SpaMedica Portsmouth

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

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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 learned to continually identify and embed good practice.

Staff knew what incidents to report and how to report them, this included near misses. They did this using and online incident reporting system which notified leaders. Staff reported all incidents that they should report. and were able to explain how they used incident reporting system. There was a clear policy for staff to follow when reporting an incident and all staff at the service had completed training on reporting them.

The service had no serious incidents in the 12 months since opening in August 2024. A serious incident is a harmful, potentially harmful, or traumatic event which requires a heightened response due to the risk of significant harm, loss, damage, or disruption to individuals or the organisation itself. Although the service had not had any serious incidents, leaders told us there was a provider level policy to ensure staff were debriefed and received support after a serious incident. We reviewed the previous 3-month incident report data for the service and saw these had been correctly categorised as low level with no physical harm.

There was a provider level Duty of Candour (DOC) policy, and this could be accessed by all staff. This was reviewed 3 yearly and in date. The policy clearly outlined the roles of all staff, dependent on role, and their responsibilities regarding DOC. Staff understood DOC. They were open and transparent and gave patients and families a full explanation if things went wrong. All staff had completed mandatory training on ‘Duty of Candour and Being Open’ and ‘Handling Complaints’. Managers undertook DOC training specific to their role. Evidence provided showed all managers had completed this training.

The service operated within the network of a large provider with multiple locations within the UK. Staff received feedback from investigation of incidents, both internal and external to the service. These were shared with staff electronically in weekly bulletins. Staff met to discuss that feedback. Leaders also reminded staff to review these for learning and to ensure changes in practice were implemented.

Safety bulletins from national safety organisations, such as the Medicines and Healthcare products Regulatory Agency (MHRA) were shared with all staff within the wider organisation. This was done through electronic safety updates and there was also a flash bulletin folder within the medicines area for staff to review.

We scored the service as 3. 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.

The service had a referral and admission process that ensured all essential information about the patient was received to determine if the patient’s needs could safely be met. At the time of our assessment, most patients receiving treatment were NHS Funded. The service received referrals from a range of Ophthalmic providers and patients’ own GPs. Bookings for the service were centrally managed bookings for the location, this was to ensure consistency and to give patients a choice of location to suit their needs.

When a new patient booking was received, staff at the service prepared patient notes which gave details of any additional requirements.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge. Following discharge, the service gave patients their own copy of essential information and onward care details. These were also sent electronically, or in some cases by post, to referring clinician and patients GP.

There was a provider operated support line for patients to contact if they had additional questions or post treatment. This was available 24 hours a day and advice was provided by ophthalmic clinicians. If a patient required emergency treatment there was a dedicated out of hours service that patients could attend. This was located at another SpaMedica site that was around 30 mins away from this location.

We scored the service as 3. 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 received training specific for their role on how to recognise and report abuse. Staff received training specific for their role on how to recognise and report abuse. We saw that 100% of staff had completed their required safeguarding training. Staff received mandatory safeguarding children and adults training. All staff, including non-clinical staff, were trained to level 2 safeguarding adults and children. There was 1 staff member on site who was 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.

Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act. We spoke with staff who were able to give examples of the kinds of abuse that patients with protected characterises may experience.

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.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. This included working in partnership with other agencies. There was a safeguarding policy in place which was readily available on a centrally managed system. This gave clear guidance for staff to follow. There was also safeguarding pathways on display in all areas clearly instructing staff on how to raise safeguarding concerns.

Staff followed safe procedures for children visiting the service. The service did not provide treatment for patients under the age of 18 years. If a patient attended an outpatient’s appointment with a child, they were advised to bring a second adult to accompany and supervise the child while diagnostic tests were completed. Children were not able to attend when a patient received surgical services.

The hospital had a defined recruitment pathway and procedures to help ensure 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 scored the service as 3. 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 communicated with patients so that they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties. Leaders spoke about their role in removing barriers to care by ensuring they could support all patients.

