Item 7 07... · 2019. 3. 28. · 1. Introduction The Care Quality Commission (CQC) ... Return...

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Report to Trust Board 26th January 2017

Report title CQC inspection: outcomes and next steps Report from David Probert, Chief Executive Officer Prepared by Ian Tombleson, Director of Corporate Governance

Kaajal Chotai, Head of Compliance and Quality Improvement

Previously discussed at Management Executive Attachments Appendix 1: CQC overarching provider report

Appendix 2: CQC recommendation / action tracker Appendix 3: CQC quality summit draft agenda

Brief summary of report

Explanation of the CQC inspection in May and its process Inspection report summary Summary of our process for action plan delivery and process of monitoring Forthcoming Quality Summit meeting and its purpose and desired outcome

Action Required/Recommendation

The Board is asked to note the inspection outcome as GOOD. Progress with action planning and delivery has started. As required by the CQC a Quality Summit is being organised.

For Assurance For decision For discussion To note

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Executive Summary

This paper provides a summary of the outcomes of Moorfields’ CQC inspection in May 2016 including receipt of a final inspection report in January 2017 and next steps. Section 1, p3: introduction – overview of inspection activities and initial feedback from the CQC. Section 2, p4: background – briefly describes the organisation’s journey from May 2014 to the announcement of inspection including how the CQC inspection has been incorporated within our quality improvement journey. Section 3, p7: inspection report summary – highlights from the inspection report about areas of good practice and areas for improvement. Section 4, p11: post inspection action planning and improvement works – summarises the action planning process and actions that have already commenced. Section 5, p12: quality summit and next steps – describes the purpose of the quality summit and the desired outcome, as well as the next steps post-inspection and the future CQC regulatory model. A more detailed report analysing the learning for the project team and the organisation as a whole will be available in due course.

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1. Introduction

The Care Quality Commission (CQC) undertook an announced inspection of Moorfields Eye Hospital NHS Foundation Trust for five days from 9 to 13 May 2016. Scheduled inspections took place across nine of our sites: City Road, St George’s, Queen Mary’s Roehampton, Croydon, Purley, Barking, Bedford, Ealing and Mile End. The CQC also undertook an unannounced inspection of Northwick Park and unannounced “pre-inspection” medicines management checks at Mile End and Barking. The CQC undertook further unannounced inspections between 14 – 26 May, and revisited Queen Mary Roehampton and City Road, re-inspecting outpatients and surgical services. As part of the inspection, the CQC spoke to patients, visitors, carers and staff (in the hospital, in focus groups and formal interviews) to gain a view of Moorfields’ four core services - outpatients, surgery, urgent & emergency services and children & young persons’ services. The CQC methodology seeks to rate each of these in relation five domains:

Were services safe? Were services effective? Were services caring? Were services responsive to people’s needs? Were services well led?

Starting in December 2015, during and after inspection, the Trust provided large amounts of documentation to the CQC via a process called the Provider Information Return (PIR). The CQC use this information to provide focus during their inspection and triangulate their inspection results. Requests for information continued until October 2016, when the trust received its draft reports for factual accuracy review. All responses were provided within deadline and the trust’s final reports were received on Tuesday 3 January 2017. Robust communications and engagement plans were initiated to ensure as many staff as possible were sighted on the embargoed outcome prior to publication by the CQC on 6 January. Moorfields was rated Good overall. The inspection ran smoothly as a result of robust preparation and engagement with staff at all levels and the CQC commented very positively on how timely the Trust’s responses had been.

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2. Background

In September 2014, the CQC confirmed a new inspection regime and a revised methodology, resulting in Ofsted style outcomes, reports and improvement measures. This comprehensive assessment method includes inspection teams (the size of which is be determined by the size of the organisation being inspected) made up of experts (inspectors and patients) and specialist advisers (i.e. peers from relevant backgrounds), making judgements about quality of care and whether or not a service is safe, effective, caring, responsive and well led. This would be achieved using a mixture of announced and unannounced inspections and multiple sources of evidence to support findings. The quality and safety team commenced preparation for a “new style” CQC inspection during the last quarter of 2014/15. The major activity for the first two quarters of 2015/16 was a self-assessment ‘baseline’ by all clinical and non-clinical areas and subsequent improvement action planning. Strategic corporate planning took place in parallel. A summary of the timeline is as follows:

Inspection notification was received on 21 December 2015.

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A summary of the inspection timeline is set out below:

Once the inspection was announced, a number of phases (as per a full project plan) commenced:

1. Data requests (provider information returns, or PIR) commenced from 22 December 2015. PIR 1 was requested over Christmas 2015 and submitted on 12 January 2016. PIR2 was requested mid-February 2016 and was delivered mid-March 2016 in line with the CQC's requirements. PIR2 was a much more detailed request compared with PIR1, and a pre-emptive process and working group were established to collate vast sets of data.

2. Continued data requests and general inspection planning (in conjunction with the CQC) took place right up until the week before the inspection. This included arranging interviews with staff and focus groups for the medical, nursing, allied health professionals and administrative staff. The CQC also had a patient stall at City Road on 4 May 2016 collecting up to date patient feedback.

3. An internal CQC hub (staffed by the quality and safety team and supported by the communications and performance and information teams) was set up to manage and coordinate both the data requests and the feedback received from staff about their inspection experience. The hub also managed communications with staff about the inspection, and provided the executive team with a daily update.

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4. The onsite inspection took place from 9-13 May 2016, as detailed in the sections above. The CQC chose to visit a mixture of sites to ensure they obtained a broad view of our care models across all our services.

5. Post onsite inspection, two weeks of unannounced inspection followed for our City Road site as well as a visit to Queen Mary Roehampton, and data requests continued to come through until just before the draft reports were received.

6. Following receipt of the draft reports a factual accuracy process and response took place. Planning for that commenced in July 2016.

7. The factual accuracy process commenced on the 10 October 2016 when the draft reports were received. The CQC aims to provide organisations with their draft inspection report 50 days post inspection - we received our report around 140 days post inspection. The factual accuracy response was submitted in the required timescales on 2 November.

8. Final reports were received on Tuesday 3 January 2017. Robust communications and engagement plans were implemented to ensure as many staff as possible were sighted on the embargoed outcome prior to publication by the CQC on 6 January. Moorfields was rated Good overall.

Whilst it was a challenge for the organisation, solid preparation ensured that Moorfields was in a good position when the inspection was announced to respond to the Provider Information Requests (PIR), and to implement the inspection planning and preparation in earnest. Much was learnt from the first round of data submission about how the organisations manages data and information, how it is stored and how readily accessible it is. Data quality issues were also identified, and as a result streamlined processes and additional resourcing were put in place to support the next stage of data provision.

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3. The inspection report summary

To provide a view of Moorfields’ network, the CQC has presented its findings using six reports:

an overarching provider report (summary report of all sites and services inspected)

Bedford City Road St George’s Outpatient and diagnostic imaging services – satellite sites (which includes

all satellite outpatients services other than City Road, St George’s and

Bedford) Surgical services – satellite sites (which includes all satellite surgical services

other than City Road, St George’s and Bedford)

These reports were published on the CQC and Moorfields websites on Friday 6 January 2017. The overall ratings for the trust by domain are:

Safe – Requires improvement Effective – Good Caring – Good Responsive – Requires improvement

Well-led – Good

How this translates into an overall rating

In deciding on a rating, the CQC seeks to answer the following questions:

Does the evidence demonstrate a potential rating of good? If yes – does it exceed the standard of good and could it be outstanding? If no – does it reflect the characteristics of requires improvement or

inadequate? Each service inspected is rated against each domain: safe, effective, caring, responsive and well led. For the purposes of the inspection services are rated in isolation. However, they do not operate in isolation. Only by multi-disciplinary working and cohesive and supportive leadership have services achieved the ratings they have. In particular, outpatient and diagnostic services underpin our urgent and emergency and surgical services, contributing to our overall ‘Good’ rating for ‘Caring’. Although not rated for ‘Effective’ (the CQC does not rate trusts for ‘Effective’ in outpatients) the reports contain robust indications that outpatients and diagnostic services deliver effective care comparable with other trusts.

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The overall rating for the trust is Good with the following sub-elements:

Satellite services

City Road

St George’s

Bedford

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What we can be proud of The CQC found several areas of Outstanding practice including:

The trust had a pivotal role in the development of ophthalmic services, as a lead in one of the hospital vanguard systems selected by NHS England to develop new models of care.

The development of staff skills, competence and knowledge and the development of extended nursing and allied health professional roles. Staff reported that they felt well supported and received good training opportunities.

There was an extensive research portfolio that was recognised at a UK and global level, directly benefiting patients.

There was a clear proactive approach to seeking out and embedding new and more sustainable models of care from all staff levels within the services, and across the Moorfields network.

The CQC noted the trust had made significant investments in leadership and quality improvement.

At City Road services for children and young people and urgent and emergency services were rated ‘Good’ overall. Services for children and young people were rated ‘Outstanding’ for Caring at City Road. Surgical services were also reflected well across the trust. Services for children and young people

Systems and processes were in place to promote the delivery of safe care. Children and young people benefited from a multi-disciplinary approach to

care within a purpose built setting. Parents, children and young people were overwhelmingly positive about the

kindness and compassion of staff and their cheerful and calm approach. There was good clinical leadership and staff felt supported. A comprehensive

programme of research was being undertaken, new services were being developed and the expertise within the service was reflected by the published research in national journals.

Urgent and emergency services

The number of patients attending urgent and emergency services had risen by 15% at City Road in the previous two years. The service was able to respond to the increased demand and had consistently achieved the national quality standard for seeing 95% of patients in less than four hours. The department achieved this standard every month since August 2014.

Care and treatment was evidence based and the hospital participated in national and local audits to monitor patient outcomes. Clinicians were involved in the development of national standards and guidelines.

There were effective systems in place to protect patients from harm and a good incident reporting culture. Learnings from incident investigations were disseminated to staff in a timely fashion.

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Surgical services There were comprehensive and robust governance and risk management

processes in place with appropriate systems to ensure information was shared.

There were a low number of serious incidents. Good processes for reporting incidents and systems were in place for learning to occur.

Clinical areas were visibly clean and there was good compliance with hygiene processes resulting in low infection rates.

Friends and Family Test results were consistently good across surgery services.

The satellite sites had systems in place to keep patients safe. Patient safety was protected on a day to day basis and patients were safeguarded from harm. Safeguarding processes were followed.

Staff morale across satellite sites was high and most staff felt supported by their managers. Staff felt proud to work at the trust and enjoyed their work. There were many opportunities to progress and development was encouraged. Where we need to do further work There are many aspects of the CQC reports that are a fair reflection of the services the trust provides and the very positive experiences of our patients and staff. There are also elements of the reports that identify where the trust has further work to do. With our combined and concentrated efforts, we will now work together to address the areas identified for improvement by the CQC and have already started to address some of the more pressing of these in response to initial feedback after the inspection in May. Some of these we can do relatively easily and quickly, others require significant behavioural change across the trust.

Fully embed the World Health Organisation safer surgery checklist, in terms of both documentation and the quality of staff engagement in the process, across the organisation.

Ensure adequate audit and monitoring systems are in place to monitor performance and compliance of the WHO safer surgery safer surgery checklist to guide improvement.

Continue to improve and monitor our record keeping practices. This includes addressing where storage space is lacking and ensuring that patient records are fully and legibly completed.

Review the governance process around Service Level Agreements (SLAs) with partner organisations, and ensure these fit the existing and future models of care delivery.

The next section provides more detailed information about the action plan to address the findings of the inspection report. Please see appendix 1 for the overarching provider report.

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4. Post inspection action planning and improvement works

Key areas for improvement from CQC’s reports were explained in section 3. In total, reports contain 78 improvement actions set out in three priority categories of:

1. requirement notices1 2. must do’s 3. should do’s

Moorfields started planning and delivery of these after receiving CQC’s draft reports in October. However, following the factual accuracy checking process a number were redefined or removed by the CQC by the time the final reports were published on 6 January. The final list of 78 improvement actions has been grouped and arranged into themes to support delivery. The compliance team have developed project tools and monitoring processes to support delivery. All actions have been allocated to Executive Directors to lead and delivery has commenced. Rigorous monitoring is taking place every two weeks at Management Executive. The Board will receive monthly summary progress updates. The table below summarises the CQC actions per report. CQC report Requirement

notice Must Do

Must / Should Do*

Should Do

Total

Provider 13 13 Satellite outpatients

4* 4

Satellite surgery

5* 5

Bedford 4 7 11 City Road 5 5 16 26 St Georges 4 5 10 19 Total 9 27 9* 33 78 *In some cases the CQC has provided an overlapping definition. The CQC require a Quality Summit to take place about one month after report publication. The purpose of the Quality Summit is for the CQC, NHSI and other key stakeholders to support the trust’s action planning. This is explained further in the section below. Please see appendix 2 for a summary of the action plan.

1 CQC: Where a registered person is in breach of a regulation or has poor ability to maintain compliance with regulations, but people using the service are not at immediate risk of harm, we may use our power to require a report from the provider. We will do this by serving a Requirement Notice on the provider.

