SpaMedica Carlisle

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.

The service had a positive learning culture allowing staff and patients to raise concerns. Managers investigated incidents thoroughly to identify learning. Improvements identified were shared with staff. Patients were protected and kept safe because staff understood local safeguarding arrangements and safe systems of working. Staff recruitment processes met national guidance and managers made sure staff had regular appraisals. There were enough staff with the right skills, qualifications and experience to ensure high quality care and treatment. Potential risks in the care environment, for example the laser treatment room, were sufficiently mitigated. The facilities and equipment were visibly clean and well maintained. The service had systems for identifying and responding to deteriorating patients in the clinics, operating theatre and recovery areas. Staff assessed patient risks and made sure there was continuity of care, through effective record keeping. There were safety processes arranged before procedures and operations started, with staff working together to ensure the right patient had the correct procedure. Medicines were managed safely.

However, the service did not always ensure all staff mandatory training was always kept up to date.

This is the first assessment for this service. This key question was rated good. This meant 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 evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. Staff and leaders listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Learning was shared with staff.

The service managed patient safety incidents well. The provider’s patient safety incident response policy and plan (PSIRP) aligned to the NHS patient safety strategy, and the NHS Patient Safety Incident Response Framework (PSIRF).

Staff recognised and reported incidents and near misses on the electronic reporting system. Managers investigated incidents and shared lessons learned with the team. For example, there were discussions during the twice-daily safety huddles and post investigation debrief sessions. Managers shared learning more widely with other SpaMedica locations, through monthly hospital management and regional management meetings.

The rate of incidents against activity for the service was low and aligned to the overall incident reporting rate across the organisation, proportionate to activity.

Managers analysed incidents to identify trends or themes and potential links to individual practitioners. Where concerns with practice were identified, appropriate action was taken.

Staff we spoke with understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong. Staff received feedback from investigation of incidents, both internal and external to the service.

Changes were made because of reported incidents and feedback. For example, strengthened systems were implemented to improve record keeping.

There was a system in place to manage and monitor compliance against national safety alerts.

Managers used changes in national guidance, incidents, safeguarding and appraisals to identify gaps in learning.

The evidence showed a good standard. The service worked with patients and healthcare partners to establish and maintain safe systems of care, in which safety was managed and monitored. Staff made sure there was continuity of care, through effective record keeping and communication with patients, their GP and other referrers.

Safety and continuity of care was a priority throughout people’s care pathway.

Staff used secure logins and SMART cards to access patients' NHS electronic care records. This enabled staff to quickly access, update and exchange critical patient information though connected systems. In addition, patients completed a lifestyle questionnaire and health questionnaire online or on paper.

Patients completed pre-operative assessment and findings were taken into account when planning care and treatment. This included delaying surgery where an underlying condition was identified or where alternative arrangements were needed to ensure patients received safe and appropriate care.

If urgent onward referral to the local NHS ophthalmology service was needed, the patient’s consultant discussed directly with the patient in the first instance. A formal referral letter was then sent and the patient received a courtesy copy.

There were systems and processes to ensure the correct patients were treated. We followed the patient journey and tracked patient care from initial assessment, admission to the operating theatre and follow up clinics. Patients received appropriate care throughout their journey.

We observed handover of patient information including all related identification checking processes. Once in theatre, the World Health Organisation (WHO) surgical safety check list was used to avoid harm. We observed good completion of the process. Staff demonstrated confidence in speaking up, confirming information and challenging decisions where needed. This represented effective implementation of National safety standards for invasive procedures (NatSSIPS) and reflected a mature safety culture.

Staff used a recognised early warning tool (NEWS2), to monitor patient’s vital signs and detect any deterioration in their condition. The service’s Management and Transfer of a Deteriorating Person procedure referenced current best practice national guidance and detailed clear steps for staff to follow. In addition, there were “999” calls instruction cards displayed in every room and reception area.

The transfer of patients from the operating theatre to the recovery was managed safely, with the consultant deciding when they were ready. Suitably skilled and qualified staff accompanied patients in all areas.

Patient records were a mixture of electronic and paper. Paper documents were scanned into the central electronic patient record system and the service aimed to be paper-free by the end of 2026. The information technology (IT) connectivity was consistently available across the service to meet the needs of staff completing the records.

When overall responsibility for the care and treatment of a patient moved to a different service provider, such as transfer to the NHS, there was effective communication, which allowed for seamless transfer.

Care and support were planned and organised with people, together with partners and communities in ways which ensured continuity.

The evidence showed a good standard. 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.

The corporate human resources (HR) department held up to date enhanced Disclosure and Barring Service (DBS) certificates for all staff.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so.

Staff were up to date with adult and children's safeguarding training, which included PREVENT anti radicalisation training.