Patients had all treatment under local anaesthetic and did not use general anaesthesia. Staff worked closely with other clinicians, including opticians and GPs to ensure they understood the patient risks. Staff reviewed risks using a recognised tool upon arrival. Patients were risk assessed for falls, mobility issues and dementia. Patients were assessed to check they could tolerate lying flat during surgical procedures.

Staff undertook dynamic risk assessments on patients’ health and wellbeing from the point of arrival. We saw risk assessments that had been completed by staff to highlight concerns and record health information such as blood pressure, past medical history and allergies. This information was also recorded within electronic records to ensure easy access for staff to relevant medical information.

Patients were informed about any risks that treatment posed and advised 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. Patients were allocated to operating lists that reflected their risk rating e.g. a patient at higher risk of complications would be allocated a more senior surgeon and increased time for their procedure.

The service employed a patient porter to greet and accompany patients as they entered and moved within the service to safely navigate the building. We saw patient were greeted warmly as they arrived and given clear orientation information. There was also a reception desk in this area which manned by clerical staff.

The staff completed a team brief with all the staff at the beginning of each shift followed by an additional and safety huddle for theatres. We reviewed the meeting notes from the past weeks team briefs and safety and saw these contained relevant information such as procedural changes, surgical lists and any safety notes such as allergies or communication restrictions.

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.

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.

Staff enabled patients to give feedback on the service they received. We saw there were patient information leaflets within all areas of the service. This included information on how patients could raise concerns. Leaders told us that in the first instance they would always aim to speak to patients directly on the day to support rapid response and resolution to any concerns.

The service took potential risks to patients seriously and ensured patients who had surgery were safe. We reviewed patient journey information from admission to discharge and saw safety checks were completed diligently and at multiple stages. 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.

The service undertook audits to monitor compliance to NatSIPPS2 8 steps to safer surgery and WHO compliance. We saw that for August and July 2025 these were 100% compliance. However, we reviewed 8 WHO checklists in patient records and found that for 5 of these areas had not been completed in full. We brought this to the attention of leaders following our inspection who told us they would be taking actions to address this and review how their audits were completed.

We scored the service as 3. 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.

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. We saw that an annual buildings inspection had been undertaken by contractors in June 2025, this monitored aspects such as health and safety, fire zones, and maintenance, this had shown the environment to be compliant with relevant national guidance.

The porter met patients in the reception area or from the car park if needed. All patients we spoke were positive about environment. A patient we spoke with told us that they felt the reception area was welcoming and clean. We saw the service had areas with ample space which was well lit, and we saw there was good ventilation in the operating theatre.

Patients in the preoperative area had access to a call buzzer and staff were always present in clinical areas to ensure they could respond if needed. There was CCTV in all waiting areas of the service which sent a livestream to dedicated monitors in managers and reception areas.

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.

The service monitored potential risks in the care environment took actions to minimise them. Staff made sure equipment, facilities and technology supported the delivery of safe care.

A contracted Laser Protection Adviser (LPA) had completed a statutory risk assessment around the risks associated with using a laser or intense light source at a workplace, ensure compliance with regulations like the Control of Artificial Optical Radiation at Work Regulations (AOR) 2010. The operating theatre had clear signage for laser surgery above all entry points. Staff could describe the safety precautions used for managing safe use of lasers. here was a provider level laser safety policy, and this had been reviewed in August 2025. We saw that there was an in-date copy of local rules for laser safety, and all relevant staff had reviewed these and signed to say they had done so.

We saw that the service was fully compliant with laser safety checks including protective equipment availability, access security and usage reports for each laser unit. All records completed demonstrated that staff had performed these well, with clear records to show when any additional action had been undertaken.

Laser safety audits were undertaken monthly. We saw that the audit in June 2025 had highlighted an area for improvement in that the details for the Laser Protection Advisor & Laser Protection Supervisor were not displayed int all rooms where the laser was used. This had been actioned immediately, and we saw that these signs were clearly displayed during our inspection.

