Spire Little Aston 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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. Leaders had systems for identifying and responding to deteriorating patients. Medicines were managed safely. Patients were safe from neglect, abuse, and discrimination. Patient’s gave informed consent prior to procedures and where they were unable to consent, those close to them were involved in decisions made in their best interests.

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 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 service had a strong proactive and positive culture of safety, based on openness and complete honesty. Staff and leaders actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Learning was shared widely across the service and more widely with the other provider locations, where appropriate.

The service managed patient safety incidents well. Staff recognised and reported incidents and near misses. They were able to give examples of incidents and shared learning. Managers investigated incidents and shared lessons learned with the whole team and the wider service and took action to reduce the risk of recurrence.

Incidents learning and actions were discussed in team meetings. When things went wrong, staff apologised and gave patients honest information and suitable support. Leaders ensured actions from patient safety alerts were addressed and progress was monitored.

Staff recorded incidents on an electronic recording system. We reviewed the last 2 incidents logged and saw they included a description, severity, action taken as well as lessons learned. We reviewed the most recent health and safety committee minutes and noted that incidents were discussed.

Incidents were analysed to identify trends or themes. We saw the main incident theme was post operative wound management and pathology sample quality and handling. Leaders had analysed trends and found in relation to wound management that outpatient safety activity was heavily concentrated on follow up management of post-operative wounds and that records repeatedly showed patients returning for reasons that included wound review, swabs and antibiotics.

Staff received feedback from investigation of incidents, both internal and external to the service. We saw shared learning from incidents displayed on notice boards in the staff kitchen.

There was evidence that changes had been made because of feedback. Managers debriefed and supported staff when needed.

Managers used changes in national guidance, incidents, safeguarding, and appraisals to identify gaps in learning.

The service worked with patients and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when responsibility for patient care moved between different areas of a service and between providers.

The main source of referrals to Spire Little Aston Hospital was through a GP. In the period 2024 to 2025 they made 4,860 referrals. GP referral waiting times ranged widely. The largest group of patients (2,610) were seen within a month, followed by 1,390 who waited 1 to 2 months. 25 were seen on the day of the referral whereas longer waits were uncommon with 15 patients waiting 12-18 months and 10 waiting more than 18 months.

Spire policy was that young people aged 16-18 years as part of the risk assessment a registered nurse reviewing the referral letter from the consultant and for those children attending phlebotomy, they must be referred by a named GP. However, there was no requirement for children to be referred to the hospital by a GP. Leaders told us if the parents did not consent to information being shared with the GP, they would carefully explore the rationale behind parent’s decision, taking into account the wider clinical context and the child’s overall well being, as well as family dynamics. They would then follow their safeguarding policies. They also told us the GP would be contacted to understand the reasons behind the parent’s request not to be informed. This would also provide an opportunity for the GP to share any relevant safeguarding concerns or contextual information, enabling a coordinated and appropriate response.

Patient records were mainly paper based and were kept securely. IT connectivity was consistently available across the service to meet the needs of staff reviewing patient information.

We noted that when a patient had fell in the car park whilst exiting a vehicle, they were transferred to clinical care. Staff then followed this up afterwards and completed a welfare check on the patient.

As of February 2026, patient surveys showed that 95.8% of patients said hospital staff told them who to contact if they were worried about their condition or treatment after they left hospital.

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 hospital had 4 safeguarding champions including the interim hospital director, director of clinical services, clinical governance manager, and a physiotherapist. All were trained to level 4 in safeguarding. Their photographs were displayed in outpatient areas.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff received adult and children's safeguarding training. Data showed 100% of staff in outpatients were up to date with both their level 3 children and adults safeguarding training. There were current safeguarding policies, and these reflected the national guidance for adults and children.

Staff knew how to make a safeguarding referral and who to inform if they had concerns. They were able to give an example of when they had taken action to safeguard a patient.

Safeguarding concerns were considered when an incident occurred and a referral or further advice sought, when necessary. There were links to external agencies and staff knew what happened when they raised concerns.

Staff knew how to identify adults and children at risk of, or suffering, significant harm and worked with other agencies to protect them.

