Spire Norwich Hospital

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

This means we looked for evidence that the service met people’s needs.

At our last assessment we rated this key question good. At this assessment the rating has remained good.
This meant people’s needs were met through good organisation and delivery.

We have not awarded this service a score for Responsive.

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

The service made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.
Patients told us that the referral and booking process gave them choice around consultants and appointments. The service offered evening appointments and appointments on alternate weekends adding to this choice.
They said they would raise any concerns around their treatment of care with their consultant and other staff, confident that they would be listened to. These discussions aided treatment to be tailored to the needs and expectations of the patient. Information given either before the consultation or during enabled patients to make informed decisions and choices to remain in control of their treatment and care.

The service understood the diverse health and care needs of people and their local communities, so care was joined-up, flexible and supported choice and continuity.
Staff across different specialties worked collaboratively to ensure that appointments, investigations and follow-up care was well coordinated. For example, any diagnostic imaging that was required would need to be pre-planned so that the images were ready in time for the consultation.
Pathology results were not always ready. This was due to incomplete or inaccurate patient identification on the samples. This information was handwritten on the samples and was not always legible this could lead to patients needing a further sample taken. A quality improvement initiative was set up to improve this and although improvements had been seen this issue remains on the department risk register.
Following a consultation, if a minor procedure was required and enough staff were within the department to allow the procedure to safely go ahead it would be completed on the same day. This provided the patient with join-up care and continuity of treatment.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.
Most patient care records were kept in a paper format. The service followed a Patient Health (paper) records policy. All staff had access to this policy on the internal internet system. The policy laid out the details of managing patient health records from creation to destruction.

All patient records were handled safely and securely. Records up to three months old would be kept on site, these would be requested from the medical records department, and they would be delivered to the department in a sealed tamper proof box and tagged. This would then be scanned so that they could be tracked throughout the hospital. This kept the service compliant with UK General Data Protection Regulation (GDPR). Staff within outpatients were aware of the importance of keeping patient information confidential and 90% of staff had completed training in Information Governance. Records over 3 months were stored at a national distribution centre and requested when needed. Staff would report any missing records as an incident. There had been 1 instance in the 6 months prior to our assessment when notes were not available for an appointment. The patient was still seen; a new record was made for the day and amalgamated with the old records when they arrived.

The service also had an Accessible information Standards Policy that was available to staff. This policy gave information of the resources available for making information more accessible to people with additional needs for example, larger print, Autistic Society patient passport, Dementia Passport (This is me), however it was not clear whether these forms of communication were being used within the outpatient department. Staff had completed training in Autism, Learning Disabilities and Dementia and were aware of the challenges that people living with these conditions often face in communicating their needs.

Hearing loops were available at receptions. Translation services were available for people who did not speak English.

Information was displayed around the department informing people how to raise concerns and make complaints. People told us that they felt that information was given in a way that they understood, some had received information regarding their treatment prior to the appointment. They said they had enough time within consultations to ask questions and clarify any concerns. Following a patient survey 92% of patients overall agreed to feeling fully informed at all times.

The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.
The service had a complaints policy and a process of investigating complaints. They also subscribed to the Independent Sector Complaints Adjudication Service (ISCAS) this allowed any complaints, where a resolution could not be achieved, to be escalated for independent review. Complaints were investigated by the governance teams and Head of Departments. They were also discussed at hospital safety, quality and risk meetings.
Information for people on how to make a complaint was displayed around the department and staff knew how to advise people how to complain if they were asked.
People told us they would make a complaint and felt confident to do so if the need was to arise.
From August 2025 – February 2026 3 complaints were logged within the department. One was related to the incorrect removal of sutures. A full investigation was carried out, an apology sent, staff received additional training and a visual guide was developed to help with the removal of sutures.
The department also displayed “You said, we did boards” This displayed feedback received from patients and the actions that had been taken in response. One example was in reference to the Ella May Barnes satellite outpatient’s department. People had stated that there was not enough signage within the department and as a result more signs were displayed.
Patients were invited to join patient forums to discuss their experience at the hospital and make suggestions to improve services. These forums took place twice a year, private patients, NHS patients and self-funded patients were invited to ensure inclusion. The last forum took place in October 2025 following a Patient Led Assessment of Environment (PLACE) audit. This feedback resulted in additional signage at the Ella May Barnes satellite site and decorating and refreshing different areas of the hospital.