Staff carried out safety checks of specialist equipment prior to treatment taking place. We checked a random sample of electrical equipment. We saw that all items had evidence of a recent portable appliance testing (PAT) safety test.

Staff disposed of clinical waste safely and used appropriate systems for the management of sharps. The service used service level agreements to manage waste streaming, including the storage and disposal of hazardous waste, in line with national standards. Processes were compliant with DHSC health technical memorandum (HTM) 07/01 in relation to the safe management and disposal of healthcare waste.

We saw that clinical waste was managed well, there was an in-date provider level waste clinical waste policy that all staff could access. There were clear clean and dirty sluice areas. These were well maintained and secure. Employers are legally required to assess risks from sharps injuries and put appropriate control measures in place. All sharps’ bins and sharps’ practice we observed were complaint with Health and Safety (Sharp Instruments in Healthcare) Regulations 2013.

Cleaning and disinfection arrangements for the surgical theatre included continuous air filtration using specialist equipment. Staff used single-use equipment for minor surgery. They documented serial numbers in patient records, which meant items were fully traceable in line with national guidance. The provider had a service level agreement in place for the sterilisation of reusable equipment.

We scored the service as 3. 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.

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. Staff members included a hospital manager, registered nurses, healthcare technicians, a porter, patient coordinators, and optometrists. The service employed permanent staff who moved between other SpaMedica services in the region to support safe staffing levels. This meant that when other locations within the network had higher levels of patient activity, they were required to work elsewhere. Staff told us they understood this was a necessary requirement to maintain patient safety and were happy to do this.

There was a standard operating policy in place to support leaders in ensuring staffing levels complied with best practice guidance. We reviewed this policy and saw that it outlined clear staffing levels for a range of clinical patient scenarios and treatment areas and drew standards from Association for Perioperative Practice (AfPP) and Royal College of Ophthalmologist standards. We reviewed staffing levels for the 3 months prior to inspection and saw there were appropriate staffing levels and skill mix to make sure patients received consistently safe, good quality care that met their needs. These records showed the service planned staffing levels based on patient activity to allocate shifts. We heard how leaders held meetings to assess and plan staffing in line with activity.

Staff had received and were up to date with appropriate mandatory training. The training was appropriate for the patient group using the service. Training compliance data showed 96% of mandatory training had been completed.

Leaders told us they monitored mandatory training and were provided with weekly updates of staff compliance so that these could be addressed with staff. All staff received yearly appraisals with 6-month interim review. Staff appraisals included conversations about career development and how it could be supported. We heard how staff were supported to develop in their careers. Administrative staff told us how they had undergone training appropriate to their role which enabled them to support patients and each other. We saw data that demonstrated all staff had received an annual appraisal and 6-month interim review.

There were robust and safe recruitment practices to make sure all staff were suitably experienced, competent and able to carry out their role. Staff received training appropriate and relevant to their role. All staff had an induction, and staff were provided with supervision as standard. We saw that there was an employee handbook available containing relevant information such as company values, and learning and development.

All clinical staff competencies were aligned with the system which allocated staff to clinics based on their competency. Competencies were mostly updated every 3 years. There were training and development competencies for staff to complete before being able to undertake procedures such as eye drop administration, sedation, and general anaesthetic. There were also role specific competencies such as Scrub practitioner for Cataract surgery. Staff were not allocated to work in areas that they had not completed competencies and leaders supported all staff to complete these.

The provider 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 regional training lead, regional lead and director of optometry supported optometrists. The training lead supported new optometrists with their competencies and conducted appraisals and 6-month interim reviews. The service was a designated teaching location for the provider and provided experience for pre-registration optometrists.

However, 66% of staff had not yet undertaken mandatory training in ‘Understanding sexual misconduct in the workplace’.

We scored the service as 3. 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.

All areas within the service were visibly clean, had furnishings that were well-maintained and easy to clean. We saw that there was a provider level infection prevention and control (IPC) policy which had been reviewed in July 2025, and this gave clear guidance to all staff for a wide range of IPC scenarios including sharps, food hygiene and linens.

