SpaMedica Taunton

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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 people were protected from abuse and avoidable harm.

This is the first assessment for this service. This key question has been rated good. This meant people 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 provider 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.

The service managed patient safety incidents well. The service had a proactive and positive safety culture, based on openness and honesty. Staff were encouraged to report all incidents by management and staff felt safe and supported to do so in line with policy. Staff reported incidents using an online incident reporting system which notified leaders.

All managers had completed their Health Services Safety investigation Body (HSSIB) training in line with the patient safety incident framework. Managers investigated incidents and shared lessons learned with the team and the wider service. The hospital manager held a “SWARM” meeting following any incidents to discuss learnings as a team. A SWARM is designed to start as soon as possible after a patient safety incident occurred to identify immediate learning. Leaders shared an example where a patient collapsed, staff followed the correct process, and learning was discussed with the team. We observed learning from an incident at another location was shared at the morning meeting with staff.

Incidents were monitored at a national and local level. During the last 12 months prior to the assessment, 136 incidents were reported, the majority were biometry/diagnostic input error. Because of this, leadership had conducted a quality summit of biometry errors. Recommendations from this were currently ongoing to make improvements. Although the total number of incidents was above SpaMedica’s national average, none of the incidents led to moderate harm, with majority being no harm and was felt to demonstrate a healthy reporting culture.

Staff understood the duty of candour. Staff apologised and were open and transparent if and when things went wrong. There was a provider level Duty of Candour (DOC) policy and all staff had access to this.

At the time of the assessment usual workload had dropped due to the current commissioning arrangements. Management had used this time productively to review learning from incidents and staff training needs.

The evidence showed good standard. The provider 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.

The service had a referral and admission process. This ensured all essential information about the patient was received to determine if the patient’s needs could safely be met.

There was an admission criterion for both NHS and private patients. These criteria set out where SpaMedica had limitations in services and minimised risks by appropriately excluding some patients. SpaMedica Taunton was able to provide to support patients with bariatric needs, which some SpaMedica locations were unable to support. At the time of our assessment, most patients receiving treatment were NHS funded.

Referrals were sent by ophthalmic providers and patients’ own GPs to the head office. Appointments were made by head office for pre-assessment if the patient was eligible. Once patients had their pre-assessment at SpaMedica Taunton, the patient co-ordinator would book the theatre day and post-operative appointments.

Safety and continuity of care was a priority throughout people’s care pathway. Patients were assessed prior to surgery and findings considered when planning care and treatment. Patient pathway signage was clear throughout the building diagnostics, vision measurements, medical history and consultation.

There were systems and processes to ensure the correct patients were treated throughout the patient journey. We tracked the patient care journey from pre- assessment, admission, operating theatre to recovery and discharge. 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 and improve team communication. We observed safety checks being carried out before and during surgery. We reviewed 5 sets of patient records and found the WHO checklist completed correctly. Quarterly WHO audits were undertaken and current compliance was 98.7%.

Patient records were a mixture of electronic and paper based. Records were stored securely.

There was clear guidance in each exam room for staff to follow if they had safeguarding or mental capacity concerns.

The provider operated a support line for patients to contact if they had additional questions or concerns. This was available 24 hours a day and advice was provided by ophthalmic clinicians.

The evidence showed a good standard. The provider worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve it. Staff 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 provider shared concerns quickly and appropriately.

The service had up-to-date policies and procedures to keep people safe from abuse or improper treatment. Staff followed processes to report concerns. Staff had access to the online policy. There were safeguarding pathways on display in all areas clearly instructing staff how to raise safeguarding concerns.

Staff understood how to protect patients from abuse. Staff provided examples of safeguarding referrals they had raised. All staff were trained in Level 2 safeguarding, and the manager was trained in Level 3. The Safeguarding Lead was Level 4 trained and supported staff in escalating concerns.

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.

The evidence showed a good standard. The provider 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.

