SpaMedica Carlisle

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of patient who used services and wider communities. We checked that managers proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

Managers and staff knew the service’s local vision, aims and objectives and understood how their service aligned with this. There was a culture based on speaking up, listening, learning and trust. Managers were visible, knowledgeable and supportive that helped staff develop in their roles. Staff felt able to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities and those with protected characteristics felt supported. Managers had sound oversight of the quality of service being delivered through effective governance and risk management systems. There was a culture of continuous improvement with staff able to contribute ideas through a quality improvement programme.

This is the first assessment for this service. This key question was rated good. This meant the service management was consistent and patient’s needs were met through good organisation and delivery.

We have not awarded this service a score for Well-led.

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

The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs patients and their communities.

The service had a vision for what it wanted to achieve and a strategy to turn it into action. This vision reflected the overarching provider aims and objectives. Staff we spoke with had awareness of how their work contributed to achieving targets.

Staff were focused on the needs of patients receiving care. The service promoted equality and diversity in daily work and provided opportunities for career development. The service had an open culture where patients, their families and carers as well as staff could raise concerns without fear.

Staff told us they felt respected, supported and valued. Staff reported that the leadership culture was inclusive and how they felt valued and respected. Relationships between staff of all grades were mostly positive, with strong teamwork and collaboration.

Staff felt motivated about the future and planned changes for the service.

Team and Individual staff achievement and success were recognised and celebrated. Staff were thanked for their work.

The evidence showed a good standard. The service had managers who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Managers had the skills, knowledge and experience to lead effectively. They did so with integrity, openness and honesty and understood the impact their behaviours and leadership had on patient outcomes and experience.

Managers had a range of experience, skills and abilities to run the service, and they understood and managed the priorities and issues the service faced.

Staff we spoke with told us managers were visible and approachable in the service for patients and staff. Staff felt they supported them to develop their skills and take on more senior roles.

Managers took incidents seriously and knew how to deal with concerns when raised which promoted a positive culture in the service.

Staff and patient survey results were acted upon appropriately.

The evidence showed a good standard. The service fostered a generally positive culture where patients and staff felt they could speak up and their voice would be heard.

The provider had a freedom to speak up (whistleblowing) policy which clearly described the process for staff to speak up without fear of repercussions. There were various routes available for speaking up. For example, online, through local and regional managers, HR, governance team and named freedom to speak up guardians.

There were posters displayed which promoted the National Guardian freedom to speak up guardians, with their photographs and contact details. There were also a Quick Response (QR) codes to allow people to speak up anonymously or email the team.

The annual Freedom to Speak Up Guardian report 2025-26, identified 2 main themes; concerns about day-to-day working relationships / team dynamics and pay/entitlement concerns. In response, managers took staff survey results seriously and implemented measures to support a positive culture. They encouraged staff to speak up and strengthened teams through demonstrating the shared values. Staff wellbeing was a focus in team meeting minutes.

Staff and managers acted with openness, honesty and transparency. Staff were encouraged to raise concerns and offer ideas; the culture allowed staff to be confident their voices were heard.

Staff we spoke with told they felt empowered to raise concerns without fear of consequences.

Patients, their families and carers were provided with information to explain how they could raise a concern and how this would be investigated.Senior staff were encouraged to respond to immediate concerns or complaints with a view to resolution. There were policies to support the complaints process.

The evidence showed a good standard. The service valued diversity in their workforce. Staff work towards an inclusive and fair culture by improving equality and equity for everyone.

Managers acted to improve where there are any disparities in the experience of staff with protected equality characteristics. They took steps to remove bias from practices to ensure equality of opportunity and experience for the workforce within their place of work, and throughout their employment. This was also reflected in the last staff survey results.

Staff we spoke with told us they had opportunities to apply for project work, new roles and to undertake external studies through an open application process.

The service acted to prevent and address bullying and harassment at all levels and for all staff, with a clear focus on those with protected characteristics under the Equality Act (2010) and those from excluded and marginalised groups. Staff felt everyone was treated fairly and that they would be able to report behaviour or attitudes which were negative in style.

