Spire Norwich 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 as requires improvement. At this assessment the rating has changed to good. This meant that people were safe and protected from avoidable harm.

Improvements have been seen since our last assessment in children safeguarding training and consultant documentation.

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 proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had a clear process for reporting incidents. Between March 2025 and February 2026, 393 incidents were reported. Most incidents related to administration, documentation, or communication issues resulting in no or low physical harm. Investigation outcomes from these incidents resulted in stronger controls being put into place around booking appointments, clinic changes and pre-appointment communication with reminder calls. Improvements were also put into place for patient record tracking.
One incident resulted in moderate physical harm around infection control and post-procedure care. The outcome from this incident resulted in improvements in post procedure safety netting information and earlier outpatient review.
Staff were aware of the type of incidents to report and were confident and supported to do so. Incident reporting information and how to report an incident was displayed around the department. Incidents were raised using an electronic reporting system and investigated by the governance team and head of departments. Head of departments attended a daily safety meeting where incidents were amongst the topics discussed on the agenda.
Learning was shared with staff at outpatient department daily morning safety huddles. The briefing was also printed and kept in a folder; staff signed this briefing to acknowledge attending the safety huddle or reading the information if they came into work on a later shift.
Learning outcomes from incidents were shared widely across all hospital departments allowing cross department learning.
Incident learning was also displayed around the department by way of “bitesize learning” and “Friday feedback" bulletins.
Consultants received a Medical Advisory Committee (MAC) Newsletters which also informed them of any incidents that have occurred.
Staff and leaders understood duty of candour and were aware of the legal and ethical obligation of being open, honest and transparent with patients and their families when things go wrong. The service investigated 3 incidents between August 2025 -January 2026 where duty of candour was triggered. Two incidents were in relation to Venous Thromboembolism (VTE) and one in relation to the incorrect removal of sutures.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The services received referrals from both NHS and private patients. Of which 40% were private referrals funded by private health insurance, 40% were self-funded, and 20% were NHS referrals. Appointments could be made online or by calling a centralised patient service centre. Patients told us the system worked well; they were given choice around appointments and consultants. Follow-up appointments were made directly with Spire Norwich hospital. Patients could also open a “My Spire” account this was a secure portal that allowed them to manage their appointments, complete prehospital health questionnaires and keep personal information updated giving them control and access when they needed it.
The centralised booking system had brought challenges to the outpatient department. Communication issues and availability of consultants for clinics had resulted in cancellations. Between March 2025 - February 2026 there had been 27 incidents of clinic cancellations. Patients were contacted, apologies were made, and explanations given; rebooking was offered. Senior staff were involved and complaint information given. Preventative measures were put into place to reduce reoccurrence by improving communication between booking systems, the department and consultants.
Staff told us patients often arrived that were not on the planned list for the day; this was because patients can book appointments online. These patients would still be seen even though they are not expected. This did not have any impact on staffing levels as the staffing tool used looked at the number of patients a clinic could accept rather than the number expected.
The service stored and kept patient notes securely. The service followed the Patient Health (paper) records policy. Patient records were kept on site for 3 months and then moved to a national distribution centre. Records were requested when needed from the onsite records team and delivered to the department in tagged tamperproof bags or boxes. They were then scanned, enabling them to be tracked across the hospital.
Following a consultation or minor surgical procedure Consultants made brief handwritten notes that would be added to the patient care record. A more detailed and thorough account of the consultation would then be typed up and filed with the patient care record once completed. This meant that patient care records were kept updated and available across the site should the patient move across departments, aiding continuity of care. It is a condition of consultants’ practicing privileges at the hospital that consultants ensure that a copy or the original of their notes were included in the patient care record.
Consultant documentation was audited quarterly. Quality compliance targets were set at 95%; however, the services last audit showed that 88% was achieved. Actions were put into place for this to be discussed at Medical Advisory Committee (MAC) meetings and for Head of Departments to speak to consultants regarding the completion of documentation.
In the 6 months before our assessment there had been 1 occasion where a patient’s notes were not accessible at the time of their appointment. The patient still had their appointment; new notes were made and added to the expected notes when they arrived.
Following consultations, patients received a letter documenting what was discussed, treatments and plans. With the consent of the patient, this letter was also sent to their GP, to allow for appropriate information sharing and smooth transitions across the services.
Any required diagnostic testing, for example X-rays, MRI scans or blood test, was arranged prior to any consultations to allow for results to be discussed at the time of the appointment.
Staff described positive working relationships which aided with the smooth running of the department.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while 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 service had policies for safeguarding adults and children, and young people both could be accessed by staff through the internal internet system. However, the policy for safeguarding children and young people was found to be out of date. Photographs of safeguarding leads and champions were displayed within the department so that staff knew who to approach for help and guidance.
The head of the outpatient department was also a safeguarding lead trained to level 4 in the safeguarding of adults, children, and young people. All staff within the department had completed level 1 and 2 safeguarding for adults and children with 75% completing level 3 for adults and children. Staff had until the end of March to complete their training; this was monitored by the head of the department. This reflected good practice in line with the Royal College of Nursing intercollegiate document on safeguarding competencies for health care staff.
Staff were able to recognise signs of abuse and neglect including Female Genital Mutilation (FGM) and make referrals appropriately. Staff felt supported by senior managers to make referrals. Staff were supported following referrals; one member of staff told us that they were very well supported after a distressing referral regarding a child safeguarding. Staff also told us of the importance of using an independent interpreter if a patient did not speak English as considerations needed to be given regarding controlling or coercive abuse and behaviours. Information was available in public areas about Female Genital Mutilation (FGM) and domestic abuse with telephone numbers and website details for people to seek help.
On our first visit to the service, the children’s waiting areas, at all 3 outpatients’ sites, were not separated from the adult waiting area. This was brought to the attention of senior leaders. We revisited the service 1 week later and this had been rectified. Provision had been made at 2 of the sites for a separate children’s area, a screen was available at the site in the main building.
Information was displayed informing staff of the process to follow if a child did not attend their appointment, who to contact and how to escalate making a safeguarding referral if necessary. There was also information about the process to follow should a child go missing from the department.
Learning from safeguarding was cascaded to staff in staff bulletins and at daily safety huddles.
Safeguarding was discussed at clinical governance meetings.

