Spire Wellesley 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.  

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. Leaders had systems for identifying and responding to deteriorating patients on the wards, in the operating theatre and recovery. People received treatment and care to reduce the risk of avoidable harm, such as pressure damage, blood clots or falls. There was safety processes arranged before surgical procedures and operations started, with staff working together to ensure the right patient had the correct procedure. Medicines were managed safely. Patients were safe from neglect, abuse and discrimination. Patient’s gave informed consent prior to procedures and where they were unable to consent, those close to them were involved in decisions made in their best interests.

This key question has been rated as good.

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.

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.  

Staff had access to current incident reporting and reviewing policy, which reflected the provider and national guidance.

Staff managed patient safety incidents well. Staff recognised and reported incidents and near misses in line with local policy. Managers investigated incidents and shared lessons learned with the whole team and the wider service. The service reported 96% of incidents as ‘no’ or ‘low’ harm.  

Incidents were analysed to identify trends or themes that could be used to support learning from incidents. Staff received feedback from investigation of incidents, both internal and external to the service. Incidents and learning were shared with other providers.

We reviewed the incidents reported and recent examples included deferral of surgical procedure and actions to take and management of post-op complications in line with policies and procedures.

Never Events are serious, preventable safety incidents which should not occur if the available preventative measures are followed. They include things like wrong site surgery or foreign objects left in a person’s body after an operation. There were zero never events reported in the last 12 months in relation to surgery services.  

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if things went wrong. There was evidence that changes had been made because of feedback. Managers debriefed and supported staff after any serious incident. 

All staff were provided with mandatory training in key skills. Managers monitored mandatory training and alerted staff when they needed to complete updates. The compliance rate across all mandatory training for surgical staff was 94%. However, infection prevention and equality, diversity and inclusion were below 90% for qualified surgical staff.    

Managers ensured actions from patient safety alerts were addressed and progress was monitored. 

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.

Staff 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.  

Staff prioritised safety and continuity of care throughout people’s care pathway. Staff assessed patients prior to surgery and adapted care and treatment when necessary. This included cancelling or delaying surgery in cases where an underlying condition was identified. 

The service had an admission criteria for both private and NHS patients. These criteria defined the limitations of the services and helped  minimised risks by excluding some patients whose needs could not be safely met. Patients requiring tests and investigations were given enough information to enable them to understand their procedures. Staff attended multidisciplinary admission assessment meetings  where they reviewed information from pre-assessment  and discussed patients with additional needs, for example early onset dementia.  

There were systems and processes to ensure the correct patients were treated throughout the patient journey. Staff used the World Health Organisation (WHO) surgical safety check list to avoid harm. We observed staff completing  this checklist process for 3 patients. The service achieved 100% compliance from January to June 2026 of the WHO surgical checklist theatres observational audit. This surpassed the hospital’s compliance target of 95%.

The transfer of patients from the operating theatre to the recovery area was managed safely, with the anaesthetist retaining responsibility for determining the readiness for transfer. Suitably skilled and qualified staff accompanied patients in all areas.

Patient records were paper based and were kept securely.

Staff considered  to whether a patient was likely to require a higher level of medical and nursing support and when this was necessary, this was discussed ahead of the procedure. 

Staff communicated effectively with other providers when responsibility for a patient’s care and treatment transferred to another service, such as an NHS provider, to support a seamless transition of care.

Staff planned and organised care with patients, partners and community services to  support coordinated care and continuity between services. 

 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.

Staff 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. Staff shared concerns quickly and appropriately.

The service had current safeguarding policies, which reflected national guidance for both adults and children.

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 from the safeguarding lead. Staff knew how to contact them. There was 1 safeguarding lead.

Staff considered safeguarding concerns when an incident occurred and made a referral or sought further advice, when necessary.  Staff were informed of outcomes after they had raised concerns.

Staff understood how to protect patients from abuse and worked well with other agencies to do so. Staff had access to links to external agencies. 

Staff completed adult and children's safeguarding training. Compliance with level 3 safeguarding training was high among surgical staff, with 97% compliance for safeguarding adults and 98% for safeguarding children. However, compliance with level 1 and level 2 safeguarding training among non- clinical staff was lower, at 71% and 76% respectively. 

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.

Staff 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 patients to do the things that mattered to them.

Treatment and care met patients' needs in a way which was safe and supportive and enabled them to do the things that mattered to them.

We spoke to several 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. For example, a patient told us that they received information about the sedation they would receive and were kept informed about their treatment.

In the latest patient satisfaction survey 88% of patients were likely to use Spire again. 

 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.

Staff detected and controlled potential risks in the environment. Leaders and staff took steps to make sure equipment, facilities and technology supported the delivery of safe care. The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use equipment and to manage different types of waste safely.

Staff completed a falls risk assessment for every patient and a ‘traffic light’ system was used in relation to risks of falling. We observed that every patient had clear signage and documentation indicating their falls risk category. Patients were provided with socks that had grips to prevent a fall.  

During the inspection we observed that patients were being transported from the surgical ward to theatres with the bed rails in the down position which presented a risk of falling. Staff informed us that if the patients ‘traffic light’ rating was green then there was no to little risk of them falling and therefore bed rails were left down. We highlighted this as a concern and assurance was provided. We did not see staff risk assessing the environment each time a patient was transported from surgical wards to theatres.  

The service designed the environment to follow national guidance. Where required, areas were secure and protected patients. Access was restricted by swipe card to theatres. 

The service had fire safety equipment which had been serviced. Fire exits were clear and free from obstruction.

