St Catherine's Health Centre · St Catherine's Health Centre is a registered location for Spamedica...

This report describes our judgement of the quality of care at this location. It is based on a combination of what wefound when we inspected and a review of all information available to CQC including information given to us frompatients, the public and other organisations

Ratings

Overall rating for this location Good –––

Are services safe? Good –––

Are services effective? Outstanding –

Are services caring? Good –––

Are services responsive? Good –––

Are services well-led? Good –––

StSt Catherine'Catherine'ss HeHealthalth CentrCentreeQuality Report

St Catherine's HospitalChurch RoadBirkenheadMerseysideCH42 0LQTel: 0330 058 4280Website: spamedica.co.uk

Date of inspection visit: 5 December 2019Date of publication: 23/01/2020

1 St Catherine's Health Centre Quality Report 23/01/2020

Letter from the Chief Inspector of Hospitals

St Catherine's Health Centre is a registered location for Spamedica Ltd. The service is located on the third floor in StCatherine's Health Centre in Birkenhead. The service is accessible by either stairs or lifts and facilities include oneoperating theatre, consulting rooms, and two waiting areas.

The service provides cataract surgery and yttrium-aluminium-garnet laser (YAG) capsulotomy services for NHS patientsover the age of 18 years.

We inspected this service using our comprehensive inspection methodology. We carried out the unannounced part ofthe inspection on 5 December 2019.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are theysafe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and compliedwith the Mental Capacity Act 2005.

Services we rate

We rated it as Good overall.

We found good practice in relation to surgery:

• The service monitored the effectiveness of care and treatment. Outcomes compared well against the nationalaverage and benchmarked well against other providers.They used the findings to make improvements andachieved outcomes for patients that were consistently better than the national average.

• Key services were available seven days a week, if needed, along with a consultant-led 24-hour advice line tosupport timely patient care. Additional appointments were scheduled at weekends to meet patient demand.

• The service planned care to meet the needs of local people, took account of patients’ individual needs and workedwith others in the wider system and local organisations to plan and delivery care. People could access the servicewhen they needed it and waiting times were in line with the national standard.

• Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported themto make decisions about their care, and had access to good information.

• The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understoodhow to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staffassessed risks to patients, acted on them and kept good care records. They managed medicines well. The servicemanaged safety incidents well and learned lessons from them. Staff collected safety information and used it toimprove the service.

• Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of theirindividual needs, and helped them understand their conditions. They provided emotional support to patients,families and carers.

• Leaders ran services well using reliable information systems and supported staff to develop their skills. Staffunderstood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported andvalued. They were focused on the needs of patients receiving care. Staff were clear about their roles andaccountabilities. The service engaged well with patients and the community to plan and manage services and allstaff were committed to improving services continually.

Summary of findings


However, we found areas of practice that require improvement in surgery

• Patient records were not always stored securely.

• Not all policies were reviewed within the documented date.

We found areas of outstanding practice in surgery:

• Staff worked especially hard to make the patient experience as pleasant as possible.

• The service achieved good outcomes that were continually monitored with patients reporting a positiveexperience.

• The service had an endophthalmitis box on site in case of an emergency.

Following this inspection, we told the provider that it should make improvements, even though a regulation had notbeen breached, to help the service improve. Details are at the end of the report.

Ann FordDeputy Chief Inspector of Hospitals

Summary of findings


Our judgements about each of the main services

Service Rating Summary of each main service

Surgery Good ––– We rated this service good in safe, caring, responsiveand well-led and outstanding in effective.

Summary of findings


Contents

PageSummary of this inspectionBackground to St Catherine's Health Centre 7

Our inspection team 7

Information about St Catherine's Health Centre 7

The five questions we ask about services and what we found 9

Detailed findings from this inspectionOverview of ratings 13

Outstanding practice 30

Areas for improvement 30

Summary of findings


St Catherine's Health Centre

Services we looked atSurgery

StCatherine'sHealthCentre

Good –––


Background to St Catherine's Health Centre

St Catherine's Health Centre is a registered location forSpamedica Ltd and is located within St Catherine’s healthcentre. The service opened in 2014. It is a private clinic inBirkenhead, Merseyside. The clinic primarily serves thecommunities of the Merseyside and the surroundingareas offering cataract surgery and

yttrium-aluminium-garnet laser (YAG) capsulotomyservices for NHS patients (YAG capsulotomy is a speciallaser treatment used to improve your vision after cataractsurgery). The registered manager had been in post sinceFebruary 2019. However, the service has had a registeredmanager in post since it opened.

