Spire London East Hospital

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• 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 good. At this assessment, the rating has remained good. This meant people were safe and protected from avoidable harm. The environment was clean and well maintained, equipment was checked, and medicines were stored securely. Staff understood safeguarding processes and used systems to assess and manage risks. However, the learning culture was not consistently open or supportive. Some staff did not always feel confident to speak up or assured that concerns would be listened to, acted on or fed back. Staffing pressures also affected some areas, particularly outside core hours.

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 did not have a consistent culture of proactively encouraging staff to raise safety concerns. Senior managers did not always listen to staff concerns about safety. However, there were processes in place for senior managers to investigate incidents.

Feedback from staff interviews indicated that some staff did not feel comfortable speaking up and were not always confident that concerns would be listened to, taken seriously or acted upon. Staff described challenges with escalation, limited feedback when concerns were raised and management behaviours that could discourage open reporting. This reduced assurance that staff could consistently raise concerns and contributed to limited psychological safety within parts of the service, indicating that the learning culture required improvement.

Despite concerns about wider speaking-up culture, the service had systems and processes to support learning from patient safety incidents. Staff knew what patient safety incidents to report and understood the formal incident reporting process. There was a high level of incident reporting, with 288 patient safety incidents recorded within a six-month period. Incidents were triaged, investigated and closed through structured governance processes, including Key Safety Indicator (KSI) reviews, rapid reviews and Patient Safety Incident Response Framework (PSIRF) investigations where required. Outcomes, rationale and actions were recorded electronically, monitored and signed off through governance arrangements, with rapid reviews completed within 24 to 72 hours and formal reviews completed within agreed timescales.

We reviewed examples which showed action planning linked to identified risks. Action taken in response had strengthened a range of clinical processes, including consent procedures, intra-operative and discharge documentation, pre-operative escalation arrangements, theatre specimen checks, and medicines labelling, verification and sign-off. Incident data was analysed to identify trends, inform changes to policy, training and clinical pathways, and share learning through governance meetings and organisational reports. Staff understood and applied the duty of candour. Policies supported openness with patients and families when things went wrong, and patients were involved in investigations where appropriate.

While governance processes supported incident review and learning, evidence about speaking up and inconsistent feedback showed that the service had not embedded a consistently open and supportive learning culture. This meant leaders could not demonstrate that learning and improvement processes were fully effective across all areas.

The service had systems to support safe pathways and transitions, although some pathways needed more standardised guidance and clearer oversight.

Referral and admission processes were generally safe. Evidence showed structured pre-operative pathways, including use of an electronic pre-operative assessment (POA) tool and multidisciplinary team (MDT) review before admission. Assessments were completed, reviewed and escalated where needed, including anaesthetic input and multidisciplinary team discussion. This supported decisions about whether care could be safely delivered at the service.

The service had clear arrangements to support safe admission decisions. Pre-assessment clinics, triage processes and additional checks were used for higher-risk cases. National guidance informed decision-making, and systems were in place to review patients who may not meet criteria for surgery at the site. This reduced the risk of inappropriate procedures taking place.

The service followed nationally recognised surgical safety procedures, including use of the World Health Organisation (WHO) surgical safety Checklist. Audit data showed compliance was monitored and findings were used to support improvement.

Systems were in place to support inpatient and ward pathways, including admission, bed allocation, monitoring and escalation processes. MDT input supported the planning and delivery of care. However, some pathways were not underpinned by consistently standardised guidance and relied on local practice. As a result, leaders could not be fully assured that care was delivered consistently across all patient groups, increasing the potential for variation in practice.

The service used electronic systems, dashboards and triage tools to monitor patient progress, identify risk and support escalation between teams. However, evidence showed variation in how these processes were applied, particularly for less frequently used pathways. This meant leaders could not consistently demonstrate oversight of pathway implementation or identify variation across all patient groups.

