SpaMedica Solihull

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

Leaders had created a positive and proactive culture of safety-based openness and honesty. Concerns about safety were fully investigated. The managers' ensured lessons were learnt to identify and embed good practices. There was a very positive learning culture with staff managing incidents and safeguarding patients well. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. Staff assessed risks to patients, acted on them and kept good care records. There were processes to ensure the service had enough staff with the right training, skills and qualifications to keep patients safe.

This is the first assessment for this service. This key question has been rated good. This meant patients were safe and protected from avoidable harm.

This service scored 78 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Patients experienced care based on the latest updates and learning which followed national updates and safety incidents. Patients and staff were encouraged and supported to raise concerns. They felt confident that they would be treated with compassion and understanding and would not be blamed or treated negatively if they did so.

There was a positive culture for incident reporting and learning. Staff were aware of changes made following incidents and what and how to report an incident. All incidents were reviewed by a manager within 24 hours of it being reported. In 2025, the service reported 60 incidents, 53 of them were no harm and 7 were low harm. Trends from these reported incidents were seen in record-keeping and consent documentation. These were closely monitored by the hospital manager and clinical governance teams with appropriate actions taken in response.

Managers investigated and reported on incidents and complaints. The hospital manager held a "SWARM" meeting following any incidents to discuss learnings together as a team. A swarm is designed to start as soon as possible after a patient safety incident occurs to identify immediate learning. We reviewed 3 SWARM reports and saw actions were taken to make improvements. For example, a recent incident had occurred where a patient had fallen in the car park. It was announced over the tannoy system to alert staff and receive help. Staff fed back in the SWARM meeting that it was difficult to hear what was said. The service has since completed daily tannoy checks which ensure the tannoy was set at full volume. There was also a clear guide for what information needed to be communicated over the tannoy.

Managers shared learning from patient safety events meeting every week. They discussed any outcomes from ‘SWARM' meetings and looked at any immediate learning. This meeting produced a weekly email to the company to provide staff with an update on any learning and any potential changes required.

Nurses told us they learned from shared experiences. They met to have informal clinical supervision which provided clinical support. Staff discussed difficult patients and shared experiences together. Staff felt this was beneficial to their learning and development.

Lessons were learned from safety incidents or complaints, resulting in changes that improved care for others. The service had a clear policy for significant events and incident management. Incidents reported were discussed in team meetings and learning was shared and embedded.

Staff were aware of the duty of candour, but no serious incidents had occurred where it needed to be used.

The service worked with patients and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored.

Safety and continuity of care was a priority throughout patients’ care journey. This happened through a collaborative, joined-up approach to safety that involved patients along with staff and other partners in their care. This included referrals, admissions and discharge, and where patients were moving between services. Staff shared information about patients’ treatment appropriately with relevant healthcare professionals, such as their GP and optometrists.

Where required, staff held multidisciplinary meetings prior to bringing a patient into the service if they had additional needs. The patient’s optometrist was involved as well as the patient to ensure any additional needs were discussed prior to attending the hospital.

There was a strong awareness of the risks to patients across their care journeys. The approach to identifying and managing these risks was proactive and effective. The effectiveness of these processes was monitored to keep patients safe.

The service worked with patients and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving patients' lives while protecting their right to live in safety, and be free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

There was a strong understanding of safeguarding and how to take appropriate action. Patients were supported to raise concerns when they do not feel safe, or if they have concerns about the safety of other patients. Staff gave examples of concerns they would report and knew the contact details for the agencies they would report to.

There were effective systems, processes and practices to make sure patients were protected from abuse and neglect. There were flow charts displayed in each room throughout the service, clearly instructing staff on how to raise safeguarding concerns. An up-to-date safeguarding policy was available.

Staff received training specific for their role on how to recognise and report abuse. Staff received mandatory safeguarding children and adults training. All staff, including non-clinical staff, were trained to level 2 safeguarding adults and children. There were 2 members on site who were level 3 safeguarding adults and children trained. The safeguarding lead for the service was trained to level 4 and supported staff in escalating concerns and supported referral processes to the relevant local authorities.

