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. However, we found some concerns with medicines management governance and overview. Processes and record keeping were not always in line with good practice and policies.

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 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, 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 November 2025 and April 2026 there had been 292 incidents reported. A majority of incidents had reported with no harm. Themes included medication errors, and falls. Each incident was investigated, actions taken and lessons learnt to continually identify and embed good practice. Staff regularly updated processes in response to incidents, such as increasing checks on allergy status to ensure this information was clearly recorded.

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. Patients were reviewed at preoperative assessment and relevant tests would be carried out, such as blood tests. Consultants and nursing staff would discuss the care of the patient throughout their stay. Prior to admission each patient was discussed at the weekly theatre scheduling meeting. Staff from all departments involved in the patients care would attend this including, theatre manager, ward manager, imaging staff, preoperative assessment (POA), children and young peoples lead nurse (CYP) and the director of clinical services (DOCS). Patients care was discussed with the multidisciplinary team and planned to ensure all needs were met. The patients procedure was discussed and information shared such as allergies, diabetic patients and patients with protected characteristic to ensure all staff were aware and plans could be adapted to meet the patients needs. We saw at the meeting that a theatre list was amended to meet the patient’s needs.

The POA team told us that on occasions patient were booked onto theatre list at short notice. This meant that patients were having assessment and tests close to the surgery date. Staff told us is some cases patients were cancelled at short notice, or on the day of surgery. This lead to delays in patients treatment and poor patient experience. We saw this was on the hospital risk register with plans in place to mitigate the risk.

Patient were safely collected from the ward to go to theatre. 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.

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. We saw there were service level agreement with local NHS trusts to transfer patients.

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 DOCS and CYP 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 2 training was recorded at 100%.

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.

Prior to surgery all patients completed a health questionnaire that was assessed by the POA team. Each patient was triaged and the patients age, procedure and medical history would be taken into consideration to determine the preoperative actions. Following the triage, patients had telephone call assessments, face-to-face appointments and tests taken. The service had a No Further Contact pathway which identified patients with no health concerns and specific list of procedure that did not require further contact prior to admission. Staff told us they had identified patients through their assessments who required further reviews with medical staff. There were 2 clinics per week that anaesthetists held and would review patients with complex surgery and higher risk patients. POA nurses told us they could contact the anaesthetist for advice and support at any time.

There was also an elective surgical admission criteria in place to ensure only those patients suitable for care were admitted to the hospital. Patients that required high dependency or intensive care would not be treated at the hospital.

Staff used a nationally recognised tool to identify deteriorating patients and escalated them appropriately. The service used the National Early Warning Score 2 (NEWS2) for the detection and response of deteriorating patients. We reviewed 9 complete 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. Audits showed an 88% compliance. The service had developed an action plan which included a further review of patients notes and the actions which has been taken, review the frequency of observations, review staff training, staff to undertake audits and meet with the ward manager. The information was shared with all staff.

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

Staff were aware of sepsis and told us they completed sepsis screening for patients when concerns were raised. At the time of our inspection, we did not identify any patients who were showing signs of sepsis. Staff could raise any concerns about patients and request a review by senior staff or the resident doctor.

Risks were assessed and people 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 skin damage, malnutrition risks, manual handling, venous thromboembolism (VTE) (blood clots) risk, and falls risk. We reviewed the risk assessments completed for 9 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.

There was good compliance with safety checks in the operating theatres. We observed staff completing the World Health Organisation (WHO) surgical safety checklist, all staff were engaged in the process. Audits completed showed there was 99% compliance.

Theatre had a difficult airway trolley, a chest drain trolley and haemorrhage trolley set ready to use in an emergency.

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. There was adequate car parking directly outside the building.

The wards were visibly clean and tidy with appropriate equipment available to maintain safe levels of care.

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, fire exits were signs pointing out throughout the hospital. There were dedicated fire wardens on duty daily. Fire doors were on the hospital risk register due to some noncompliance. Action plans were in place to replace some fire doors in May 2026 and carry out maintenance of other fire doors in May and June to ensure compliance. Actions included fire marshals for each department, additional training, evacuation plans and tabletop exercises.

The hospital had 2 wards over 2 floors. Henley ward was on the first floor, accessible via stairs and a lift with 21 single rooms and 2 double rooms, all with ensuite facilities. Lapworth suite was on the ground floor with 14 single rooms all with ensuite facilities. They were equipped with wipeable furnishings and oxygen and suction ports. There were 4 theatres in total on the first floor, 3 had laminar flow (ultra clean air flow) and 1 theatre was a conventional theatre.

