harm incidents in detail to ensure learning was captured.

The front‑desk team used a red emergency phone that connected straight to the ambulance service so staff could request urgent help if a patient became unwell. The hospital operated as a Level 0 service, meaning it was set up for planned, low‑risk procedures rather than complex or emergency surgery. Because of this, it did not treat patients who had more serious or unstable health conditions, known nationally as ASA grade 4. The bookings and theatre teams checked each patient in advance to make sure they were suitable to receive care safely at the hospital.

Emergency calls triggered an immediate response from nurses, the resident doctor, porters and Advanced Life Support‑trained staff. Staff managed minor issues on site and escalated serious concerns promptly. A recent ear, nose and throat incident demonstrated how staff contacted 999 without delay and coordinated a patient’s transfer to the local acute hospital. Staff also used virtual meetings with partners to plan safe transfers. Daily buzzer tests ensured consistent response.

Staff used an Adult Pre‑operative Assessment (POA) Policy dated July 2025, owned by the Pre‑operative Assessment Leads Group. It outlined procedures, staff responsibilities and standards for the POA service. Pre-operative Assessment nurses arranged for all high‑risk patients to be discussed at an Admission Assessment Meeting, with evidence recorded in the notes and tracker. The policy and terms of reference were shared with staff. Staff completed a gap analysis, displayed the meeting flowchart and ensured standard POA forms were in use.

There were a small number of gaps in systems and information flow that affected safe pathways and continuity of care. Staff raised concerns, that due to pressures within the system, blood test results could accumulate before action was taken.

Leaders reviewed workflows to reduce delays. Staff reported that some consultants saw patients without a formal referral, and leaders strengthened referral processes to ensure consistent pathways. Staff also said they did not always receive complete patient information, including dementia status or how the patient arrived at the hospital, which made safe preparation more difficult. The team identified a continuity risk where only one agency staff member carried out Electrocardiograms (ECGs), creating a single point of failure if they were unavailable.

Staff were trained in safeguarding, knew how to raise a safeguarding alert and did so when required. Staff gave clear examples of how they protected people from harassment and discrimination, including those with protected characteristics under the Equality Act.

Managers described a clear safeguarding structure within the hospital. The named safeguarding lead was displayed each day, so staff always knew who to contact. Two Level 4 practitioners were always available, with a trained children and young people safeguarding lead providing cover when needed. Staff routinely checked the board, so they knew who to escalate concerns to.

Safeguarding processes were embedded in daily practice. All new starters received safeguarding and Duty of Candour training at corporate induction. Duty of Candour requirements were built into the incident management system, which prompted staff automatically when conversations with patients or families were needed.

Staff demonstrated an understanding of safeguarding thresholds and logged all concerns through the electronic reporting system. The safeguarding lead on duty reviewed each submission, completed necessary checks and escalated concerns to the Local Authority through its online portal when thresholds were met. The Local Authority usually responded within 24 hours, enabling timely decisions.

Leaders ensured safeguarding training reflected current risks. Modules included Female Genital Mutilation, PREVENT (to stop people becoming terrorists or supporting terrorism and extremist ideologies) and county lines (a form of criminal exploitation where organised crime groups use children, young people, and vulnerable adults to move, store, and sell drugs across different counties). Leaders added content on coercive control and complex situations so staff could identify emerging patterns. Staff applied this training in practice.

When patients experienced an unexpected outcome in theatres, staff completed the initial Duty of Candour discussion in recovery. When this was not possible, staff ensured it was carried out later by the ward team or consultants. Staff sought early advice from the Local Authority when thresholds were unclear, which helped ensure consistent and safe decision making.

Staff raised concerns when patterns of behaviour suggested someone might be vulnerable. In one case, staff escalated concerns about possible emotional distress and potential coercive control. The Local Authority confirmed the referral was appropriate.

Teams discussed safeguarding learning in daily huddles and department meetings. Children and young people consultants highlighted the number of children attending each day to maintain oversight and ensure safe processes were followed.

Leaders promoted a safeguarding culture. Staff said they felt confident raising concerns, even when unsure. Staff looked out for signs that something did not feel right. Staff gave an example involving a patient with dementia where they queried whether the accompanying family member had Power of Attorney. This led to a best‑interests discussion to ensure safe and appropriate decision making.

