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

Spire Little Aston surgery services had a proactive, systematic approach to managing safety. Leaders embedded, maintained and sought to continuously improve a culture of openness and collaboration, and safety was everyone’s top priority. Staff recognised and reported incidents and near misses and reported them appropriately. Incidents were robustly investigated and learning was used and widely shared to improve practice.

There was a comprehensive safeguarding system. Staff had clear roles and responsibilities. This meant safeguarding risks were identified, managed actioned and reduced.

Spire Little Aston consistently applied person centred care with a positive culture which supported patient choice. This created trust between patients and staff and protected the safety and wellbeing of all people using services.

There was a collaborative approach to working with partners to comprehensively identify and manage shared risks and joint processes for monitoring their effectiveness. This led to enhanced standards of treatment and care at each step of patients’ care journey.

The design, maintenance and use of facilities, premises and equipment kept patients safe.

There were enough staff with the right skills, qualifications and experience in departments, wards and in theatres to ensure high-quality care and treatment. Managers made sure staff received training and had regular appraisals to maintain high-quality care.

Staff controlled infection risk well. They used equipment and control measures to protect patients, themselves, and others from infection. They kept equipment and the premises visibly clean.

The service used systems and processes to safely prescribe, administer, record and store medicines.

At our last assessment we rated this key question good. At this assessment the rating has remained good. Patients 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 had a current incident reporting and reviewing policy, which reflected the provider and national guidance.

Leaders had implemented the NHS Patient Safety Incident Framework to develop effective systems and processes to respond, learn and improve from patient safety incidents. Incidents were comprehensively investigated and there was clear analysis of incident data and trends with comparison with previous reporting periods. Incidents were discussed at the hospital clinical governance meetings, to review trends and lessons learnt. There was a rapid review of incidents that needed immediate investigation and action.

Managers investigated incidents with the whole team. Incidents and any complaints were shared during the daily hospital wide safety huddle which included all departments. Any subsequent learning was shared both individually with the staff or department and hospital wide. Patient safety incidents were also shared both within Spire Healthcare and more widely with other local NHS services to ensure learning was shared as widely as possible and sufficient action taken to reduce the risk of recurrence. When things went wrong, staff apologised and gave patients honest information and suitable support.

There had been 797 clinical indents reported between 1 June 2025 and 31 May 2026. Clinical incident trend analyses were undertaken to proactively address themes and trends. The service identified 22 incidents where patients were cancelled due to equipment being faulty, unavailable, or loan kits not being ordered or delivered in time. These avoidable cancellations negatively impacted patient experience, theatre efficiency, and service capacity. A quality improvement plan introduced a robust loan kit management process within theatres to reduce avoidable patient cancellations related to equipment availability. The project had delivered significant quality and operational benefits including a reduction of patient cancellation on the day of surgery, improved theatre efficiency, a better utilisation of operating capacity and reduced disruption to theatre lists. The success of this initiative has been recognised across the wider organisation and has been highlighted within Spire Healthcare as an example of good practice. The approach has subsequently informed a national Spire priority for 2026, demonstrating the project's contribution to service improvement beyond the Spire Little Aston Hospital.

We were informed about the recent cancellation of a patient’s operation on the day of surgery. Information about the patient cancellation was shared in the hospital wide safety huddle. Staff told us there had been a rapid review meeting with all departments involved. Learning had been identified and implemented, including a two-person verification process at both the ordering stage and receipt of stock, ensuring that the correct item was available onsite prior to the day of surgery. This strengthened process had introduced an additional layer of oversight and aimed to minimise the risk of error through independent verification at key stages.

There was evidence that changes had been made because of feedback. Staff told us following a patient fall they had worked with this patient to understand why they had fallen and not called for assistance. The patient had not understood the falls signage regarding their ability to mobilise unaided. New signage had since been introduced which was clearer and understood by patients we spoke with. Managers debriefed and supported staff after any serious incident.

There were no reported never events in the preceding 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. Spire Little Aston Hospital had introduced an additional element to their surgical checklist which was a check on prosthesis (brand and size) following never events in other services. The Spire Little Aston initiative had subsequently been introduced throughout Spire Hospitals.

