Spire South Bank 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

The service had a good learning culture and staff and patients could raise concerns. Managers investigated incidents thoroughly and lessons learned and improvements were identified and shared with staff. Patients were protected and kept safe because staff understood local safeguarding arrangements and safe systems of working.  

There were enough staff with the right skills, qualifications and experience in departments, wards and in theatres to ensure high quality care and treatment. Managers made sure staff received training and had regular appraisals to maintain high-quality care. Where training was overdue or appraisals were not undertaken in line with policy, there was a plan in place for these to be completed. 

Staff managed medicines safely. Staff identified and reacted to unexpected deterioration in a patient’s condition. Staff understood and managed risks from the environment. The facilities and equipment met the needs of patients, were clean and well-maintained and any risks were mitigated. 

 However, we found:  

There were environmental concerns, including limited storage and signs of wear and tear, such as damaged fixtures, which impacted effective cleaning and maintenance. In addition, Personal Protective Equipment (PPE) use was not always consistent with national guidance, with staff observed wearing theatre PPE on the ward.

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

The service had a current incident reporting and reviewing policy, which reflected the provider and national guidance. There were 969 incidents reported across surgery from 1 April 2025 to 31 March 2026. Incidents were categorised by the level of harm, including no harm, low and moderate harm, or death. The most common themes from incidents were poor documentation, including patient information and patients not attending their appointments. Incidents were classified as no or low harm.

Staff raised concerns and reported incidents and near misses in line with provider policy. We saw evidence incidents were investigated, and sufficient action had been taken to reduce the risk of recurrence. An electronic system was used to report incidents and staff we spoke to had access to it.

From 1 April 2025 to 31 March 2026, the service reported 1 never event, which involved a retained object. Never events are serious, preventable safety incidents that should not occur, such as wrong site surgery or retained objects. We found that the incident had been appropriately reported and immediate action had been taken. Staff escalated the incident and duty of candour was carried out. Duty of candour is the requirement to be open, honest and transparent with patients when care has resulted in harm or has the potential to cause harm.

The service was open, transparent and gave patients and families a full explanation if things went wrong. Staff received feedback following the investigation of incidents, both from within the service and externally.

Incidents were analysed to identify trends or themes and potential links to individual practitioners. The hospital held a weekly key safety indicator (KSI) meeting, where a multidisciplinary team reviewed incidents reported across the hospital. These meetings provided an opportunity to identify themes, share learning, and monitor actions taken in response to incidents. We saw evidence that learning from incidents were discussed and embedded into practice through changes and processes, staff education, and reinforcement of safety procedures to support ongoing improvement.

Risks were reported through established systems, including incident reporting processes and regular team discussions. Staff told us they felt confident to raise concerns and were assured these would be taken seriously and acted upon.

Reported risks were reviewed through governance processes, including safety meetings, where actions were monitored and learning shared to support improvements in practice. Where there was an immediate risk of harm to patients or others, staff felt confident to intervene to prevent harms occurring.

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.

The service used an admission process to ensure the hospital only provided care for patients where their needs could be safely managed. An acceptance criteria policy was used to ensure staff could determine if patient needs could be met. For example, patients with cardiac conditions were not operated upon as the hospital did not have onsite access to high dependency care if needed.

The service held admission meetings 3 times a week to review patients due for treatment. Staff discussed any identified risks and considered patients medical history, individual needs and mental capacity. This helped ensure patients were suitable to be admitted and that any risks were identified and managed before admission

Staff demonstrated an understanding of surgical safety standards, including the ‘stop the line’ process. This is a patient safety principle that allows any member of the theatre team to halt the procedure if they identified a potential risk. Staff told us they felt confident to use this process and provided examples of when they had done so.

There were no high dependency or critical care facilities within the hospital. The service had a policy in place for the safe transfer of patients between healthcare facilities if further advance patient care was necessary. This policy had been recently reviewed. Staff we spoke to understood the policy and what to do in the event of a patient deteriorating and requiring transfer. There were 6 unplanned transfers in the 12-month period prior to our inspection. An internal review of these cases had been carried out which demonstrated all transfers were unavoidable.

Care and support was planned and organised with people, together with partners and communities in a way which ensured continuity. For example, letters were sent to GPs confirming details of the hospital admission, treatment provided, and any ongoing care or follow-up arrangements, helping to support safe and coordinated care across services.

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 both adult and children safeguarding training. Data showed 99% of staff had completed level 3 safeguarding for adult and children, against a 95% compliance target. All staff had completed preventing radicalisation training.

Safeguarding policies were in date and available for staff. They reflected national guidance for adults and children, including visitors. The service did not admit patients under the age of 18.

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 safeguarding leads. The service had a named safeguarding lead trained to level 4 and identified safeguarding champions. This information was clearly displayed on notice boards, along with contact details, to ensure staff could access support when required.