The service worked with patients to understand and manage risks. 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. Staff spoke about their role in removing barriers to care by ensuring they could support all patients.

Risk assessments were person centred, proportionate and regularly reviewed with the person. Patients had all treatment under local anaesthetic; the provider did not use general anaesthesia.

Staff worked closely with other clinicians, including opticians and GPs to ensure they understood the patient risks. Patients were informed about any risks and how to keep themselves safe. The patients we spoke with stated they were involved in their care and treatment, and the staff had explained the risks involved with their treatment.

At the beginning of each shift, the staff completed a team brief followed by a surgical team brief in the theatre. We observed a theatre brief where staff allocation and the theatre list was discussed in detail. Staff highlighted patients with additional needs such as diabetes.

The service took risks to patients seriously and ensured patients who had surgery were safe. We followed 2 patient journeys from admission to discharge and saw safety checks were completed diligently, with time given for the patient to ask questions.

There were sepsis posters around the hospital to alert staff and patients to the signs and symptoms of sepsis. Sepsis training was at 100%.

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. Staff we spoke to were aware of the process.

The evidence showed a good standard. The provider detected and controlled potential risks in the care environment and made sure equipment, facilities and technology supported the delivery of safe care. However, we found evidence that some equipment was missing or had expired use by dates in an area not used by patients.

Facilities, premises and equipment were purpose-built and met the needs of all patients who used the service. The building was modern, and although the service was split over two floors, patients only had access to the ground floor. The admission area, theatres and recovery area were designed to allow smooth transfer between the different areas.

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.

The building was bright, spacious and clean with sufficient ventilation and heating. The waiting area had sufficient seating. There were chairs for people with bariatric needs in the waiting area, along the corridors and in some of the rooms All chairs were easy to clean. Hot and cold drinks were available in the patient waiting area. There was CCTV which was monitored from the main reception desk. The pre theatre ward area had call buzzers and badge access doors. There was ample free parking directly outside.

There was a comprehensive system to proactively manage the safety, maintenance and repair of facilities, premises and equipment in patient areas. Back-up generators were available in the event of a power failure. Leaders maintained oversight of equipment to ensure it was safe and ready to use. Fire safety equipment was available and had been serviced. Fire exits were clear and free from obstruction. There was an evacuation chair on the first-floor landing area although this area was not yet used by patients.

The site risk register was reviewed monthly in line with the Risk Management Policy. There was a named Laser Protection Advisor and laser safety audits were regularly conducted. The most recent audit was January 2026 which showed 100% compliance. A risk assessment for the use of the laser had been completed. There was a laminated sign used when the laser was being operated.

Stock was in a secure area and stored off the floor. Stock rotation records were completed monthly. We checked several consumable items, and these were all in date. Electrical items did not have their ‘PAT’ sticker of compliance, the management team assured us this was because they were still within the 2-year warranty period.

We reviewed records which showed the hoist and slings were maintained, cleaned and regularly checked. A hoist and sling pre-use checklist was completed by staff trained to use the hoist.

Staff disposed of clinical waste safely daily and used appropriate systems for the management of sharps. There was a contract for the weekly collection of clinical waste. Staff theatre ‘scrubs’ were laundered twice a week.

The resuscitation trolley on the ground floor where patients were located was regularly checked. It was noted to be clean and all items in date. The first floor had unused clinical rooms, the staff room and staff changing facilities. There was a resuscitation trolley and ‘grab bag’ on the first floor. We noted this resuscitation trolley and ‘grab bag’ were not kept up to date. There was 1 item out of date on the trolley and 1 item missing against the inventory. A ‘grab bag’ had 2 items expired and had not been checked in over 2 months. We raised this to the management team who confirmed no patients accessed the first floor but agreed to risk assess the need for the resuscitation trolley and the ‘grab bag’. When we returned on 16 March 2026, the resuscitation trolley on the first floor had been removed. The ‘grab bag’ on the first floor remained and contents were complete, in date with regular checks undertaken.