Our inspection team

The team that inspected the service comprised a CQClead inspector and one other CQC inspector. Theinspection team was overseen by Judith Connor, Head ofHospital Inspection.

Information about St Catherine's Health Centre

The service was located on the third floor of a sharedbuilding. It has one operating theatre, consulting roomsand two waiting areas and is registered to provide thefollowing regulated activities:

• Diagnostic and screening procedures

• Surgical procedures

• Treatment of disease, disorder and injury

During the inspection, we visited all areas. We spoke with12 staff including registered nurses, health caretechnicians, optometrist and senior managers. We spokewith eight patients and three relatives. During ourinspection, we reviewed five sets of patient records andfive staff files.

There were no special reviews or investigations of thehospital ongoing by the CQC at any time during the 12months before this inspection. The service has notpreviously been rated.

In the reporting period July 2018 to June 2019 there were:

• 2,839 visits in the operating theatre

• There were 4,002 day case episodes of care recordedat the hospital.

• There were 5,097 outpatient total attendances.

• All patients were NHS-funded.

Two surgeons worked regularly at the hospital underpractising privileges. There were seven registered nursesemployed, two optometrist, nine healthcare techniciansand five patient co-ordinator who worked across twolocations in the Merseyside area.

Track record on safety

• No Never events

• There were no serious incidents, no deaths and noincidents classified as severe harm.

• No incidences of hospital acquiredMeticillin-resistant Staphylococcus aureus (MRSA)

• No incidences of hospital acquiredMeticillin-sensitive Staphylococcus aureus (MSSA)

• No incidences of hospital acquired Clostridiumdifficile (c.diff)

• No incidences of hospital acquired E-coli

The service had received two complaints between August2018 and July 2019.

Services provided at the clinic under service levelagreement:

Summaryofthisinspection

Summary of this inspection


• Out of hours call handlers

• Sterilisation / Decontamination

• Interpreter services

• Laundry service

• Pharmacy




The five questions we ask about services and what we found

We always ask the following five questions of services.

Are services safe?We rated it as Good because:

• The service provided mandatory training in key skills to all staffand made sure everyone completed it.

• Staff understood how to protect patients from abuse and theservice worked well with other agencies to do so. Staff hadtraining on how to recognise and report abuse, and they knewhow to apply it.

• The service controlled infection risk well. The service usedsystems to identify and prevent surgical site infections. Staffused equipment and control measures to protect patients,themselves and others from infection. They kept equipmentand the premises visibly clean.

• The maintenance and use of facilities, premises and equipmentwere designed to keep people safe. Staff were trained to usethem. Staff managed clinical waste well.

• Staff completed and updated risk assessments for each patientand removed or minimised risks. Staff identified and quicklyacted upon patients at risk of deterioration.

• The service had enough staff with the right qualifications, skills,training and experience to keep patients safe from avoidableharm and to provide the right care and treatment. Managersregularly reviewed and adjusted staffing levels and skill mix,and gave agency staff a full induction.

• The service had enough medical staff with the rightqualifications, skills, training and experience to keep patientssafe from avoidable harm and to provide the right care andtreatment.

• Staff kept detailed records of patients’ care and treatment.Records were clear, up-to-date, and easily available to all staffproviding care.

• The service used systems and processes to safely prescribe,administer, record and store medicines.

• The service managed patient safety incidents well. Staffrecognised incidents and near misses and reported themappropriately. Managers investigated incidents and sharedlessons learned with the whole team and the wider service.Managers ensured that actions from patient safety alerts wereimplemented and monitored.

However, we also found the following issue that the service providerneeds to improve:

Good –––




• Patient records were not always stored securely.

Are services effective?We rated it as Outstanding because:

• Staff monitored the effectiveness of care and treatment. Theyused the findings to make improvements and achievedoutcomes for patients that were consistently better than thenational average and were benchmarked well against otherproviders.

• Key services were available seven days a week including aconsultant-led 24-hour advice line to support timely patientcare. Additional appointments were scheduled at weekends tomeet patient demand.