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5. Quality Summit and next steps

Purpose of the Quality Summit Following inspection publication the CQC requires a Quality Summit to take place. At this the trust meets with the CQC and the trust’s key stakeholders. The purpose of the Quality Summit is to develop a plan of action and recommendations based on the inspection team’s findings. This plan will be developed with partners from within the health economy and the local authority. Quality Summits consider: The inspection findings. Whether planned action by the trust to improve quality is adequate or whether

additional steps need to be taken. Whether support should be made available to the trust from other stakeholders

such as commissioners to help them improve. How does the Quality Summit fit into the inspection process? The inspection model for NHS providers (including acute, mental health, community combined and ambulance providers, both foundation and aspirant), is a specialist, expert and risk-based approach to inspection that allows the CQC to get at the heart of what really matters to patients and the public. It aims to better enable the CQC to highlight where care is good or outstanding and to expose where care is inadequate or requires improvement. All comprehensive NHS inspections follow the following stages:

Preparation (including intelligence input and planning). Inspection visits. Reporting (including making judgements and ratings, quality assurance, and

quality summits). Quality Summit agenda The session lasts approximately 3 hours and is split into two parts: Part one – The CQC Inspection Team Leader / Head of Inspection (HOI) / Inspection Chair) chair this section and summarise the results of the trust’s inspection report. Following the CQC presentation, the Chief Executive will present the trust’s response to the inspection’s findings, what the trust is doing to address the issues raised and where they feel additional support will be needed. Part Two – The second part of the Quality Summit will be facilitated by a representative NHS Improvement and Moorfields and will be focused on agreeing a high level action plan in response to the findings of the inspection. The summit will provide a robust challenge to ensure that actions are not short term but are focused on sustainable change. The actions should be agreed by the trust, the CQC and other partners present.

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This part of the Summit will consider: Whether planned action by the provider to improve quality is adequate and

whether additional steps should be taken.

Whether support should be made available to the provider from other stakeholders such as commissioners to help them improve.

Any areas that may require regulatory action in order to protect patients.

After the Quality Summit The CQC will circulate the minutes from the Quality Summit to all invited parties within a week of the Summit. The recommendations for action will be captured in a high level action plan(s). Further work will be required by the trust and its partners following the Quality Summit to develop the detail beneath the high level actions. This should be completed within approximately one month of the Quality Summit. Action plans are owned by the trust and the trust will use their own action plan templates and tools. CQC will expect to be consulted on the adequacy of the action plan before it is agreed. Once agreed, action plans should be shared with the CQC Inspection Team Leader / Head Inspection to ensure all key areas highlighted during the inspection have been appropriately addressed and stored on CQC systems. Future inspections As Moorfields continues work towards becoming an outstanding organisation we should assume that the CQC may re-inspect at any time in the future and should be ready for this. As well as delivering a timely and comprehensive action plan the trust will further embed quality improvement methods, systems and learning so this practice becomes business as usual across all services and business areas. The CQC’s inspection regime is changing to be more light touch. The CQC are developing a risk based, combination model of self-assessment, inspection (or a form of investigation/deep dive review proportionate to risk) with continuous monitoring. This model is similar to the compliance assessment framework implemented by Moorfields in 2014. The CQC will undertake smaller, annual risk based inspections of organisations, and will inspect as a minimum, one service which has areas of improvement/concern, until there is evidence of improvement. They will review the well led domain every year. The CQC is currently consulting on its future inspection methodology. Please see appendix 3 for the quality summit draft agenda.

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Appendix 1 - CQC Provider Report (Separate document attached or link here)

http://www.cqc.org.uk/sites/default/files/new_reports/AAAF5076.pdf

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Appendix 2 - CQC recommendation status overview 78 individual actions have been grouped into 54 collated actions

Action

no. Theme

Action

ID

CQC

recommended

action

Reports

where

actions

appear

CQC action

priority type

Executive

Lead

1. Anaesthesia 01

Ensure patient’s body temperature is monitored during surgery under general anaesthesia

Satellite Surgery

(Northwick Park)

MUST take Declan Flanagan

2. Clinical

effectiveness 06

Ensure staff are able to benchmark clinical outcomes and quality indicators

Bedford SHOULD

take Declan Flanagan

3. Controlled

drugs 08

Ensure all controlled drugs records are completed in line with Trust Policy and carry out regular audits to monitor compliance

Bedford MUST take Declan Flanagan

4. Emergency

cover 10

Ensure Mile End displays clear medical emergency arrangements and every staff member knows the procedure.

Satellite Surgery

(Northwick Park)


5. Emergency cover (out of

hours) 12

Formalise and implement the agreement with St George’s University Hospitals NHS Trust for the management of patients who became unwell out of hours.

Provider St

Georges MUST take

Declan Flanagan

16

Action

no. Theme

Action

ID

CQC

recommended

action

Reports

where

actions

appear

CQC action

priority type

Executive

Lead

6. Equipment 20 Anaesthetic equipment checks

St Georges

SHOULD take

Declan Flanagan

7. Patient records

32

Ensure that patient records are fully and legibly completed

City Road Provider

Requirement Notice

Declan Flanagan

8.

Policies, procedures and clinical protocols

39

Ensure policies and clinical protocols are updated regularly and there is a system which allows effective monitoring of it.

Bedford SHOULD

take Declan Flanagan

9. Surgical safety

checklist 50

Ensure adequate audit and monitoring systems are in place to monitor performance and compliance of the WHO five steps to safer surgery checklist to guide improvement.

City Road Provider

St Georges

Requirement Notice

Declan Flanagan

10. Surgical safety

checklist 51

Ensure the WHO safer surgery checklist is consistently implemented for all surgical procedures including the five steps of team brief, sign in, sign out and debriefing.

City Road St

Georges

Requirement Notice

Declan Flanagan

11. Surgical safety

checklist 52

Fully embed the WHO safer surgery checklist, in terms of both

Provider Satellite Surgery

(Northwick Park)


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Action

no. Theme

Action

ID

CQC

recommended

action

Reports

where

actions

appear

CQC action

priority type

Executive

Lead

documentation and the quality and staff engagement in the process, across the organisation.

12. Computer systems

07

Ensure all locations have access to and use the same computer systems and that additional systems used are compatible.

Satellite Outpatient (Croydon)

SHOULD take

Elisa Steele

13. Duty of candour

09

Ensure all staff have knowledge and awareness of the duty of candour principles.

City Road SHOULD

take Ian Tombleson

14. Incident reporting

22 Incident reporting process

City Road SHOULD

take Ian Tombleson

15. Managing

risk 24

Improve recording of risks and ensure all information is included on risk registers.

St Georges

MUST take Ian Tombleson

16.

Policies, procedures and clinical protocols

38

Ensure all policies and procedures are up to date and staff receive training as required for specific roles such as laser protection.

City Road SHOULD

take Ian Tombleson

17.

Children and young people

strategy

05

Develop a strategy for services for children and young people

City Road SHOULD

take Johanna Moss

18

Action

no. Theme

Action

ID

CQC

recommended

action

Reports

where

actions

appear

CQC action

priority type

Executive

Lead

18. Patient and

staff engagement

27

Improve engagement with patients, staff and member of the public in service development / improvement.

St Georges

SHOULD take

Johanna Moss

19.

Patient information (including signage)

29

Ensure patient information leaflets are available for visually impaired and blind patients

Bedford SHOULD

take Johanna Moss

20. Service Level

Agreement 43

Ensure SLAs with partner organisations are in place and that the governance processes fit the existing and future models of care delivery.

Provider MUST take Johanna Moss

21. Cancelled

clinics 04

Put a process in place to ensure that clinics are not cancelled because of consultant’s annual leave.


MUST take John Quinn

22. Environment: outpatients

15

Ensure environment is appropriately assessed and adjusted to meet visually impaired patients’ needs.

Bedford SHOULD

take John Quinn


16

Ensure that the environment of the outpatient department is routinely monitored and appropriate actions are

City Road SHOULD

take John Quinn

19

Action

no. Theme

Action

ID

CQC

recommended

action

Reports

where

actions

appear

CQC action

priority type

Executive

Lead

taken to ensure patient safety, comfort and welfare.

24. Mixed sex breaches

25

Reduce the number of mixed sex breaches at the St George’s site.

Provider St

Georges MUST take

John Quinn

25. Patient records

30

Consider implementing the business plan for an electronic record system and scanning of casualty cards. This will free up space within the administration office and eliminate the risks of trips.

City Road SHOULD

take John Quinn

26. Patient records

31

Ensure patient’s records are available when they attend for an appointment.

St Georges

SHOULD take

John Quinn

27. Patient records

33

Improve the availability and storage of medical records.

City Road SHOULD

take John Quinn

28. Patient safety

34

Ensure that risks relating to patient waiting times are fully mitigated

City Road Requirement

Notice John Quinn

29. Patient Safety

35

Ensure that the quality and safety of the outpatients and surgical services provided are fully assessed, monitored and improved.

St Georges

Requirement Notice

John Quinn

20

Action

no. Theme

Action

ID

CQC

recommended

action

Reports

where

actions

appear

CQC action

priority type

Executive

Lead

30. Patient safety

36

Ensure that the quality and safety of the outpatients service are fully monitored, including patient waiting times and clinic finish times.

City Road Provider

Requirement Notice

John Quinn

31. Patient safety

37

Ensure that the risks related to patient safety in outpatients and surgical services provided in outpatients provided are fully mitigated.

St Georges

Requirement Notice

John Quinn

32. Privacy and

dignity 41

Look for ways to improve patient privacy in the OPD, emergency department and day case wards

City Road SHOULD

take John Quinn

33. Staff safety 44

Ensure emergency buzzers are available in radiology.

Provider MUST take John Quinn

34.

Theatres: waiting times

and cancellations

53

Work to reduce patient waiting times for surgery and the theatre cancellation rate

City Road Satellite Surgery

(Northwick Park)

St Georges

SHOULD take

John Quinn

35. Waiting times

56

Ensure that the risks to patient waiting times are fully mitigated.

Provider MUST take John Quinn

36. Environment:

general 57

Consider how reasonable adjustments could be

St Georges

SHOULD take

John Quinn

21

Action

no. Theme

Action

ID

CQC

recommended

action

Reports

where

actions

appear

CQC action

priority type

Executive

Lead

made for people with visual impairment.

37. Environment:

A&E 13

Make necessary environmental improvements (records storage, ventilation, and waiting area for children) in A&E at City Road

City Road Provider

MUST take

John Quinn (PR02 & CR15) Steve Davies (CR13)

38. Environment:

theatres 18

Take action to ensure the environment in theatres is safe and meets with national guidance, and consider how the environment could be made more friendly

Provider St

Georges MUST take

John Quinn (SG17) Steve Davies (PR05 & SG05)

39. Appraisals 02 Improve the uptake of appraisals

City Road St

Georges

SHOULD take

Sally Storey

40. Bullying and harassment

03

Take necessary action to deal with reports of bullying and harassment among staff

Bedford SHOULD

take Sally Storey

41. Staff training 46

Ensure all staff complete all aspects of mandatory training, including adult basic life support

Bedford City Road Satellite

Outpatient (Croydon)

SHOULD take

Sally Storey


14

Address the environmental conditions of outpatients at the St George's site.

Provider St

Georges MUST take

Steve Davies


17 Richmond Desmond

City Road SHOULD

take Steve Davies

22

Action

no. Theme

Action

ID

CQC

recommended

action

Reports

where

actions

appear

CQC action

priority type

Executive

Lead

Children’s Eye Centre - glass walls

44. Equipment 19 Accessibility of resuscitation equipment

St Georges

SHOULD take

Tracy Luckett

45. Infection control

23 Slit lamp decontamination

Bedford MUST take Tracy Luckett

46. Pain relief 26

Ensure adequate pain relief is provided in a timely manner to all ophthalmic patients on the day surgery unit at Bedford Hospital.


47.

Patient information (including signage)

28

Consider how documentary information and signage could be improved for people visual impairment.

City Road SHOULD

take Tracy Luckett

48. Privacy and

dignity 40

Ensure Ealing patient’s privacy and dignity is protected at all times. (see page 20 of draft report)

Satellite Surgery

(Northwick Park)

MUST take Tracy Luckett

49. Safeguarding 42

Ensure all relevant staff receive safeguarding training at appropriate level as guided by job roles and duties.



Ensure all staff are aware of their responsibilities in relation to the Mental Capacity Act 2005.

City Road SHOULD

take Tracy Luckett

23

Action

no. Theme

Action

ID

CQC

recommended

action

Reports

where

actions

appear

CQC action

priority type

Executive

Lead


Ensure staff have the correct training and implement formalised systems to monitor and record staff training information for paediatrics within the theatre department.

City Road SHOULD

take Tracy Luckett


Ensure staff on the day surgery unit at Bedford Hospital received appropriate training to care for patients following ophthalmic surgery.


53. Vulnerable

patients 54

Consider introducing an electronic flagging system for vulnerable patients, such as those living with dementia or a learning disability in the outpatients department.

City Road St

Georges

SHOULD take

Tracy Luckett

54. Vulnerable

patients 55

The trust should ensure that processes to support patients living with learning disabilities are consistent across the trust


MUST take Tracy Luckett

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Appendix 3 - CQC quality summit draft agenda Item Timing Lead Comments Welcome and introductions

5 mins CQC

Presentation of inspection team key findings

15 mins CQC The inspection team present the key findings from their visit.

Questions and clarification

10 mins ALL Opportunity for Quality Summit attendees to ask clarification questions of the inspection team and / or provide their own perspective on issues being considered.

Summary of key risks and actions

5 mins NHSI

Presentation by MEH

30 mins MEH 1. Tessa Green will provide a statement on behalf of the Board

2. David Probert will present MEH response to the inspection findings (focus on 3-4 key inspection findings) to feedback on what we have done already

3. Rosalind Given Wilson will provide assurance on behalf of the Quality and Safety Committee

4. Rob Jones will provide a statement on behalf of the Membership Council

Questions and clarifications

10 mins ALL Opportunity to ask questions of the Trust to further develop an understanding of the Trust’s perspective in the review findings and plans for improvement.