Incidents were analysed to identify trends or themes and potential links to individual practitioners. For example, complications such as foot drop, pain and infection. Managers told us consultants’ performance was proactively monitored against national outcome data centrally, and this information was shared with Spire Little Aston Hospital.

Managers also told us they welcomed “soft” intelligence raised by physiotherapy staff which highlighted a slight increase in a particular surgical complication which was investigated and learning actions identified. Where there was an immediate risk of harm to patients or others, staff told us they were confident to intervene to prevent harms occurring.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation when things went wrong. Staff received feedback from investigation of incidents, both internal and external to the service.

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.

Safety and continuity were embedded as core principles throughout the entire patient journey. A fully integrated, collaborative approach united patients, their families and carers, staff teams, and partner organisations to ensure a safe, seamless experience across referrals, admissions, transitions, and discharge, including when patient interacted with multiple services.

There was a collaborative approach to working with partners to comprehensively identify and manage shared risks and joint processes for monitoring their effectiveness. This had led to enhanced standards of treatment and care at each step of the patient’s care journey.

Safety and continuity of care was a priority throughout people’s care pathway. There was a robust admission criterion for both private and NHS patients. The criteria set out where they had limitations in services and therefore potential risks were minimised risks by excluding some patients. Staff explained this was particularly important as they were unable to treat some patients who had increased health risks as they had no enhanced care facility (for example an intensive or high dependency unit) at Little Aston Hospital. This meant the risk of having to transfer a deteriorating patient to another care provider was minimised.

The service continuously reviewed and developed its admission and discharge processes to ensure seamless patient pathways and flow through the system. Patients were comprehensively assessed prior to surgery and findings considered when planning care and treatment. There were comprehensive pre-admission assessment procedures which included completion of electronic information virtually by the patient, a telephone call appointment with the pre-assessment nurse, blood tests and for most patients a face-to-face pre assessment appointment. Information was then assessed by an anaesthetist who was the pre assessment lead to agree the patient was suitable for the identified surgery at Spire Little Aston Hospital.

Patients may have their surgery cancelled, delayed or rebooked depending on the decision following pre assessment. The anaesthetist may also arrange a face-to-face appointment, for example a patient who had been assessed as suitable for theatre had their operation cancelled on 2 occasions on the day of surgery due to recurrent chest infections. All patients suitable for theatre were discussed during a suitability for theatre meeting. There was also a weekly multidisciplinary theatre meeting for all departments to discuss patients planned for theatre in the next 7 days. Discussions included additional needs such as diabetes or patients with increased anxiety, order to theatre and availability of equipment.

There were systems and processes to ensure the correct patients were treated throughout the patient journey. We walked the patient journey and tracked patient care from admission to the ward for 3 patients to the operating theatre. We observed handovers of patient information including all related identification checking processes. Staff checked patients name, date of birth, consent form and procedure prior to leaving the ward, in the anaesthetic room and prior to administering any medication. Each member of staff introduced themselves to the patient and informed them of what was happening. Once in theatre, the World Health Organisation (WHO) surgical safety check list was used to avoid harm. We observed completion of the World Health Organisation (WHO) surgical safety checklist and found all staff were fully engaged in the process. Compliance with surgical safety checks was consistently high, with audit results demonstrating 100% compliance. Staff were familiar with key surgical safety standards, including the ‘stop the line’ process, and understood their responsibility to raise and escalate concerns where patient safety could be compromised.

The transfer of patients from the operating theatre to the recovery was managed safely, with the anaesthetist retaining responsibility for determining the readiness for transfer. Suitably skilled and qualified staff accompanied patients in all areas.

Patient records were a mixture of electronic and paper based and were kept securely. The IT connectivity was consistently available across the service to meet the needs of staff completing the records.

When overall responsibility for the care and treatment of a patient moved to a different service provider, such as transfer to the NHS, there were effective and robust systems in place, which allowed for seamless and safe transfer of care.

Discharge and follow up arrangements were organised safely. Patients knew what to expect and when they would be next seen by a nurse or doctor. At the time of the patients discharge they were given a paper copy of their discharge letter, and an electronic discharge letter which was immediately sent to the patient’s GP. The patient also received their next appointment to see their consultant, if they had orthopaedic surgery a physiotherapy appointment and an appointment to have their sutures or clips removed if required.

