Spire Parkway 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

Leaders had created a positive and proactive culture of safety-based on openness and honesty. Concerns about safety were fully investigated. The managers’ ensured lessons were learnt to identify and embed good practices. There was a very positive learning culture with staff managing incidents and safeguarding patients well. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. Staff assessed risks to patients, acted on them and kept good care records. There were processes to ensure the service had enough staff with the right training, skills and qualifications to keep patients safe.

At our last inspection we rated this key question as good. At this inspection the rating has remained the same. This meant 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 proactive and positive culture of safety, based on openness and honesty. Staff knew how to raise incidents and concerns and reported them on an electronic system and managers were alerted immediately. Incidents and complaints were reviewed daily at the staff huddles and fully investigated. Lessons were learnt to continually identify and embed good practice.

Leaders had implemented the NHS Patient Safety Incident Framework to develop effective systems and processes to respond and 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.

Staff understood the duty of candour and applied this wherever necessary.

Between May 2025 and April 2026 there had been 313 incidents reported for outpatients (OPD) and Physiotherapy. A majority of incidents had reported with no harm. Themes included administration errors, missing documentation and waiting times. Each incident was investigated, actions taken and lessons learnt to continually identify and embed good practice. The OPD manager told us there was group set up to review patient notes and access to information.

Spire group implemented a Patient Support Centre (PSC) for booking appointments and arranging clinic times. Since the implementation in July 2025, 125 incidents had been reported relating to administrative issues. None resulted in patient harm, issues included cancelled clinics and wrong appointments. The hospital has a weekly meeting with PSC to review clinics and discuss any issues. Spire Group Hospital Directors and PSC leadership reviewed key performance indicators and activity and reviewed themes across all Spire hospitals. The OPD manager told us that things had improved, and they had good communication with PSC to resolve any issues.

The service worked with people 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 people moved between different services.

Safety and continuity of care was a priority throughout the patients’ care journey. This happened through a collaborative, joined-up approach to safety that involved patients along with staff and other partners in their care.

Staff told us there were strong links with both internal and external partners. This enabled any transitions and continuity of care to be managed in a safe and effective way.

There was good oversight of how long patients had been waiting to be seen for appointments and who needed to be seen urgently. Booking staff and medical secretaries could make appointments. NHS patients could make appointment via the choose and book system and private patients could contact the hospital or consultant secretary directly to make appointments. Patients could self-refer online; these referrals would be reviewed to ensure they had selected the correct speciality and were appropriate for the hospital.

Staff completed risk assessments for each patient during consultation and updated them when necessary and used recognised tools. We saw that risks to patients who used the service were assessed, monitored and managed as appropriate. There were clear pathways and processes for the assessment of patients within the outpatient department.

Staff monitored clinic waiting times daily. Staff had overview of the patients in the waiting areas. Patients would be informed of any delays of appointment times or clinics. During our inspection all clinics were running on time.

Doctors sent letters to patients summarising what had happened at their appointment. A copy of this letter was sent to patient's GP. To ensure continuity of care discussions about patients that took place in multidisciplinary team meetings were recorded in patient notes.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff 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.

Staff understood their safeguarding responsibilities and knew how to take appropriate action when necessary. The provider had a clear safeguarding policy which was available for staff to access. Staff told us they rarely had the need to raise any safeguarding concerns themselves, however, were able to share examples of when they had to act to ensure patients were kept safe.

Staff received mandatory safeguarding children and adults training. All staff were trained to level 3 safeguarding adults and level 3 children. The Director of Clinical Services and Children and Young peoples’ lead nurse had level 4 safeguarding training and staff knew to report any concerns directly to senior staff. They supported staff in escalating concerns and supported referral processes to the relevant local authorities.

Safeguarding adult level 3 training was recorded at 98% compliance Safeguarding children level 3 training was recorded at 96%.

Patients were supported to understand their rights, including their human rights, their rights under acute services, the Mental Capacity Act 2005 and the Equality Act 2010. Staff understood the importance of supporting equality and diversity and ensured care and treatment was in accordance with the Act. Staff gave examples which demonstrated their understanding and showed how they had considered the needs of patients with protected characteristics.

There had been no safeguarding incidents reported in the 12 months prior to our inspection.

Recruitment pathways and procedures were in place to ensure relevant recruitment checks had been completed for all staff. These included a disclosure and barring service (DBS) check, occupational health clearance, references and qualification and professional registration checks. The human resources team checked these monthly and prompted staff that required renewals.