Break 15 mins MEH Refreshments to be provided by MEH Development of outline action plan

45 mins MEH and NHSI

Workshop segment – the attendees split into 3-4 groups, each taking on one of the 3 – 4 key inspection findings. They get 20 mins group working time and then 20 mins to summarise feedback on the action plans for each key finding.

External support offer

15 mins NHSI Agree key areas in which external support may be required to enable implementation of the action plan.

Agreement to next steps

15 mins NHSI Timescale for development of detailed action plan. Handling and communications plan. Monitoring arrangements.

Total time 165 mins (2h 45)

This report describes our judgement of the quality of care at this trust. It is based on a combination of what we foundwhen we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from patients, thepublic and other organisations.

Ratings

Overall rating for this trust Good –––

Are services at this trust safe? Requires improvement –––

Are services at this trust effective? Good –––

Are services at this trust caring? Good –––

Are services at this trust responsive? Requires improvement –––

Are services at this trust well-led? Good –––

MoorfieldsMoorfields EyeEye HospitHospitalal NHSNHSFFoundationoundation TTrustrustQuality Report

162 City Road,London EC1V 2PDTel: 020 7253 3411Website: www.moorfields.nhs.uk/

Date of inspection visit: 9 - 13 May 2016Date of publication: 06/01/2017

1 Moorfields Eye Hospital NHS Foundation Trust Quality Report 06/01/2017

Letter from the Chief Inspector of Hospitals

This was the first inspection of Moorfields Eye HospitalNHS Foundation Trust under the new methodology. Wehave rated the hospital as good overall, accounting forthe delivery model of care and the large volume ofactivity which takes place at the City Road Hospital site.

We carried out an announced inspection between 9 - 13May 2016. We also undertook unannounced visits duringthe following two weeks.

We inspected four core services: urgent and emergencycare, surgery, outpatients and diagnostics, and childrenand young people's services. This trust operates acrossmultiple outreach locations. Due to the unique deliverymodel of this organisation we inspected services at theCity Road and Moorfields Eye Centre at St George'sHospital. We also inspected a range of the outreach sitesas part including:

• Surgery and outpatients at Bedford Hospital• Surgery and outpatients at Moorfields Eye Centre at St

George's Hospital• Surgery at Ealing Hospital• Surgery at Croydon Hospital• Surgery at Mile End Hospital• Outpatient and diagnostics at Queen Mary's

Roehampton Hospital• Outpatient and diagnostics at Purley War Memorial

Hospital• Outpatient and diagnostics at Barking, Havering and

Redbridge Hospital

Our key findings were as follows:

Safe

• Mandatory training levels in some areas were belowtrust targets including resuscitation training andadult life support.

At the City Road site:

• The paediatric waiting area in the A&E wasunsuitable for the purpose it was being used. We sawpaediatric patients and their families waiting in themain waiting area with adult ED patients.

• There was a lack of storage space for patients’ notesin ED and the administrative office was overcrowdedwith boxes, which presented trip hazards and abarrier to evacuation.

• In surgery, improvement was required to fully embedthe World Health Organisation safer surgerychecklist, in terms of both documentation and thequality and staff engagement in the process.

• The availability of medical records was an on-goingissue and temporary notes were used until therecords could be located.

• In Outpatients we found omissions in some patientrecords including staff signatures and record entrydates.

• Some clinic waiting areas were extremely warm attimes and, although temperature monitoring tookplace, actions did not fully address theheat. Space was limited and there was insufficientseating for the number of patients attending clinics.

• Availability of ‘floorwalkers’ to monitor patientwellbeing in waiting areas was limited. Staffthroughout the outpatient clinics were busy and toldus they rarely had time to take their full breaksduring their shift.

• No emergency buzzers were available in theradiology department, which could delay staffaccessing help in an emergency.

• At Moorfields Eye Centre at St George’s Hospital:

• In theatres, long standing problems with ventilationmeant that at times theatre lists had to be cancelled.Air changes in one anaesthetic room did not alwayscomply with best practice.

• The urgent care clinic reception area and treatmentcubicles lacked privacy and confidentially wascompromised.

• The outpatients department was crowded and thewaiting area in was very cramped: the chairs forpatients were very close together. There was aseparate waiting area for patients in wheelchairs

Summary of findings


however this only accommodated two wheelchairusers. When we visited the ceiling leaked due toheavy rain, this meant that some of the chairs couldnot be used as they were wet.

• Staff working in treatment areas in a corridor outsidethe main outpatient area were isolated.

• A service level agreement had been developed toformalise the relationship between the trustand St George's University Hospitals NHS FoundationTrust but, this was not yet agreed and in place at thetime of the inspection.

• At the Bedford site;

• We observed some poor infection control practicewith regards to slit lamps decontamination.

• Patients undergoing surgery under a generalanaesthetic were transferred to the day surgery unitat Bedford hospital but staff caring for these patientshad not received ophthalmic training.

However, we found many good examples of safe careincluding:

• Wards and other patient areas were clean and staffwere seen to be adhering to hand hygiene policiesand protocols. Audit results for cleanliness andinfection prevention control demonstrated a goodtrack record and improvements and infection rateswere low.

• Adequate staffing levels and skills mix was a highpriority and were planned, implemented andreviewed to keep people safe at all times. Minimalstaff shortages were responded to by senior nursingleaders using internal bank staff and rarely agencystaff.

• Safeguarding vulnerable adults was given sufficientpriority by staff who were aware to ensureimmediate safety and to discuss concerns.

• Radiation safety processes, including access to leadvests and radiation monitoring, were suitable. Theenvironment in which radiation was used was fit forpurpose and protected staff and patients fromunnecessary exposure to radiation.

Effective

• Care was evidence based and services participatedin local and national audit.

• Care was delivered in line with relevant nationalguidelines and we saw appropriate policies,procedures and clinical guidelines, which referencedthese.

• Care was delivered by an experienced team ofophthalmologists and ophthalmic trained nursesdelivered care and treatment based on a range ofbest practice guidance.

• The continuing development of staff skills,competence and knowledge was recognised asbeing integral to ensuring high quality care. Nursesand health care assistants felt well supported withgood supervision and good training opportunities.

• Consent practices and records are activelymonitored and reviewed to improve how people areinvolved in making decisions about their care andtreatment.

Caring

• Feedback from people who use the service, andthose who are close to them, was continuallypositive about the way staff treated them. Patientsthought the care they receive exceeds theirexpectations.

• Friends and Family Test results were consistentlygood across surgical services.

• Staff were seen to spend time talking to patients, orthose close to them to ensure they received theinformation in a way they could understand andwere given time to ask questions.

• We observed staff providing compassionate care andtreating patients with dignity and respect.

• Staff provided emotional support to patients andpatients were able to access the hospital multi-faithchaplaincy services, when required. Patients alsohad access to the trust counselling service and theeye clinic liaison office.

• In children’s and young people’s services, staffdemonstrated the relationships they developed withpatient’s using the service, and their commitment toensuring they had a positive experience.

Summary of findings


• Complex conditions and procedures were explainedto children and young people in a way that enabledthem to gain a full understanding of their treatmentplan and take an active role in decision making.

Responsive

• The trust met the target for the national referral totreatment pathway (RTT) target of 18 weeks foroutpatient appointments. They had robust systemsfor monitoring RTT performance.

• The trust consistently met the 4-hour ED waitingtime standard, and also measured against a locallyderived 3-hour target.

• There were clear patient pathways that eased theflow of patients within the A&E. The department hadimplemented an ‘active triage’ system wherebypatients with non-emergency conditions werereferred to the urgent care clinic.

• Patients and relatives told us they appreciatedhaving local services which meant that they didn’thave to travel far.

• The surgical services had implemented a number ofimprovements throughout the patient pathway,including a ‘one-stop’ nurse led assessment clinicwhich including investigations if needed and a livepatient tracking system.

• There was a proactive approach to understandingthe needs of different groups of people and todeliver care in a way that meets that recognised andpromoted those needs.

• Patients were given the flexibility to access servicesin a way and at a time that suited them.

• Outpatients clinics at City Road clinics werefrequently overbooked and finished late. Patientsconsequently had a long waiting time in clinics andthe hospital did not have a system in place to keeppatients informed about the waiting time and didnot monitor this performance data.

• In outpatients at City Road patients were seen inopen bays within clinic areas. In some clinics thisresulted in a lot of noise and it was difficult to hearwhat was being said by both patients and staff. Attimes these areas became very busy, with no seatingavailability for patients and relatives.

• At St George's there was no signage or informationavailable for patients about waiting times and thismeant that patients did not know how long theywould need to wait. The department did not monitorthis performance data.

• At St George's the main outpatient reception area wassituated so that patient’s confidentiality and privacywas maintained. However, the reception area wherepatients booked into the UCC was situated next to thewaiting area close to where patients sat, which meantthat patients privacy and confidentially wascompromised.

• Cancellation rates were high for hospital cancelledappointments in Moorfields South (both St George’sand Croydon).

• Service planning for satelite clinics at Moorfields Northrequired improvement. We observed these clinicswere often overbooked due to the lack of a system forknowing when consultants were on leave. We weretold that at Moorfields Queen Mary’s Hospital clinicswere often cancelled at very short notice and thatpatients were not always informed and turned up fortheir appointment. We were informed this happenedat least one a month.

Well Led

• There were a clear set of vision and values within thesurgical services that were driven by quality care andsafety. Staff were clear of their involvement indelivering these objectives.

• We found a cohesive and supportive leadership teamwho functioned effectively, with well-establishedmembers of staff. Staff were complimentary about thesupport they received from their seniors andcommented that they were visible and approachable.Structures, processes and systems were in place toensure information sharing across the trust waseffective.

• There was a clear proactive approach to seeking outand embedding new and more sustainable models ofcare from all staff levels within the trust.

• There are high levels of staff satisfaction across allequality groups. Staff were proud of the organisationas a place to work and spoke highly of the culture andopportunities.

Summary of findings


• There was good governance and qualitymeasurement. Numerous audits were undertakenregularly, including quality and safety audits.

• There were good risk management processes in placeand risks were identified and acted upon.

However;

• Key issues relating to flow within the outpatientclinics, such as patient waiting times and clinicsoverrunning, were not formally monitored by theleadership team and therefore the benefit of anyservice changes could not be effectively assessed.

• A service level agreement had been developed toformalise the relationship between the trustand St George's University Hospitals NHS FoundationTrust but, this was not yet agreed and in place at thetime of the inspection.

• We were concerned that there was not a robustgovernance system around SLA's with partnerorganisations, which resulted in a lack of formalmechanisms or powers to drive improvement ormake changes where required.

• The senior leadership team were open about thechallenges the services at Moorfields Eye Centre at StGeorge's Hospital faced and recognised theimportance of improving the environment in whichthe service was provided. We saw evidence of atransformation programme to relocate patients,however there were no firm plans in place toimprove the environment.

• In outpatients at St George’s senior staff identifiedissues with the current environment and identifiedre-providing the services at St George’s the means toaddressing this. The trust advised us of its short/medium term plans to address its currentunsuitability.

We saw several areas of outstanding practice including:

• The development of staff skills, competence andknowledge, and development of extended nursing andallied health professional roles. Staff reported thatthey felt well supported and received good trainingopportunities.

• There was an extensive research portfolio, which wasrecognised at a UK and global level, directly benefitingpatients.

• There was a clear proactive approach to seeking outand embedding new and more sustainable models ofcare from all staff levels within the services, and acrossthe Moorfields network. For example the Bedford teamworked closely with a group of local optometrists andoperated a system called Bedford Shared CareCataract Pathway.

• The organisation had taken a pivotal role in thedevelopment of ophthalmic services, as the lead inone of the hospital vanguard systems selected by NHSEngland to develop new models of care.

• We noted the trust had made significant investmentsin leadership and quality improvement, and hadinvited international speakers to attend a specialistevent following our inspection.

However, there were also areas of poor practice wherethe trust needs to make improvements.

Importantly, the trust must:

• Address the lack of storage space for patients’ notes inED and the administrative office and remove barriersto evacuation.

• Fully embed the World Health Organisation safersurgery checklist, in terms of both documentation andthe quality and staff engagement in the process,across the organisation.

• Ensure adequate audit and monitoring systems are inplace to monitor performance and compliance of theWHO five steps to safer surgery checklist to guideimprovement.

• Take action to ensure the environment in theatres issafe and meets with national guidance.

• Reduce the number of mixed sex breaches at the StGeorge's site.

• Ensure that the quality and safety of the outpatientsand surgical services at Moorfields at St George's arefully assessed, monitored and improved.

• Ensure that all risks related to patient safety inoutpatients and surgical services at Moorfields at StGeorge's are fully recorded with actions to mitigatethem.

• Address the environmental conditions of outpatientsat the St George’s site.

• Ensure that the quality and safety of the outpatientsservice at the City Road site are fully monitored,including patient waiting times and clinic finish times.

Summary of findings


• Ensure that risks relating to patient waiting times arefully mitigated.

• Ensure that patient records are fully and legiblycompleted, including staff signatures, record entrydates and documentation errors are correctly marked.

• Review the governance process around Service LevelAgreements with partner organisations, and ensurethese fit the existing and future models of caredelivery.

In addition the trust should:

• Ensure all policies and procedures are up to date andstaff receive training as required for specific roles.

• Improve the uptake of appraisals and ensure all staffare aware of their responsibilities in relation to theMental Capacity Act 2005.

• Ensure all staff complete all aspects of mandatorytraining.

• Ensure all staff are aware of the incident reportingprocess.

• Ensure all staff have knowledge and awareness of theduty of candour principles.

• Ensure all anaesthetic equipment is checked andchecks are recorded.