• The service provided care and treatment based on nationalguidance and best practice. Managers checked to make surestaff followed guidance.

• Staff offered patients enough food and drink to meet theirneeds and maintain their health.

• Staff assessed and monitored patients regularly to see if theywere in pain and gave pain relief in a timely way.

• The service made sure staff were competent for their roles.Managers appraised staff’s work performance and heldsupervision meetings with them to provide support anddevelopment.

• Doctors, nurses and other healthcare professionals workedtogether as a team to benefit patients. They supported eachother to provide good care. The service engaged with externalstakeholders to enhance the patient experience.

• Staff gave patients practical support and advice to leadhealthier lives.

• Staff supported patients to make informed decisions abouttheir care and treatment. They followed national guidance togain patients’ consent. They knew how to support patients wholacked capacity to make their own decisions or wereexperiencing mental ill health.

Outstanding –

Are services caring?We rated it as Good because:

• Staff treated patients with compassion and kindness, respectedtheir privacy and dignity, and took account of their individualneeds.

• Staff provided emotional support to patients, families andcarers to minimise their distress. They understood patients’personal, cultural and religious needs.

Good –––




• Staff supported and involved patients, families and carers tounderstand their condition and make decisions about theircare and treatment.

Are services responsive?We rated it as Good because:

• The service planned and provided care in a way that met theneeds of local people and the communities served. It alsoworked with others in the wider system and local organisationsto plan and deliver care.

• The service was inclusive and took account of patients’individual needs and preferences. Staff made reasonableadjustments to help patients access services. They coordinatedcare with other services and providers.

• People could access the service when they needed it andreceived the right care promptly. Waiting times from referral totreatment and arrangements to treat patients were in line withthe national standard.

• It was easy for people to give feedback and raise concernsabout care received. The service treated concerns andcomplaints seriously, investigated them and shared lessonslearned with all staff. The service included patients in theinvestigation of their complaint

Good –––

Are services well-led?We rated it as Good because:

• Leaders had the skills and abilities to run the service. Theyunderstood and managed the priorities and issues the servicefaced. They were visible and approachable in the service forpatients and staff. They supported staff to develop their skillsand take on more senior roles.

• The service had a vision for what it wanted to achieve and astrategy to turn it into action, developed with all relevantstakeholders. The vision and strategy were focused onsustainability of services and aligned to local plans within thewider health economy. Leaders understood and knew how toapply them and monitor progress.

• Staff felt respected, supported and valued. They were focusedon the needs of patients receiving care. The service promotedequality and diversity in daily work, and provided opportunitiesfor career development. The service had an open culture wherepatients, their families and staff could raise concerns withoutfear.

Good –––




• Leaders operated effective governance processes, throughoutthe service and with partner organisations. Staff at all levelswere clear about their roles and accountabilities and hadregular opportunities to meet, discuss and learn from theperformance of the service.

• Leaders and teams used systems to manage performanceeffectively. They identified and escalated relevant risks andissues and identified actions to reduce their impact. They hadplans to cope with unexpected events. Staff contributed todecision-making to help avoid financial pressurescompromising the quality of care.

• The service collected reliable data and analysed it. Staff couldfind the data they needed, in easily accessible formats, tounderstand performance, make decisions and improvements.The information systems were integrated and secure. Data ornotifications were consistently submitted to externalorganisations as required.

• Leaders and staff actively and openly engaged with patients,staff, the public and local organisations to plan and manageservices. They collaborated with partner organisations to helpimprove services for patients.

• All staff were committed to continually learning and improvingservices. They had a good understanding of qualityimprovement methods and the skills to use them. Leadersencouraged innovation and participation in research.

However

• Policies were not consistently reviewed within documentedtimelines.




Overview of ratings

Our ratings for this location are:

Safe Effective Caring Responsive Well-led Overall

Surgery Good Good Good Good Good

Overall Good Good Good Good Good

Detailed findings from this inspection


Safe Good –––

Effective Outstanding –

Caring Good –––

Responsive Good –––

Well-led Good –––

Are surgery services safe?

Good –––

Mandatory training

The service provided mandatory training in key skillsto all staff and made sure everyone completed it.

Annual mandatory training for all staff included topics suchas health, safety and welfare, conflict resolution, basic lifesupport with automated external defibrillation (AED),moving and handling (level two), information governance,infection control, and fire safety. Training was accessedeither via e-learning or within a classroom setting.