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. Safety was a priority that involved everyone, including staff as well as people using the service. Staff made sure that people understood the care and treatment that was being provided.

OPD staff met at the beginning of the day and staff were allocated specific roles, such as dressing clinics, minor procedures and a specific area of the clinic.

Physiotherapy staff had dedicated clinics to see new patients, follow up patients and those discharged following surgical procedures. They could contact the consultants direct if they had any concerns about the patients’ progress.

The Resident Medical Officer (RMO) would visit the OPD daily and review test results such as blood results. Any concerns would be notified to the consultant caring for the patient. The RMO would also review any patient wounds if staff had concerns.

Some medical secretaries worked off site. They could visit the hospital to review patient notes. Letters were sent electronically to be printed and added to patients notes.

Patients told us they were involved in decisions about their treatment and felt well informed about their care. Consultants gathered relevant information from patients to assess risk. They provided clear explanations and treatment options to support informed decision-making and any associated risks. We saw these were clearly documented in patients notes.

Staff demonstrated a clear understanding of how to respond to a deteriorating patient and were able to locate the deteriorating patient policy. Resuscitation equipment for both adults and children were located in the main outpatient department. The trolley had a tamper evident tag to ensure they could not be accessed by unauthorised people. The trolleys were fully equipped and checked daily by the nurse in charge.

There was a service level agreement with the local acute hospital to support staff when they identified a patient who deteriorated.

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

The service had suitable facilities to meet the needs of patients and was purpose built. Facilities and premises were appropriate for the services being delivered. The OPD and physiotherapy departments were on the ground floor of the hospital and was accessible to those using mobility aids. Each consultation room had a door handle with a keypad lock.

There was adequate car parking directly outside the building. It had its own entrance from the car park, which was easily accessible.

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.

Fire extinguishers had within date service checks and fire exits were signposted. There were dedicated fire wardens on duty daily.

One of the treatment rooms in OPD was undergoing refurbishment and upgrading the ventilation system to comply with required air changes. The department was currently using 1 of the endoscopy rooms to carry out minor procedures such as removal of lumps and bumps.

The hospital has a decontamination and Sterile Services Department in the theatre environment and carried out decontamination of all equipment.

Sharps bins were available and labelled correctly. Disposable curtains were used, dated and changed in line with guidance. Medical equipment in both OPD and physiotherapy had been appropriately tested and was within date. Sterile equipment was stored off the floor on appropriate shelving and all equipment was in date. The linen room, storeroom and dirty utility room were all visibly clean and tidy and equipment was stored correctly.

We saw the clean nasendoscope trolley was positioned outside the sluice door, which meant staff were passing the trolley and moving it out the way to access the sluice, potentially passing with body fluids. We raised this during our inspection and the trolley was moved.

We saw some stained tiles on the ceiling in one physiotherapy treatment rooms. We raised this during our inspection. Following our inspection, we were informed that 90% had been replaced with plans to replace them all.

Substances deemed hazardous to health were locked cupboards in the housekeepers room. This meant people using the service did not have access to substances which could damage their health.

Staff carried out daily safety checks of specialist equipment, such as the resuscitation trolley. Resuscitation equipment was easily accessible and located within the main OPD. Resuscitation equipment had been checked daily by the nurse in charge and an up-to-date checklist confirmed all equipment was ready for use. Beside each trolley was a list of the location of all the resuscitation trolleys within the hospital.

There was a process to manage the safety, maintenance and repair of facilities, premises and equipment. The equipment in physiotherapy was serviced every 6 months. They could contact contractors anytime if there were any maintenance issues.

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

The service had enough staff to keep patients safe. The service employed permanent and bank staff. Managers limited their use of bank staff and used regular staff familiar with the service. All staff had a period of induction, and supervision on commencing work at the service. Managers told us they had recently reviewed staffing levels and were staffed for 85% activity due to the fluctuation in activity. They would use bank staff when required. The staffing establishment was updated 3 times per year to ensure it was based on latest activity and service data. The hospital used a rostering tool to identify the number of staff needed on shift to support clinics.

There were robust and safe recruitment practices to make sure all staff were suitably experienced, competent and able to carry out their role.

Consultants led and delivered the OPD 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 services values and vision. The granting of practising privileges is 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 45-minute radius of the hospital.