• Reduce the theatre cancellation rate.• Consider how the theatre environment at St George's

Hospital site could be made more child friendly.• Ensure the trust is responsive to any issues of bullying

and harassment raised.• Ensure patient's records are available when they arrive

to attend an appointment.• Improve recording of risks and ensure all information

is included on risk registers.• Improve engagement with patients, staff and members

of the public in service development/improvement.• Address issues relating to flow within the outpatient

clinics, such as patient waiting times and clinicsoverrunning.

• Ensure emergency buzzers are available in radiology.

• Ensure staff are aware of the electronic flagging systemfor vulnerable patients, such as those living withdementia or a learning disability in the outpatientsdepartment.

• Look for ways to improve patient privacy in theoutpatient department, A&E and day case wards.

• Repair the ventilation system within the A&E at the CityRoad site.

• Consider implementing the business plan for anelectronic record system and scanning of casualtycards. This will free up space within the administrationoffice and eliminate the risk of trips.

• Improve the waiting area for children and youngpeople in the main A&E.

• Consider improving the checklist for the difficultairway trollies in the recovery areas to includeequipment and expiry date checks.

• Ensure staff have the correct training and implementformalised systems to monitor and record staff traininginformation for paediatrics within the theatredepartment.

• Develop a strategy for services for children and youngpeople and consider how reporting about plans,priorities and the quality and safety of the servicecould be improved.

• Ensure that the environment of the outpatientdepartment is routinely monitored and appropriateactions are taken to ensure patient safety, comfort andwelfare.

• Consider how signage in the satellite locations couldbe improved for people with visual impairment.

• Ensure the service level agreement betweenMoorfields Eye Hospital NHS Foundation Trust and StGeorge’s University Hospitals NHS Foundation Trust isfinalised and implemented to ensure medical coverand estates management are working effectively.

Professor Sir Mike RichardsChief Inspector of Hospitals

Summary of findings


Background to Moorfields Eye Hospital NHS Foundation Trust

Moorfields Eye Hospital NHS Foundation Trust is thelargest provider of eye health services in England. Thehospital trust has a long history, developed over twocenturies, and describe themselves as a “World classcentre of excellence" for ophthalmic research andeducation. In 2009 the trust became a founding memberof a local Academic Health Science Centre (AHSC) and in2013 they became an accredited AHSC.

The organisation houses approximately 24 inpatientbeds, and 43 day case beds. In 2015/16 they delivered35,907 surgical spells and 529,681 outpatientattendances across multiple sites (excludes Bedfordfigures), and provides emergency ophthalmic care to103,926 patients per year.

The trust delivers care across 32 different outreachlocations in a network model across Greater London andBedford. They employ in the region of 1,925 staff (as atMarch 2016) and have a financial revenue of £198 million,generating a financial surplus of £4.4 million during 2014/15.

There is a recently appointed executive leadership team,including a new interim Chairman, Steve Williams, a newChief Executive, David Probert, a new Chief FinancialOfficer and a new Chief Operating Officer.

The trust's vision and mission is to be the leadinginternational centre in the care and treatment of eyedisorders, driven by excellence in research andeducation.

The trust has introduced a set of organisational values todrive the approach to delivering its' "Vision of Excellence".

Long term commissioner plans were not defined in detail,at the time of our inspection. It is the general direction oftravel for clinical services to be delivered away from acutehospital settings, and for care to be provided on a day today basis. This is consistent with the trust strategy and wethe trust have continued to develop the services in thatway during 2015/16.

The trust have commissioning relationships with a widerange of organisations in London and the rest of England.It seeks to engage with commissioning colleagues onservice developments and commissioning initiativeswhich include schemes such as creating referral hubs,establishing telephone advice services, reducing A&Eattendances and creating shared care pathways withcommunity eye professionals.

The trust anticipate that The National Institute for Healthand Care Excellence (NICE) approved treatments,population growth and the ageing population willincrease the activity over the next year and beyond.Consistent with previous years, the trust plans to betransparent about these growth assumptions withcommissioners and will seek to work with them toaddress the growing demand for ophthalmic care.

We inspected Moorfields Eye Hospital NHS FoundationTrust , including the core services: urgent and emergencycare, surgery, critical care, services for children and youngpeople, and outpatients and diagnostic services. Weinspected the main acute sites at the City Road and StGeorges campus, along with a cross-section of satelliteservices.

Our inspection team

Our inspection team was led by:

Chair: Dr Pete Turkington, Medical Director, Salford NHSFoundation Trust

Team Leader: Nicola Wise, Head of Hospital Inspection

Care Quality Commission

The trust was visited by a team of CQC inspectors andassistant inspectors, analysts and a variety of specialists.There were consultant ophthalmologists as well a nursewith a background in ophthalmology. Members of theinspection team also had experience in theatres, childrenand young people's care and board-level experience, andone expert by experience.

Summary of findings


How we carried out this inspection

To get to the heart of patients’ experiences of care,we always ask the following five questions of everyservice and provider:

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

The inspection team inspected the following coreservices:

• Urgent and emergency services• Surgery• Services for children and young people• Outpatients and diagnostic imaging

Before our inspection, we reviewed a range ofinformation we held and asked other organisations toshare what they knew about the trust. These

organisations included the clinical commissioninggroups, NHS Improvement, Health Education England,General Medical Council, Nursing and Midwifery Council,Royal College of Nursing, NHS Litigation Authority and thelocal Healthwatch.

As part of the inspection, we visited a number of satellitesites including: Moorfields Eye Centre at Bedford Hospital(South), Moorfields Eye Centre at Ealing Hospital,Moorfields Eye Centre at Croydon University Hospital,Moorfields Eye Unit at Mile End Hospital, Moorfields EyeUnit at Queen Mary's Hospital, Moorfields Community EyeClinic at Purley War Memorial Hospital and MoorfieldsCommunity Eye Clinic at Barking Hospital.

We observed how patients were being cared for, spokewith patients, carers and/or family members andreviewed patients’ personal care or treatment records. Weheld focus groups and interviews with a range of staffacross the trust, including doctors, nurses, allied healthprofessionals, administration, senior managers, andother staff.

What people who use the trust’s services say

Public Event

To capture the views of local people who use the trust wearranged a feedback stall. We received many positivecomments about most of the services. Staff weredescribed as caring and supportive.

Friends and Family Test

The percentage of patients who indicated they wouldrecommend the trust was consistently higher than theaverage in England between August 2014 and December2015.

Patient led assessments of the care environment(PLACE)

The trust was above the England average in all measures(food, cleanliness, privacy, dignity and well-being) in2015.

Healthwatch

What people who use the trust's services say, 1stparagraph: Healthwatch Harrow and HealthwatchCroydon provided feedback from patients. There wereboth positive and negative comments. Concerns raisedcentred around the organisation of urgent appointments,staffing levels at Moorfields at Northwick Park and over-running clinics at Moorfields at Croydon Hospital.

Clinical Commissioning Groups (CCGs)

Islington CCG offered feedback on behalf of localcommissioners and NHS England specialistcommissioners. The commissioners were generally verypositive about services provided by the trust andbelieved that quality and outcomes were good.

They commented that there had been a rapid expansionof the organisation, over the past three years whichpresented challenges to the organisation. Through theacquisition of new sites the organisation has changed itsorganisational structure with a greater focus ondirectorates and a more de-centralised approach. The

Summary of findings


CCG receives assurance on the quality of care beingdelivered across all services through divisional andsatellite focused presentations at the Clinical QualityReview meeting. There is an added level of complexity toassure quality across a 'chain of services' or ‘franchise’model of this sort with numerous geographically spreadsites.

Areas of concern were highlighted as; access timesagainst the 18 week referral to treatment time process, aseries of Never Events at the Bedford site, the theatrerefurbishment programme not being in adherence totheatre ventilation requirements.

Overall they described the trust as having "positiverelationships” with commissioners and partners, andhighlighted that they had seen service improvements andinnovations.

Royal College of Nursing (RCN)

The RCN described previous issues around theatremaintenance, however recognised that this had beenaddressed and commented that the trust had madesuccessful provisions for increased capacity at weekendsincluding sourcing additional capacity at alternative sites.

The RCN referred to historical problems with the accuracyof the trust’s reporting on target information, such asrecording data incorrectly so some patients had beenwaiting longer than appropriate. However, commentedthat the trust has worked to address these issues and isnow compliant in this area.

General Medical Council (GMC)

The GMC provided feedback in relation to concerns raisedvia its' members. Issues highlighted included the over-running of clinics and the impact on training. Theavailability of on call doctors to attend an eye centre inperson, and the ability of doctors to report incidents. TheGMC stated that any open actions were being monitoredby the GMC.

NHS Improvement (NHSI)

The NHSI (formerly Monitor) provided feedback ahead ofthe inspection. NHSI commented that the trust hadrapidly expanded but had not always managed demandeffectively. It commented that the organisation did notalways utilise demand management techniques to avoidpatients bypassing other services to get treatment at theorganisation.

Trust Governors

Trust Governors commented that they attend the trust’sboard meetings and have access to information aboutthe trust. The board meetings were described as beingtransparent in manner and governors can participate inthe same way as directors. There has been a recentsurvey by Deloitte on the “well led”. They understand thatthis has come out positive, however, the result of thesurvey has not yet been released.

Areas of concern included: the high cost of car parking atMoorfields at St Georges Hospital, and that there werelong waiting times for specialist clinics due to the highdemand for Moorfields specialist’s services. Governorscommented that they are working actively on this andthat patients are happy with the care provided.

Facts and data about this trust

Moorfields Eye Hospital NHS Foundation Trust delivered35,907 surgical spells and 529,681 outpatientattendances across multiple sites in 2015/16. Theyprovide emergency ophthalmic services to 103,926patients per year. The organisation houses approximately24 inpatient beds and 43 day case beds.

The trust delivers care across 32 different locations in anetwork model across Greater London and Bedford. Theyemploy in the region of 1,925 staff (as at March 2016) andhave a financial revenue of £198 million, generating afinancial surplus of £4.4 million during 2014/15.

The Moorfield's operational delivery model is split intofour directorates: Outpatients and Diagnostic services,Surgical Services, Moorfield's North and Moorfield'sSouth. Within these directorates, the organisationprovides care across a complex network of locationswhich include: Moorfield's Eye Centres (district hubs),Moorfields Eye Units (local surgical units), MoorfieldsCommunity Eye Clinics and Moorfield's Partnerships(partnerships and networks)

Summary of findings


Moorfield's Eye Centres include: Bedford Hospital,Croydon University Hospital, Ealing Hospital, NorthwickPark Hospital and St George's Hospital.

Moorfield's Eye Units include: Darent Valley Hospital, MileEnd Hospital, Potters Bar Community Hospital, St Ann'sHospital, St Bartholomews Hospital.

Moorfield's Community Eye Clinics include: BalhamHealthcare Centre, Bedford Hospital (North), BrocklebankHealth Centre, Doddington Health Centre, LoxfordPolyclinic, Nightingale Nursing Home, Parkway HealthCentre, Purley War Memorial Hospital, SandersteadHealth Centre, Teddington Memorial Hospital, TootingBec Medical Centre, The Nelson Health Centre, BarkingHospital, Watford General Hospital, Sir Ludwig GuttmanHealth and Wellbeing Centre and Moorfield'srelationships with other acute providers.

Moorfield's Partnerships include: Boots Opticians,Watford; Hackney Ark; Parker & Hammond Opticians;Homerton Hospital; Visioncare Medical Eye Centre.

The trust have commissioning relationships with a widerange of organisations in London and across England.The trust seek to engage with commissioning colleagueson service developments and commissioning initiativeswhich include schemes such as creating referral hubs,establishing telephone advice services, reducing A&Eattendances and creating shared care pathways withcommunity eye professionals.

Facilities at the City Road

Patients attending the City Road site have guidance fromthe main tube station in the form of a green line directingtowards the hospital. Once on site, staff are at hand tolead and guide patients to the appropriate clinical area.All staff undergo leading and guiding training.

The environmental layout including colour schemes hasbeen designed in colloboration with the RNIB.Documents are available in large font and whenrequested, leaflets are available in Braile.

The patient lifts are audible. Most sites have access to anEye Clinic Liaison Officer (ECLO), and at some of thesmaller sites, emotional support workers. ECLO andemotional support workers provide advice and supportduring the patients' visit. The trust has a number ofvolunteers available in the clinical setting who also offerhelp and support.

Staff survey

The trust scores well on the NHS staff survey and aboveaverage in a number of key areas, the most notable beingthe overall level of staff engagement.

The trust also scored well and has improved in levels ofstaff satisfaction with their level of responsibility andinvolvement, and support from immediate managers.

The top ranking scores included the quality of appraisals,staff motivation at work, satisfaction with resourcing andsupport, recognition and value of staff by managers andthe organisation, and satisfaction with the quality of workand patient care they are able to deliver.

The trust has scored less well and remains worse thanaverage in questions about staff experiencing bullying,harassment, abuse, discrimination or physical violence atwork, and staff believing that the trust offers equality ofopportunity in career progression or promotion.

The trust launched The Moorfields Way, a long termprogramme of cultural change, in the Spring of 2014, indirect response to concerns within the staff survey. This isa 3 year programme which the trust hopes to seeimprovement on these scores.

Top risks on the trust risk register

Top risks on the trust risk register include: failure toaddress significant patient experience concerns; inabilityto maintain financial surplus at required levels each year;risk to vulnerable patient care, as well as legal,reputational and financial risks due to staff within theorganisation not following the principles of the MentalCapacity Act 2005; non-compliance with paediatric NSFand CQC requirements on other sites; Moorfields achievesa rating below expectation (minimum good) in any futureCQC inspection; poor quality data could impact onpatient care, targets and income.