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. The service performed well for cleanliness. The service was consistently above 95% compliance for theatre infection prevention and control audits with the most recent audit demonstrating 100% compliance.

During our assessment we saw housekeeping staff working continuously to maintain high cleanliness in all areas. Housekeeping staff spoke with pride about their work and ensured all areas were thoroughly cleaned. All areas of the service were visually clean and demonstrated a commitment by staff to maintain high IPC standards.

Staff completed daily cleaning check lists to record compliance with cleaning schedules and standards. Cleaning records were up to date and demonstrated that all areas were cleaned regularly. Deep cleans could be requested when the service thought that this required. We saw that the service had performed routine water testing in August 2025 for bacteria such as legionella and pseudomonas in line with health and safety guidance for high-risk areas, such as theatres. This showed there was no evidence of these bacteria in these areas.

There were clear roles and responsibilities around infection prevention and control. We reviewed training records which showed all staff had completed their infection prevention and control mandatory training. Relevant staff also undertook additional manufacturer training in how to clean specific clinical equipment such as probes.

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. We observed staff undertaking effective hand hygiene in line with best practice guidance. Staff were observed to be ‘bare below the elbow’ and following best practice guidelines for hand washing. We reviewed hand hygiene audits completed by the service and saw that these showed 100% compliance.

There were adequate supplies of (PPE) and scrubs available. Staff were observed wiping 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 maintained equipment well and kept it clean. Any ‘clean’ stickers were visible and in date. 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 an online forum for the IPC link nurses across the company to ask questions and offer each other support.

Staff followed protocols to avoid the incidence of surgical site infections. Staff checked sterilisation records before surgery took place, and the provider maintained end-to-end tracking for surgical instruments sent off site for sterilisation. The service documented tracking details for consumables and reusables and for sterilised instruments in surgical records. This enabled tracing to take place in the event of a suspected infection.

Information about the risk of infection was shared appropriately with relevant partners, including agencies and patients using the service and visitors. The service had no confirmed endophthalmitis cases since they had opened.

We scored the service as 3. 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 involved people in planning, including when changes happen.

Staff followed good practice in medicines management and did it 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. Patients’ medicines were appropriately prescribed, supplied and administered in line with the relevant legislation, current national guidance or best available evidence.

There was a medicines management committee at provider level who met quarterly. They had a fixed agenda which included the governance report, medicine risks, new policies, training compliance and new relevant national guidance. The provider had an in-date medicines management policy that outlined relevant areas such as exclusion, duties and responsibilities.

Medicine management audits showed good compliance. The service conducted medicine audits of the department which showed compliance of 97% for departmental medicine management, and 96% in medicine management for patients.

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.

The service actively sought ways to make aftercare easier for patients. For example, patients who may struggle to administer eye drops were given a ‘training’ eye drop following their outpatient’s preoperative assessment. This was to enable them to practice before surgery and get them used to this.

Only staff who had completed competencies in the management of medicines dispensed and administered medicines to patients. Medicines competencies included medicines management, awareness, disposal, and storage. Records showed this had been completed by 100% of staff who required it.

Access to areas where medicines were stored was restricted to only relevant and appropriate staff. We saw that staff stored and managed all medicines and prescribing documents safely in their medicines store. Within the medicines areas there were dedicated refrigeration, and ambient medicines storage areas. All fridges were securely accessed with keys.

The service had 6 fridges for medicine storage; these were all monitored for temperature. We saw that each fridge had laminated cards on the door to indicate which medicines were contained within.

Medical gases were stored safely and securely. Empty and full oxygen cylinders were stored separately, ensuring these would not be easily mixed up.

There were appropriate arrangements for the safe management, use and oversight of controlled drugs (CDs). CDs 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. CDs were securely accessed within the medicines area via a dedicated lock box which held the access keys to a secure wall mounted safe.

However, there were some inconsistencies with documentation relating to medicines that had been disposed of when not required. This was highlighted to leaders following our assessment and we received assurance this had been resolved.