Staff were offered reasonable adjustments where required, to support them to carry out their roles well.

The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. Staff used these to manage and deliver good quality, sustainable care, treatment and support. Staff act on information about risk, performance and outcomes, and shared this with others when appropriate.

The service operated effective governance processes through various committees and on-site activities, as described in the corporate Patient Safety and Quality Improvement Strategy for 2025 to 2028, and the Risk Management policy. The committees reported into the monthly Quality and Patient Safety Board and Risk Assurance Committee, which reported up to the SpaMedica Board.

There was a range of information collected, monitored and communicated internally at the relevant committee meetings and was fed upwards to the provider. Performance data were analysed and compared within the organisation and where improvements were needed at local level, action plans were developed to make this happen.

There was a medical advisory committee led by a Chair and supported by the service leadership. This was held every 3 months. We reviewed minutes for March and June 2026 meetings. Items discussed included performance, IPC, and shared learning from other locations.

However, the minutes did not demonstrate review of practising privileges as a fixed agenda item. The policy stated consultants were required to submit documentation annually for approval of practicing privileges and review of clinical outcomes of individual doctors was monitored through individual performance dashboards. If there were any concerns with performance, there were processes to follow and if necessary, information would be shared with professional bodies as required.

Staff at all levels were clear about their roles and accountabilities. Staff had job descriptions, and these set out expectations and responsibilities. Where senior staff had tasks assigned to them related to audit and monitoring quality of services, they understood what was required of them.

Managers could find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements. The information systems were integrated and secure. Data or notifications were consistently submitted to external organisations as required.

Managers made sure that accurate information was discussed and shared with key staff. For example, through twice-daily safety huddles and formal team meetings. Governance was discussed routinely, including incidents and complaints, safeguarding, audit results and actions, IPC, medicines optimisation, policies and training compliance.

Risks were clearly identified and a formal risk register used to keep oversight and manage mitigations and/or bring to resolution. Staff contributed to decision-making to help improve sustainability and improve quality of care.

Audit processes and the outcomes were used to ensure quality of services was maximised. Where improvements were required, managers ensured action plans and the monitoring of these led to positive changes.

The service had plans to cope with unexpected events and had a business continuity plan, which included major incident plans. The plan was tested and plans were amended as appropriate.

The service had not reported any data breaches and systems were secure. Patient identifiable information was handled correctly.

We reviewed several service level and provider policies and found these were up to date and readily available to staff. There was management oversight of the accuracy and validity of each policy.

The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for patients. Staff shared information and learning with partners and collaborate for improvement.

Staff and managers at the service collaborated with relevant external stakeholders and agencies to improve care and treatment for patients using the service. For example, local NHS providers and opticians.

Service managers were part of regional networks to understand the needs of the community and the provider ambitions.

Managers actively and openly engaged with patients, staff, the public and local organisations to plan and manage services.

The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff actively contributed to safe and effective practice.

Staff were committed to continually learning and improving services. Managers we spoke with had a good understanding of quality improvement methods and were trained in this area of work.

There were processes for learning when things went wrong or of good practice, either locally or nationally.

The service told us about some of the areas of work which they had focused on. For example, implementation of an organisation-wide electronic staff rostering system, linked to a skills matrix. This meant managers could not staff a shift or activity unless the person held the correct, verified competency for that role. This was designed by the corporate inhouse IT development team and unique to SpaMedica,

The service was a recognised, well established training hub which linked with local NHS trusts and provided specialist training for doctors and pre-registration optometrists. They supported trainee surgeons through direct supervision.

The service was proactive in succession planning. Staff were supported to have the time to develop their skills around improvement, innovation and to pursue career development opportunities. Staff accessed a programme of mentorship, coaching and self-development. Where appropriate, they were enabled to complete further education to help them to achieve their career potential.

The service was accredited with the Platinum Investors in People award. This is the highest tier of the international Investors in People people-management standard. It is an elite status achieved by only around 7% to 9% of accredited organizations worldwide, recognizing exceptional leadership, continuous improvement, and deeply embedded people-first workplace practices.