Compliance with mandatory training was monitored by adesignated lead in training who was based at anotherlocation. Data provided at the time of inspection showed100% compliance for all clinical and non-clinical staff.

Staff were expected to complete mandatory core ofknowledge laser safety training every three years. Dataprovided showed that 14 of the expected 23 staff hadcompleted the training within the past three years, inaddition to four members of staff who had completed it inOctober 2016.

There were five members of staff who had not completedthe training, this included four who had recently beenrecruited. The hospital manager told us since therecruitment of the new external laser protection advisor(LPA) they were looking at arranging further refreshertraining of core of knowledge training.

Safeguarding

Staff understood how to protect patients from abuseand the service worked well with other agencies to doso. Staff had training on how to recognise and reportabuse, and they knew how to apply it.

The hospital manager was the safeguarding lead and hadcompleted level three in safeguarding of vulnerable adults.The director of clinical services was a registered nurse andwe were provided with evidence that they had completedlevel four safeguarding training after our inspection.

All staff had completed safeguarding children (level two)and safeguarding of vulnerable adults (level one and leveltwo) and apart from one recently recruited trained nursewho had not yet completed safeguarding of vulnerableadults level two.

Four members of staff including the hospital manager hadcompleted level three in safeguarding of vulnerable adults.

Training in safeguarding was provided via e-learning,however, following our inspection we were informed thedirector of clinical services was looking into arranging faceto face training for staff.

Staff had access to a safeguarding policy for adults and aseparate policy for children that had recently beenupdated. The policies included guidance for staff inrelation to types of abuse, individual’s roles orresponsibilities, what staff should do if a person disclosesthey are being abused or they suspect abuse; also, therewas reference to an app held on computers across theorganisation with contact details of local authoritysafeguarding teams. However, the safeguarding policy forchildren we reviewed referenced the intercollegiateguidance 2014 rather than the updated 2019. It did notinclude reference to working together to safeguard children(2018).

Surgery

Surgery

Good –––


During our inspection, staff we spoke to understood theirresponsibilities around keeping patients safe and told usthey would escalate any concerns they had to theirmanager.

We observed advice regarding escalating safeguardingconcerns displayed in the waiting area and consultingrooms and staff told us they could access contact details oflocal authority safeguarding services on the computer.

The service confirmed there had been no safeguardingreferrals in the last 12 months.

Cleanliness, infection control and hygiene

The service controlled infection risk well. The serviceused systems to identify and prevent surgical siteinfections. Staff used equipment and controlmeasures to protect patients, themselves and othersfrom infection. They kept equipment and thepremises visibly clean.

The provider had a designated lead (chief operating officer)along with a recently recruited nurse lead in infectioncontrol. We were told there was nominated link staffmember who had received additional infection controltraining.

The hospital manager confirmed there was an agreementin place with a microbiologist to work across theorganisation to give advice and guidance.

Staff had access to an infection control policy that providedguidance for staff follow for example hand washing andwaste disposal along with management of incidents suchas sharps injuries.

All areas we visited along with equipment were visiblyclean.

Patients had access to personal protective equipment suchas gloves and surgical attire. Staff were observed to adhereto the arms below elbow policy in clinical areas.

Staff and patients had access to hand gel and during ourinspection we observed staff washing their hands andcleaning equipment before and after patient care.

Data provided showed there had been no incidences ofMethicillin-resistant Staphylococcus aureus (MRSA),Methicillin-sensitive Staphylococcus aureus (MSSA),Clostridium difficile (C.Difficile) or E-coli reported from July2018 to June 2019.

The service had service level agreements in place withexternal companies for cleaning and laundry services.

The provider had a service level agreement in place with anexternal company to check air flow systems in theatre. Weobserved a report from March 2019 that concluded all testresults were satisfactory.

Environment and equipment

The maintenance and use of facilities, premises andequipment were designed to keep people safe. Staffwere trained to use them. Staff managed clinicalwaste well.

Staff had access to laser safety local rules specific to theservice to support staff and to ensure the safety of staff andpatients using the YAG laser were stored within the roomthat laser procedures were performed. This included theuse of goggles and signage about laser safety and weobserved these were available during our inspection.