Safeguarding systems were integrated into organisational governance. The electronic incident system captured safeguarding concerns and Duty of Candour requirements. Themes were shared through leadership meetings, boards and compliance activity.

Leaders reviewed safeguarding events in quarterly clinical governance meetings. There were no child safeguarding incidents. One adult safeguarding concern involved a person with dementia, which was managed appropriately with contact made to the general practitioner and safeguarding services.

Staff worked with people to understand their individual needs and managed risks in a way that kept them safe. Staff supported them to have the procedures that mattered to them. Staff used an electronic preoperative assessment system that allowed patients to complete an online health questionnaire before attending the hospital.

Preassessment leads and heads of department reviewed each submission. The system generated risk flags so staff could decide whether patients needed a full telephone assessment, a brief follow up call or no further contact for low-risk procedures such as routine cataract surgery.

When risk flags were triggered, nurses carried out more detailed assessments. Nurses gathered full medical and medication histories. They checked for any recent changes that could affect safety. Staff also confirmed that patients were suitable for a Level 0 hospital, which did not provide intensive care or high dependency support. Teams used anaesthetic risk scoring to guide safe decision making. They considered co‑morbidities, frailty and previous reactions to anaesthesia. Patients assessed as higher risk were booked for an in-person review with an anaesthetist.

Staff took part in two daily safety huddles. Clinical teams met at 8:15am to raise alerts, discuss high‑risk patients, review national safety updates and share changes to policies or medicines. Heads of Department met at 10:00am to review operational risks, including staffing and children’s clinic requirements, and agreed actions to keep the service safe.

A weekly hospital wide safety meeting took place every Wednesday. Staff from theatres, pre assessment, pharmacy, wards, anaesthetics and nursing attended to review high risk patients and agreed any adjustments needed. These included reasonable changes to support people with autism or others who required personalised care.

We reviewed 7 patient records which were completed to a good standard and information was easy to locate. Allergies, consent, observations, Malnutrition Universal Screening Tool (MUST) scores, moving and handling assessments, nutrition and hydration information and falls risk plans were documented where relevant. Pre-theatre checks, pain scores and discharge criteria were completed consistently, with 1 discharge checklist missing 3 signatures and dates.

Staff adapted care based on what mattered to individuals. In one example, staff recognised a patient had been tearful during a previous visit and arranged a quiet space and extra reassurance when they returned. Anaesthetic histories were documented clearly, and discharge summaries were completed in full.

Staff escalated risks promptly. A nurse raised a concern when a patient with a sensitivity to E110 was almost given ibuprofen containing the same colouring. Clinicians changed the medication immediately and reviewed other medicines containing E110 to prevent the issue happening again. The emergency red phone, which connected directly to the ambulance service, formed part of the escalation process, and staff described it as an important safety mechanism if a patient deteriorated unexpectedly.

Feedback from 5 patients and 4 carers was consistently positive. Patients and carers said doctors were patient, kind and caring, and took time to explain information in a way they understood. All patients told us they felt listened to and not rushed.

Patients and visitors accessed the hospital through an accessible entrance linked to the car park. The reception area was staffed and easy to navigate, with electronic self-check in available. Staff wore name badges and displayed photographs for identification. Patients could access wheelchairs which were positioned at the entrance for immediate use.

Clear signposting guided patients to waiting areas, reception, pharmacy, theatres and imaging. Corridors were wide, uncluttered and suitable for wheelchair use, with glazed panels, mirrors and good lighting to improve visibility. Seating was visibly clean and noticeboards displayed service information and certificates.

Parents could use a small children’s area which was located near the entrance with age‑appropriate furniture and fixed toys. A curtain was available for separation when needed.

Clinical rooms were clearly labelled and secured with coded locks. Staff kept doors closed when rooms were in use to maintain privacy. Workspaces were organised with equipment stored on shelves and trolleys for easy access. Examination chairs were prepared with paper roll and relevant patient information posters were displayed.

Sharps bins were placed at the point of use and labelled with assembly and closure dates.

Hand hygiene stations were widely available inside and outside clinical rooms alongside sinks, soap dispensers and pedal bins. Colour coded clinical waste bins were used appropriately, and emergency call buttons were positioned in treatment areas.