The service made sure that people could access the care, support and treatment they needed when they needed it.

The site provided equitable access by providing dedicated disabled parking, accessible toilets and baby changing facilities. Wheelchairs were available in the entrance to buildings and we observed staff assisting people that had mobility issues and used mobility aids.

Loop hearing was available. Translator services were available and very well signposted within the department.

Staff had access to The Accessible information standard policy and documents to aid people that had additional needs for example larger printed information sheets and easy-read documents however it is not clear that staff were fully aware of the additional resources available to them to aid communications as none of them we spoke to told us about them.

Pre-assessment questionnaires allowed time for arrangements to be made prior to appointments. Patients that required the use of a hoist could have their appointment on one of the wards where a hoist and other lifting aids could be made available. If a patient

required an interpreter arrangement for this could also be made before the appointment.

The department monitored patients who “did not attend” their appointments. Between March 2025 and February 2026, 154 patients did not attend their appointments. These patients were managed by prompt patient contact, rebooking of appointments, and clarification of the booking details. Learning from this focused-on appointment communication, the booking process and patient information.

Children and young people that did not attend their appointments were also followed up. Depending on the explanation given for the child not attending or frequency of missed appointments would result in a safeguarding referral and contact with the child’s General Practitioner (GP).

Access and flow through the department was monitored by staff to keep an oversight of any delays or clinic over runs. All patients would be seen unless they chose to rebook another appointment. Over the last 12 months, there were 4 instances of clinics starting late. There were no reported incidents of patients waiting longer than 30 minutes for their appointment. Patients we spoke to agreed with this and said that they never waited too long to be seen.

Between March 2025-February 2026, a total of 27 incidents were reported relating to clinic cancellations. Communication breakdowns were given as the reason 13 cancellations with 8 due to consultant availability the rest were administration errors. Patients were contacted, apologies, explanations and complaint information given. Rebooking of appointments were offered.

Preventative actions were put into place to reduce recurrence, this included strengthened communications between consultants and admin teams. Where booking systems contributed to the cancellations teams were reminded of the correct booking process.

With the consent of the patient, their GP would also receive details of consultations discussions and any treatments planned or received. The service did not routinely monitor the turnaround time for letters back to the patients GP, however a rapid audit from September 2025-February 2026 for 5 consultants gave an average response time of 3 days. This supported the continuity of treatments across services.

The outpatient department saw children up to the age of 18. Children up to the age of 16 were seen on a consultancy basis only and surgical procedures were not carried out. Minor elective surgical procedures were carried out on 16–18-year-olds. For these procedures to go ahead the patient had to have a children and young person assessment carried out by paediatric nurses.

Spire Norwich Hospital did not have any paediatric nurses on site; these assessments were carried out by the children and young people’s services based at the Spire hospital in Leicester. These assessments would generally be carried out virtually, to ensure that the child was suitable to be treated on an adult pathway. Once completed a report would then sent to Spire Norwich for review by the consultant and staff and added to the patient’s notes. Minor operations and surgeries would not be carried out unless this assessment report was received and in this instance the procedure would be cancelled.

The evidence showed a good standard. Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.
People told us that they felt comfortable and confident to express their views. They said staff were approachable and easy to talk to. The service invited patients to forums to express their experiences of the service.

Staff had completed training in Equality, Diversity and Inclusion supporting staff to recognise when individuals might face barriers in communication, understanding or engagement and tailor their approach accordingly. Feedback received from the family of a patient living with dementia stated that “Staff were calm, patient and generous with their time, prepared to listen and weigh up options and supportive of my husband’s dementia needs”.
The service had a multi-faith room where patients can pray or have some time of quiet reflection.
Of patients referred into the hospital, 40% were private patients, 40% were self-funded, and 20% were NHS referrals. All patients were treated equally and received the same standard of care regardless of how their treatment was funded.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future.
Patients told us that they had time in consultations to discuss their care and treatment with enough information for them to make informed decisions around their care. This was reflected in a patient survey; 92% of patients overall agreed that they always felt fully informed.
Patients with reduced mental capacity would be assessed by 2 members of staff. Discussions would be had amongst the wider team and family before any best of interest decisions were made. Staff ensured patient’s wishes and needs were reflected in the decision made.