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. We saw staff wearing appropriate protective clothing.

Sharps bins were available and labelled correctly. Disposable curtains were used, dated and changed in line with guidance. Medical equipment in the ward area had been appropriately tested and was within date. Sterile equipment was stored off the floor on appropriate shelving, 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 one sink in the dirty utility room that had some rust on the base, this had been requested to be replaced.

Substances deemed hazardous to health were locked in 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 on each ward and in theatres. 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 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. Between January to March 2026, 6% of bank staff had been used for surgical services with no agency staff used.

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 documentation 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 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.

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 DOCS 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 were available such oncology nurse specialist and breast care nurse. There is a dietician that attends the hospital and can offer advice.

The sickness rate between January to March 2026 was 5.2% for surgical services, this was in line with the Spire group average for sickness of 5.3%. There were currently 2 vacancies, for a Theatre Assistant and Nurse Manager for POA.

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. At the time of our inspection 271 staff were employed at Spire Parkway with 8 appraisals outstanding. These were due to be completed by the end of May. 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 staff had completed their mandatory training, with a target to complete all training by the end of May.

Basic life support training was available as part of mandatory training. Compliance 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). Those required to complete ALS was at 100% and those required to completed ILS was at 81%. There would always be staff on duty with ALS and ILS and this was identified on the staff allocation board.

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.

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 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.

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

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. Most patient bedrooms had clinical sinks; however, some did not have clinical hand washing sink. The lack of sinks was on the risk register and a risk assessment and action plans were in place. Actions included refraining from placing any patient with potential infection or high risk patients into bedrooms without a clinical sink, staff training, infection surveillance and placement of hand sanitisers. Staff told us they would use hand sanitisers in the bedroom and wash their hands in the clinical room.

Theatres were cleaned daily after use and had a deep clean every 6 months. In June 2025 mould was identified from one theatre. The theatre was not used while action plans were undertaken. Actions included deep cleaning of the environment and equipment, repairs and air filter changes. Test were re done in August 2025 and mould counts were still higher than expected therefore additional cleaning was carried out. Retesting was carried out in September, October and November 2025 and results were within permissible limits. Activity in the theatre continues to be reduced, no surgical site infection were identified. Managers told us they continue to monitor the situation and review at every Infection Control Committee.

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 did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

Medicines were stored safely and securely on the wards but processes to manage their use were not always in place. Record keeping for controlled drugs (CDs) was not always done in line with national guidance, which meant that corrections could not be read clearly. Paper private prescriptions were used on the wards, but record keeping was not consistent with other areas of the hospital, and this meant that some private prescriptions could not be accounted for. Following this inspection, the service had implemented a new system to improve oversight of private prescriptions.

Staff completed risk assessments prior to surgery and managed people’s regular medicines in the perioperative period. A medication history, using multiple sources of information, including record of allergies was recorded in their charts, but allergy sensitivity was not always recorded, and vital details were missed on a medication history that we reviewed. Additionally, medicines were not always prescribed on paper charts according to local guidance, but in some instances, these had been reviewed as appropriate by a pharmacist. ‘When required’ medicines were not always prescribed completely, often missing indications and maximum doses. The service was in the process of implementing a new system to use stickers for prescribing ‘when required’ medicines in one type of surgery that made sure all areas of the prescription were completed.

Audits of medicines reconciliation rates outlined action plans to improve compliance, but audits on medicines handling did not identify issues found on this inspection. There were recommendations within the pharmacy strategy to prioritise improvements to medicines management within clinical areas.

The surgical wards received support with medicines reconciliation and discharge from the pharmacy team. Pharmacy staff were available to counsel most people on changes to their medicine prior to discharge. Take home medicines were prepared in advance of people’s discharge to prevent delays in them going home.

People’s heights, weights and ages were documented on their prescription charts. Venous thromboembolism (VTE) risk assessments were completed for all the people we reviewed, and prophylaxis was prescribed where necessary.

Surgical theatres were well equipped with medicines for a range of surgeries and medicines storage areas were well maintained. Medicines, including CDs, were kept securely and there was information available outside theatres on their appropriate use and destruction. Record keeping for CDs in theatres was completed according to national guidance. Medicines being used in theatres were prepared and labelled clearly as per local guidance.

Spire Parkway had moved to using a CD accountable officer (CDAO) who also oversaw another site within the Spire group. This was recognised on their risk register as an area for improvement but has been unavoidable due to staff absence. The hospital has appropriately informed the Home Office and CQC of changes to this role and put systems in place to ensure there is oversight of CD management at Spire Parkway hospital and compliance with license requirements.