Patients were supported to understand their rights, including their human rights, rights under the Mental Capacity Act 2005 and their rights under the Equality Act 2010. Staff understood the importance of supporting equality and diversity and ensured care and treatment was in accordance with the Act. Staff gave examples which demonstrated their understanding and showed how they had considered the needs of patients with protected characteristics.

The hospital had a defined recruitment pathway and procedures to help ensure that the relevant recruitment checks had been completed for all staff. These included a disclosure and barring service (DBS) check; occupational health clearance, references and qualification and professional registration checks. We looked at 5 staff records and found these were all complete.

The service worked well with patients to fully understand and manage risks by thinking holistically. Staff provided care that fully met patients' needs and was safe, supportive and enabled patients to do the things that mattered to them.

Patients were informed about any risks and how to keep themselves safe. Staff assessed risks in collaboration with patients. All patients were automatically risk graded with a percentage following a pre-operative assessment and were classified according to this risk. This was based on their ocular history and their co-morbidities.

There was a balanced and proportionate approach to risk that supported patients and respected the choices they made about their care. Risk assessments about care were person-centred, proportionate and regularly reviewed with the person, where possible.

There was a dedicated emergency patient helpline which was available 24 hours a day, 7 days a week. It was supported by both an optometrist on-call and senior management on-call service.

Patients had all treatment under local anaesthetic. Staff did not use general anaesthesia or sedation.

Staff worked closely with other clinicians, including opticians and GPs to ensure they understood the patient risks. Each patient had a risk assessment upon arrival. Staff reviewed risks using a recognised tool. Patients were risk assessed for falls, mobility issues and dementia. Patients were assessed to check they could tolerate lying flat during surgical procedures. We saw a patient undertaking a lying flat assessment.

Staff completed the World Health Organisation (WHO) safety checklist for surgery that had been adapted and improved following learning from incidents in the organisation. The WHO checklist was a simple tool designed to improve team communication. We observed safety checks being carried out before and during surgery. We saw the theatre team complete the WHO checklist. We reviewed 10 WHO checklists and found they were all 100% complete.

The staff completed a team brief with all the staff at the beginning of each shift followed by a team brief in theatre. We observed both a team brief and the theatre brief and found them to be informative.

The team completed a debrief at the end of each theatre list where positives and areas of improvement were discussed. We saw on the 3 June 2025 the team documented the positives from the list which detailed that staff had pulled together on a very challenging list. However, things they could improve included communication and continuity of staff on the list. These debriefs were reviewed by managers and discussed monthly.

The service took risks to patients seriously and ensured patients who had surgery were safe. We followed a patient journey from admission to discharge and saw safety checks were completed diligently, and patient risks were checked multiple times. We saw a patient cancelled on the day of surgery due to them disclosing new information about their health which was deemed to be a risk.

Staff responded promptly to any sudden deterioration in a patient's health. There was an escalation policy directing staff to call 999 to transfer patients to an acute NHS hospital.

Data showed 93.3% of staff were trained in basic life support and 75% of clinical staff were trained in immediate life support. The service had a patient the previous week who had required a transfer to hospital. The team did a debrief following the incident and felt they had responded well.

There was an unannounced simulation training every 6 months where a different emergency was simulated. The staff response was recorded and analysed for any learning points. We reviewed the simulation report from December 2024 which simulated a cardiac arrest. The report identified learning points and celebrated good responses by staff.

All staff had completed sepsis training online. There were sepsis posters around the hospital to alert staff and patients to the signs and symptoms of sepsis. At the time of the assessment, there had been no cases where patients had developed sepsis.

The service was fully aware of all potential risks in the care environment and controlled them well. Staff made sure equipment, facilities and technology supported the delivery of safe care.

Facilities, premises and equipment were purpose-built and used to meet the needs of all patients who used the service. The building was modern, and the service was located on the first floor with lift access. The admission area, theatres and recovery area were designed to allow a smooth flow. The hospital had employed a porter who met patients in the car park and escorted them to the reception area.

All patients we spoke with fed back to us that flow through the hospital was exceptional. The space was bright, with good ventilation in the operating theatre. They had previously had high humidity levels in the theatre and had fitted dehumidifiers which had resolved the issue. Clinical areas were restricted with access using a swipe card.