Staff knew how to identify adults and children at risk of, or suffering, significant harm and worked with other agencies to protect them. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act (2010).

The service had a policy in place that followed safe recruitment practices to help ensure staff were suitable for their roles. Pre-employment checks were completed before staff started work. This included identity and right to work checks, employment references, occupational health clearance, professional registration checks and enhanced Disclosure and Barring Service.

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 to do the things that mattered to them.

The service worked with patients to understand and manage risks. For example, personalised pre-assessments were undertaken to establish any risks associated with the patient prior to their admission. This included their medical history, prescribed medications and social and support needs. We spoke to 4 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.

Processes to quickly identify and safely manage deteriorating patients were implemented and followed. There was a clear policy to support staff in managing deteriorating patients. Staff used the National Early Warning Score 2 (NEWS2) to identify patients whose condition was getting worse and took appropriate action. The service ensured that each shift had access to staff competent in Basic Life Support (BLS), Immediate Life Support (ILS) and Advanced Life Support (ALS).

Leaders monitored the recognition and response to patient deterioration through regular NEWS audits. Compliance was not consistently achieved, with a recent audit showing a 94% completion rate. There were gaps identified in the recording and escalation of observations; however, action plans were in place to address these issues.

Staff followed up-to-date policies and delivered care in line with recognised best practice guidance. We observed staff consistently completing the World Health Organisation (WHO) surgical safety checklist appropriately for all patients undergoing surgery. Audit results over the previous 12 months provided further assurance of compliance, demonstrating consistently high levels of completion, with compliance rates of 98% for general procedures and 99% for cataract procedures.

The service had a sepsis policy and screening pathway in place to support the early identification and management of patients at risk of sepsis. There was a sepsis folder visible on the ward and staff understood how to escalate concerns promptly if sepsis was suspected.

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

The design, maintenance and use of facilities, premises and equipment kept people safe. There were limitations in storage, and the condition of some fixtures. which meant the environment was not consistently maintained to the expected standard. However, the hospital had a planned preventative maintenance plan in place to mitigate these risks.

The environment of the wards and other areas used for patient care reduced the risk of patient harm, for example, safe flooring, handrails and clear and uncluttered walkways. Access to the surgery department was restricted and controlled through a fob-entry system. During the inspection, we observed that the department was secure

Leaders maintained oversight of equipment to ensure it was safe and ready to use. They monitored the management of medical devices through regular audits. However, audit results were not consistently met. Action plans were in place to address compliance issues. Staff told us they had enough equipment to carry out their work safely and to support the treatment and care needs of patients.

Staff disposed of clinical waste safely, both inside and outside the building. Waste was segregated and labelled in accordance with the provider’s policy. The risk of sharps injuries was minimised as staff followed the safe management of sharp implements hospital policy. Fire safety equipment was available and had been serviced. Fire exits were clear and free from obstruction.

Cleaning storerooms were secure, and staff stored chemicals subject to Control of Substances Hazardous to Health (COSHH) appropriately in a locked cupboard. COSHH (Control of Substances Hazardous to Health) is a set of rules to help make sure potentially harmful substances, such as cleaning chemicals, are stored and used safely.

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 (HSE) guidance.

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

Managers reviewed the number and grade of clinical staff, healthcare assistants and other key roles, needed for each shift in accordance with national guidance. The service had a policy of ensuring there was 80% employed staff on shift, with 20% of bank staff supporting if needed. Managers could adjust staffing levels daily according to the needs of patients.

Theatre and recovery staffing was planned based on theatre patient activity and the required skills needed. We reviewed ward and theatre staff duty rotas from 1 February 2026 to 30 April 2026, which showed there were measures in place to ensure safe staffing was maintained.

Managers limited the use of bank and agency staff and, where possible, requested staff who were familiar with the service. When agency staff were required, they were expected to complete all relevant in-house training, with competencies assessed and signed off by a manager. Temporary bank and agency workers had a local induction to the area they were working and were expected to complete the same inhouse training as permanent staff members.

The service had low staff turnover and vacancy rates. In the 12 months prior to our inspection, 7 people left the surgical service. The turnover rate at Spire Southbank was 8.5%, which was below the Spire group average (13.6%). The service did not have any vacancies.

New staff received a full induction tailored to their role before starting work. For example, a personal induction checklist was completed by all staff within their first 12 weeks of employment. New staff were also paired with an experienced member of the team through a ‘buddy’ system, which provided practical and emotional support during their initial period of employment.

The service was supported by a Resident Medical Officer (RMO) on site, who provided immediate medical input and supported patient safety. The RMO worked closely with nursing staff, consultant surgeons and consultant anaesthetists to review patients and respond to deterioration. They provided 24-hour medical cover, ensuring patients who deteriorated received timely assessment and appropriate intervention.

