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.

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 on the wards, in the operating theatre and recovery. People received treatment and care to reduce the risk of avoidable harm, such as pressure damage, blood clots or falls. There was safety processes arranged before surgical procedures and operations started, with staff working together to ensure the right patient had the correct procedure. 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. 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 evidence showed a good standard. 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 current incident reporting and reviewing policy, which reflected the provider and national guidance.

The service managed patient safety incidents well. Staff recognised and reported incidents and near misses in line with local policy. Managers investigated incidents and shared lessons learned with the whole team and the wider service.

Incidents were analysed to identify trends or themes and could be used to support learning from incidents.

When things went wrong, staff apologised and gave patients honest information and suitable support. Managers ensured actions from patient safety alerts were addressed and progress was monitored. Incidents and learning were shared with other providers.

Staff received feedback from investigation of incidents, both internal and external to the service.

We reviewed the incidents reported and recent examples included deferral of surgical procedure and actions to take and management of post-op complications in line with policies and procedures.

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. There had been two reported never events in the preceding year related to incorrect lens type being placed in the correct eye. These were both investigated and found not to be the case.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if things went wrong.

There was evidence that changes had been made because of feedback. Managers debriefed and supported staff after any serious incident.

The service provided mandatory training in key skills to all staff. Managers monitored mandatory training and alerted staff when they needed to complete updates. The compliance target was 95% and compliance at the time of the assessment was below 95% but plans were in place to address this by March 2026. Moving and handling level 1 training was only 54% for qualified staff at the time of the assessment.

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

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 of care was a priority throughout people’s care pathway. Patients were assessed prior to surgery and findings considered when planning care and treatment. This may include cancelling or delaying the surgery in cases where an underlying condition was identified.

There was an admission criterion for both private and NHS patients. These criteria set out where they had limitations in services and therefore risks were minimised by excluding some patients. Patients requiring tests and investigations were given enough information to enable them to understand the procedure. The service held an admission assessment meeting which was a multidisciplinary approach to review patients from pre-assessment with needs for example early onset dementia.

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 wards to the operating theatre. We observed handover of patient information including all related identification checking processes. Once in theatre, the World Health Organisation (WHO) surgical safety check list was used to avoid harm. We observed completion of the process for 4 patients. Staff confirmed the surgical safety standards but there was an error noted by the Consultant for one patient and the procedure did not proceed until further checks were made. A WHO surgical checklist theatres observational audit was 100% over the last 6 months (target 95%).

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 paper based and were kept securely.

Consideration was given to whether a patient was likely to require a higher level of medical and nursing support and when necessary, this was ahead of the procedure.

When overall responsibility for the care and treatment of a patient moved to a different service provider, such as transfer to the NHS, there was effective communication, which allowed for seamless transfer.

Care and support was planned and organised with people, together with partners and communities in ways which ensured continuity.

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 adult and children's safeguarding training. Data showed for registered ward and theatre staff safeguarding adults and children level 3 compliance was 82.5% but staff had until 31 March 2026 to reach the target of 95%. Compliance for adult and children’s safeguarding training for levels 1 and 2 for unregistered staff was 100%.

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. Expert safeguarding advice was available to support staff from Monday to Friday. Staff knew how to contact them. There were 4 safeguarding leads.

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.

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's to do the things that mattered to them.

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 to several patients during our assessment who told us they felt listened to, risks had been explained, and they were involved in decisions about their care and treatment. For example, a patient told us that they received information about the sedation they would receive and were kept informed about their treatment.

In the latest patient satisfaction survey 95% of patients either strongly agreed or agreed that they felt really cared for.

The service detected and controlled potential risks in the 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 swipe card to theatres.

The environment of the areas used for patient care including Lavender and Poppy wards, had safe flooring and handrails to reduce the risk of patient harm.

Fire safety equipment was available and had been serviced. Fire exits were clear and free from obstruction.

There was suitable equipment provided and used correctly, such as for patients who were at increased risk of pressure damage. 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 maintenance was carried out comprehensively. Over the preceding year the adherence to the maintenance for equipment was 92%. 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 or replacement of broken or missing equipment.

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

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 service policy. The risk of sharps injuries was minimised because of safe sharps management.

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 had a full induction tailored to their role before they started work.

Managers reviewed the number and grade of clinical staff, healthcare assistants and other key roles, needed for each shift. Managers could adjust staffing levels daily according to the needs of patients. Theatre and recovery staffing was planned, based on activity and the skills needed for everyday and emergency work, including out of hours cover. We saw duty rotas for the last 4 weeks for medical and nursing staff. We were informed that there had been some recent challenges regarding staffing levels following the implementation of an 85% permanent staffing level and 15% flexible staffing model. A daily safe staffing meeting was held with all Heads of Departments, and a safe staffing tool was used to ensure that safe staffing levels were in place.

The service had low vacancy rates with a turnover rate of 17% over the last year and a low sickness absence rate of 4.8% over the last year.