Patients were observed by staff so that they could responded quickly when called and all patients had access to a call buzzer. There was CCTV in the ward area. There were 4 separate bays within the ward where patients were seated. A member of staff checked in with each patient and carried out regular comfort checks with patients waiting in the ward area prior to surgery.

There was a comprehensive system to proactively manage the safety, maintenance and repair of facilities, premises and equipment. The facilities team worked to ensure all equipment was well maintained, with regular service contracts for all equipment They were proactive in servicing the equipment when required. For example, we saw an incident where a piece of the microscope had fallen off during surgery and hit the patient on the head. The following day the microscope was serviced.

The facilities team completed a quarterly health and safety audit of the building. We saw compliance was 98.4% in May 2025.

Service leads from the provider completed regular checks of the environment. We saw a check of the theatre was completed in May 2025 and it was 100%.

The service had worked with a person who was registered blind to look around the facility and give feedback about the safety of the environment. After this, the service had created actions to make improvements. One suggestion that was made was the information boards could have QR codes on them which read out the information for patients who were partially sighted; the service were looking into facilitating this.

The service had found at times the hospital was difficult to find due to its location in a large business park. They had created a unique identifiable code which was displayed in each room so if required, an ambulance could be alerted to their specific location.

The service was an on-call site for the region, providing 24-hour clinical support to ensure patients received timely care when required. There was a standard operating procedure for attendance out of hours for an emergency. This was for staff to follow if they were called on site and included environment and equipment pictures for staff who were not familiar with the environment, so they knew where items were located.

Clinical waste was well managed. The service had transitioned to a new clinical waste management system. This had been communicated effectively to staff including a detailed presentation and leaflet informing them of the new processes.

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

The service had enough staff to keep patients safe. The service employed permanent and bank staff. Staff members included a hospital manager, registered nurses, healthcare technicians, a porter, patient coordinators, and optometrists.

There were appropriate staffing levels and skill mix to make sure patients received consistently safe, good quality care that met their needs. The service used an auto roster based on the patient activity to allocate shifts. All staff competencies were aligned with the system which only allocated staff to clinics based on their competency. Competencies were mostly updated every 3 years. Data showed 3 out of 18 members of staff had out of date competencies. One member of staff told us they were well supported to complete their competencies in line with their requirements and found this incredibly effective.

Managers held meetings to assess and plan staffing in line with activity. Staff were moved between other hospitals in the region to support staffing levels. Staff we spoke with were happy to do this.

There were robust and safe recruitment practices to make sure all staff were suitably experienced, competent and able to carry out their role. We reviewed 5 staff files and found recruitment processes were fair and were reviewed to ensure there was no disadvantage based on any specific protected equality characteristic.

Staff received training appropriate and relevant to their role. All staff had an induction, and staff were provided with supervision as needed. Training compliance data showed 96% of staff had completed their mandatory training.

Staff received the support they needed to deliver safe care. This included supervision, appraisal and support to develop, and where needed, professional revalidation. Data showed 100% of staff had an up-to-date appraisal. Staff told us they were supported to develop in their careers. One member of staff told us the training was "second to none" and another said, "there are lots of opportunities to grow and develop". A nurse told us they had been trained by the advance nurse practitioner to perform age-related macular degeneration injections. They had been observed undertaking 120 injections before completing practical and theoretical examinations; all this training was performed in-house. There was also a scrub academy for developing surgical skills in theatre.

There were no vacancies at the time of the assessment. The service had reduced their vacancy rates. Staff retention had improved since the appointment of the new hospital manager in February 2025, and a successful recruitment programme had brought in 7 new starters in the previous 3 months. Between 1 June 2024 and 31 May 2025, the service had a low sickness rate of 1.59%.

The service had enough medical staff to keep patients safe. Surgeons worked under practising privileges. All ophthalmic surgeons were reviewed by the medical director to ensure the appropriate practising privileges were up to date. Managers monitored compliance with their practising privileges policy and through the medical advisory committee. Surgeons were granted practicing privileges following a trial graded by a senior SpaMedica surgeon.