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.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff received both adult and children's safeguarding training. Data showed 99% of all staff working within surgery (includes wards, theatre, pharmacy and physiotherapy) had received the required level of adults and children safeguarding training. There were current safeguarding policies, and these reflected the national guidance for adults and children, including visitors.

Whilst the hospital did not provide surgery to under 16-year-olds, young people between 16 and 18 who were deemed to have capacity were operated on following by assessment by a paediatric nurse. There were both adult and children’s safeguarding leads and appropriate arrangements in place to keep young people safe whilst on an adult ward. Each day the hospital safety huddle included whether any child or young person was attending for either an outpatient or surgery

Staff knew how to make safeguarding referrals and who to contact if they had concerns. The hospital had 4 safeguarding leads, all trained to level 4, including the interim hospital director, director of clinical services, clinical governance manager and a physiotherapist. Their photographs were displayed throughout the hospital, ensuring safeguarding support was visible, accessible and readily available to staff.

Safeguarding leads present in the hospital that day was identified during the daily safety huddle and was also identified on the staff on duty board, so staff were fully aware who to contact if they had any potential safeguarding concerns. There was a safeguarding lead onsite Monday to Friday and were available on call out of usual office hours including weekends. Staff knew how to contact them.

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. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act.

The director of clinical services who was one of the safeguarding leads had oversight of safeguarding within the service. Where relevant, staff checked that people claiming Lasting Power of Attorney had the appropriate documents to support this.

Staff followed safe procedures for visitors visiting the wards and patients we spoke to told us they felt safe.

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.

We spoke with 7 patients, and they had been told about treatment options, possible complications and management of pain control. Patients said they felt listened to, risks had been explained, and they were involved in decisions about their care and treatment. Patients also told us they had an email which included a link to “My Spire” a booklet and videos which provided additional information about their operation, complications and the use of equipment or medicines to reduce the risk of complications.

Prior to surgery all patients had a comprehensive assessment of their medical history to identify any potential additional risks to them and may mean they could not have their surgery at Spire Little Aston Hospital or may be used to determine other preoperative actions.

The service used the National Early Warning Score 2 (NEWS2) for the detection and response of deteriorating patients. We reviewed 11 sets of patient records and found observations were completed according to the frequency required for the patient and escalated according to policy. The service audited their compliance with escalating NEWS2 scores 4 times a year. The most recent audit showed 94% compliance. The audit result was shared across the service for awareness around completion of NEWS scores but if full compliance was not achieved at the next audit an action plan would be identified.

There was a service level agreement with the local acute hospital trust and independent ambulance service to transport patients requiring intensive or high dependency care to support staff when they identified a patient who deteriorated and required critical care.

Staff all had training in sepsis and told us they completed sepsis screening for patients when concerns were raised. Staff told us about actions they had undertaken to escalate their concerns and arrange for the patient to be transferred to an NHS hospital. The hospitals most recent audit of sepsis management identified 100% compliance with required standards in the management of sepsis / potential sepsis.

Risks were assessed and patients and staff understood them. Staff completed risk assessments for each patient on admission, using recognised tools, and reviewed these regularly, including after any incidents. These risk assessments included, but were not limited to, a patient’s risk of venous thromboembolism (VTE) (blood clots), skin damage, malnutrition, manual handling, and falls risk. We reviewed the risk assessments completed for 11 patients and found all risk assessments were completed within the expected timeframe and where action was required, staff had taken this.

The service audited the compliance with VTE risk assessments monthly, with consistently high scores the most recent audit identified 98% of patients had a VTE assessment. Managers told us they had a lead clinician actively monitored VTE completion to ensure patients had a required risk assessment.

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 around the built environment. Where required, areas were secure and protected patients. Access was restricted by keypads.

The environment of the wards and other areas used for patient care reduced the risk of patient harm, and included, for example, safe flooring, handrails and window restrictors.

Fire safety equipment was available and had been serviced. The hospital tested its fire alarms weekly. Fire exits were clear and free from obstruction. A fire risk assessment had been completed by an independent comply in December 2025. The company had identified the replacement and repair of fire doors which was being undertaken at the time of our visit.

There was suitable equipment provided and used correctly, such as for patients who were at increased risk of pressure damage or a blood clot developing. Staff carried out daily safety checks of specialist equipment. There was ready access to resuscitation equipment on the ward and in theatres.

