Spire Wellesley 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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.
 

At our last assessment we rated this key question good. At this assessment the rating has remained good.
 

This meant people 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.

We scored the service as 3. The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.
 

Patients using the service were supported to raise concerns. The service managed patient safety incidents well and in line with the service’s policies. 
Staff we spoke to knew how to report incidents and were included in any investigations and received feedback.  

Learning was shared with staff through newsletters, bitesize learning and internal communications across departments. Staff received feedback from investigations and had support from managers following incidents. 
 

Staff understood the importance of being open and honest when things went wrong.  Medical care staff completed duty of candour training at the time of our assessment. Duty of candour is a legal requirement for all health and social care providers to act in an open and transparent way with people receiving care. This means when something goes wrong that causes, or could cause, significant harm, the provider must inform the person (or their family), explain what happened, offer an apology and outline next steps. There was an up-to-date policy in place, and we saw evidence of it being applied appropriately.
 

There had been 46 incidents reported in medical care in the last 6 months prior to our assessment. There had been no reported never events or patient safety incident investigations in the same time period.  
 

The services investigated incidents in line with the service’s policy and timeframes. Learning was implemented as a result of investigations. For example, the service arranged new signage for the oncology department following a delay in ambulance crews finding the department during an emergency. 
The service submitted statutory notifications for patient safety incidents to external partners in line with legislation. 
 

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.
 

The service provided oncology care and endoscopy services for self-funding and private insurance patients.
 

The service had a medical care admission policy that set out the admission criteria for each service. Staff used systems to identify high risk patients, they were assessed before treatments or procedures were undertaken to ensure their suitability and reduce risk. Patients who had more complex needs were referred back to NHS services and staff supported them through this transition. 
 

Oncology patients had access to a 24-hour support telephone line following the UK Oncology nursing society guidance (UKONS). Staff were giving specific training to support this provision.
 

Staff understood the service’s acceptance criteria for patients. Endoscopy pre-admission assessments were carried out over the phone or face to face. Staff completed detailed documentation to record the patients’ care during procedures and treatment. 
 

Staff involved other health care partners to ensure smooth transition between services. Patients needing additional care post discharge were supported by staff to arrange care. For example, ensuring patients had care available at home following procedures, communicating with next of kind or carers. 

 

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They 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.
 

The service understood how to protect people from harm and abuse. Staff understood safeguarding and recognising signs of abuse or neglect. There was a clear safeguarding structure, led by the director of clinical services, as the safeguarding lead. The senior management team understood their responsibilities to safeguard their patients. Staff met safeguarding training compliance. The service had robust governance process to identity risks and lessons learnt from incidents. The service shared learning from safeguarding incidents through newsletters, posters and shared learning summaries, for example, bite size learning was shared, with the strapline " Improving healthcare, one bite at a time". 
 

The service had systems in place to avoid harm and improve the patient outcome through robust governance processes. There was learning from incidents and complaints via huddles, newsletters, emails, and scrutiny panels. For example, a death led by Inquest was brought back by the legal team for shared learning. Staff understood their responsibilities to adhere to the duty of candour. 
 

An example given by staff demonstrated a detailed response and effective escalation of a potential risk of harm to children. Safety checks and processes were followed through collaboratively working with multi agency partners like social services and child safeguarding.  Another example given by the senior lead described how they supported a patient with autism to reduce his anxieties, when preparing for surgery. 
 

Staff had good knowledge and understanding for consenting and the Mental Health Capacity Act 2005. Staff supported people who may lack capacity by following due process. One example given was when it was identified legal documents for a lasting power of attorney for health was not validated.  Staff decided to postpone the surgery until a best interest process was followed. However, most of the senior team were not aware of the recent legal changes for deprivation of liberty made by the Supreme Court. 
 

Although the service issued few deprivation of liberty safeguards, changes to restrictions and valid consenting applies for people who may lack capacity, whether temporary or permanent to their care planning and arrangements. The service at time of assessment had no systems or processes in place to train staff around the new legislation that came into force in June 2026.
 

We scored the service as 3. The evidence showed a good standard. 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.
 

Patients using the service felt supported and able to raise concerns during their care. Staff knew how to identify risks and manage them in line with the service’s policies and national guidance. 
Patients discussed all aspects of their care and included health checks and risk assessment at their pre-admission assessments. For example, endoscopy patients received daily living assessments to record mobility and communication needs. 
 

The service worked with patients and system partners to understand and manage risk. Patients told us they felt well informed and were included in treatment and procedural options. For example, safe sedation options were discussed and recorded prior to procedures. 
 