There were current safeguarding policies, and these reflected the national guidance for adults and children, including visitors.

Staff knew how to contact the regional safeguarding lead, how to make a safeguarding referral and who to inform if they had concerns. The registered manager had oversight of safeguarding within the service and expert safeguarding advice was available to support staff during operational hours.

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

All nursing staff had completed learning disability and autism awareness training. However, the data provided did not include data for consultant compliance.

There were posters and information at the service which staff could refer to, to signpost patients to safeguarding help if they needed it.

The evidence shed a good standard. 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. Managers were clear about service limitations which may impact on safe care. For example, patients who required sedation were seen at an alternative SpaMedica service.

Pre-operative assessment processes used a score system which considered patient’s medical health history in addition to eye-health. Patients with a high score were listed as complex cases and operated on by an expert vitreo-retinal surgeon. A vitreoretinal surgeon is an eye specialist who treats complex medical and surgical diseases of the eye. These experts complete medical eye training plus extra fellowship years in microscopic back-of-the-eye operations, managing urgent conditions like retinal detachment and diabetic eye damage.

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 with 2 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, staff discussed information about current symptoms, past medical history, social history, family history, medicines and any recent diagnostic tests and investigations.

The evidence showed a good standard. The service detected and controlled potential risks in the care environment. Leaders and staff took steps to make sure equipment, facilities and technology supported the delivery of safe care. Where they were unable to do so, they mitigated the risks.

The service operated from a modern, purpose-built facility, which was well signposted and had ample car parking. The environment was spacious, uncluttered and visibly clean throughout.

The ground floor accommodated outpatient clinics together with diagnostic services and yttrium aluminium garnet (YAG) laser facilities. There was a large diagnostic imaging suite which provided ample space for patients and staff whilst accommodating modern ophthalmic scanning equipment. The clinical layout reduced unnecessary patient movement and supported efficient patient flow.

The first floor included a range of patient treatment areas, including the private Freedom Vision service.

The second floor contained the surgical department. The layout separated theatre, recovery, staff facilities, and pharmacy areas in a way which supported safe practice and efficient movement of patients.

Each floor had its own reception and waiting area. There were suitable toilet facilities to meet the needs of patients and visitors. Despite the clinic being extremely busy throughout the inspection, all reception areas remained calm, tidy, and well organised. Reception staff greeted patients warmly and we observed courteous, professional interactions with patients and their companions.

Fire safety equipment was signposted and serviced within the last year. Fire exits were free from obstruction and fire evacuation information was displayed prominently. Staff had participated in a fire drill within the last 12 months.

Wheelchairs were available and there were evacuation chairs to assist immobile patients in the event of an evacuation. Evacuation chair refresher training formed part of the staff emergency preparedness programme.

The environment of the clinical areas reduced the risk of patient harm, and included, for example, safe flooring, handrails and window restrictors.

Managers maintained oversight of clinical equipment to ensure it was safe and ready to use. There was a planned preventative maintenance programme for all equipment. All equipment we checked was in good order and serviced in accordance with the manufacturer’s instructions. Other equipment, such as office equipment and seating were in good order, visibly clean, and could be wiped clean after use.

Staff told us they had enough equipment to carry out their work safely and to support the treatment and care needs of patients. Specialist equipment, including the YAG laser, was used in accordance with national guidance and regulatory requirements.

There was ready access to emergency resuscitation equipment.

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 because of the safe management of sharp implements.

Items subject to the Control of Substances Hazardous to Heath (COSHH) regulations were stored safely and information about products was available to staff.

The service had a named laser protection advisor, provided through a formal service level agreement, to manage risk associated with the YAG laser.

Health and safety policies were in date and reflected current bast practice guidance. There were procedures for managing medical devices, which detailed routine checks required for diagnostic equipment, to ensure that it continued to function correctly. These included pre-use checks, specified daily/weekly checks, reporting faults or damage and discontinuing use and calibration.

Managers monitored environmental safety through periodic audit of fabric plant and infrastructure of the premises. Scores were 94.23% and 98.66% respectively and there were action plans in place to address any non-compliance.

The evidence showed some shortfalls. Not all staff were up to date with mandatory and role specific training. However, the service made sure there were adequate numbers of qualified, skilled and experienced staff, who received effective support, supervision and development. The service demonstrated safe recruitment processes. Staff worked together well to provide safe care, which met patient’s individual needs.

The service supported the learning and development needs of staff and provided specialist training for their role. Mandatory training was delivered face to face and through e-learning as appropriate. Theatre and diagnostic competency training was signed off by the lead nurses.

Managers monitored mandatory training through weekly reports and alerted staff when they needed to complete updates. While most staff were up to date, the 95% target was not met for some role related mandatory modules.