The service provided suitable equipment which was used correctly, such as for patients who were at increased risk of pressure damage. Staff carried out daily safety checks of specialist equipment. Staff could access resuscitation equipment on the ward and in theatres.

Leaders maintained oversight of equipment to ensure it was safe and ready to use. Staff carried out equipment maintenance in line with planned schedules and records showed 100% compliance. Staff told us they had enough equipment to carry out their work safely and to support the treatment and care needs of patients. Staff used effective  systems to identify, repair or replace broken or missing equipment.

Staff used specialist equipment in the operating theatres  in line with national guidance and regulatory requirements.

The service had suitable facilities to meet the needs of patients’ families when necessary.

Staff disposed of clinical waste safely, both inside and outside the building. They segregated and labelled waste in accordance with the services policy. The service reduced the risk of sharps injuries through the safe sharps management policy.

The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Leaders made sure there were adequate numbers of qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together  to provide safe care, which met patient’s individual needs.

There were 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. Staff were made aware of their shifts in advance and could make requests for changes.

New staff had a full induction tailored to their role before they started work.

Managers reviewed the number and grade of clinical staff, healthcare assistants and other key roles, needed for each shift using a staffing tool. Managers could adjust staffing levels daily according to the needs of patients. Theatre and recovery staffing was planned, based on activity and the skills needed for everyday and emergency work, including out of hours cover. We saw duty rotas for the last 4 weeks for medical and nursing staff. leaders informed us that there had been some recent challenges regarding staffing levels following staff resignation and currently bank and agency staff were being utilised. Leaders held a daily safe staffing meeting with all Heads of Departments, and a safe staffing tool was used to ensure that safe staffing levels were in place.

The service had a turnover rate of 12.5% over the last year and a low sickness absence rate of 5.0% over the last year. There were 3 perioperative practitioner posts which were filled in by agency and bank during our assessment.

Staff said whilst the hospital was busy at times that they were a team working together to support colleagues to maintain safe services.

Staff said they felt the service was safe and that they were able to take breaks during their shift.

Patients said their needs were met in a timely way, and we observed staff responding to patient needs. We saw patients were attended to in a kind and supportive way. 

Leaders 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.  

Managers made sure staff attended team meetings or had access to the information shared, when they could not attend. We saw newsletters from senior leaders and other general information was shared on notice boards.

Managers supported staff to develop through constructive recorded, annual appraisals of their work and regular clinical supervision. If poor staff performance was identified, this was dealt with in a supportive way, with a view for improvement.  

The service had formal arrangements for a resident medical officer (RMO) to be on-site when patients were receiving treatment and care. The RMO informed us that they had received a good induction and felt supported by consultants.  

Consultant surgeons and anaesthetists were subject to a full assessment through the practising privileges process. They were required to provide evidence of appraisal and re-validation.

Surgical procedures and clinical decisions were carried out by doctors with appropriate seniority and speciality training. Patients could identify the doctors responsible for their care and treatment.  

The service achieved 87% compliance for staff appraisals for ward staff and 97% for theatre staff between July 2025- June 2026. 

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.

Staff assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading by following policies. They collected and reviewed data on infection, prevention and control. Where required, actions were taken to drive improvements.

Staff managed infection risks well. Theatres and ward areas were visibly clean, free from clutter and had suitable furnishings which were clean and well-maintained.   

The service designed the theatre environment in line with national guidance, with separate areas that supported flow of equipment and material from clean storage and preparation areas through to dirty equipment and waste management areas. The service provided dedicated storage for equipment including sterile packs, uniforms and linen.

The service had processes to enable staff to respond to infection prevention and control risks such as transmittable infections.

For example, there was a screening policy for methicillin resistant staphylococcus aureus (MRSA) and management of Clostridioides difficile infection policy that was accessible to staff. The providers guidelines reflected national Infection Prevention Control (IPC) guidance. Staff had access to expertise in infection control as needed.

The service had a programme of infection, prevention and control audits including for example, national standards for healthcare cleanliness weekly audit, hand hygiene audit and urinary catheter insertion audit.

The service generally performed well in local IPC audits. In the most recent audits from 2026, the scores showed compliance with infection prevention and control measures in clinical areas.

Staff cleaned equipment after patient contact and labelled equipment to show it was cleaned.

We saw staff were following infection control principles including compliant with handwashing and the use of personal protective equipment (PPE). 

Staff followed theatre practices that minimised the risk of cross infection and we saw staff following best practise regarding the treatment and care of their patients.

Staff managed clean and used surgical equipment safely, and the flow of equipment through theatre reduced the risk of cross contamination. Staff checked the condition of sterile packs before they were opened and prior to use.

Staff supported infection prevention and control measures by following the uniform policy. 

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 involve people in planning, including when changes happen.  

Staff made sure that medicines and treatments were available, and met people’s needs, capacities and preferences.  

Staff stored medicines, including controlled drugs (CDs), securely, with appropriate temperature monitoring, and access was restricted to authorised staff. Staff maintained accurate CD balances, and we saw evidence that quarterly audits were undertaken.

Staff recorded allergies clearly, and medicines were administered as prescribed; including venous thromboembolism (VTE) prophylaxis to prevent blood clots. When staff omitted doses, there was clear documentation as to why this had occurred.  

A pharmacist reviewed prescriptions and attended the daily safety huddle and was involved in pre-admission discussions for patients with any complex medicine requirements. Staff told us the pharmacy team could be contacted easily, and there were mechanisms in place to be able to access medicines out of hours. The pharmacy was not open at weekends however, the service had procedures to enable staff to supply medicines required for discharge.

Emergency medicines were available for use and checked daily.