Fire extinguishers were mounted, labelled and in date, electrical equipment was PAT tested and marked. Flooring was even and free from trip hazards. Double doors separated clinical zones to reduce noise and maintain privacy.

The outpatient gynaecology area was arranged to protect dignity. A changing room had an engaged/free indicator. Privacy curtains and internal privacy doors were fitted inside clinical rooms to prevent accidental entry during sensitive procedures. Procedure couches, lighting and monitoring equipment were positioned safely within reach.

Staff displayed clinical checklists, schedules and reminders where needed. Safety signage, including chemical store warnings, was in place. Changing areas remained uncluttered with good lighting and clear access. Wi‑Fi boosters ensured strong signal throughout the building. A backup generator activated within 7 seconds during a power outage to maintain essential services.

Staff raised emergency calls through red buttons and call bells, which alerted nurses, the resident doctor and Advanced Life Support trained staff. Staff carried out daily buzzer tests to ensure alarms and pagers worked reliably. Staff had access to a resus trolley and knew where it was.

Emergency exits and fire wardens were clearly displayed, and information was shared during morning meetings. Staff escalated faulty equipment promptly, and items were repaired or replaced quickly to keep clinical areas safe.

Risks linked to the planned building move were recorded on the risk register, and weekly rapid response updates helped staff stay aware of environmental or equipment risks.

Staff completed a full fire risk assessment in October 2024 as part of its 3‑year cycle with annual reviews. Fire safety was checked again during the Annual Engineering Audit in June 2025. An internal review took place during the Group Fire Officer visit in August 2025. Staff who attended quarterly Fire Safety Meetings monitored progress, and the next external fire safety review was booked for 25 February 2026.

Service leads designed the layout so that ophthalmology functions were located close together, supporting efficient patient flow. This included 4 ophthalmology consulting rooms, Optical Coherence Tomography (OCT) scanning areas and associated biomedical spaces. A dedicated ophthalmology theatre enabled high‑volume eye surgery, with additional clinics operating from rooms 7, 8 and 9. Theatre 7 provided extra capacity for ambulatory patients not requiring a general anaesthetic.

The wider site included 22 consulting rooms, 3 treatment rooms, a gynaecology room, a dedicated ultrasound room and the gynaecology consulting and changing suite. Clinical environments were purpose designed for specialist services such as ophthalmology, ENT, audiology, plastics and gynaecology, supporting high‑volume daily activity.

Leaders reviewed staffing requirements daily against planned activity. Staff were rostered to meet demand. A formal staffing establishment model was reviewed twice a year and aimed for an 85% permanent and 15% temporary workforce to allow flexibility.

Leaders carried out reviews in July 2025 and January 2026 which showed staffing levels and skill mix matched requirements. Leaders increased establishment slightly in line with activity. There were no active vacancies, giving a vacancy rate of 0%. Turnover was low at 4.8 percent, and sickness rates remained low for both registered and non‑registered staff.

Bank and agency use was minimal and mainly covered by registered or specialist staff such as cardiac physiologists. When agency workers were used, they were inducted locally and were familiar with the department.

Shifts across 2025 were covered primarily by contracted hours, with small amounts of bank, agency and overtime used to maintain safe staffing. Staffing levels in clinics showed an appropriate balance between Registered General Nurses and Healthcare Assistants. Most clinics operated with dedicated chaperones. Medical cover was always appropriately maintained.

Workforce planning was proactive. Leaders used a strong internal bank workforce who completed full local induction and competency checks. Apprenticeships and international recruitment supported future workforce needs. Nurse‑led services expanded, including a wound care clinic and nurse‑led urodynamics and urology clinics. Which improved access for patients and made effective use of specialist nursing skills.

The Registered Manager oversaw practising privileges through a robust process. This included twice‑yearly reviews, monitoring national governance data, reviewing professional reporting dates and holding multidisciplinary reviews when needed. The governance team met quarterly with healthcare providers to review documentation, discuss performance and address concerns.

Leaders held 2 daily consultant lists. There were core schedules and late‑change lists. This meant activity always matched capacity and staff with the right skills were allocated to each clinic or theatre session.