Medical staff whose substantive roles were in the NHS, received their mandatory training through their substantive employer. Managers we spoke with told us consultants who worked primarily at SpaMedica, attended face to face training and e-learning as appropriate, and those who were not up to date, were not permitted to work, as compliance was a condition of their practising privileges agreement. However, training data we received did not include medical staff compliance rates, and mandatory training compliance was not a requirement identified in the practising privileges policy.

There were comprehensive recruitment and staff induction policies. The provider’s human resources team kept electronic personnel files for all staff. Those we looked at contained appropriate documents as required in the provider’s policy.

The service had enough clinical staff including medical, 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. Rotas were planned 8 weeks in advance and staff could make requests.

New staff received a full induction tailored to their role when they started in their role. Managers supported staff to develop through constructive recorded, annual appraisals and constructive clinical supervision of their work. Compliance with staff appraisals was 100%.

Consultants were subject to a full assessment through the annual practice privilege process. They were required to provide evidence of appraisal and re-validation annually.

Temporary bank workers had a local induction to the area in which they were working.

Staff we spoke with told us they felt the service was safe and they were able to take sufficient rest breaks during their shift.

Surgical procedures and clinical decisions were carried out by doctors with appropriate seniority and speciality training. Patients we spoke with were clear who the doctors involved in their treatment were. They said their needs were met in a timely way and we observed staff responded quickly to patients. We observed staff attended to patients in a kind and supportive way and patients appeared comfortable and were engaged in conversations with staff.

The evidence showed some shortfalls. Although all areas appeared visibly clean and infection rates were very low, the service did not ensure all staff completed all mandatory infection prevention and control training, in accordance with the service’s policy.

The service did not always manage infection risks well. We found some staff were not up to date with mandatory training, including hand hygiene, sepsis management and theatre cleaning protocols. In addition, environmental infection prevention and control (IPC) audits showed areas where improvements were needed to meet the provider's expected standards.

The provider’s quality and patient safety board minutes showed hand hygiene audit data was discussed and described ongoing efforts to provide direct training and education, and the development of a video to clarify the five moments of hand hygiene, to drive up compliance.

However, all areas we visited were visibly clean, free from clutter and had suitable furnishings which were clean and well-maintained. Staff cleaned equipment after patient contact.

The theatre environment followed national guidance, with separate areas to enable flow from clean storage, preparation through to an area for dirty equipment and waste management. There was storage for equipment including sterile packs.

Surgical instrumentation was managed off site under a service level agreement, which involved the processing of items, delivery of these and collection after use for cleaning and sterilisation.

Staff accessed the provider’s infection prevention and control policy and supporting guidance that reflected national IPC guidance. There were processes to enable staff to respond to infection prevention and control risks such as transmittable infections. Staff also had access to expertise in infection control, and to a microbiologist.

The service monitored surgical site infection rates and infection rates were low. Meeting minutes for June 2026 showed zero methicillin-resistant staphylococcus aureus (MRSA) bacteraemia cases for the previous quarter year and zero ophthalmitis cases. Ophthalmitis is a serious infection, and it is a medical emergency that can lead to permanent vision loss if not treated very quickly.

Theatre practice minimised the risk of cross infection and we observed staff following best practise regarding the treatment and care of their patients.

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.

There was appropriate periodic testing of water outlets to monitor for Legionella.

All staff supported infection prevention and control measures by following the uniform policy. Nail varnish and jewellery was not worn, and staff in clinical areas had bare arms below their elbows to allow for full hand decontamination. There were sufficient supplies of personal protective equipment (PPE).

The evidence showed a good standard. The service made sure that medicines and treatments were safe and met patient’s needs, capacities and preferences. Staff involved patient in planning, including when changes happened.

There were 2 secure pharmacy areas with controlled access.

The service used systems and processes to safely prescribe, administer, record and store medicines. Within the pharmacy areas we observed effective medicines governance arrangements, including clearly organised medicines storage, evidence of temperature monitoring for medicines refrigerators, comprehensive medicines traceability systems and appropriate stock management processes.

Emergency treatment boxes for patients developing serious complications were labelled clearly and immediately accessible. We did not find any expired medicines.

Staff followed systems and processes to prescribe and administer medicines safely. In theatres, drugs were not drawn up ahead of a list. There were accurate records of medicines administered in theatre and recovery.

Medicines including eyedrops, were stored in line with local and provider policy and reduced the risk of misuse and errors. Medical gases were stored securely.

There was oversight of medicines optimisation, including periodic audits and support for staff, from a pharmacist, employed through a formal service level agreement. The most recent annual audit showed 94% compliance against the 95% target. There was an action plan in place to address non-compliance. A corporate chief pharmacist also supported staff.