Leaders maintained oversight of equipment to ensure it was safe and ready to use. Equipment audits were completed and outcomes shared with staff. Staff told us they had enough equipment to carry out their work safely and to support the treatment and care needs of patients. There were effective means of ensuring repair of replacement of broken or missing equipment.

Specialist equipment used in the operating theatres was used in accordance with national guidance and regulatory requirements.

Patients could reach call bells. Call bells were positioned by patient beds, and staff showed patients how to use them to summon help. We saw call bells were responded to swiftly and the noise level from unanswered call bells was minimal.

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

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.

Hazardous substances were stored safely and information about products was available to staff.

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.

New staff (which included bank staff) received a full induction tailored to their role before they started work. Managers supported staff to develop through regular annual appraisals and constructive clinical supervision. Staff received feedback on their performance and were supported in their professional development.

The service had not used clinical agency staff for more than 12 months.

Managers reviewed the number and grade of clinical staff, healthcare assistants and other key roles, needed for each shift in accordance with national guidance. Managers could adjust staffing levels daily according to the needs of patients.

Theatre staffing requirements were determined by list type and patient acuity, with defined team sizes and skill mix for each theatre session and was in line with the Association of Perioperative Practice guidelines. Information we saw demonstrated planned staffing against actual deployment (including contracted, overtime, and bank hours), with clear visibility of any variance. Any variances to required staffing were reviewed daily, risk assessed and formally documented with clinical rationale (e.g. case mix changes, cancellations, redeployment, or nonclinical duties such as training, decontamination, and administration). Supernumerary roles (theatre manager and coordinator) provided additional flexible support and contributed clinically when required. Information about planned against actual staffing showed just decision making to ensure theatre staffing safely met patients’ needs.

The hospital safety huddle was attended by a senior manager for each department (both clinical and non-clinical) to identify required and actual staffing across hospital wide and mitigating actions if there was reduced staffing for example staff changes and use of bank staff and changes from nonclinical duties such as training, decontamination, and administration.

There were robust and safe recruitment practices to make sure all staff were suitably experienced, competent and able to carry out their role. We reviewed 5 staff records and found recruitment processes were in line with schedule 3 of the HSCA (RA) Regs 2014. Nursing staff had completed their Nursing and Midwifery Council re-validation checks and updates to develop their competencies.

Consultants led and delivered the surgical service at the hospital under practicing privileges. There was a robust system for onboarding new consultants and ensuring their practice and behaviours were in line with the service’s values and vision. The granting of practising privileges was a well-established process within independent healthcare whereby a medical practitioner is granted permission to work in an independent hospital or clinic, in independent private practice, or within the provision of community services. Practising privileges were overseen and approved by the medical director (MD) and medical advisory committee (MAC). Consultants lived within a 30-minutes travel time from the hospital. Consultants only carried out agreed procedures that they carried out in their NHS roles. Any new procedures would be reviewed by the MAC and specialist for that area. The medical governance and risk lead ensured consultants records were updated annually, including training and appraisals. They would raise any concerns or out of date data directly to the MD. We reviewed 4 consultant files and found they were all up to date with relevant information including up to date DBS checks, appraisals and training. There were copies of appraisals carried out in the NHS for consultants who worked in the NHS. Consultants that worked only in private practice could access the Spire central revalidation team to carry out appraisals.

Day to day medical cover was provided by the resident medical officer (RMO). The RMO worked on a week on week off rota and were available 24 hours a day on site to attend any emergencies. The RMO supported staff if a patient’s health deteriorated. Staff could contact consultants by telephone 24 hours a day for advice or to raise concerns about patient care. The RMO and staff told us consultants were responsive and supportive. In an emergency, staff would request an ambulance to transfer the patient to the local acute NHS emergency department.

There was a senior manager on-call every day and out of hours. There was a duty manager on site between 9am to 4pm every day. Theatre teams had an on-call anaesthetist, operating department practitioner and scrub nurse. Physiotherapy staff were on-call out of hours and over the weekend.

The service had low staff turnover rates. Across inpatient wards, theatres, pre-assessment, pharmacy and inpatient physio, there have been 9 leavers in the past 12 months. This is a turnover rate of 7.7%. The average turnover rate across the Spire group for clinical colleagues was 11.1% 3 of the 9 leavers were due to retirement with an average length of service of 24 years.