The service had processes in place to support staff with understanding and managing patient risks and deterioration. This included National Early Warning Scores (NEWS2). We observed this being used during our assessment. All medical care staff were compliant with NEWS2 training at the time of assessment. 
Patients were able to give feedback about their care through patient surveys. 
 

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

During our assessment, medical care areas and equipment were visibly clean and fit for its intended purpose. The service undertook regular fire drills and staff received fire safety training. Set staff had received additional fire marshal training to support the departments during an emergency, 
Staff carried out daily equipment checks. Equipment found to be faulty was reported and replacements were put in place. 
 

The service had emergency resuscitation equipment was available throughout the departments; all equipment was checked daily, compliance checks logged and tag to minimise the risk of tampering. All equipment checked at time of assessment had been serviced and Portable Appliance Tested (PAT).  
 

Endoscopy and Oncology equipment were serviced in line with the service’s policy. Audit data for 3 months prior to our assessment showed 100% compliance with medical device equipment. 
 

Access to clinical areas was security card controlled to ensure safety and privacy of patients. Patients had access to call bells should they need assistance which were answered by staff promptly. 
 

Staff managed cytotoxic waste safely and in line with the services policies. All medical staff were compliant with their Fire Safety and Health and Safety Awareness training. 
 

The service was working towards a Joint Advisory Group on Gastrointestinal Endoscopy (JAG) accreditation. This is an independent accreditation scheme that assesses whether an endoscopy unit meets nationally recognised standards for patient experience, safety, quality, and clinical outcomes.

We scored the service as 2. The evidence showed some shortfalls. The service made sure there were enough qualified, skilled and experienced staff who received support, supervision and development. However, there were gaps in mandatory training compliance due to staff vacancies in permanent roles in the endoscopy department. 

They worked together well to provide safe care that met people’s individual needs. 
Staff received yearly appraisals and clinical supervision from unit managers in line with policy. Consultant practicing privileges were monitored and reviewed annually. Practising privileges are formal permissions granted by a healthcare organisation that allow a licensed professional to perform specific clinical activities within that organisation’s facilities.
 

The service reviewed its staffing provision every 3 months to adapt to changes in activity and service demand. Leaders acknowledged the difficulties in recruiting permanent members of endoscopy staff and a recruitment strategy had been put in place for positions to be filled.

Leaders told us endoscopy staffing had been a challenge over the past 12 months. The unit at time of our assessment was mainly covered by bank staff and there was also a vacant position for an Endoscopy Practitioner. Bank staff we spoke to had endoscopy nursing training with the skills and knowledge to perform their role. Staffing in the unit at time of assessment was safe and met patients’ needs.

All medical care staff had undergone mandatory training to perform their role. However, compliance rates for course completion were variable. For example, manual handling training level 1 was at 28% compliance across all 4 staff grades, which was against the target of 90%. 
Patients we spoke to said they were supported and the service had enough staff to enable their care and treatment.

We scored the service as 3. The evidence showed a good standard 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.
 

During assessment patient and clinical areas were visible clean and free from clutter. Patient waiting areas were bright and inviting with suitable seating that was infection prevention control (IPC) compliant. 
 

We observed staff following IPC control measures including the use of personal protective equipment (PPE) and hand washing. Staff working in clinical areas were seen to be bare below the elbow, in line with the services and national guidance. 
 

The service carried out quarterly IPC audits across medical care areas. Compliance rates  were at 99% across all IPC domains, including hand hygiene and sharps audits. Staff training for IPC had varying compliance rates across staff groups. For example, senior health care assistants had 0% compliance with IPC training. The services vacancies for permanent roles contributed to lower staff training compliance rates. 
 

Staff disposed and dealt with cytotoxic medicine safely, in line with the service’s policies and national guidance. Audits carried out for 6 months prior to our assessment showed 90% compliance with clinical waste disposal across medical care departments. 
 

Staff and patients had access to recycling bins. Service leaders had a focus on sustainability and limiting their environmental impact and carbon footprint. 
 

We scored the service as 3. The evidence showed a good standard. The service 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.
 

Patients received full medical history assessments prior to starting treatments or procedures. This included allergy recording, venous thrombolytic embolism (VTE), and prescribed appropriate prophylaxis if needed.

Staff had access to pharmacy support, available 24 hours, 7 days a week. Departments stored controlled drugs securely with daily checks and audits carried out regularly. 
 

Patient’s receiving chemotherapy were given pre-treatment blood tests to ensure it was safe to administer treatment. 
 

Staff handled cytotoxic medicine safely and in line with the service’s policies and national guidance. These medicines were sourced externally and arrived on the day of treatment for patients. The service did not manage or store cytotoxic medicine, however staff did dispose of cytotoxic waste. Audits for waste management carried out 6 months prior to our assessment showed a compliance rate of 90% across oncology and endoscopy departments.