Consultants would only carry 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 5 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 in private practice only, arranged their own appraisals and could access Spire central revalidation team to carry out appraisals.

There were 2 GPs that worked at the hospital. GP appointments were available every weekday for self-paying patients.

Day to day medical cover was delivered by the resident doctors who were employed by the service. They worked on a week on week off rota and were available 24 hours a day.

Every morning, the Director of Clinical Services recorded safe staffing levels for each department. Each department gave staffing levels for that day and the next day including sickness, bank usage and any gaps. Discussions included staff working across department to support each other.

There was a senior manager on call every day and out of hours, they would be on call for a week at a time. 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.

Some specialist nurses are available such oncology nurse specialist and breast care nurse. They would attend some of the clinics. There was a dietician that attended the hospital and could offer advice.

At the time of our inspection there were no staff vacancies for OPD and Physiotherapy. Staffing levels and were staffed for 85% activity due to the fluctuation in activity. The sickness rate between December 2025 to April 2026 was 5.9% for OPD, and 3.1% for Physiotherapy. This was in line with the Spire group average for sickness of 5.3%.

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 These were on target to be completed by the end of April. At the time of our inspection all staff in OPD and Physiotherapy had an up-to-date appraisal. There were a variety of online learning platforms that staff could use to develop their skills and experience to enhance their development.

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 80% of all staff had completed their mandatory training, with a target to complete all training by the end of May.

All staff at the hospital completed basic life support. Compliant with this training was 72% at the time of our inspection. With a plan for all staff to have updated this by the end of May. Some staff completed advanced life support (ALS) and intermediate life support (ILS). Staff that were required to completed ALS had completed the training, and those required to completed ILS was at 81%.

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 ALS, European paediatric advanced life support (EPALS), blood transfusion, infection prevention and control, safeguarding children level 3.

Some physiotherapists had specialised in some conditions such as orthopaedic, hand, gynaecology and spinal. Physiotherapist worked on the ward and OPD clinics, which enabled them to follow the patient throughout their treatment.

All staff had completed sepsis training; there was a policy for recognition and management of sepsis and sepsis shock. In the last 12 months there had been no cases of sepsis reported. Staff we spoke with were aware of how to recognise sepsis and how and when to raise concerns.

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

All areas were visibly clean, tidy and had suitable furnishings which were well-maintained. There were adequate storage facilities, no items were stored on the floor. Storage areas were tidy and free from clutter.

The environmental cleaning was provided by housekeeping staff who had enough equipment and daily checklist. Staff carried out daily cleaning of the equipment and environment. We saw cleaning and alcohol wipes were available throughout the service.

The service had an up-to-date corporate infection prevention and control policy which included information on roles and responsibilities, monitoring, training and the Infection Control Committee.

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. We observed staff using hand sanitising gel and PPE appropriately during the inspection.

The service performed consistently to a high standard for infection prevention and control, hand hygiene, waste, and sharps management. Audits were completed and consistently 100% compliance for environmental cleaning and hand hygiene.

There was an infection prevention and control nurse who worked across 3 Spire hospitals and visited Spire Parkway 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.

There had been no infections such as MRSA, E Coli or C. Difficile at the hospital in the last 12 months.

The evidence showed some shortfalls. We were not assured that the service had a clear oversight of medicines in all areas of the hospital. On the day of or inspection, the pharmacy manager was covering all areas and was very stretched and it was difficult to see how oversight would be maintained at peak times.

The service generally 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.

Private prescriptions were used in this area to provide people with medicines based on clinical need. However, we found that record keeping was incomplete, which meant that we were unable to account for all the private prescriptions that had been given out from this area. We raised this during the inspection. Following this inspection, the service implemented a new system to ensure private prescriptions could be traced.

Medicines were kept safely and securely in this area. All medicines checked were in date and there were systems to ensure staff were aware of medicines due to expire. Temperature monitoring had been completed in all medicine storage areas inspected and medicines were being kept within safe levels as recommended by the manufacturer.

Pre-pack medicines were available for pre-operation clinics, and staff had a good awareness of protocols for safe dispensing and counselling of these medicines.

People’s care records contained information on their reason for referral, including diagnoses, and relevant background information from their GP, such as medicines they are regularly prescribed. Medication histories had been taken for all people whose care records we reviewed and documented clearly in their notes.