The registered manager had oversight of safeguarding within the service. We saw notice boards displayed pertinent safeguarding information such as telephone numbers, safeguarding referral processes, as well as information on how to support children’s mental health and the contact numbers of a national children's charity.

The service worked with patients to understand and manage risks by thinking holistically. Staff provided care to meet patient’s needs which was safe, supportive and enabled patient to do the things that mattered to them.

The service worked with patients to understand and manage risks. Treatment and care met patients' needs in a way which was safe and supportive and enabled them to do the things that mattered to them. There was sepsis recognition and management guidelines.

We reviewed patient records and found they contained pertinent information such as GP letters and surgery notes including National Early Warning Scores, World Health Organisation Surgical Safety Checklists and Venous Thromboembolism assessments.

We observed a consultant explaining the risks and benefits of surgery to a patient. If a patient became acutely unwell during an outpatient appointment the hospital would contact the emergency services. There was a deteriorating patient policy in place, for further information about transfers out of the hospital see the surgery report.

Patient survey results showed that 87.3% of patients felt they were involved as much as they wanted to in decisions about their care and treatment.

We saw leaders displayed the top 3 risks on the risk register in the staff area. There was an outpatient's huddle and communication sheet which was completed daily. This included information such as how many staff were on duty, who were the safeguarding leads and on call, a focus of the week and a section on above and beyond. There was also information such as daily cleaning check, the bleep holder, any flash alerts. We noted in 1 huddle it was discussed how a patient had been transferred to theatre following anaphylaxis and how well it had been managed by the team.

The service detected and controlled potential risks in the care environment. Leaders 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 managed different types of waste safely.

Fire safety equipment was available and had been serviced. Fire exits were clear and free from obstruction. A fire risk assessment had been completed by an independent company in December 2025. The company identified that 20 fire doors needed replacing and multiple other fire doors required repair. Actions were ongoing to address identified issues this such as additional training for staff to do this in house by upskilling 2 engineers, quotes had also been obtained. The local fire service had also completed a walk around. The hospital tested its fire alarms on a weekly basis.

There was ready access to resuscitation equipment for adults and children in the department. We reviewed a sample of consumables and found these were in date. There was also a process in place for staff to check expiration dates monthly and complete an expiration date check sheet. Security tags were in place and checked including adult and paediatric anaphylaxis boxes.

We saw when incidents had occurred relating to equipment such as a faulty fridge alarm, this had been escalated promptly and actions were taken.

Staff disposed of clinical waste safely, both inside and outside the building. Waste was segregated and labelled in accordance with the trust policy. The risk of sharps injuries was minimised because of the safe management of sharp implements.

There was a safe water policy in place. This included scope, roles and responsibilities. Policies and risk assessments were in place to manage the risk of legionella. Risk assessments and audits had been carried out by external companies. Water outlets and sinks were flushed to reduce the risk of legionella build-up in line with Health and Safety Executive guidance. There was a water safety subcommittee that sat under the patient safety committee.

The service made sure there were adequate numbers of qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care, which met patient’s individual needs.

The service had enough clinical staff including nursing and support staff with the right qualifications, skills, training, and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Staff were made aware of their shifts in advance and could make requests. There were no occasions in the last 3 months when the outpatients department had not met the agreed staffing levels.

Managers reviewed the number and grade of clinical staff, healthcare assistants and other key roles, needed for each shift in accordance with guidance developed by Spire. Managers could adjust staffing levels daily according to the needs of patients. This was completed at least 24 hours in advance to predict staffing needs based on activity and patient acuity allowing early action if demand increased. Staff spoken with were able to take breaks during their shift.

The department utilised bank staff to ensure safe staffing levels. Over the last 12 months the sickness rate was 4.96%, however this included pharmacy and outpatients' physiotherapy. 43% of these absences were from long term sick leave. The vacancy rate was 0%. There was an active vacancy for additional bank nurses, and 2 new staff were in preboarding.

The policy was that staffing shortfalls, missed care and delays in treatment triggered a red flag event, triggering immediate escalation and action. Leaders assessed staffing on the day and responded to any emerging risks, red flag incidents were reviewed and reported daily. There had not been any reported red flag staffing incidents in the last 12 months.