All staff had completed revalidation with their professional bodies. The People Team carried out monthly checks of professional registrations and alerted leaders to upcoming renewal dates. The Director of Clinical Services completed an annual spot check, most recently in October 2025, to confirm compliance.

The Registered Manager and governance team monitored each consultant’s scope of practice and restricted activity where required, such as limiting children’s care when safeguarding training was not up to date. A safety huddle board showed which clinicians were working together and supported appropriate skill mix and chaperone availability.

Mandatory training was role‑specific and monitored through rapid response processes. Staff completed required modules before undertaking further development. Heads of Department approved additional training when it aligned with the role and when safe cover could be maintained.

Staff used a HR learning platform to monitor mandatory training compliance. Mandatory training compliance between November 2025 and January 2026 was high. The target was 95%, and most modules, including safeguarding, life support, infection prevention, equality and diversity, information governance and moving and handling, were close to or above the expected standard.

Training related to equipment, learning disability, mental health and autism awareness also showed strong engagement. Staff accessed a wide range of clinical skills training, including phlebotomy, cannulation, airway management and preoperative assessment.

Safeguarding training followed a tiered structure, with all staff trained to Level 2, clinical staff trained to Level 3 and safeguarding leads to Level 4.

Advanced Life Support (ALS) training was maintained across key roles. The resident doctor, theatre staff and nurses all held ALS. Theatre recovery always had at least 1 ALS‑trained staff member on duty, including 1 who slept on site to provide immediate cover.

Leaders invested in staff development, including apprenticeship programmes. Two Operating Department Practitioners and one Registered Nurse had qualified through apprenticeship routes, with 6 further apprentices in training.

Staff accessed role‑specific development such as phlebotomy, cannulation, airway management and endometriosis pre‑assessment. Staff also completed additional courses relevant to their clinical duties, including dressing skills needed for treatment clinics.

Staff assessed and managed infection risks effectively. There were systems in place to detect concerns early, prevent the spread of infection and share information through the appropriate governance routes.

All infection prevention and control policies were in date. Leaders identified infection prevention leads and local champions who supported staff and reinforced good practice. Routine audits, including regular hand hygiene audits, were carried out to monitor compliance, and results were used to prompt improvement where needed.

Staff maintained equipment to a high standard and kept it visibly clean. All items checked were clinically clean with in‑date “clean” stickers attached. Ward areas were well furnished, well maintained.

Cleaning schedules were displayed in the correct areas and showed that routine cleaning had been completed and recorded. Staff said cleaning records were kept up to date. Staff sometimes remained on site until early evening to ensure areas were maintained.

Staff followed infection control principles, including effective hand hygiene. Handwashing stations were available throughout clinical areas, with wall‑mounted soap dispensers, hand sanitiser units and instructional posters. Examination couches were prepared with paper roll between patients.

Sharps bins were positioned at the point of use and labelled with assembly and closure dates, and clinical waste was disposed of correctly using colour‑coded bags and pedal bins. Clinical sinks were available, and one room contained a stainless‑steel scrub sink with wall‑mounted gloves and aprons.

Staff told us infection prevention arrangements had strengthened under the new manager. Cleaning status posters were consistently displayed on doors to show the status of each room. Staff said that although organisational changes had been challenging for part‑time colleagues, regular updates and monthly team meetings helped keep everyone informed.

Leaders explained that the Control of Substances Hazardous to Health (COSHH) assessment templates were due for review in March 2026. They were being updated onto a new template valid until 2028. Existing assessments remained valid and continued to be reviewed annually, with full reassessments every 3 years. Staff gave an example COSHH assessment, based on the relevant Safety Data Sheet and local circumstances of use, was provided for Acetic Acid.

Leaders reviewed infection prevention issues in quarterly clinical governance meetings. There were 10 infection control incidents recorded in Quarter 1, which was lower than the previous quarter. Most involved confirmed surgical site infections. Leaders noted two minor wound infections and confirmed that there were no wider concerns about infection prevention standards.

Staff followed good practice in medicines management (that is, transport, storage, dispensing, administration, medicines reconciliation, recording, disposal, use of covert medication) and did it in line with national guidance.

Staff escalated a medication incident involving an unrecognised allergen, and although the cross‑site learning belongs in the learning culture section, the underlying issue related to medicines safety and allergy checking processes.