SpaMedica Swindon

On this page

• 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

This means we looked for evidence service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first assessment for this service. This key question has been rated good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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 provider 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 of people and their communities.

The provider had 3 main objectives: patient safety, excellent care and patient satisfaction. They were centred around ensuring every patient had the best possible experience of their services, and the best possible outcome every time. Leaders and managers had made adjustments to how they provided the service to make it more accessible for patients. This had included providing facilities for patients who required sedation for their procedure.

The organisation’s values of safety, integrity, kindness and transparency encouraged staff to achieve the objectives. This was encouraged at team meetings to embed company values and encourage ideas for improvement.

Staff focused on the needs of patients receiving care and worked well together to ensure they achieved good outcomes for patients to achieve the organisation’s objectives. Staff were passionate about the care they provided for patients.

Information was displayed to staff demonstrating how care was delivered in line with the 5 Care Quality Commission domains of safe, effective, caring, responsive and well-led. The management team advised they performed a monthly cascade to ensure they engage with frontline staff and ensure they uphold the company’s vision and values.

Staff spoke positively about the team culture and the support from leadership. When there had been lower work activity, staff had used this time to time to develop their skills. Staff described potential new opportunities like supporting patients with Age-Related Macular Degeneration (AMD).

The provider showed a good standard. The provider had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had the experience, capacity, capability and integrity to ensure the organisational vision could be delivered, and risks were managed. The southwest structure had an allocated hospital director, area manager, and a hospital manager who was the registered manager. The registered manager was the person who was registered with CQC and was legally responsible person to oversee the daily operation.

Leaders were visible and approachable to staff. The hospital manager follows the ethos of lead by example. Staff told us they felt well supported and would confidently raise concerns to the hospital manager.

We spoke separately to the hospital manager who managed two locations since September 2025 and shared their time across both sites but remained visible, approachable and contactable by staff. Senior staff deputised for the manager role and could access senior support if needed. They stated how they do regular ‘walk rounds’ of the service and individually speak with all the staff. They had an excellent understanding of the service they managed and could access appropriate senior support.

Leaders held regular staff meetings where staff told us they could safely voice their views and. Agenda items from team meetings included the risk register, recruitment, audit compliance as well as staff member of the month.

Senior managers represented staff views when they attended regional and national meetings with the senior leadership team. There were opportunities for staff to develop their skills by using the SpaMedica learning and development team.

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

Staff felt they could speak up and be listened to. There were ‘Freedom to Speak Up’ posters on the walls with links for staff. Staff were actively encouraged to speak up and raise concerns.

The evidence showed a good standard. The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had recently launched an equality, diversity and inclusion strategy. This was a 3-year plan to create an inclusive environment where everyone felt safe, valued and respected. Leaders continually reviewed and improved the culture of the organisation in the context of equality, diversity and inclusion.

The leadership monitored workforce data. Leaders also supported staff by providing reasonable adjustments and individualised plans to support staff in their roles.

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

There were clear and effective governance, management and accountability arrangements. Staff understood their role and responsibilities. Managers could account for the actions, behaviours and performance of staff. There was a well-led and effective clinical governance structure with clear systems and processes. Swindon had a regional governance lead who supported the hospital manager with compliance.

The service had effective systems, such as audits and risk assessments, to monitor the quality and safety of the service. There was a comprehensive audit schedule of clinical and non-clinical audits set by the corporate team. Leaders took additional steps to ensure good governance and compliance and had developed their own monthly quality audits.

Additional policies, and assurance had been developed to manage the conscious sedation service. The audits aligned to national guidance. Any learning from these audits had been fed back to the site action plan and reported to corporate governance leads.

As well as a corporate risk register, the service had a location risk register. This included risks such as risk of not recruiting or retaining staff. It was clear who the responsible person was to monitor each risk.

An operations balanced scorecard was available for each location. This scorecard included monitoring of patient’s quality and safety and operational activity. This was reviewed by the hospital manager on a fortnightly basis to identify opportunities for improvement and to look for barriers affecting progress. Surgeon performance was regularly monitored at monthly meetings.

There were suitable arrangements for the availability, integrity and confidentiality of data, records and data management systems. All staff had to complete data management training. There was a named Data Protection Officer. Information was used effectively to monitor and improve the quality of care.

Policies and procedures were developed and reviewed at corporate level. Staff were sent a weekly update email which included new policies and any tasks needing to be actioned. These were discussed at monthly team meetings.

The service conducted peer review audits. A manager from another site conducted the audit. Any concerns were added to the site improvement action plan and the manager monitored progress.

The service had an up-to-date business continuity plan should a major event interrupt the provision of care and treatment.

The evidence showed a good standard. The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

SpaMedica had community champions across their hospital sites. These roles were a key enabler to maximise fundraising. SpaMedica supported a charity raising funds and signposting and improving information for patients with Age-related Macular Degeneration.

Locally SpaMedica Swindon staff had completed various charity events including a charity bake sale sales to raise money for various national charities. These were demonstrated in their ‘Feel Good Friday’ newsletters to the team.

SpaMedica Swindon built links with local community optometrists and their local acute NHS trust. Nationally, SpaMedica offered a Specialist Registrar Induction, supporting trainees by being paired with experienced surgeons.

The evidence showed a good standard. The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Leaders demonstrated a commitment to improvement. Performance was used to promote learning. Learning was shared across the organisation. The senior leadership team shared a wide range of innovation and research across all locations.

Staff were encouraged to raise ideas for innovations and solutions. The manager also had anonymous boxes for staff to suggest ways to improve. Suggestions were considered at team meetings.