There were processes in place to ensure the traceability oflens implants. Each lens had four identity stickers.Following surgery, one was placed in the patient’s records,one in the operations’ register stored in the theatre, oneplaced in the track and traceability register and the fourthwas placed in a lens replenishment folder to aid stockcontrol.

Electrical safety testing was completed by an externalprovider. We reviewed the asset log and found allequipment had been tested within the expected date.

In each room, environmental temperature was checkedand recorded daily. There were also daily check lists foreach room. These had been completed in each roomvisited. In theatre, humidity was checked daily also.However, we observed this was recorded on the roomtemperature and fridge recording sheet that did notdocument the expected humidity range. We raised this atinspection. The area manager confirmed there was nospecific form to log this information, but they were going totrial a new system that recorded the temperature andhumidity in theatre electronically.

Resuscitation equipment, including a defibrillator waslocated within easy reach of all rooms at the location. Wereviewed daily and weekly checklists for the previous threemonths and observed these had been completed.

Surgery

Surgery

Good –––


However, we observed consumables (green needles and anasopharyngeal tube) had exceeded the expiry date ofNovember 2019. We raised this at inspection and thesewere removed and replenished immediately.

We observed that the disposal of sharps, such as needlesticks followed good practice guidance. All sharpscontainers we observed were dated and signed uponassembling them with the temporary closure in place apartfrom in theatre as this was being used at the time.

Assessing and responding to patient risk

Staff completed and updated risk assessments foreach patient and removed or minimised risks. Staffidentified and quickly acted upon patients at risk ofdeterioration.

There was an optometrist who was the designated laserprotection supervisor (LPS) at this location. The service hadrecently recruited a new external laser protection advisor(LPA) who had conducted an audit and a RAG riskassessment in November 2019. We were provided with anupdated risk assessment and observed actions had eitherbeen completed or were going to be discussed at theclinical effectiveness group meeting in December 2019.

Information relating to the procedure and process was sentout to the patient and we were told if any additionalinformation was required relating to the patient, thereferring clinician were contacted.

Staff had access to guidance in relation to patients withspecific conditions such as diabetes and advice on theprocess for patients with latex allergies. During ourinspection we observed staff asking patients regardingcurrent medical conditions and allergies and observed apatient wearing a red risk band to highlight an allergy.

Data provided stated all patients were required to have apre-assessment performed to provide information to thesurgeon and ensure they were suitable for surgery, theprocess included:

• Ocular coherent topography (OCT) scans on patientswho had presented with or had any previous retinalpathology.

• A detailed eye examination pre-operatively. The imagesproduced could identify other eye related disease fordiagnosis.

• A biometry test to calculate the power of the lens thatwill be implanted during the cataract operation.

• An A-scan test that measured the length of the patientseye to determine the lens selection for patients withdense cataracts.

• An epithelial cell count (ECC) was performed beforesurgery for patients who were at higher risk ofdeveloping corneal issues post operatively.

• Corneal topography map on those patients who hadpresented with corneal problems pre-operatively toassist with prognosis.

• A couch test to ensure they could lie flat for a period oftime during their procedure.

Patients who were at a higher risk of complications wereidentified during their pre-assessment. We were toldpatients with a risk score of 8% and above of posteriorcapsule rupture were added to the complex case list with aspecialist vitreoretinal surgeon performing the procedureat another location in the north west.

Data provided showed seven complex patients had beenredirected to the other location for their treatment fromJuly 2018 to June 2019.

The service had recently introduced daily safety huddles todiscuss staff responsibilities, theatre lists and any concerns.

Operation sites were clearly marked and a revised versionof the World Health Organisation (WHO) Surgical SafetyChecklist for cataract surgery was used to keep patientssafe.

We were told quarterly audits of the WHO checklist wereperformed and observed 100% compliance for auditsperformed in February, April and July 2019.

The service offered a 24-hour clinical emergency supportservice for patients. Calls were triaged by an optometristand advice given and any concerns were escalated to aspecialist doctor on call.

Data showed that all qualified nursing staff had completedtraining in advanced life support in 2018. However, we weretold training requirements for life support had changed anda recent decision had been made that it was more relevantfor staff to attend immediate life support training. Dataprovided showed seven qualified nurses had attended thistraining so far.