The service worked with other healthcare providers to support continuity of care. Arrangements were in place to share information and coordinate care where patients required transfer or additional input. Unplanned transfers to National Health Service (NHS) providers were monitored and used to inform pathway improvements. Discharge planning arrangements supported effective coordination with community and primary care services, including communication of relevant information and follow-up requirements. Patient information materials had been updated following feedback, which supported safer transitions after discharge.

The service had implemented improvements to strengthen pathways and transitions. This included more structured pre-assessment documentation, clearer escalation pathways and strengthened MDT review processes. Additional controls included enhanced verification checks in theatre before specimen transfer, improved use of electronic dashboards to monitor patient flow, and strengthened triage systems to identify and escalate risk earlier. Medication management processes were also improved through clearer labelling, defined documentation requirements and strengthened verification and sign-off procedures. These changes improved consistency, reduced variation in practice and strengthened oversight of patient flow.

However, evidence showed that some pathways relied on individual knowledge and experience rather than clearly defined and consistently applied systems. Although escalation processes were in place, this variability meant leaders could not evidence a standardised approach for patients with complex or infrequent needs and needed to strengthen oversight of pathway consistency.

Staff were trained in safeguarding and understood how to raise concerns. However, training compliance was below the service target in some areas.

Safeguarding adults and children level 1 training compliance was 100% for theatres, pharmacy, and physiotherapy teams. This training was recorded as not applicable for wards and POA teams. Compliance with level 3 safeguarding adults training varied. Ward, POA and physiotherapy teams met the service target of 95%, but compliance was lower in theatres at 63.6% and pharmacy at 66.7%. Safeguarding children level 3 training showed a similar pattern. Wards, POA and physiotherapy teams met the 95% target, while theatres achieved 69.7% and pharmacy 66.7%. The service had an action plan to improve compliance. This included monitoring training completion, escalating gaps to line managers, and supporting and reminding staff to complete outstanding training. These actions aimed to reduce risk and improve safeguarding training compliance.

Staff demonstrated a good understanding of safeguarding processes and knew how to report concerns. Staff described using internal reporting systems and contacting safeguarding leads when concerns arose. Clear safeguarding posters were displayed on information boards and in staff rooms, which included contact details for safeguarding teams and supported staff to escalate concerns appropriately. The hospital lead for adult safeguarding was the director of clinical services, who provided oversight of safeguarding processes.

Staff understood how to identify adults and children at risk of harm. Staff described recognising safeguarding concerns during POA and admission, including for vulnerable patients or those lacking capacity. Safeguards included best interest decision-making, involvement of relatives and MDT discussions. Staff also worked with external safeguarding teams and designated officers to escalate concerns where required.

Staff understood how to protect patients from harassment, abuse and discrimination, including those with protected characteristics. There was a clear code of conduct and a zero-tolerance approach to inappropriate behaviour. Safeguarding flowcharts and contact information were available across clinical areas, supporting staff to follow correct procedures and escalating concerns through management and external agencies, including the police where required. Safeguarding risks relating to dignity, sexual safety and inappropriate behaviour were recognised and acted upon.

Children’s safeguarding processes were clearly defined and embedded in practice. This included supervision, appropriate staffing and safeguarding oversight at all stages of care. Children were assessed in person, and safeguarding risks were monitored, including follow-up where children were not brought to appointments. Additional safeguards were in place for intimate procedures, including the use of chaperones and clear documentation.

The service managed restrictive practice appropriately. Staff understood the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS). Staff told us restraint had not been used in surgery, and there were no blanket restrictions. Where patients lacked capacity, decisions were made in their best interests, with involvement from families and the MDT.

The service involved patients in understanding and managing risks associated with their care. However, processes were not applied consistently across all stages of the pathway.

Staff communicated clearly with patients about treatment, recovery and associated risks. They adapted information to meet individual needs, including using accessible information and involving families where appropriate. Staff supported patients to make decisions about their care, including advance decisions where relevant. Information about decision-making, consent and lasting power of attorney was available on information boards. Staff also supported patients who lacked capacity through established mental capacity processes, including best interest decision-making, involvement of relatives and MDT discussions. This helped ensure decisions followed legal frameworks and were documented.