We reviewed End of Year 2025-2026 Enabling Excellence appraisal completion list, and as of 1st April 2026 there was a 97% compliance score. Staff completed various competencies such as administration of medicines, assessment and management of pain, aseptic non touch techniques and taking and recording vital signs.

All outpatients clinical staff were trained in Paediatric Basic Life Support through a resuscitation quality improvement programme with yearly updates. Staff also had to complete a care of children and young people module.

There was a programme of mandatory training. This included topics such as duty of candour, National Early Warning Score, information governance and infection prevention and control. Compliance levels as of June 2026 were good overall with most topics achieving above 93% compliance.

There were processes for new staff to receive a full induction tailored to their role before they started work. Leaders told us when someone new started they would be supernumerary for 2 weeks and this could be extended if required. As part of the induction process leaders also told us staff would have the opportunity to spend time in different departments. We reviewed 2 outpatient staff files and saw there was evidence of employment history, references, and ID verification. There was a Disclosure and Barring Service policy. We saw all staff were up to date with their disclosure and barring checks. A log was kept of this including expiration dates.

Managers supported staff to develop through constructive recorded annual appraisals and constructive clinical supervision of their work. We reviewed several appraisals and saw they had information such as setting objectives, mid-year reviews, what had gone well and around values. We also saw staff were encouraged and enabled to visit other areas to support their knowledge if they wished and were able to raise any suggestions. If poor staff performance was identified this was dealt with in a supportive way, with a view to improvement.

The service supported the learning and development needs of staff and made sure staff received any specialist training for their role. Managers identified any training needs their staff had and gave them the time and opportunity to develop their skills and knowledge.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading by following policies. Infection and prevention and control data was collected and reviewed. Where required, actions were taken to improve shortcomings.

Staff used equipment and control measures to protect patients, themselves, and others from infection. They kept equipment and the premises visibly clean. Areas were free from clutter and had suitable furnishings which were clean and well-maintained.

We reviewed the most recent infection prevention control audits which showed over the last 6 months the department had mostly achieved 100%. Audits completed included aseptic non-touch technique, cleanliness, and hand hygiene.

There were no healthcare associated infections reported at Spire Little Aston Hospital between 1 October 2024 and 30 September 2025.

There was a provider infection and prevention and control policy and supporting guidance that was accessible to staff. Staff had access to expertise in infection control as needed.

Staff cleaned equipment after patient contact and labelled equipment to show when it was last cleaned. Chairs in the waiting areas were wipe clean. There was hand sanitiser available for patients and staff.

Regular cleaning took place in areas such as clinic rooms and toilets with signature charts to show when they had been cleaned. We saw cleaning staff carrying out their duties.

Staff supported infection prevention and control measures by following the uniform policy. Nail varnish and jewellery was not worn, and staff in clinical areas were bare below their elbows to allow for full hand decontamination.

There was an infection control lead who visited Spire Little Aston Hospital once a week. Their role included overseeing if the hospital met the required standards, identifying any trends, audit, and providing education sessions to staff; they also attended and assisted in relevant committees and assisted the pharmacy in anti-microbial stewardship programmes. Each department had an infection control link nurse.

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 used systems and processes to safely prescribe, administer, record and store medicines. There was an on-site pharmacy and only registered nurses had access to medication keys.

Staff completed medicines records accurately and kept them up to date. Expired medications were returned to pharmacy. All medications were recorded appropriately in patient notes and were signed and dated.

Medications were ordered weekly and fridge temperatures checked daily. Staff reported any issues to pharmacy. There was a short date drug log which was managed by a designated registered nurse. Prescription pads were stored securely with each consultant having their own prescription pad. An audit for storage and security of medicines audits over the last 6 months showed a compliance rate of 96%.

Temperatures in treatment rooms were recorded to ensure they did not deviate from the required range. Oxygen cylinders were in date and stored appropriately.

Staff learned from safety alerts and incidents to improve practice. There was a review of medicines errors and steps to prevent recurrence. For example, we noted in health and safety meeting minutes that health and safety flash alerts had been issued, for example, when it had been determined that portable heaters should no longer be used and as such, they had been removed from use. We also saw safety alerts were discussed in outpatient team meetings.