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

The service had a deteriorating patient policy which staff had access to. A deteriorating patient algorithm was displayed in treatment rooms, informing staff of how and when to escalate patients who deteriorate. A sepsis recognition and management guide was also available.
Staff were aware that changes in patient’s observations and appearance could indicate changes in their condition. Staff were trained in National Early Warning Score 2 (NEWS2) and Paediatric Early Warning Signs (PEWS). NEWS2 and PEWS are standardised tools used to assist and respond to acute illness in adults and children. By using NEWS2 and PEWS staff would recognise changes in a patient’s condition and escalate accordingly.
There was a red emergency call button that staff could pull in treatment and consulting rooms to raise the alarm for immediate help and assistance. Staff said that they would get support from the consultants within the department and the Resident Medical Officer (RMO) from the main hospital. They would also call 999 in cases of emergency. Staff did this when a patient suffered a seizure whilst attending the satellite outpatient site.
There was a 95% training compliance of staff that were trained in Intermediate Life Support (ILS) and 90% of staff were trained in Basic Life Support (BLS). The department ensured that there was an ILS trained member of staff on every shift. None of the staff in the department were trained in Advanced life Support (ALS) but would receive support from staff, trained within this competency, from the main hospital site and by calling 999.
We spoke to people, at different stages of their consultation and treatment journeys. They told us that they were involved in the decisions around their treatments and were given time to ask questions and discuss any concerns, treatment options and associated risks.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The outpatients department at Spire Norwich Hospital had 23 consulting rooms split over 3 sites. Hill house, in the main hospital building and the Ella May Barnes (EMB) Clinic which was a satellite clinic a short drive from the main hospital site.
Carparking with designated disability spaces was available. Wheelchairs were available in the entrance of the departments for people to use.
The reception areas were staffed, with people having the option to check in with the receptionist or self-check in using an electronic device. Wi-Fi was available.
The departments were well signposted. The EMB clinic was on the first floor and a lift was available.
All staff were observed to wear name badges and the departments displayed staff photographs.
The departments were visually tidy, chairs and other furnishings within the waiting areas were in good condition and fit for purpose. Hot and cold refreshments were available. Accessible toilets were available and baby change facilities. The departments had children’s waiting area with toys available, however they were not separated from the adult areas. We fed this back to leaders and when we revisited a week later, provision had been made at the Hill House site and EMB clinic for the children’s waiting areas to be separated from the adults area. A screen had been provided at the site within the main hospital.
The EMB clinic housed a physiotherapy suite with gym equipment available. The equipment looked visually clean and in good working order.
Patient information boards were displayed with information for both adults and children and young people.
Closed Circuit Television (CCTV) was available, and all consultancy and treatment rooms were secured with coded locks. Engaged and vacant signs were also available on doors for added privacy.
There were signs informing people of the chaperone service that the hospital provides. People we spoke to said that they were aware of it but had not had the need to use it.
Fire action information was available on patient information boards informing people what to do if a fire was discovered. Fire extinguishers were in date, serviced and a safely mounted to the walls. Fire risk assessments were completed annually for the hospital; the last one completed in October 2025.The days and times of the weekly fire alarm test was clearly displayed. The EMB clinic was on the first floor of the building. At each stairwell there was a fire evac chair to aid with the evacuation of people with mobility issues, when the lift cannot be used, in the event of a fire.
Staff had received fire safety training with 90% compliance. Staff have until the end of March to complete training, this was monitored by the head of the department.
Legionella risk assessment were completed yearly with the last one completed December 2025. Control of Substances Hazardous to Health (COSHH) risk assessments were carried out with an inventory list for the department. Substances were stored safely.
Equipment looked visually clean, in good condition and fit for purpose. Data received following our onsite assessment showed all equipment had undergone Portable Appliance Testing (PAT). All equipment apart from 7 examination lamps had been serviced within the last year. Staff told us they had access to enough equipment to treat and care for patients safely.
Red emergency buttons were available for staff to call for assistance in an emergency; this call system was tested weekly. There was a risk that nurses cannot respond to the emergency alarms when they are in clinic rooms at the EMB site as the alarm may not be heard. This is on the EMB site risk register. Portable radios were held at reception and the nurse in charge so immediate assistance could be accessed.
Clinical areas were organised and tidy. Sharps bins were labelled and dated and not overfilled. Clinical waste bins were used appropriately. Clinical waste disposal reminders were displayed to remind staff of the correct way to dispose of clinical waste using the correct bin or container.
Hand washing facilities were available with soap and paper towels. Hand sanitising gel was also available. Accessible toilets and baby change facilities were also available. Evidence received that the flooring within the depart met the health and safety standard.
Each site had access to resuscitation trolley and defibrillator which was checked daily. Signage indicated the nearest location for emergency equipment.
Photos of staff uniforms were displayed so that people can identify the level of staff training and clinical scope of practice of staff.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision, and development. They worked together well to provide safe care that met people’s individual needs.