Surgery

Surgery

Good –––


The hospital manager told us simulation emergencyexercises including cardiac arrest were facilitated by amember of the resus council and we observed this wasdocumented as part of the audit matrix with a recordedpass in January 2019. The hospital manager confirmed theservice also passed one performed in September.

The hospital manager told us simulated emergencyexercises were performed twice a year but there were plansto increase to quarterly. We observed, in thecardiopulmonary resuscitation policy, that there should bea minimum quarterly emergency simulation conducted.

Each treatment room had a phone that had a tannoyfacility. In the event of an emergency, a call could be madeto alert other staff at the location.

Nursing and support staffing

The service had enough staff with the rightqualifications, skills, training and experience to keeppatients safe from avoidable harm and to provide theright care and treatment. Managers regularlyreviewed and adjusted staffing levels and skill mix,and gave agency staff a full induction.

The service had seven registered nurses, nine health caretechnicians, two optometrist and five patient co-ordinatorswho worked across two locations in the Merseyside area.

We were told at the time of inspection there was 1.5 wholetime equivalent vacancies for registered nurses andinterviews were due to be conducted the following week.

We reviewed examples of rotas and saw that it was clearlyidentified what activities were planned including any newstarters or training as well as clinics and surgery. Staff wereallocated to the planned activities.

Staff sickness for registered nurses during August 2018 toJuly 2019 was 0%, apart from October 2018 (8%) and April2019 (2%). For the same time period staff sickness foruntrained staff was 0% apart from September (5.5%),December 2018 (2.5%) and April 2019 (2%). The service didnot have a target.

Data provided showed from August 2018 to July 2019 theuse of agency trained nurses in theatre ranged from 0% to5% apart from September 2018 that reported 20%. For the

same reporting period the use of agency trained nurses inoutpatients was reported as 0% apart from May 2019 (7%)and June 2019(13%). No other staff groups reported anyagency use.

The hospital manager confirmed agency staff was mainlyused in theatre and the same agency staff were used. Noother staff groups reported any agency use.

Data showed there were no unfilled shifts from May 2019 toJuly 2019.

From August 2018 to July 2019 turnover for all staff intheatre was 0%.

Medical staffing

The service had enough medical staff with the rightqualifications, skills, training and experience to keeppatients safe from avoidable harm and to provide theright care and treatment.

The service employed 12 consultant ophthalmologistsunder practising privileges, of those six had performedbetween 10 and 99 episodes of care and six had performedover 100. The granting of practising privileges is awell-established process within independent healthcarewhereby a medical practitioner is granted permission towork in an independent hospital or clinic, in independentprivate practice, or within the provision of communityservices.

Records

Staff kept detailed records of patients’ care andtreatment. Records were clear, up-to-date, and easilyavailable to all staff providing care. However, thesewere not always stored securely.

Patient details were collected and stored on theorganisations electronic records system. This includedinformation following pre-assessment, theatre, dischargeand post-operative care. Paper records were maintained forconsent, demographics, copy of biometry, outcome formsand referrals. All scans could be viewed electronically.Biometry scans could be viewed electronically as well asprinting of hard copies if required at the hospital.

In the three months prior to inspection, 100% of recordswere available for appointments.

On the day of inspection, we observed a set of patientrecords in a clear plastic cover stored in plastic filing tray on

Surgery

Surgery

Good –––


top of the reception desk. We observed reception staffwithin close proximity and were always present at thereception desk. However, there was still a risk that patientrecords could be viewed or accessed by unauthorisedpersons. We raised this at the time of inspection and thepatient records and plastic filing box were removed tobehind the reception desk.

Computer monitors could only be viewed by receptionstaff.

Records followed patients and stayed in rooms with staff.

Confidential waste was placed in shredding bins availableon site.

Data provided stated in the event of a misplaced medicalrecord, the patient would be re-consented on the day ofsurgery and diagnostics and referrals could be re-printed.Any misplaced or missing patient record incidents wouldbe logged on the electronic incident reporting system andan investigation commenced.

We reviewed records for five patients and found they hadbeen completed appropriately.

A records audit, in March 2019 and June 2019 reportedcompliance of 95% and 90%. We reviewed an audit of 20patient records performed in July 2019 and observedcompliance was 90% with three WHO checklists not signedby the surgeon and one with no printed name. The hospitalmanager told us following this audit , amendments hadbeen made to the WHO checklist. However, we did notobserve a version control on the WHO checklist andtherefore it wasn’t clear what version what being currentlyused.