Risk was identified and managed through comprehensive assessments. We reviewed 10 patient records and found that risk assessments, including venous thromboembolism (VTE) which is crucial for identifying patients at risk of developing blood clots, co-morbidities, and relevant investigations, were completed and used to inform care planning. Audit data provided by the service supported this. Between January and March 2026, compliance with VTE risk assessments was 99% against a 95% target, and compliance with pre-operative fasting guidance was 100%.

Staff understood how to recognise and respond to deterioration. They used nationally recognised tools, including the National Early Warning Score 2 (NEWS2) and Paediatric Early Warning System (PEWS), alongside clear escalation pathways. This supported timely identification and response to changes in patients’ conditions and helped ensure patients were monitored effectively throughout their pathway.

Communication systems supported safe transitions of care. Handovers were observed across surgical areas, and processes included key clinical information needed to maintain patient safety. This helped ensure risks were understood and managed as patients moved between services.

In theatres, staff followed recognised safety processes and involved patients in risk management before procedures. Observations of 3 theatre cases showed staff completed the WHO five steps to safer surgery checklist before procedures started. This supported a shared understanding of patient risks and provided opportunities for concerns to be raised before surgery.

However, pre-operative planning was not always consistently evidenced. Although risk assessments were completed, records and feedback showed that concerns such as ongoing pain, social support needs and wider clinical issues were not always escalated or followed through with clear plans before surgery. This limited assurance that identified risks were being effectively managed and that patients were consistently prepared for surgery and ongoing care.

The service generally detected and controlled risks in the care environment and maintained equipment to support safe care. However, some processes relied on local practice, and documentation was not always completed in a consistent or standardised way.

The environment and facilities were appropriate for surgical activity. Theatre, pre-operative and recovery areas were well organised, with equipment stored appropriately and clear working spaces. Layouts supported safe movement of staff and patients, and recovery areas were set up to allow continuous monitoring, with appropriate equipment available at each bed space. Children and young people (CYP) did not have access to a dedicated day room, as children were scheduled for morning cases only. However, children were settled into their own rooms and provided with activity packs, including puzzles, crayons, colouring packs and arts and crafts.

The service had processes to ensure equipment was safe and ready for use. Records showed routine checks were completed across key areas, including emergency equipment, recovery equipment and point-of-care testing equipment. Reviewed records showed 100% completion of daily and weekly equipment checks. Specialist equipment had up-to-date maintenance, portable appliance testing (PAT) and servicing certificates, which provided assurance that equipment was safe to use.

Emergency equipment was available and monitored. We reviewed resuscitation trolleys, emergency grab bags and medication boxes, which were available, sealed and checked regularly. Checklists showed equipment was reviewed in line with policy, and staff used visual prompts and logs to support compliance. The service had a resuscitation policy which set out roles, responsibilities and expected standards for emergency response.

Risk assessments were used to identify and manage environmental risks across the surgical pathway. These included risks relating to theatre environments, recovery monitoring, emergency response arrangements and specialist equipment. Risk assessments covered safe positioning of equipment in theatres, monitoring requirements in recovery areas, and processes for responding to deteriorating patients. They were reviewed through governance systems and updated in response to changes in service activity or identified risks.

However, systems for documenting, escalating and reviewing environmental risks were not consistently embedded. Staff described variation in how issues such as missing equipment, faults and environmental concerns were escalated, and some matters were managed informally without clear documentation. Records did not always demonstrate who was responsible for follow-up actions or whether identified issues had been resolved. While environmental risk assessments were in place, their application and review varied between teams, particularly in supporting areas such as storage and equipment preparation spaces. This limited assurance that environmental risks were managed through a consistently standardised and auditable process across the service.

The service did not always have sustainable staffing arrangements across the surgical pathway, although workforce data showed staffing was stable in most areas.