The evidence showed a good standard. The provider 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.

There was sufficient qualified, skilled and experienced staff to operate the service. All staff received effective support, supervision and development opportunities. Staff worked together well to provide safe care that met patients’ individual needs.

The service ensured they had enough staff to keep patients safe. Staff members included a hospital manager, registered nurses, healthcare technicians, patient coordinator, and optometrists and surgeons. The service employed permanent and bank staff. It was rare to use agency staff. Where necessary agency doctors had been used to cover the optometrist role. At the time of assessment, the service was recruiting for additional patient coordinators. The team was small and turnover had appeared to be high due to the low numbers of staff. The hospital manager confirmed there had been no change in staff over the last 3 months.

The service employed permanent staff who moved between other SpaMedica services in the wider regions to support safe staffing levels. This was aligned with their Clinical Safer Staffing Levels Standard Operating Procedure. Staff were aware this was a necessary requirement to maintain patient safety.

Safe recruitment processes were followed to make sure all staff were suitably experienced, competent and able to carry out their role. we reviewed 5 staff files and found no concerns. All staff had an induction and had structured progress meetings. All staff were provided with a mid-year review and annual appraisal. All the staff we spoke with confirmed they had received an appraisal. All current appraisals, probation reviews and mid-year check ins were currently at 100%.

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

All staff competencies were aligned to ensure staff were allocated based on their competency. Nursing and healthcare technician staff completed competencies every 3 years. We saw evidence competencies had been signed off. Staff told us they were reminded if competencies or mandatory training was due to expire and they were given the time to complete.

Staff received training relevant to their role and had access to mandatory training, which included online and face to face learning. Mandatory training which included use of hoist, sepsis awareness and infection control was 100% compliant. Although an additional infection control course showed 2 nurses had not yet commenced. The provider was assured any outstanding practical training needs had been escalated to their learning and development team.

The evidence showed a good standard. The provider assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

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

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. Regular clinical audits were completed on a rolling programme. Infection prevention audits were completed every 3 months at over 98% compliance. Hand hygiene audits were completed monthly and was 100% compliant over the last 6 months. A humidity decision making tree was in place for theatres. This provided a process for staff to follow if humidity levels increased. There was a hoist and sling cleaning record.

Staff followed infection control principles including the use of personal protective equipment (PPE). Hand-washing and sanitising facilities were available for staff and visitors throughout, and we observed staff practising effective hand hygiene. Adequate supplies of PPE were available. Staff wiped down equipment after patient contact and between patients. There were multiple large pieces of equipment in the operating room, and these were kept clean, well maintained and dust free.

Staff followed protocols regarding decontamination. Reusables were managed well and instruments were sent to an external contractor for sterilisation. Where staff used single-use equipment for minor surgery, they documented serial numbers in patient records. This meant items were fully traceable in line with national guidance.

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

Staff followed good medicines management in line with national guidance. The service always made sure medicines and treatments were safe and met patients’ needs, capacities and preferences.

Staff followed systems and processes to prescribe and administer medicines safely. Only staff who had completed competencies in the management of medicines dispensed and administered medicines to patients. Staff compliance for medication management was 100%. Medication records were recorded on paper and an electronic system.

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. Allergies were clearly recorded.

Medication was securely stored and restricted to appropriate staff. Medical gases onsite were stored safely and securely. The service had medication stored in a temperature-controlled room. Those medicines which required refrigeration were stored in fridges on the ground floor and the temperatures were monitored daily and within normal limits. There were additional fridges on the first floor which was a staff only area, only weekly temperature checks were recorded but these were not currently used to store medication. In the event of failure of the downstairs fridges, the fridges on the first floor would be checked and used and ongoing daily temperature monitored.

A resuscitation trolley was available on the ground floor; this was regularly checked by staff. All expiry dates of items were listed in the audit record and those expiring soon were highlighted. A ‘grab bag’ was available and the record was regularly checked.