Clinical staff completed training on recognising and responding to patients with for example, patients with mental health needs, learning disabilities and dementia.

The service had low sickness rates. In the last 12 months the sickness rates across the surgical service (wards, theatre, pre-assessment, pharmacy and inpatient physio) was 3.6% this was lower than the Spire average sickness rate which was 5.1%.

Managers limited their use of bank and requested staff familiar with the service. The service had not used any clinical agency staff in the last 12 months. Bank staff usage was also minimal across surgical services.

Staff spoken to said they felt the service was safe. They were able to take breaks during their shift.

Patients spoken with felt their needs were met in a timely way. We saw patients were attended to in a kind and supportive way. Patients appeared comfortable and were engaged in conversations because there were sufficient staff.

Staff received training appropriate and relevant to their role. All staff had an induction, and staff were provided with appraisals and supervision as needed. Staff could access mandatory training online and some face-to-face sessions. Managers received a monthly report to show compliance with mandatory training. Training compliance data for all staff showed 96.1% of all staff had completed their mandatory training, with a target to complete all training by the end of June 2026. There were a variety of online learning platforms that staff could use to develop their skills and experience to enhance their development.

Managers supported staff to develop through constructive recorded, annual appraisals of their work and regular clinical supervision. If poor staff performance was identified, this was dealt with in a supportive way, with a view to improvement. All staff received an annual appraisal with a mid-year review, which included objective setting. Staff could raise any issues or learning needs or opportunities with their line manager. For 2025 -2026 the appraisal completion rate was 97.6% (130 contracted colleagues.3 staff were not eligible due to maternity leave or long-term sickness. Of the 127 eligible contracted colleagues, 122 completed an end of year 2025-2026).

The service supported the learning and development needs of staff and made sure staff received any specialist training for their role.

Managers made sure staff attended team meetings or had access to the information shared when they could not attend. We saw notes from team meetings and other general information was shared on notice boards.

The service had enough allied health professional staff to keep patient's safe and meet their needs. Allied healthcare professionals formed an integral part of the patient care and treatment pathway and promoted recovery and rehabilitation. Patient pathways and their discharge was not delayed because of a lack of allied healthcare professional input.

Surgical procedures and clinical decisions were carried out by doctors with appropriate seniority and speciality training. Patients were clear who the doctors involved in their treatment were.

The overnight and weekend provision was adequate, with access to the admitting consultant for advice or to attend, if necessary. The admitting consultant reviewed their patients regularly, including at weekends.

All staff at the hospital completed basic life support. Compliance with this training was 95% at the time of our inspection. With a plan for all staff to have updated this by the end of June 2026. Some staff completed advanced life support (ALS) and intermediate life support (ILS). Those required to complete ALS was at 100% and those required to completed ILS was at 92%.

Medical staff received and kept up to date with their mandatory training, this was completed via their employing NHS trust, this was checked and updated by the hospital. Records of mandatory training for visiting consultants were held on site. Resident medical officers (RMOs) completed mandatory and yearly update training with their agency. The hospital received training certificates that verified RMOs training status. This included advanced life support (ALS), European paediatric advanced life support (EPALS), blood transfusion, infection prevention and control, safeguarding children level 3.

The service assessed and managed the risk of infection well. 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.

The service used systems to identify and prevent surgical site infections. Staff used equipment and control measures to protect patients, themselves, and others from infection. They kept equipment and the premises visibly clean.

Theatres and ward areas were visibly clean, free from clutter and had suitable furnishings which were clean and well-maintained.

There was a provider infection and prevention and control policy and supporting guidance that was accessible to staff. The policy included information on roles and responsibilities, monitoring, training and the Infection Control Committee. The providers guidelines reflected national Infection Prevention Control (IPC) guidance from Public Health England (PHE), and the Royal College of Surgeons. Staff had access to expertise in infection control as needed.

The environmental cleaning was provided by housekeeping staff who had enough equipment and there was a daily checklist in place. Staff carried out daily cleaning of the equipment and environment, this was documented daily.