Staff feedback, interview evidence and patient experience showed that staffing pressures were greatest on wards and outside core hours, particularly during evening and night shifts. Staff identified reduced registered nurse cover, variation in skill mix and limited access to support services such as pharmacy and physiotherapy as factors that increased workload, affected staff wellbeing and created delays in some aspects of care. Some patients feedback also identified concerns about staffing levels and timely access to support. Together, this evidence showed that staffing pressures affected consistency, continuity and responsiveness in parts of the surgical pathway.

Evidence from the September 2025 staff survey further supported these concerns. Some staff raised concerns about redundancies, increased workload and the use of bank staff. Survey feedback also referred to low morale, stress, work-life balance and the impact of staffing pressures on staff wellbeing. Staff also identified specific safety risks, including resuscitation team coverage, occasions when there was no nurse in charge, deviation from national policies and limited security visibility. This feedback indicated that staffing pressures were contributing to concerns about workforce sustainability and the effectiveness of some operational and safety arrangements.

However, workforce data provided by the service showed staffing was stable in most areas and above establishment in theatres. The theatre workforce included 38 staff, equivalent to 36.03 whole-time equivalent (WTE), against a required establishment of 32.42 WTE. This was a positive variance of 3.61 WTE, with no active vacancies. Registered nurse staffing met requirements, with 24.43 WTE in post against 24.36 WTE required. Healthcare assistant staffing exceeded requirements, with 8.60 WTE in post against 6.31 WTE required. This showed theatre staffing was above establishment and aligned to activity levels.

The service relied on temporary staffing to maintain capacity. In theatres, 31 staff were bank workers, which represented a significant proportion of the workforce model. Regular bank staff supported continuity because they were familiar with the service, and onboarding and induction processes were in place for bank, agency and practising privileges staff. However, this level of reliance on temporary staff created potential risks to consistency of care and team stability.

Staffing in ward and POA areas was more variable. The ward establishment was 17.11 WTE, with no active vacancies, but staff reported pressure on shifts, particularly at night when cover was reduced. In POA, there were 2 registered nurse vacancies at the time of review, with recruitment ongoing. The service used bank and overtime arrangements to mitigate these gaps, which supported cover while recruitment was ongoing.

Sickness absence was generally in line with organisational averages but varied by area. Theatre sickness was 5.3% in quarter 1 of 2026, and ward sickness was 5.2%. Sickness was higher in POA at 12.9% and ward administration at 13.8%. These higher rates were mainly linked to long-term absences, which reduced staffing resilience and required mitigation through temporary staffing and overtime.

Turnover and vacancy rates were low overall, with no active vacancies in theatres. The last theatre vacancy was filled in November 2025, and the last permanent leaver was in July 2025, indicating stable retention in core theatre teams. Across most areas, staffing aligned with establishment models. Managers calculated staffing requirements using activity and case mix, adjusted staffing levels daily and used handovers to share key patient information and maintain continuity of care. The service also had arrangements for 24-hour medical cover through practising privileges, which supported access to medical support when required. The wider staffing concerns set out above related to ward, POA and out-of-hours clinical staffing arrangements, rather than medical cover.

The service had systems to ensure staff were trained, competent and supported to deliver safe surgical care. Consultants were subject to appraisal, revalidation and practising privileges processes to maintain professional standards. Staff had access to induction, competency-based programmes, mandatory and specialist training, leadership development, apprenticeships and ongoing education. Managers maintained oversight of competence and development through structured induction, supervision and appraisal. New healthcare assistants completed a 12-week induction aligned with Care Certificate standards, and appraisal compliance was 100% across POA, theatres, wards, pharmacy and physiotherapy departments, excluding staff on long-term leave. Managers identified learning needs and addressed them through training, practical learning opportunities, informal teaching, audit feedback and structured performance management processes where required.

The service mostly protected people from the risk of infection through effective infection prevention and control systems, clean environments and high audit compliance.

Infection prevention and control (IPC) arrangements were generally well established. Staff followed IPC, and we observed good hand hygiene practice in clinical areas. Equipment was clean, well maintained and labelled with “I am clean” stickers to show when it had been cleaned. Theatre and recovery environments were organised and supported safe care. Clinical areas, including wards and theatres, were clean, well maintained and appropriately furnished. Cleaning records were up to date and showed that regular cleaning took place. Observations confirmed that equipment was checked appropriately, sterile supplies were stored correctly, and waste was segregated and disposed of safely in line with policy. Morning and evening cleaning schedules were in place and embedded into routine practice.

