Spire Wellesley Hospital

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

We looked for evidence that patients and communities had the best possible outcomes because their needs were assessed. We checked that patient’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring patients were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant patient’s outcomes were consistently good, and patient’s feedback confirmed this. 

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

The evidence showed a good standard. The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Staff made sure patient’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Staff shared key information to keep patients safe when handing over their care to others. During shift changes and handovers staff included all necessary key information to keep patients safe.

Staff with appropriate seniority had discussions about the patients’ preferences and wishes if their condition deteriorated. They made decisions about care  that reflected the wishes of the patient and/or their family.

Staff documented patients falls risk assessments in the patients room and notes. Staff provided all patients with grip socks to prevent falls.  

There was support available from the RMO when a patient had complex pain needs. 

 The evidence showed a good standard. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.  

Staff usually planned and delivered patient’s care and treatment with them, including what was important and mattered to them. Staff did this in line with legislation and current evidence-based good practice and standards.

Staff followed up-to-date policies to plan and deliver high quality care according to best practice and national guidance. All policies we looked at contained a creation and review date, and clear references to current national guidelines. The service had systems to communicate changes in guidance through meetings and newsletters.

Senior leaders reviewed polices and processes to keep up to date with any changes to the Royal Colleges guidelines and National Institute of Care and Excellence (NICE) guidelines.

The organisation had a cosmetic intervention policy. Compliance for the cooling off period of 2 weeks from consent to procedure for cosmetic surgery over the last 6 months was 100%.

We reviewed 5 care records and 4 theatre care records. Staff had completed care plans and risk assessment in all records reviewed. Staff did not leave patients waiting to have surgery nil by mouth for longer than necessary. When necessary, Intravenous fluids were used to ensure pre-operative optimisation for emergency surgery. Staff monitored patients for potential deterioration and sepsis using the national early warning score (NEWS).

Staff fully and accurately completed patients’ fluid and nutrition charts where needed. They used this information to inform care planning and delivery.

Staff reported information to the Private Healthcare Information Network (PHIN). Intelligence reports were reviewed by service leaders. These reports contained data on PHIN’s existing performance measures, including patient experience, never events, Patient Reported Outcome Measures (PROMs), infections and data submission levels. In addition, it also includes complaints data.

The evidence showed a good standard. The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff worked well across teams and services to support patients. Staff made sure patients only needed to tell their story once by sharing their assessment of needs when patients moved between different services. A patient informed us that they were an NHS patient and had returned for the second time for surgery and observed great communication between staff groups and their care had been handled ‘seamlessly.’

Doctors, nurses, and other healthcare professionals worked together as a team to benefit patients. They supported each other to provide good care.

Staff reported healthy working relations across staff groups including between medical and nursing teams. We saw and heard examples of effective team working which was based on mutual respect and trust.

The services plans for discharge considered people’s individual needs, circumstances, ongoing care arrangements and expected outcomes. Staff planned discharges to ensure they were safe and appropriate for the person’s needs. They provided patients with contact details if they were worried after being discharged. 

Staff shared information between teams and services to ensure continuity of care. Staff held multidisciplinary reviews and meetings for some specialities, for example an admission assessment meeting was held to discuss patients who had been identified from pre-assessment and required support.

We viewed examples of 3 patients who had been reviewed by a multi-disciplinary team who did not meet the admission criteria for surgery following the pre-operative assessment standards. This provided assurance that the healthcare team reviewed patient suitability for surgery and made decisions based on individual risks, needs and clinical outcomes.

Peoples’ records showed there was input from a range of clinicians and that they shared information to ensure a consistent approach to care and treatment pathways.

The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

Staff supported patients to manage their health and wellbeing to maximise their independence, choice and control. The service supported patients to live healthier lives and where possible, reduce their future needs for care and support. For example, for joint replacement surgery patients.  

Staff provide patients undergoing elective operations with information about their condition, their treatment and how best to prepare for surgery. For example, pre-operative patients who were undergoing joint replacement surgery were encouraged by staff to be physically fit and strong. Staff spoke with them about how best to optimise their outcomes after surgery and how to modify their choices to ensure better health. 

The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Staff monitored patient’s care and treatment to continuously improve it. Staff ensured outcomes were positive and consistent, and they met both clinical expectations and the expectations of patients themselves.

Staff monitored the effectiveness of care and treatment through audit and benchmarking to compare with other similar services. Staff used the findings to make improvements and achieve good outcomes for patients. Staff participated in relevant national and local clinical audits at varying frequencies. For example, sepsis audit (quarterly), venous thromboembolism audit (monthly) and reducing surgical site infection (bi-annually).

The service had a  low number of readmissions for patients having elective care within 31 days of discharge. 

The surgical site infection rate in the last 12 months were 13 superficial infections over the period July 2025 to July 2026.

Staff monitored avoidable deaths and harms. All deaths underwent an initial case review and then reviewed by an Associate Medical Director. Leaders completed a structured judgement review (SJR) and presented this to the corporate mortality committee. Staff discussed learning points and improvement actions were taken.

The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff told patients about their rights around consent and respected these when delivering person-centred care and treatment.

Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent. Staff knew how to support patients who lacked capacity to make their own decisions or were experiencing mental ill health.

Staff followed the services policies related to consent, mental capacity, deprivation of liberty and restrictive practice, as relevant.

The hospital has an up-to-date consent policy. Where possible, staff gained consent from patients for their care and treatment in line with legislation and guidance.  Chaperones were provided if requested.

Staff completed consent audits and leaders discussed  consent concerns at team governance meetings. In the preceding 6 months the consent audit compliance was 97.8% against a target of 100%.

Patients said they were involved in decision making about their care and treatment. They could describe the risks and benefits they were told about prior to surgery. Relatives said they were kept informed about the care and treatment of their family member.

Interpreters could be used to support patients to give informed consent.