Safe

There were nine serious incidents including threetreatment delays and two surgical errors. There was onenever event reported between March 2015 and February2016, a surgical error (wrong type of lens inserted into eyeduring cataract surgery).

Never events are serious incidents that are whollypreventable, as guidance or safety recommendationsthat provide strong systemic protective barriers are

Summary of findings


available at a national level and should have beenimplemented by all healthcare providers. Each neverevent has the potential to cause serious patient harm ordeath. However, serious harm or death is not required tohave happened as a result of a specific incident for thatincident to be categorised as a never event.

The trust is about the same as the national average forconsultant and middle career doctors whole timeequivalents (wte). The organisation has zero juniorDoctors, but has significantly higher numbers of registrarlevel Doctors than the national average.

The organisation has consistently met the four hourwaiting time standard in A&E. The trust performed betterthan the 95% standard each month between August 2014and January 2016.

A slit lamp decontamination survey carried out for allsites in mar 15 showed an overall compliance rate of 75%which was classed as minimal compliance by infectioncontrol team. A repeat audit was done in November 2015(which was sent in PIR2) that states that after the Trustachieved 93%.

Effective

In the 2014 CQC accident and emergency (A&E) survey thetrust scored better or about the same as other trusts whotook part in the survey. For two questions, waiting to beexamined and pain control they scored worse than othertrusts.They scored better than other trusts in the questionabout the patient’s overall A&E experience.

The unplanned re-attendance rate to A&E within sevendays was worse than the standard for all of 2014 and2015, but has improved and fallen below the Englandaverage since June 2015.

There was good performance in the 2015 CQC children'squestionnaire relating to effective domain.

Caring

Performance was good in the 2015 Patient Led Asessmentof Caring Environment (PLACE) audit for cleanliness,privacy/dignity/wellbeing, facilities and dementia.

The Friends and Family Test (FFT) performance betweenJanuary 2015 and December 2015 was better than theEngland average.

The numbers of reported complaints fell from 291 in2012/13 to 174 in 2014/15, a fall of 40% over the twoyears.

Responsive

Bed occupancy rates were below the England averagebetween Q4 2013/14 and Q3 2015/16.

All 92 delayed transfers of care at the trust wereaccounted for by one of three categories, ‘awaiting carepackage in own home’ (40.2%) ‘waiting further NHS non-acute care (33.7%) and ‘Awaiting Nursing HomePlacement (26.1%).

Referral to Treatment (RTT) rates were above the 92%standard for incomplete pathways.

There are higher numbers of cancelled operations in thetwo most recently reported periods (Q2 and Q3 2015/16).Almost all operations were rescheduled within 28 days.

There has been consistently good performance ondiagnostic waiting times, with no patients waiting morethan six weeks for diagnosis. ?

Did not attend (DNA) rates at all Moorfields sites werelevel higher than the England average. The highest rateswere seen at Moorfields at Croydon University Hospital.

Well Led

The trust scored better than expected for access toeducational resources in the 2015 GMC Survey.

Areas of good performance in the 2015 NHS staff surveyinclude staff satisfaction with the quality of care they candeliver, communication and recognition frommanagement, team working and support.

There was poor performance in the 2015 NHS Staff surveyfor questions relating to violence, harassment andbullying from patients and staff, as well as discriminationand provision of equal opportunities for all staff.

Summary of findings


Our judgements about each of our five key questions

Rating

Are services at this trust safe?The trust is rated as requires improvement for safety. We foundexamples of safe care in many of the services we inspected.However, we rated a number of services as requires improvementunder the safe domain. These included: surgical services andoutpatients departments at City Road site, surgical services andoutpatient and diagnostic services at the St George’s Hospital site,surgical services at the Bedford Hospital site and surgical services atthe satellite sites.

Across the organisation we found:

• Mandatory training levels in some areas were below trusttargets including resuscitation training and adult life support.

• A number of site specific estates challenges which had not beenadequately resolved.

• The trust had not fully implemented the five steps of the WorldHealth Organisation (WHO) Surgical Safety Checklist.

• Long in-clinic waiting times within outpatients and poormonitoring of this.

At the City Road Hospital site:

• There was a lack of storage space for patients’ notes in ED andthe administrative office was overcrowded with boxes, whichpresented trip hazards and a barrier to evacuation.

• In surgery, improvement was required to fully embed the WorldHealth Organisation safer surgery checklist, in terms of bothdocumentation and the quality and staff engagement in theprocess.

• Some clinic waiting areas were extremely warm at times and,although temperature monitoring took place, actions did notfully address the heat.

• Availability of ‘floorwalkers’ to monitor patient wellbeing inwaiting areas was limited. Staff throughout the outpatientclinics were busy and told us they rarely had time to take theirfull breaks during their shift.

• No emergency buzzers were available in the radiologydepartment, which could delay staff accessing help in anemergency.

• Within the Richard Desmond Children's Eye Centre there werelow glass walls around the atriums on each floor with a handrail approximately a metre above the floor. This was a potentialsafety issue, as a child or other person could attempt to climb

Requires improvement –––

Summary of findings


over the barrier and fall to the ground floor below. There wasalso the possibility that toys or other objects could be thrownover the barrier. The risks had been identified on the riskregister and they were assessed as ongoing. Divisional leaderssaid the controls in place were felt to be sufficient to managethe risk.

At the St George’s Hospital site:

• There were some long standing problems with the ventilationsystem which affected both the theatre preparation room(theatre 4) and anaesthetic room (theatre 5). This issue wasreviewed by the Moorfields infection control team and anexternal NHS microbiology team who assessed the risks. Theyadvised changes in practice to mitigate the risks, which we wereadvised have been implemented. Estates staff told us that theyfelt the equipment could breakdown at any point.

• The outpatients department was crowded and the waiting areain was very cramped: the chairs for patients were very closetogether. There was a separate waiting area for patients inwheelchairs however this only accommodated two wheelchairusers. When we visited the ceiling leaked due to heavy rain, thismeant that some of the chairs could not be used as they werewet.

• Staff working in treatment areas in a corridor outside the mainoutpatient area were isolated.

However, we found many good examples of safe care including:

• Wards and other patient areas were clean and staff were seento be adhering to hand hygiene policies and protocols. Auditresults for cleanliness and infection control demonstrated agood track record and improvements, and infection rates werelow.

• Adequate staffing levels and skills mix was a high priority andwere planned, implemented and reviewed to keep people safeat all times. Minimal staff shortages were responded to bysenior nursing leaders using internal bank staff and rarelyagency staff.

• Safeguarding vulnerable adults was given sufficient priority bystaff who were aware to ensure immediate safety and to discussconcerns.

• Radiation safety processes, including access to lead vests andradiation monitoring, were suitable. The environment in whichradiation was used was fit for purpose and protected staff andpatients from unnecessary exposure to radiation.

For more detailed information please refer to the reports for theindividual site location reports.

Summary of findings


Duty of candour

• Most staff were aware of the requirements of the duty ofcandour, including apologising and sharing the details andfindings of any investigation, and were able to offer recentexamples of such. We found limited awareness of duty ofcandour amongst some junior staff.

Cleanliness, infection control and hygiene

• The environment in the majority of areas we inspected wasclean and complied with infection prevention and controlguidance. Clinical areas we visited were visibly clean, tidy andwell organised. Adequate hand washing facilities were in placeat all sites we visited. We observed staff washing their hands,using hand gel between patients and complying with the ‘barebelow the elbows’ policy.

• Hand hygiene audit results were displayed at the entrances toeach department and demonstrated compliance, with results95% or greater.

• There had been no cases of methicillin-resistantstaphylococcus aureus (MRSA) or clostridium difficile for the 12months prior to inspection.

• However, at the Bedford site we found there was a slit lamp bio-microscope (an instrument used in assessment of the patientseyes). Although alcohol wipes were available within that area todecontaminate the machine after use with each patient, wesaw pen marks and residual make-up on the machine, whichwould suggest the alcohol wipes were not used after eachpatient examination. A slit lamp decontamination surveycarried out for all sites in March 2015 showed an overallcompliance of 75%, which was classed as compliance by theinfection prevention and control team.

Environment and equipment

• Some areas of the trust we visited were cramped, withinadequate space to store equipment. In surgery at City Road,we found trolleys lined up against walls, resulting in crampedspaces for staff and patients to manoeuvre. We found evidenceof equipment being checked on a daily basis across theorganisation.

• Within the A&E at City Road, we observed the records room wasalso used as an administrative office. This environmentpresented safety risks to staff. For example, it was overcrowdedand boxes presented trip hazards and a barrier to evacuation.

Summary of findings


The room could not be adequately temperature controlled andstaff had submitted incident reports in relation to ill health as aresult of the environment. This included breathing difficultiesdue to the lack of natural airflow.

• In outpatients at the City Road site, some of the patient waitingareas were very warm. Temperature monitoring was in place insome areas, such as clinic 11 where a temperature checkingdocument was in use. However, actions did not fully addressthe heat. During our unannounced inspection, the airconditioning was working in clinic 11 and the temperature wasmuch more comfortable.

• The outpatients department at Moorfields Eye Centre at StGeorge's Hospital site was crowded and the waiting area in wasvery cramped: the chairs for patients were very close together.There was a separate waiting area for patients in wheelchairshowever this only accommodated two wheelchair users. Whenwe visited, the ceiling leaked due to heavy rain, this meant thatsome of the chairs could not be used as they were wet.

• Staff were generally happy with the equipment, however, it wasreported that some estates and equipment issues were slow tobe fixed at some satellite clinics, due to the contract being withthe local trust.

Records

• We observed the trust used mainly a paper based recordsystem for recording care and treatment. We reviewed a rangeof records and found them to be accurate, fit for purpose,stored securely and were mostly completed to a goodstandard.

• We noted that the trust had completed a record keeping auditconducted between December 2015 and January 2016. Thisreviewed a sample of 20 records from nine of the larger satellitesites. The audit assessed compliance with trust policy. Areasidentified for improvement included NHS numbers on the frontof records and legibility of handwritten notes. The trustbenchmarked itself against previous results and the auditfound improvements had been made in most areas since the2015 audit. It was also noted that future audits needed toconsider a more in depth examination of electronic records.

Safeguarding

• In line with statutory guidance the trust had named nurses,named doctors and safeguarding teams for child protectionand safeguarding vulnerable adults. The Trust had policies andprocedures in place in relation to safeguarding adults andchildren. Safeguarding was embedded as part of mandatory

Summary of findings


training and induction. Staff were confident in reportingconcerns to the relevant teams. Staff were able to explain whatconstituted a safeguarding concern and the steps required forreporting on these concerns. This included bank staff we spokewith at the satellite sites.

• The trust child and adult safeguarding leads were able toprovide rapid support to ED at the City Road site on demand.Where children presented in the main ED out of hours, a nursecompleted their initial visual acuity checks instead of ahealthcare assistant (HCA). This strategy ensured staff with ahigher level of child safeguarding training cared for children.

• Staff in the A&E at City Road demonstrated a proactiveapproach to supporting frequent attendees to the departmentand to patients who were in need of safeguarding. The teamdiscussed the top 50 most frequent attendees at monthlyservice meetings and identified patients who might benefitfrom a psychiatric or safeguarding referral.

Mandatory training

• The trust’s corporate induction for a new staff was part ofmandatory training. The mandatory and statutory trainingprogramme covered a range of subjects, including basic lifesupport for adults and paediatric, conflict resolution, equality,diversity and human rights, fire, health and safety, infectioncontrol, information governance, manual handling,safeguarding children and adults. The standard set by the trustwas 80%.

• All staff are trained in helping visually impaired people as partof their corporate induction. Compliance rates were 92% acrossall staff groups for this training, against a target of 90%.

• In addition to the leading and guiding training which all staffcompleted at induction, the Trust had introduced a videoentitled 'Helping Visually Impaired People' to its mandatorytraining. This module of training was introduced in April and byMay 2016, 48% of staff had completed the training.

• There were some areas of the trust where mandatory trainingwas below the trust’s benchmark of 80% compliance across anumber of subject areas, including resuscitation training ofwhich 34 staff within the surgical services needed to complete.

Use of the ‘five steps to safer surgery’ procedure

• The trust had not fully implemented the five steps of the WorldHealth Organisation (WHO) Surgical Safety Checklist. We foundevidence of good compliance with the three compulsoryelements: sign in, time out and sign out. We noted a time outtaking place without the surgeon present and twice we noted

Summary of findings


sign out completed after the patient had left the theatre.Furthermore, we noticed staff distractions while the checklistwas being completed and in one instance, it was unclear whowas leading the time out process.

• A recent audit of the WHO checklist had been carried out in May2016 which looked at 29 sets of patients notes betweenFebruary and April 2016 to determine compliance with the WHOsurgical safety checklist. This audit looked at the three steps ofthe checklist including sign in, time out and sign out, howeverdid not audit compliance with steps one or five of the checklist(team brief and debrief). Results demonstrated 52% of WHOchecklists had not been fully completed. Audit data measuringstaff engagement and quality of the checklist process had notbeen completed and was not available.

Assessing and responding to patient risk

• Patients’ clinical observations were recorded and monitored inline with NICE guidance ‘Acutely Ill-Patients in Hospital.’ Ascoring system known as a national early warning score (NEWS)was used to measure patients’ vital signs and identify patientswhose condition was at risk of deteriorating.

• An audit of the national early warning system was conducted in2015 to assess the levels of compliance across all sites in theTrust. The audit found good levels of compliance with scores of100% for the frequency of observations and escalation if apatient’s condition deteriorated. The only area identified forimprovement related to the frequency of physiologicalobservations. These were not being carried out as frequently asthe Trust’s policy recommended.