Staff told us that they felt that whilst the hospital was busy at times that they were a team working together to support colleagues to maintain safe services.

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

Managers limited their use of bank and agency staff, with 9.3% bank and 1.1% agency staff used in 2025.

Patients spoken with felt their needs were met in a timely way and we observed staff responded to patient needs. 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.

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. For example, some staff had access to the Driving Clinical Excellence in Practice Programme and Senior Healthcare Assistant training.

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

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. There was 100% compliance for staff appraisals in 2025.

Allied healthcare professionals formed an integral part of the patient care and treatment pathway and promoted recovery and rehabilitation.

The service had enough allied health professional staff to keep patients safe, meet their needs and support timely discharge.

There was oversight of medicines optimisation and ward-based support for staff from a pharmacist. However, we were informed that the pharmacy service was short staffed at the time of the inspection, but plans were underway to recruit staff and use bank staff.

The service had formal arrangements for a resident medical officer (RMO) to be on-site when patients were receiving treatment and care. The RMO informed us that they had received a good induction and felt supported by consultants. They also had the opportunity to get involved in quality improvement projects such as the management of low sodium levels.

Consultant surgeons and anaesthetists were subject to a full assessment through the practising privileges process. They were required to provide evidence of appraisal and re-validation.

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 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.

The service managed infection risks well. Theatres and ward areas were visibly clean, free from clutter and had suitable furnishings which were clean and well-maintained.

The theatre environment followed national guidance, with separate areas to enable flow from clean storage, preparation through to an area for dirty equipment and waste management. There was storage for equipment including sterile packs, uniforms and linen.

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

For example, there was a screening policy for meticillin resistant staphylococcus aureus (MRSA) and management of Clostridioides difficile infection policy that was accessible to staff. The providers guidelines reflected national Infection Prevention Control (IPC) guidance. Staff had access to expertise in infection control as needed.

There was a programme of infection and prevention and control audits including for example, national standards for healthcare cleanliness weekly audit, hand hygiene audit, urinary catheter insertion audit.

The service generally performed well in local IPC audits. In the most recent audits, the scores showed compliance with infection prevention and control measures in clinical areas. Where the audit score was below the standard required, action plans were in place to reach compliance, for example, sharps audit.

Staff used records and data to identify how well the service prevented infections. The service monitored surgical site infection (SSI) rates. For example, the UK Health Security Agency Mandatory Surveillance SSI rates (readmission/inpatient) for the year March 2025 to March 2026 was for hip arthroplasty 0.23% and 0.17% for knee arthroplasty.

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

We saw staff were following infection control principles including compliant with handwashing and the use of personal protective equipment (PPE).

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. Staff checked the condition of sterile packs before they were opened and prior to use.

Staff supported infection prevention and control measures by following the uniform policy.

At the time of the inspection IPC advice was being provided by the regional lead who provided expert advice and support across the hospital.

The service made sure that medicines and treatments were available, and met people’s needs, capacities and preferences. Governance of medicines safety needs strengthening in a couple of areas

Medicines, including controlled drugs (CDs), were stored securely, with appropriate temperature monitoring, and access was restricted to authorised staff. CD balances were accurate, and we saw evidence that quarterly audits were undertaken.

Allergies were clearly recorded, and medicines were administered as prescribed including venous thromboembolism (VTE) prophylaxis if needed to prevent blood clots. Where doses were omitted, there was clear documentation as to why this had occurred. Medicines requiring specific timings for administration such as medicines for Parkinson’s disease were given at times appropriate for patient’s needs and medicines requiring separation from other medicines or food, were given appropriately.

A pharmacist reviewed prescriptions and attended the daily safety huddle and was involved in pre-admission discussions for patients with any complex medicine requirements. Staff told us the pharmacy team could be contacted easily, and there were mechanisms in place to be able to access medicines out of hours. The pharmacy was not open at weekends and procedures were in place to enable staff to supply medicines required for discharge.

The daily safety huddle reviewed compliance with any new safety alerts, however, we did find that the provider was not compliant with an historical safety alert regarding providing people information about the fire risk with emollient creams.

Upon admission, there was a process to reconcile medication (the process of gathering accurate information about a person’s prescribed medicines) and staff continued to use patients own medicines which were stored in a locker at the bedside. However, the codes for these lockers had not been changed in the last year.

Emergency medicines were available for use and checked daily. In addition, the cytotoxic spillage kit (needed to protect people if there was a spill of a cytotoxic drug) was not signposted should staff need it in an emergency, and there was no routine check of this taking place. The service took immediate action to rectify this issue.

Medicines management meetings had been restarted in January 2026 following new pharmacy leadership. Audits and incidents were reviewed and learning across the organisation took place, this was shown by a recent change in the procedure to oversee the prescription stationary.

The service had a self-administration policy in place to enable people to administer their medicines themselves if they wished to do so, although we saw one patient who had not had the correct risk assessment completed in line with the provider’s policy.