Audit data showed high compliance with IPC standards. Between January and March 2026, weekly audit compliance was 96%, bimonthly compliance was 98%, monthly compliance was 97% and quarterly compliance was 100%. Other audits also showed strong performance, including the One Together assessment audit and hand hygiene audit, both at 100%, and standard IPC at 99%. The service told us that personal protective equipment audits were not performed during this period and no related action plan was needed.

Additional audit information showed effective oversight of IPC risk processes. The sepsis audit was only required for patients with suspected sepsis. The service reported there had been no suspected sepsis cases in the previous 3 months, so no sepsis audits were performed during this period. The clinical risk assessment audit achieved the required target compliance, and no action plan was provided by the service because compliance targets were met. The methicillin-resistant Staphylococcus aureus (MRSA) and infection screening audit covered the period January to March 2026 and achieved 99% compliance.

However, some shortfalls in routine checks and environmental compliance meant standards were not always consistently maintained. During the assessment, we found several out-of-date disinfectant wipes stored on patient trolleys in the recovery area. This showed that routine checks were not always effective. The issue was addressed promptly, with the recovery manager informed and the out-of-date items removed immediately.

Audit findings provided by the service identified further areas requiring improvement, including the replacement of fridges in patient and staff areas and kitchen cupboards that were not IPC-compliant. Although these did not present immediate risks, action plans were required. These were being progressed and monitored, with improvements completed or tracked against agreed timelines, demonstrating appropriate oversight.

The service generally made sure that medicines and treatments were safe and met people’s needs, capacities and preferences by enabling them to be involved in planning, including when changes happened.

Staff followed good practice in medicines management, including prescribing, administration, recording, storage and disposal, and this was broadly in line with national guidance. Medicines reconciliation processes were in place to support safe admission, transfer and discharge, and patients were given information about their medicines when leaving the service. Patients’ allergy status was clearly documented in patient records, and colour-coded wristbands were used to alert staff to allergies and support safe administration. Staff also had access to pharmacy support, and medicines incidents were discussed within departmental meetings to support shared learning and improvement

The service had effective systems to support day-to-day medicines management. Staff were observed preparing medicines using aseptic techniques and had suitable space for preparing intravenous antibiotics when required. Controlled drugs were subject to strong governance arrangements. Audits covered the theatre-controlled drugs register, ward controlled drugs register, storage and security of controlled drugs, and receipt and recording of patients’ own controlled drugs. These audits all met the required target, with compliance rates between 98% and 100% from January to March 2026, and no action plans were required. This provided assurance that higher-risk medicines were managed safely.

Additional monitoring arrangements supported medicines optimisation and reduced risk. Refrigerator temperature logs were used to check safe storage conditions, warming cabinet checks supported the safe use of patient warming equipment, and point-of-care testing logs supported reliability. These checks showed 100% compliance, demonstrating a structured approach to monitoring key safety controls. Emergency grab bags and medication boxes were also available, sealed and checked regularly, which supported timely access to emergency medicines when needed.

The main area for improvement related to the storage and security of medicines other than controlled drugs, in particular temperature monitoring and documentation. The service had identified this through its own audit processes and had already put actions in place, including daily checks, clearer recording and staff reminders. Spot checks, logs and ongoing monitoring were being used to demonstrate compliance and maintain oversight. This showed that where shortfalls were identified, the service responded through governance and monitoring arrangements.

However, the service could not fully demonstrate that medicines management arrangements were consistently effective outside core hours. Staff described reduced registered nurse cover, variation in skill mix and limited access to pharmacy support during evening and night shifts. These arrangements increased pressure on staff and created a risk that medicines-related advice and support may not be available in a timely way. This limited assurance that medicines management processes were consistently supported throughout the day and night.