• Senior staff in the A&E at City Road told us that only patientswith ophthalmic diseases were treated at the trust. However, onrare occasions, patients presented in the A&E seeking treatmentfor general health problems or patients who presented with anophthalmic problem became acutely unwell due to a generalhealth problem. Patients who presented with potentiallyserious life threatening conditions were assessed by medicaland nursing staff, stabilised where possible and kept underobservation while arrangements were made to transfer themvia an ambulance to the nearest A&E department for care andtreatment.

• Assessment tools were used for assessing and responding topatients risks and these were fully completed in patient’s notes.For example: the Waterlow Pressure Ulcer Risk Assessment

Summary of findings


(2010), Venous Thromboembolism tool (VTE) and Safer SkinCare (SSKIN) were all in use within the patient assessment andtreatment record. This information was utilised to manage andpromote safe patient care.

• Staff in satellite clinics knew where to direct patients for out ofhours and emergency care. For example at the Purley clinic stafftold patients to go to the Moorfields Eye Centre at StGeorge's Hospital as this provided an emergency service.

• In surgery at the St George’s site, patients on the Duke Elderward who became unwell were cared for by medical staff whoworked for St George’s University Hospitals NHS FoundationTrust. However, staff told us there was no formal serviceagreement in place with St George’s University Hospitals NHSFoundation Trust for medical staff to review patients on DukeElder ward. We saw this was included on the local risk register.When we asked the trust about this they provided us withguidelines which had been developed in April 2016 for caringfor patients on the Duke Elder ward when they becamemedically unwell. The notes of a meeting between the medicaldirectors of St George’s University Hospitals NHS FoundationTrust and Moorfields Eye Hospital NHS Foundation Trust heldon the 19th April 2016 showed these guidelines had beenagreed in principle. However, Moorfields and St George’smedical staff had separate record systems. The guidelines didnot specify the arrangements for a clinical handover. Theguidelines did not specify the timescales for medical staffresponding where treatment was urgent. For example, theguideline starts patients with sepsis or cellulitis would be seenwithout delay but it was not clear who was responsible and theexact timescales for medical staff responding.

Staffing

• The trust had vacancies across staff groups but staffing levels inmost clinical areas were maintained at a safe level with the useof regular bank, agency and locum staff.

• Within the A&E at City Road, we observed that vacant postswere mitigated by nursing staff working overtime and byincreasing the use of bank staff. The department receivedsupport from the human resource (HR) team to speed up therecruitment process for permanent posts. Temporary staff wererequired to complete a competency-based assessment to workon the unit.

• We were told that ward managers used an acuity tool once ayear to measure and monitor staffing level in their areas.

Summary of findings


• Planned and actual staffing levels for each day were displayedoutside each department and during inspection; the actualstaffing numbers met the planned numbers for each ward area.

• Nursing staff we spoke with told us that staffing numbers weregood and they were able to effectively care for patients.

• Most staff worked across multiple sites within their directorateand managers monitored levels to ensure that enough staffwere at each outpatient clinic.

Are services at this trust effective?We rated the services at Moorfields Eye Hospital NHS FoundationTrust as ‘good’ for effective. We found:

• Care was evidence based and services participated in local andnational audit.

• Care was delivered in line with relevant national guidelines andwe saw appropriate policies, procedures and clinicalguidelines, which referenced these.

• Care was delivered by an experienced team ofophthalmologists and ophthalmic trained nurses delivered careand treatment based on a range of best practice guidance.

• The continuing development of staff skills, competence andknowledge was recognised as being integral to ensuring highquality care. Nurses and health care assistants felt wellsupported with good supervision and good trainingopportunities.

• Consent practices and records are actively monitored andreviewed to improve how people are involved in makingdecisions about their care and treatment.

However• Internal training was not always recorded or formalised.

Appraisal completion rates were 72% against an internal trusttarget of 80%.

• Staff did not always have access to patient informationelectronically before providing care and treatment due todiffering IT systems being in use. However, all patients have apaper based casenote file with the exception of Croydon whereall records are held on the local IT system and any paper isscanned into the electronic IT record. Temporary records wereused rarely (0.4% per month).

• Pathology and radiology test records for patients seen atsatellite clinic were not always accessible electronically at the

Good –––

Summary of findings


main site due to IT systems not being integrated with the hostprovider system. However, hard copies of these records wereprinted and placed into the casenotes, with the exception ofCroydon, where results could be scanned into the system.

For more detailed information please refer to the individual locationreports.

Evidence based care and treatment

• The trust’s policies and treatment protocols were based onorganisational guidelines from professional organisations suchas the National Institute for Health and Care Excellence (NICE)and the Royal Colleges. Staff were able to access guidelines onthe intranet.

• There was an audit policy and a dedicated clinical audit teamto assist staff in completing clinical audit activities. We sawevidence the trust carried out regular audits to ensure theirpractice was in line with national guidelines and benchmarkedthemselves against other ophthalmic services. All audits hadrecommendations and actions plans and we observed changesto the patient pathway or practice following audit results.Consultants had contributed to the development of nationalbest practice guidelines published by the Royal Colleges.

• Some consultants were undertaking very specialist activity andhad the opportunity to develop practice in their specialist area.For example, Moorfields, in conjunction with other specialisttrusts treat the majority of children with microphthalmia andanophthalmia (small eyes and no eyes).

• Within the A&E at City Road, clinicians and managerscontributed to the British Emergency Eye Care Society, whichhad been set up to recognise emergency eye care inophthalmology. This meant resident staff could contribute todeveloping practice in line with national benchmarks andguidance. Membership of the group had resulted in the creationof a number of clinical fellowships, which provided specialisttraining for junior doctors.

Patient outcomes

• The trust showed no evidence of risk against mortality rates,according to the intelligent monitoring system. The trustengaged local audits with a focus on surgical outcomes. Resultsfrom these local audits demonstrated an improvementcompared to the previous 2010 audit.

Summary of findings


• As a single speciality ophthalmic emergency unit, the A&E atCity Road did not participate in the Royal College of EmergencyMedicine (RCEM) audits. However, there was trust-wideparticipation in the national ophthalmology database audit

• The trust contribute to the Royal college of OphthalmologistsNational Ophthalmology Database (NOD). The NOD collectsdata from services to show current and national performanceand improve cataract care. Croydon and Bedford automaticallysubmit their Medisoft data through the central Medisoft portal.Other Trust sites submitted a complete dataset of audit to theNOD from OpenEyes last year. At City Road alone, 1292 cataractoperations took place 'within the Cataract Service only' in 2015/2016Participating in such audits allows ophthalmologists theopportunity to compare their surgical outcomes with those ofanonymised peers. It also provides information to patients tohelp them choose their care based on available evidence. Thetrusts monitored core outcomes such as posterior capsulerupture (PCR) and visual acuity post cataract surgery.Secondary outcomes such as deviations from post-operativepredicted refraction and endophthalmitis was also monitored.

• The trust use the BOSU study on strabismus complications tobenchmark against and have been running a continuous auditof complications of strabismus surgery since 2011. The trustrecently presented results and findings to BIPOSA (British IslesPaediatric Ophthalmology and Strabismus Association).

• An audit of the outcomes of strabismus surgery indicated acomplication rate from January to December 2015 of 0.23%which is better than the national standard of <2.2%.

• Compliance with premature baby eye screening was 99.7% in2015/2016 against a national standard of 99%.

• Activity by the trust was reported to the World Association ofEye Hospitals (WAEH), which compiled an annual reportdemonstrating the numbers of attendances and interventionsin comparison with other eye hospitals globally. Data in thisreport showed an increase in outpatients activity at MoorfieldsEye Hospital which was in line with the global average.

• Patients had access to new and innovative treatments throughparticipation in research studies. At the time of our inspectionthere were a significant number of studies underway, including:six adnexal, 12 age related macular degeneration, three

Summary of findings


cataract, nine corneal external disease, three diabeticretinopathy, eight glaucoma, 14 inherited retinal disease, 16medical retinal, six neuro ophthalmology, five uveitis, threevitreoretinal and seven paediatric studies.

• The Moorfields at Croydon services's diabetic macular oedemaanti-VEGF injection outcome audit for January to December2015 showed that the percentage of eyes with an injectiondelay of greater than two weeks was 13.2%. Therecommendation was that the service needed to build injectionclinic capacity. The report then stated the progress made,which was capacity building, plans were underway with onenew fully-trained injection nurse and two injections rooms wereto be utilised when staffing was adequate. The aim was toreduce delay to 7% in 2016.

Multidisciplinary working

• Multidisciplinary (MDT) working was embedded and effectiveacross the trust. Staff spoke positively about MDT working andwe found evidence of good multidisciplinary relationshipssupporting patients’ health and wellbeing.

• Staff in the A&E at City Road worked closely with other serviceswithin the trust to provide an effectively co-ordinated servicefor patients. The A&E received support from specialist clinics,including clear pathways for referral for emergency sub-specialist care. A subspecialist consultant out of hours on-callrota provided senior support for all conditions.

Access to information

• An information hub was available within the hospital at CityRoad, where patients could access written information abouteye conditions and other public health information. We sawengagement with other charitable services outside of theorganisation.

• Leaflets about different types of eye conditions and treatmentswere available throughout the trust. We were told that thesewere available in other languages on request.

• We were told that staff could view images taken at City Roadbut this didn't work the other way round because they used alocal server at the host provider site. This was reported as aproblem with patients from the North West sites who had to goto City Road to be seen in an emergency. We were informed bythe trust that access to local ophthalmic image servers onmajor sites, including City Road, was available via the clinicalservices portal, on request by the clinician.

Summary of findings


• The trust was looking at ways to ensure that all locations werefully utilising the electronic medical records system. The systemused in Moorfields South (Croydon) sites is accessible allMoorfields sites via the Clinical Services Portal.

Consent, Mental Capacity act and Deprivation of LibertySafeguards

• Mental Capacity Act 2005 (MCA) training was mandatory withinthe trust. Data provided demonstrated variable compliancewith the trust 100% target; some areas had compliance of 19%.

• Within the A&E at City Road, 50% of medical staff hadcompleted the recently introduced mental capacity act trainingat the time of our inspection against a target of 30%. Therewere no training records available for nursing andadministrative staff. The trust informed us that mental capacityact was part of the safeguarding training. However, it was notedthat staff demonstrated a good understanding of consent andcapacity for consent. Staff said they usually sought verbal orimplied consent when examining patients.

• The trust’s Deprivation of Liberties Safeguards (DoLS) policyand process was also available for staff to access on the trustintranet including single page summary sheets.

• We saw DoLS information displayed on staff boards. A flowchart had been developed to aid staff decisions of whether aDOLs application was appropriate.

• The majority of nursing and medical staff we spoke withdemonstrated a good understanding of mental capacity andknew about the importance of assessments of people withmental health needs or learning disabilities.

Are services at this trust caring?We rated the services at Moorfields Eye Hospital NHS FoundationTrust as Good for caring. All areas were rated as good, with theexception of children’s and young people’s services which wererated as outstanding. This was because:

• Feedback from people who use the service and those who areclose to them was continually positive about the way stafftreated them. Patients thought the care they receive exceedstheir expectations.

• Friends and Family Test results were consistently good acrosssurgical services.

• Staff were seen to spend time talking to patients, or those closeto them, to ensure they received the information in a way theycould understand and were given time to ask questions.

Good –––

Summary of findings


• We observed staff providing compassionate care and treatedpatients with dignity and respect.

• Staff provided emotional support to patients and patients wereable to access the hospital multi-faith chaplaincy services,when required. Patients also had access to the trust counsellingservice and the eye clinic liaison office.

• In children’s and young people’s services, staff demonstratedthe relationships they developed with patients using theservice, and their commitment to ensuring they had positiveexperiences.

• Complex conditions and procedures were explained to childrenand young people in a way that enabled them to gain a fullunderstanding of their treatment plan and take an active role indecision making.

However:

• We observed that other people could overhear consultationswith patients due to the open plan layout of the ED at CityRoad. The trust advised that the environment is in line withRoyal College of Ophthalmologist guidance.

• In surgery at the St George’s site we found adults and childrenhad been sharing the recovery area. Managers acknowledgedthis was not good practice. They had reviewed the operatingtimetable and planned to provide children’s surgery on adifferent day to avoid an overlap between adult patients andchildren. Children waiting for a pre-operative assessmentwaited to be seen on an adult in-patient ward. They waited inthe ward corridor to be seen.

• During our inspection we did not find a private room wheredistressed patients could spend time. The trust have informedus that there are private rooms available, however we did notsee evidence of this.

Compassionate care

• Staff were caring and treated patients with respect. They tooktime to interact with people who used the service. Patients toldus and we observed staff introduce themselves to patients atthe clinics we visited. Staff were courteous, professional andengaging and demonstrated compassion to all patients.

• Patients we spoke with were positive about the care they hadreceived and told us nurses and doctors were kind andcompassionate. Patients told us they had been put at ease bystaff with one patient commenting that the “staff were fabulousand took all my fears away.”

Summary of findings


• The NHS Friends and Family Test results showed thepercentage of respondents who would recommend the serviceto friends or family were good for all directorates.

• In the A&E at City Road, we observed members of staff makinghourly announcements in the waiting areas to update patientsabout waiting times. All the patients we spoke with confirmedthat they were regularly updated about the waiting times.

• Children and young people at the City Road site talked aboutgoing to theatre as being a particularly anxious time andcommented on the kindness and understanding of theanaesthetists and theatre staff. A young person said, “Thetheatre staff and anaesthetist were lovely.” “They sort of calmedme down a bit.” Parents also said the anaesthetist put them atease.