Staffing was reviewed twice daily against expected activity within the clinics. The department used a digital staffing tool. Each outpatient site had its own staffing tool. The tool helped look at the number of clinics running and the number of staff required to run it safely. The tool also looked at the skill mix of qualified and unqualified staff.
The department used both permanent and temporary staff. They worked on a staffing establishment of 90% contracted staff with 10% flexible staff. Temporary staff were generally “in house” bank staff that were familiar with the environment and the protocols of the hospital and the department.
New staff had a probationary period of 12 weeks. They had 1-1 meetings with the head of department at 4,8 and 12 weeks to discuss development and any concerns. New starters were not included in staffing numbers for the first 2-4 weeks depending on their experience. This gave them time to become familiar with the environment and their role whilst being supported by a full complement of experienced staff.
If staffing was below the required levels this was mitigated by redeploying appropriately trained staff from other departments and if needed the head of department would work clinically. Outpatient staff rotate across the three sites every 3 months.
Mandatory training was a mixture of face to face and eLearning from an electronic online learning platform. Staff compliance with mandatory training averaged at 90%. The head of department monitored mandatory training, and staff were updated at morning huddles and daily safety briefings, email reminders were also sent.
Staff received 3 appraisals a year to discuss development and any additional training requirements. Clinical staff development courses were offered to staff for example a phlebotomy course for children. All staff had received their appraisals to date.
The departments had a staff board listing the names of staff within the department for the day and their training levels in basic and intermediate life support.
Staff and consultants said that the department had good working relationships. Staff got to know the consultants and their regular clinics, building rapport enabling the smooth running of the clinic meeting the needs and supporting the people using the services.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service referred to the National Infection and control manual (NIPCM) for England and also had their own policies for the management of communicable diseases for example viral respiratory infections and Clostridioides difficile (C. Diff).
Staff told us if a patient presented into the department with a communicable illness or disease, they would be into a separate room and isolated, staff would wear PPE and the IPC lead would be contacted for advice and cleaning.
Patient safety performance for, October, November, December 2025, stated that there had not been any cases of hospital acquired C. Diff, MRSA or E-coli. There had been 11 cases of surgical site infections (SSI).
All 3 outpatient areas were visibly clean and tidy. “I am clean stickers” were used on all equipment indicating that they had been cleaned and ready for use. The service had an Infection Prevention and Control (IPC) lead that staff could contact for additional help and guidance. Staff training in IPC was in line with the service target at 95%.
Clinical cleaning schedules were displayed, an outpatient cleaning board indicated the frequency of different cleaning tasks.
The service had a housekeeping team that undertook cleaning tasks. Daily cleaning audits were completed and evident at the back of the doors in the clinical rooms.
Personal Protective Equipment (PPE) was available with signage displayed to remind staff of the safe removal and disposal.
Sharps bins were labelled, dated and not overfilled. Clinical waste bins were used appropriately. Clinical waste disposal reminders were displayed to remind staff of the correct way to dispose of clinical waste using the correct bin or container.
Control of Substances Hazardous to Health (COSHH) risk assessments were carried out with an inventory list for the department.
Staff were observed to wash their hands and be bare below the elbows. The department was 100% compliant in the quarterly standard IPC audits and hand hygiene audits. Staff cleaned the treatment rooms after use and prepared them for the next patient using the appropriate cleaning products. The head of department informed us that one of the sinks in the treatment room used for taking blood samples at the Hill House site was not IPC compliant. This was on the department risk register. Hand sanitiser was available in all clinical areas.
The department achieved 97% compliance with the National Standards for Hospital Cleanliness.
IPC was discussed at quarterly governance meetings.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

Medicines were stored securely, with appropriate temperature monitoring, and checked regularly with access was restricted to authorised staff. There was a robust system in place to manage controlled stationary, such as prescription pads.
Emergency medicines were available and checked regularly.
We saw that sometimes people were supplied with emollient creams or ointments and patients were not supplied with the additional information recommended regarding the fire safety risk which had been the subject of numerous safety alerts from the MHRA. We escalated this concern to the service on the day of the assessment, and we received assurances that patients would receive the relevant safety information.