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.

The service provided mandatory training in key skills to all staff. Initial training data showed that some mandatory training areas were below the service's target compliance rate of 95%. The provider gave assurance that outstanding training would be completed by the end of May 2025. Updated data showed that the service had achieved the required compliance levels across all mandatory training areas, except for controlled drugs training, which remained slightly below target at 90%.

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. Staff members told us they were supported to attend external training that contributed to their continuing professional development.

Managers supported staff development through constructive, recorded appraisals of their work, which were carried out at the beginning, middle and end the year, which was in line with policy. However, appraisal completion was inconsistent across the service. While most staff had completed an annual appraisal, 40% of theatre staff had not yet received one. There was a plan in place to address this and bring compliance in line within the year. Staff were encouraged to arrange meetings with their managers throughout the year to review progress against objectives and development plans. Where poor performance was identified, this was managed in a supportive way, with a focus on improvement.

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

The service had infection, prevention and control (IPC) policies and procedures to help control infection risk. These and other related policies covered the actions required by staff to minimise the risk of infection and cross infection in the hospital and the surgery service. A regional IPC lead attended site on a regular basis to support staff in maintaining good IPC practice and to carry out audits. They provided advice to staff when required.

Staff had access to Personal Protective Equipment (PPE) such as aprons, gloves and face masks. Staff supported infection, prevention and control measures by following the uniform policy. Nail varnish and jewellery were not worn, and staff in clinical areas were bare below their elbows.

Infection Prevention Control (IPC) principles such as compliance with hand hygiene procedures embedded in practice across wards and theatres. However, there were occasions where theatre staff were observed on the ward wearing hats, face masks and scrubs, which were not compliant with national guidance.

The theatre environment had designated areas to support the flow from clean storage and preparation through to the management of dirty equipment and waste. However, we observed wear and tear within theatres. For example, theatre doors were chipped, meaning effective infection prevention and control (IPC) standards could not be fully met or evidenced. This presented a risk that surfaces could not be effectively cleaned and maintained. Senior leaders were aware of these concerns and monitored the environment through regular cleaning audits.

The service operated a fully self-contained, dedicated sterile services department on-site for the cleaning of sterile surgical instruments. The department was audited by an independent external certification body. 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.

Processes to monitor and reduce surgical site infection (SSI) rates were embedded. SSI is an infection related to surgery that occurs at or near the surgical incision within 3 days of the procedure, or within 9 days if prosthetic material is implanted. From 1 November 2025 and 1 April 2026, SSI rates for hip and knee arthroplasty were 0%, with only a small number of superficial infections identified. The service reviewed any unexpected concerns by discussing them as a team and taking action where needed. This included initiating infection prevention responses and sharing learning through their governance processes.

There was a programme of IPC audits. Staff completed weekly, monthly and quarterly audits on cleanliness, PPE compliance and hand hygiene. Most audits met targets, although some shortfalls were identified in mattress, urinary catheter, sharps and efficacy audits. Where any non-compliance with audit standards was identified, we saw action plans were in place to improve practice and reduce the risk of infection. For example, we saw evidence of an action plan in place to remove a faulty mattress due to concerns this could impact effective cleaning and increase the risk of infection.

The service made sure that medicines and treatments were safe and met patients needs, capacities and preferences. They involved patients in planning, including when changes happen.

Medicines were securely stored and managed safely in line with the service medicines management policy. Medicines were stored in locked cupboards or trolleys only accessible by designated staff. During our inspection we found the storage cupboards were well organised and tidy. Medicines we checked were in good condition, stored correctly and within the stated expiry date.

Controlled drugs (CD) were stored in a separate medicine’s cupboard in line with National guidance on the ward and in theatres. CDs are medicines requiring more control due to their potential for abuse. Keys to the controlled drug cupboard were held by the qualified nurse in charge of the ward and theatre. We observed staff following the correct procedures for the storage, administration and recording of controlled drugs.

Staff followed national guidance to check patients had the correct medicines when they were admitted, discharged or they moved between services. Doctors reviewed each patient’s medicines on admission and provided advice if there were any changes. Staff followed systems and processes to prescribe and administer medicines safely. In theatres, drugs were not drawn up ahead of a list.

The service carried out regular checks of how medicines were managed. Audit results from February to April 2026 showed high levels of compliance, with all areas achieving at least 95%. Some minor issues were identified in the completion of controlled drugs records, with compliance rates of 91% in theatres and 87% on the ward. The provider had recognised this as an area for development and put action plans in place to improve the consistency of record keeping and support safe medicines management.

Staff learned from safety alerts and incidents to improve practice. There was a review of medicines errors and steps had been taken to prevent recurrence. A pharmacist was involved in patient medicine reviews to ensure there were not identifiable drug interactions There was access to medicines needed in an emergency or at short notice at night and at the weekend.