• However, we observed that other people could overhearconsultations with patients due to the open plan layout of theED at City Road. The trust advised that the environment is inline with Royal College of Ophthalmologist guidance.

• Similarly in day surgery at the City Road site we observed stafftalking to patients about their care while sitting in the mainwaiting room, which could be overheard by other patients.

• In surgical services at the St George’s Hospital site adults andchildren had been sharing the recovery area but this practicehad been stopped by April 2016.

Understanding and involvement of patients and those close tothem

• Staff communicated well with people who used the service andensured that they understood their care, treatment andcondition. Within surgery, patients we spoke with said theywere aware of their surgical procedure and that it had beenexplained to them thoroughly and clearly. Patients told us theyhad been given time to ask questions to ensure understanding.

• “Moorfields Direct”, a phone advice and liaison service wasstaffed by ophthalmic nurses, was available Monday – Saturdayand provided information, support and reassurance to patients.

Emotional support

• Counselling, emotional and psychological support, as well aspractical advice and information on services outside thehospital was provided by the integrated patient supportservices. The team consisted of nurse counsellors, eye clinicliaison officers (ECLOs) and the certificate of visual impairmentteam. The team provided help and advice for patients who hadto deal with news about sight loss.

Summary of findings


Are services at this trust responsive?We rated the services at Moorfields Eye Hospital NHS FoundationTrust as requires improvement for responsive. We saw manyexamples of good care under the responsive domain. However wefound areas of requires improvement in the following: outpatientsand diagnostics at the City Road site, surgical services andoutpatients and diagnostics at the St George’s Hospital andoutpatients and diagnostics at the Bedford Hospital site. This wasbecause:

At the City Road site:

• In outpatients patients were seen in open bays within clinicareas. In some clinics this resulted in a lot of noise and it wasdifficult to hear what was being said by both patients and staff.At times these areas became very busy, with no seatingavailability for patients and relatives.

• During our inspection, we found that patient total visit timesthrough clinic were monitored and we saw evidence that theexpected length of the overall visit time was displayed onwhiteboards or TV screens, however the estimated length oftime patients were waiting to be seen by a doctor, nurse orother staff member was not monitored or communicated topatients.

At Moorfields Eye Centre at St George’s Hospital site:

• Signage to the service was small and there were no lines on thefloor to direct patients to the clinics.

• The outpatients department had two reception desks wherepatients booked into different eye clinics. The main receptionarea was situated so that patients confidentiality and privacywas maintained. However, the reception area where patientsbooked into the urgent care centre was situated next to thewaiting area close to where patients sat, which meant thatpatients privacy and confidentially was compromised.

• There was no signage or information available for patientsabout in-clinic waiting times and this meant that patients didnot know how long they would need to wait. The departmentdid not monitor this performance data.

• Cancellation rates were high for hospital cancelledappointments in Moorfields South (both St George’s andCroydon). Service planning required improvement as there wasno clear system for staff to know when a consultant would beon annual leave, which led to appointments being cancelled.

However;

Requires improvement –––

Summary of findings


• Staff, teams and services were committed to workingcollaboratively and found innovative and efficient ways todeliver more joined-up care to patients within the services,which aimed to reduce wait times and improve utilisation.

• The trust consistently met the 4-hour ED waiting time standard,and also measured against a locally derived 3-hour target.

• There were clear patient pathways that eased the flow ofpatients within the A&E. The department had implemented an‘active triage’ system whereby patients with non-emergencyconditions were referred to the urgent care clinic.

• The trust met the target for the national referral to treatmentpathway (RTT) target of 18 weeks for outpatient appointments.It had robust systems for monitoring RTT performance.

• Patients and relatives told us they appreciated having localservices which meant that they didn’t have to travel far.

• There was a proactive approach to understanding the needs ofdifferent groups of people and to deliver care in a way thatrecognised, met and promoted those needs.

• Patients were given the flexibility to access services in a wayand at a time that suited them.

Service planning and delivery to meet the needs of localpeople

• Information and advice was available via Moorfields Directtelephone helpline, which was staffed by ophthalmic-trainednurses. The helpline was available Monday through to Friday09.00 – 21.00 and on a Saturday from 08.30-17.00. Patients toldus this was a useful service as many patients travelled longdistances and told us it was convenient that they could accessadvice via telephone.

• Services were provided from satellite locations in communityhospitals and health centres as well as larger hospitals, whichmeant that the needs of local people were being met wherepossible. Patients and those close to them told us they valuedhaving services close to where they lived. However, somepatients told us clinics were hard to find on their first visit.

• The management team of the A&E at City Road had begun towork with local GP practices to educate them about theservices provided by the A&E. This strategy was in place toprevent patients attending the A&E when they could be treatedmore effectively by a routine referral from their GP. The servicemanager was planning to extend this method of educatinglocal service providers by discussing the scope and remit of theA&E with commercial opticians. This was to ensure opticiansreferred patients appropriately and to ensure the mostappropriate professional saw patients at their first presentation.

Summary of findings


• A “hostel” service was located on Mackeller ward at the CityRoad site and was available to patients who had to travel longdistances for their treatment.

• However, we observed at the satellite clinics in MoorfieldsNorth that outpatient clinics were often overbooked due to thelack of any system for knowing when consultants were on leave.We were told that at Moorfields Queen Mary’s Hospital clinicswere often cancelled at very short notice and that patients werenot always informed and turned up for their appointment. Wewere informed this happened at least one a month.

• The paediatric waiting area in the A&E at the City Road site wasunsuitable for the purpose it was being used. We saw paediatricpatients and their families waiting in the main waiting area withadult ED patients.

• In outpatients at the City Road site we observed waiting areasto be large with lots of seating, however became particularlybusy in the afternoons. We observed some patients and theirrelatives standing in waiting areas as there weren’t enoughseats available. Staff were aware of this issue and ‘floor walkers’provided additional portable seats when possible.

• In outpatients at City Road patients were seen in open bayswithin clinic areas. In some clinics this resulted in a lot of noiseand it was difficult to hear what was being said by both patientsand staff. This could prove a challenging environment for theteam to effectively review patients with a hearing difficulty,confusion or a learning disability.

Meeting people’s individual needs

• Documents were available in large print format and whenrequested, leaflets could be available in Braille.

• The trust provided a face-to-face and telephone interpretingservice. The trust also provided a British sign language service.

• The trust used an electronic flagging system on the electronicpatient records system and the appointment booking systemsto identify people who may need additional assistance, such asthose with a learning disability, dementia or sight-impairment.‘Helping hand’ stickers were used on paper records.

• We found examples where the trust had proactively consideredand responded to specific individual needs, including patientswith complex needs and cultural and religiousrequirements.Staff we spoke with were able to tell us in detailand give examples of how they met the needs of differentpatients.

• Patients attending Moorfields Eye Hospital at City Road haveguidance from the main tube station in the form of a green lineleading to the hospital.

Summary of findings


• A welcome pack had been developed specifically for patientswith a learning disability at the City Road site. The packdemonstrated the patients' journey through pictures andincluded information about what equipment, staff and post-opeye dressing might look like. Different sites used the ‘patientpassport’ for patients with learning disabilities and the ‘this isme’ document for patients with dementia, however we foundinconsistencies in the utilisation of these documents acrossdifferent sites.

• Most staff had received training on guiding and leading avisually impaired person, which included a film available on thetrust intranet. The leading and guiding training video becamepart of mandatory training in April 2016.

Dementia

• Staff told us they had yearly training in caring for patients with alearning disability and dementia awareness. They told us theyneeded to pass an assessment before this training wascomplete.

• Patients with a disability, a visual or hearing impairment, orelderly patients who required additional help were identified bya “helping hand” sticker on the front of healthcare records atthe City Road site. These stickers informed staff that the patientmight need extra help.

• A flagging system was available on the appointment bookingsystem. This meant that staff were able to look at theappointments for the following day to identify, and prepare ifany patients needed extra help or adjustments made for them.

• “This is me” booklets were available for patients with dementia.These are forms developed by the Alzheimer’s society which arecompleted for patients with dementia. Staff told us thesebooklets helped to inform them how best to communicate withthe patient about their likes and dislikes, however this was notconsistently used at all satellite sites.

• Each area of the hospital we visited had a learning disabilityand a dementia link nurse who could advise staff and supportthe care of patients.

Access and flow

• The trust produced monthly performance reports for eachdirectorate. There had been significant improvement projectsaddressing the patient flow through surgical services and thiswas evident in many areas of the service we visited.

Summary of findings


• Performance against the A&E maximum waiting times (4-hourtarget) was 97.5% between April 2015 and January 2016. Thiswas 99.2% in the previous year. This was better than the trust’starget of 95% and the England average.

• The hospital identified an 11-week target for patients to havetheir first outpatient appointment after referral. From April 2015to March 2016, an average of 50.8% of patients waited for morethan 11 weeks for their first appointment. (This data applies tothe City Road site only and excludes: adnexal, cataract, externaldisease & vitreo-retinal services which are reported within thesurgical directorate report).

• The hospital identified a two-week target for 93% of urgentpatients to have their first outpatient appointment after referral.From April 2015 to March 2016, an average of 91% of patientswere seen within two weeks.

• Telephone clinic appointments had been implemented toreduce patient waiting times and were available for patientswith no general health concerns.

• Cancellation rates in surgery at the City Road site, from April2015 – January 2016, were not meeting trust targets of less than6%. Data provided demonstrated 9% of operations werecancelled due to theatre cancellations. During inspection, wewere advised that theatre refurbishment had taken placebetween April – November 2015 and this had caused somedisruptions. We were advised that theatre cancellation rateswere improving since this work had been completed however;data provided demonstrated that theatre cancellationsremained above 10% from December 2015 – February 2016 andwere 9% in March 2016. The highest number of theatrecancellations occurred in January 2016, when there were 244theatre cancellations out of 1965 operations.

• Theatre cancellation rates at the St George’s site in 2015-2016up to the end of January averaged 8.5% which exceeded thetrust’s target of 6%. Cancellation rates were 12.8% in November2015, 8.4% in December and 9.3% in January. Staff told us themain reasons were problems with the air flow ventilation intheatre.

• Staff told us there was a problem with the flow of the Fridayglaucoma clinic at Moorfields Eye Unit at Queen Mary's Hospital(QMH). Eight to ten patients were booked at the same time foreach of the three consultant ophthalmologists so from 8.45amto 9.30am there were up to 20 patients waiting. This was raisedwith the administrative team leader but staff said someone newwas appointed to the post which may have caused a delay tothe problem being addressed.

Summary of findings


• Staff told us patients often complained about the length of timethey had to spend at the clinic. This was because they wereseen by a number of clinicians including nurses, optometristsand ophthalmologists. Also, patients usually had to havedilating eye drops administered which took different lengths oftime to take effect for different people.The trust monitoredpatient ‘journey times’ to assess how long patients’ visits tookfrom arrival to leaving, including all tests and measurements.

• Staff told us a number of clinics frequently finished late, forexample one morning clinic often ran until 3pm. One staffmember told us some consultants would see patients nomatter how late they arrived after their appointment time,which caused a delay to other patients.Key issues relating toflow within the outpatient clinics, such as patient waiting timesand clinics overrunning, were not formally monitored by theleadership team and therefore the benefit of any servicechanges could not be effectively assessed.

Learning from complaints and concerns

• Patient Advice and Liaision Service (PALS) posters weredisplayed at all clinics we visited, and information leaflets onhow to complain were available. Patients we spoke with wereaware they could raise any issues with staff in the departmentor seek assistance from PALS if needed.

• Staff were aware of the action to take if someone raised acomplaint or a concern with them and said they would escalateit to senior staff. They said patients would be encouraged toinvolve the PALS where appropriate.

• Within the A&E at City Road, the service had introduced atelephone simulation system to improve the call handling skillsof administration staff. They used this system to assess staffresponses in challenging situations and to improve the careprovided to people who could not communicate easily. Thiswas supplemented with random spot-checks of staffcommunication during live calls. This helped to ensurereception staff provided a good service and reducedcomplaints relating to communication.

• We reviewed examples of complaint responses that providedpatients with apologies where appropriate and full details ofthe investigation into the complaint that took place.

• We saw evidence of actions in response to patient complaints.For example senior staff introduced hearing loop systems tooutpatient clinics after a patient complained they were notavailable.

• We saw effective escalation of complaints issues through theperformance management processes within the trust.

Summary of findings


Are services at this trust well-led?We rated the surgical services at Moorfields Eye Hospital NHSFoundation Trust as good for well-led. We saw many examples ofgood local leadership across the organisation and goodengagement between the executive and clinical teams. We found:

• We found a executive cohesive leadership team who functionedeffectively, with well-established members of staff. The majorityof staff were complimentary about the support they receivedfrom their seniors and commented that members of the boardwere visible and approachable.

• There were a clear set of vision and values that were driven byquality care and safety. Staff that we spoke with were clear oftheir involvement in delivering these objectives.

• Structures, processes and systems were in place to ensureinformation sharing across the services was effective.

• There was a clear proactive approach to seeking out andembedding new and more sustainable models of care fromstaff of all levels across the organisation.

• There are high levels of staff satisfaction across all equalitygroups. Staff were proud of the organisation as a place to workand spoke highly of the culture and opportunities.

• There was good governance and quality measurement.Numerous audits were undertaken regularly including qualityand safety audits.

• There were good risk management processes in place and riskswere identified and acted upon.

However;• There was not a robust governance system around service level

agreements (SLA's) with partner organisations, which resultedin a lack of formal mechanisms or powers to drive improvementor make changes where required.