Optometrists were supported by the regional training lead, regional lead and director of optometry. The training lead supported new starters with their competencies and conducted appraisals and mid-year reviews. The service also provided hospitals shadowing experience for pre-registration optometrists.

The service offered a range of apprenticeship programmes to allow staff to gain external accredited qualifications to further their development. These included courses such as customer service specialist, coaching and mentoring, team leader supervisor and business administration.

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

There was an effective approach to assessing and managing the risk of infection, which was in line with current relevant national guidance. Patients were protected as much as possible from the risk of infection because premises and equipment were kept clean and hygienic.

There were clear roles and responsibilities around infection prevention and control. Staff completed daily cleaning check lists to record compliance with cleaning schedules and standards. Data showed 94% of staff had completed their infection prevention and control mandatory training.

Staff followed infection control principles including the use of personal protective equipment. Hand-washing and sanitising facilities were available for staff and visitors throughout.

The service mostly performed well for cleanliness. The service was consistently above 95% compliance for weekly theatre infection prevention and control audits in April, May and June 2025. However, we saw the quarterly infection prevention and control audit for April 2025 had compliance of 69%. There was an associated action plan which showed all actions were complete.

Theatre staff followed protocol to manage infection prevention and control. There was an infection prevention and control (IPC) link staff member at the hospital. They also had an IPC regional support nurse who visited the hospital monthly. There was a online forum for the IPC link nurses across the company to ask questions and offer each other support.

The service had a cleaning company who cleaned the service. Deep cleans could be requested when the service thought that this was necessary.

Information about the risk of infection was shared appropriately with relevant partners, including agencies and patients using the service and visitors. Staff followed protocols to avoid the incidence of surgical site infections.

The service always made sure medicines and treatments were safe and met patients' needs, capacities and preferences. Staff always involved patients in planning, including when changes happened.

Staff followed systems and processes to prescribe and administer medicines safely. Patients' medicines were mostly appropriately prescribed, supplied and administered in line with the relevant legislation, current national guidance or best available evidence. We reviewed 10 prescription records and found 1 was not prescribed appropriately. There was a potential the patient had received 2 doses of an eye drop, instead of 1. We raised this with the hospital manager at the time of the assessment, and they raised this as an incident for investigation. It was found that no harm was caused to the patient.

Following the assessment, the hospital manager fed back they had discussed this with other hospital managers. They had reviewed the incident and lessons learned included their prescription chart allowed room for potential error. It did not allow for clear pre- and post-operative prescriptions which could lead to errors. This was to be brought up at the next clinical governance meeting to look at a potential change to the prescription chart.

Medicine management audits showed good compliance. The service conducted quarterly medicine audits of the department which showed compliance of 96.5% in February and 98.6% in May 2025. The patient medicines management audit for March 2025 was 96.2%.

Patients were appropriately involved in decisions about their medicines. Patients were involved with assessments and reviews about the level of support they needed to manage their medicines safely and to make sure their preferences were considered. This was clearly documented in their care plan. The service actively sought ways to make aftercare easier for patients. For example, where patients were not able to effectively insert eye drops into their eyes post-surgery. This was discussed prior to their operation and a steroid injection was administered to their eye in theatre which meant they did not have to administer eye drops post-surgery.

The approach to medicines reflected current and relevant best practice and professional guidance. Only staff who had completed competencies in the management of medicines dispensed and administered medicines to patients.

Staff stored and managed all medicines and prescribing documents safely in their pharmacy. The service had 2 fridges for medicine storage. Fridge temperatures were monitored. The staff split age-related macular degeneration (AMD) medicines equally between the 2 fridges in case 1 was to malfunction; this meant they still had a stock of medicines required.

There were appropriate arrangements for the safe management, use and oversight of controlled drugs (CDs). Controlled drugs are drugs that are subject to high levels of regulation as a result of government decisions about those drugs that are especially addictive and harmful.

All staff who were eligible had completed medicines management awareness, disposal, and storage mandatory training.

There was a medicines management committee for the company who met quarterly. They had a fixed agenda which included discussing the governance report, medicine risks, new policies, training compliance and new relevant national guidance.