Staff followed infection control principles including hand hygiene, cleaning, personal protective equipment (PPE), waste, and decontamination. Hand-washing and sanitising facilities were available for staff and visitors. We saw gloves and aprons in dispensers on the walls outside patients’ rooms. We observed staff using hand sanitising gel and PPE appropriately during the inspection.

Theatre practice minimised the risk of cross infection and we saw staff following best practise regarding the treatment and care of their patients.

The management of clean and used surgical equipment and the flow through theatre reduced the risk of cross contamination. The hospital had a decontamination and Sterile Services Department in the theatre environment and carried out decontamination of all equipment. The department had a one way flow for dirty and clean equipment.

The service performed consistently to a high standard for infection prevention and control, hand hygiene, waste, and sharps management, cannula insertion, Aseptic Non-Touch Technique (ANTT). Audits were completed and consistently 100% compliance for environmental cleaning and hand hygiene. The most recent cannula audit identified 96% and had identified actions for staff which included a reminder to start the peripheral venous catheter (PVC) bundle in theatre, and this was also shared in the theatre safety huddle.

Staff cleaned equipment after patient contact and labelled equipment to show when it was last cleaned.

There were processes to enable staff to respond to infection prevention and control risks such as transmittable infections.

There was appropriate testing of water outlets and air exchange systems in theatres. 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.

Staff understood the process for managing spillage of body fluids both on the wards and in theatres.

Staff supported infection prevention and control measures by following the uniform policy. Nail varnish and jewellery was not worn, and staff in clinical areas had arms bare below their elbows to enable effective handwashing.

There was an infection prevention and control nurse who worked across 3 Spire hospitals and visited Spire Little Aston Hospital once or twice a week. They provided advice and support to staff, carried out some spot checks and monitored any infections. There was microbiology support 24 hours a day 7 days a week, via the telephone.

During the period 1/5/2025 to 30/4/2026 the percentage of surgical site infections was minimal with 0.5% of the total number of surgical cases.

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.

Staff followed systems and processes to safely prescribe, administer, record and store medicines safely. Medicines including intravenous fluids were stored in line with local and provider policy and reduced the risk of misuse and errors. There was restricted access to drug storage rooms, and the temperature of these rooms was monitored to check they were in the required range for the safe storage of medicines. Keys to the controlled drug cupboard kept securely with limited keypad access by senior clinical staff. Oxygen cylinders were in date and stored appropriately. Storage and Security of Medicines Audit (excluding CDs) for theatres and the wards identified 96% compliance for the last 6 months.

There were appropriate and safe arrangements for the management, use and oversight of controlled drugs. Controlled drugs are medicines which require additional arrangements for their storage and administration under the Misuse of Drugs legislation (and subsequent amendments). There was a controlled drugs accountable officer for the service to ensure safe management of controlled medicines.

All controlled drugs were securely stored. Staff reported all controlled drugs received and administered in a central record in addition to patients’ medicine records. Clinical staff, the pharmacist and the accountable officer followed appropriate systems to regularly check controlled medicines. Staff followed a process for the safe and appropriate disposal of controlled drugs and other medicines when they were no longer required. Controlled drugs audits for theatres and the wards for the last 6 months identified 97% compliance.

Staff followed national practice to check patients had the correct medicines when they were admitted, discharged or they moved between services. Patients who had an identified drug allergy had a red wristband with the allergy identified. Allergies were also identified on the medicine record chart and in the patients’ records.

There was oversight of medicines optimisation and ward-based support for staff from a pharmacist. A pharmacist was involved in patient medicine reviews. We observed a pharmacist came to see patients to explain their medicines including how and when they should be taken before their discharge.

There were facilities for patients who wished to manage their own medicines. Patients who were able and wished to manage their own medicines were encouraged to do so.

Staff completed medicines records accurately and kept them up to date. There were accurate records of medicines administered in the operating theatre and recovery.

Staff completed an incident report if medicines were not given as prescribed. Medicine errors were reported during safety huddles and reviewed in the medicines management committee. There had been 12 medicines errors between 1 June 2025 and 31 May 2026. Staff learned from safety alerts and incidents to improve practice. There was a review of medicines errors and steps to prevent recurrence. Managers shared learning from medicine errors with clinical staff.

There was access to medicines needed in an emergency or at short notice at night and at the weekend.