• The senior leadership team were aware of the challenges thatservices provided at the St Goerge's Hospital faced andrecognised the importance of improving the environment. Ajoint proposal to relocate the service was developed butdespite approval of these plans by Moorfields trust board, thesewere not jointly approved. Following confirmation that this hadnot been approved Moorfields developed short term localaction plans to address the environmental issues, howeverthe medium term plans were to address its current unsuitabilitywere unclear.

• Key issues relating to flow and in-clinic waiting times within theoutpatient clinics, were not clearly monitored and we did notsee evidence these issues were being progressed.

Leadership of service

Good –––

Summary of findings


• The organisation had seen significant change at Board levelprior to our inspection including the appointments of keysenior posts such as Chairman, Chief Executive, Chief OperatingOfficer, Director of Strategy and Business Development.

• Staff informed us that the Executive team were visible andapproachable.

• We noted the trust had made significant investments inleadership and quality improvement, and had invitedinternational speakers to attend a specialist event following ourinspection.

• The organisation utilised the triumvirate model of managementwhich was emulated across the clinical directorates.

• Senior staff organised sessions called “In Your Shoes” whichinvolved staff members hearing direct patient feedback of theirexperiences at the trust and offered an opportunity for staff toask questions about how they can best support patient needs.A range of staff levels from outpatients attended these sessions.

Vision and strategy for the trust

• The trust describes their vision to be the “leading internationalcentre in the care and treatment of eye disorders, driven byexcellence in research and education”. The trust had a clear setof values to strive to give people the best possible visual health,effectively and efficiently through professional teamwork andpartnerships while putting patients at the centre.

• Staff were keen to discuss ‘The Moorfields Way’ involving care,organised, excellent and inclusive. Staff told us that theirappraisals focused around these values. We asked staff howthese values contributed to their day-to-day work and staffwere able to demonstrate these values in action.

• The long term vision for the satellite outpatient services wasnot clear to staff. Some staff told us there were plans to mergesatellite clinics into fewer, larger sites.

• The leadership team had a clear focus on improving access andflow in the department to meet the demands associated withgrowing patient attendances.

• Senior clinical staff consistently identified the outpatientsdepartment's, at the St George's Hospital site, as beingunsuitable for its current use. Staff throughout outpatientsidentified a newly built hospital on a different site as thesolution to these difficulties. However, they were aware that thistype of development would take a long time to come intofruition.

Governance, risk management and quality measurement

Summary of findings


• Clinical governance structures were in place across theorganisation and senior staff we spoke with said they wereeffective. Monthly meetings took place for local specialties,which fed directly into the directorate meeting. We spoke with avariety of staff who were able to demonstrate good awarenessof the governance arrangements within their directorate.

• Staff of all levels were encouraged to attend regular clinicalgovernance meetings. The trust-wide clinical governancemeetings took place over half a day and clinics were stopped toallow staff to attend.

• Clinical directors said they met monthly with the chiefoperating officer to discuss the performance of services in theirdirectorate, who in-turn reported to the chief executive. Weobserved good ward-to-board visibility of issues, following cleargovernance structures for Board level discussion whereappropriate. Senior executives and non-executives that wespoke with were able to articulate the organisational issues andrisks in line with those identified by staff and services.

• Risk registers were updated regularly and rated appropriately,by multiplying the consequence by the likelihood. We notedsome risks had been on local risk registers since 2013 however,these were updated regularly with action points.

• Senior staff introduced ‘floorwalkers’ who were techniciansresponsible for overseeing patient welfare in the waiting areas.Clinic staff told us floorwalkers were only used when staffingallowed and we observed limited availability of these staffmembers during our inspection.

• A service level agreement had been developed to formalise therelationship between Moorfields Eye Hospital NHS FoundationTrust and St George’s University Hospitals NHS FoundationTrust but this had not been updated and was out of date. Theclinical directors and managers informed us of incidents, forexample controlled medicines left unattended in theanaesthetic room when the theatres were used by staff whowere not employed by the trust. However, there was no formalmechanism in place for resolving these issues until the servicelevel agreement was in place.

Culture within the service

• There were high levels of staff satisfaction across all staff wespoke with. All staff we spoke with told us they hadopportunities to develop and felt included in decisions thatwere made.

Summary of findings


• Staff were proud of the organisation as a place to work andspoke highly of the supportive culture. Staff we spoke with werehappy with their working environment and when asked whatstaff like most or feel most proud of a large number of staffcommented that it was their team.

• We noted higher than usual reports of bullying and harassment,according to the staff survey data for the trust. The majority ofstaff we spoke with said they would raise any concerns aroundbullying and harassment with a manager and felt that peoplewere treated equally. We discussed these concerns with thetrust executive and non-executive staff. The senior team werewell versed with the issue and articulated work that they hadimplemented to attempt to tackle these concerns. It was notedthat the organisation had difficulty in pin-pointing where theseissues were being generated however, the executive teamvoiced that this was a priority and that more work would beimplemented to address this.

• Some staff told us they had concerns about favouritism andthat the trust’s harassment and bullying policy was notenforced at all levels. We spoke with a Human Resources (HR)advisor about this and they told us there were processes inplace to address this. The human resources team offered aconfidential and anonymous reporting system for staff to use ifthey did not want to report a concern. The HR team hadimplemented a number of strategies to ensure staff felt safeand comfortable at work.

• In some clinical areas we noted, the clinical leadership teamhad worked closely with human resources (HR) to establish aninterview process for promoting staff and assessing newapplicants that was fair and transparent. This was in responseto some staff concerns about selection processes.

Public engagement

• Patient experience committee meetings take place everyquarter where patients are able to attend to give feedbackabout the services to the matrons and other senior member ofstaff.

• Staff informed us about audits completed to help improve thewording of patients letters. As part of this audit 50 patients werehanded questionnaires to complete about their views andsatisfaction of the letters. Patient representatives are alsoinvited to attend audit and effectiveness meetings to providean opportunity for patients to participate in decisions affectingtheir care.

Summary of findings


• Friends and Family Test feedback cards were available forpeople to complete at all the sites we visited. However,response rates were below target at some sites - the rate was3% for Ealing and 9.6% for Teddington in January 2016 againstan average of 16% for all satellite sites.

• The trust displayed “you said, we did” posters in waiting areas.This showed common feedback issues that patients reportedvia the Friends and Family Test and what changes the servicemade as a result.

• The trust organised an annual patient survey to collect theviews on patients' experiences. The trust had taken the decisionnot to conduct the survey in 2015 to allow transformationchanges to take effect before measuring this data again in late2016/early 2017.

• There was good local working with communities in thedevelopment of the satellite sites. For example, we were toldabout care pathways that had been created for communityoptometrists to refer patients to the department and how theyare involved in the care of the patients.

Staff engagement

• We saw staff noticeboards available throughout the City Roadsite providing staff with information about departmental andtrustwide changes, including available training anddevelopment opportunities.

• There was a monthly magazine called “In focus” circulated tostaff, patient and visitors. The magazine celebratedimprovements in care, published staff survey results includingactions and shared patient stories.

• The 2015 NHS Staff Survey indicated 75.2% of staff within theoutpatient departments across the trust felt able to contributeto improvements at work.

Innovation, improvement and sustainability

• Moorfields Eye Hospital NHS Foundation Trust is one of the newhospital vanguards selected by NHS England to develop newmodels of care as part of the next stage of implementing theNHS Five Year Forward View.

• Known as acute care collaboration vanguards they aredesigned to spread excellence in hospital services andmanagement across multiple geographies and explore radicalnew options for the future of local hospitals across the NHS.

Summary of findings


• The trust works in collaboration with the University CollegeLondon (UCL) Institute of Ophthalmology, forming a largeresearch partnership. The surgical services demonstrated therewere 20 ongoing research projects which they were involved into improve patient care.

• The organisation was actively investing in extended roles fornursing, technical and support staff. The trust planned to havea Quality Partner role implemented within each directorate toforge stronger links across the sites and facilitate positivechanges.

• Service sustainability for the A&E was a key priority of theleadership team to be able to meet the increasing demands onthe service. Innovative work was underway with the local healthand social care economy to mitigate the increased demand tothe City Road ED.

• The trusts outpatients was heavily involved in developingevidence-based practice and in trialling new treatmenttechniques. At the time of our inspection there were asignificant number of studies underway, including: six adnexal,nine age related macular degeneration, three cataract, ninecorneal external disease, three diabetic retinopathy, eightglaucoma, 14 inherited retinal disease, 16 medical retinal, 6neuro ophthalmology, five uveitis and three vitreoretinalstudies.

• A clinical research facility was situated within the RichardDesmond Children's Eye Centre (RDCEC) building and at thetime of the inspection, 11 research studies related to childrenwere being undertaken. This included national andinternational research including randomised controlled trials.

• There has been innovative work in local areas to improve carefor local people. For example, the Bedford team worked closelywith a group of local optometrists and operated a system calledBedford Shared Care Cataract Pathway, whereby theoptometrists were able to refer patients directly to the trust forcataract surgery. Evaluation of the Bedford Shared CareCataract Pathway has shown to be effective and efficient byfreeing up clinic appointments. Patients received their post-cataract surgery follow-up with their local optometrist, whichallowed for better continuity of care.

Summary of findings


Our ratings for Moorfields Eye Hospital NHS Foundation Trust - City Road

Safe Effective Caring Responsive Well-led Overall

Urgent and emergencyservices Good Good Good Good Good Good

Surgery Requiresimprovement Good Good Good Good Good

Services for childrenand young people Good GoodOutstanding Good Good Good

Outpatients anddiagnostic imaging

Requiresimprovement N/A Good Requires

improvementRequires

improvementRequires

improvement

Overall Requiresimprovement GoodOutstanding Good Good Good

Our ratings for Moorfields - St. George's


Surgery Requiresimprovement Good Good Requires

improvementRequires

improvementRequires

improvement

Outpatients anddiagnostic imaging

Requiresimprovement N/A Good Requires

improvementRequires

improvementRequires

improvement

Overall Requiresimprovement Good Good Requires

improvementRequires

improvementRequires

improvement

Our ratings for Bedford Hospital


Surgery Requiresimprovement Good Good Good Good Good

Outpatients anddiagnostic imaging Good N/A Good Requires

improvement Good Good


improvement Good Requiresimprovement

Overview of ratings


Our ratings for Moorfields Eye Hospital NHS Foundation Trust



improvement Good Good

Our ratings for Satellite Services


Surgery – satellitesites

Requiresimprovement Good Good Good Good Good

Outpatient anddiagnostic imagingservices – satellitesites

Good N/A Good Good Good Good

Overall for SatelliteServices

Overview of ratings


Outstanding practice

We saw several areas of outstanding practice including:

• The development of staff skills, competence andknowledge, and development of extended nursing andallied health professional roles. Staff reported thatthey felt well supported and received good trainingopportunities.

• There was an extensive research portfolio, which wasrecognised at a UK and global level, directly benefitingpatients.

• There was a clear proactive approach to seeking outand embedding new and more sustainable models ofcare from all staff levels within the services, and across

the Moorfields network. For example, the Bedfordteam worked closely with a group of local optometristsand operated a system called Bedford Shared CareCataract Pathway.

• The organisation had taken a pivotal role in thedevelopment of ophthalmic services, as lead in one ofthe NHS vanguard systems selected by NHS Englandto develop new models of care.

• We noted that the trust had made significantinvestments in leadership and quality improvement,and had invited international speakers to attend aspecialist event following our inspection.

Areas for improvement

Action the trust MUST take to improveThere were some areas of poor practice where the trustneeds to make improvements.

Importantly, the trust must:

• Address the lack of storage space for patients’ notes inED and the administrative office and remove barriersto evacuation.

• Fully embed the World Health Organisation (WHO)safer surgery checklist, in terms of bothdocumentation and the quality and staff engagementin the process, across the organisation.

• Ensure adequate audit and monitoring systems are inplace to monitor performance and compliance of theWHO safer surgery safer surgery checklist to guideimprovement.

• Take action to ensure the environment in theatres atthe Moorfields at St George's is safe and meets withnational guidance.

• Reduce the number of mixed sex breachesat Moorfields Eye Centre at St George's.

• Ensure emergency buzzers are available in radiology.

• Ensure that a service level agreement in placebetween Moorfields Eye Hospital NHS FoundationTrust and St George’s University Hospitals NHSFoundation Trust and ensure medical cover andestates management are working effectively.

• Formalise and implement the agreement with StGeorge's University Hospitals NHS Foundation Trustfor the management of patients who become unwellout of hours.

• Address the environmental conditions of outpatientsat the St George’s site.

• Ensure that the quality and safety of the outpatientsservice at the City Road site are fully monitored,including patient waiting times and clinic finish times.

• Ensure that risks relating to patient waiting times arefully mitigated.

• Ensure that patient records are fully and legiblycompleted including staff signatures, record entrydates and documentation errors are correctly marked.

• Review the governance process around service levelagreements (SLA's) with partner organisations andensure these fit the existing and future models of caredelivery.

Outstanding practice and areas for improvement


Action we have told the provider to takeThe table below shows the fundamental standards that were not being met. The provider must send CQC a report thatsays what action they are going to take to meet these fundamental standards.

This section is primarily information for the provider

Requirement notices


Action we have told the provider to takeThe table below shows the fundamental standards that were not being met. The provider must send CQC a report thatsays what action they are going to take to meet these fundamental standards.


Enforcement actions


Action we have told the provider to takeThe table below shows why there is a need for significant improvements in the quality of healthcare. The provider mustsend CQC a report that says what action they are going to take to make the significant improvements.

Why there is a need for significantimprovementsStart here... Start here....

Where these improvements need tohappen


Enforcement actions (s.29A Warning notice)


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Documents

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