Data provided stated designated staff with authorityarranged for patients medical records to be removed fromsite in secure locked transport carriage boxes by theorganisations internal transport service. Each transferredpatient record was recorded by completing a file transferform along with entering the details on the organisationspatient administration system (PAS) system with the datethe request of transfer and the date received at specifiedlocation. The recipient confirmed receipt of the patientrecord as soon as it arrived by signing the file transfer form.Confirmation the patient record had been stored in thepatient records area of the required location was alsorecorded.

All paper records of discharged patients were scanned andindexed to be retrieved on request for planned follow upappointments. All clinical diagnoses and episodes oftreatment records were stored electronically and wereavailable at all sites in the case of an unplanned follow up.

We were informed patient records were sent externally bycourier via recorded delivery. A log of all records dispatchedfrom the patient records department included the datesent, name, designation and location of person to whomthe records were sent, service username and volume ofrecords sent.

Medicines

The service used systems and processes to safelyprescribe, administer, record and store medicines.

The service used topical and local anaesthesia to the eyeonly. Drops were prescribed using patient specificdirections (PSD). These were administered by health caretechnicians who recorded on the paper PSD and also in thepatients electronic record.

We reviewed four PSD and found these to be completedincluding date, surgeons signature and name and GMCnumber printed.

We reviewed five prescriptions and noted that staff hadsigned to confirm they had administered the eye drop.However, we observed on one prescription both the nurseand surgeon’s signature were illegible. Names were notprinted and on another prescription the nurse’s signaturewas illegible with no printed name, therefore it was notclear who had administered the medicines. On eachprescription there was an area to document the surgeonsGMC number. However, this was not completed in allprescriptions we reviewed. We raised our observations oninspection.

The medicines management policy was reviewed andreferred to patient group directions as well as PSD’s. Thecompany were planning to implement PGD’s followingagreement from local commissioning authorities. A patientgroup direction (PGD) is a written instruction that includesthe administration of medicines to groups of patients whomay not be individually identified before presentation fortreatment. The service had plans to introduce PGD’sfollowing consultations with commissioners.

There was a service level agreement in place with anexternal pharmacy provider.

Surgery

Surgery

Good –––


The service stored diazepam to be available for patientswho were identified as anxious prior to surgery. It wasstored appropriately, and records completed for checkingand administration. The prescribing of diazepam wasincluded on the prescription chart with other medicinesgiven following PSD’s. We observed a recently updatedversion showed clear documentation of what time thediazepam was administered if it was required.

Data provided prior to inspection confirmed there was nocontrolled drug accountable officer (CDAO). However, atthe time of inspection we were provided with data thatconfirmed the director of clinical services and the hospitalmanager had recently attended accountable officertraining.

The medicines we sampled, in cupboards and fridges, wereall within their expiry dates.

The temperature of the clinical fridge was monitored andrecorded appropriately, including the maximum andminimum ranges. The hospital manager told in August2019 they had noted the recordings had been documentedas out of range and were not always being escalated. Thehospital manager told us they took immediate action andsought advice from the pharmacist and had the fridge waschecked by the manufacturer who confirmed there were noissues. The service had recently received a new fridge. Weobserved in team meeting minutes that staff werereminded to escalate any out of range temperaturesimmediately.

During our inspection we reviewed fridge temperaturechecks from October 2019 to December 2019 and observedthese were recorded within range.

A medicines audit was carried out in September 2019, bythe external pharmacy company where a number ofrecommendations were made. The action plan showedthat the majority of actions had been completed. We couldnot see evidence if another audit had been planned.

Patients were provided with discharge medicines of drops.These were labelled for dispensing and includedmanufacturer’s instructions. Staff checked that patientswere confident with administering the drops.

Trained nurses received training in dispensing medicinesand data provided showed four nurses had completed thetraining with an additional recently recruited nurseplanned to attend the training as part of theircompetencies.

Data received showed between March 2018 and February2019 there was one near miss medicine incident relating toa patient who had a documented allergy. The incidentresulted in no harm and we observed this has beenreported as an incident, investigated and action taken toprevent it from occurring again.

The hospital manager told us there had been anothermedicine incident reported recently in relation to incorrectlabelling that was identified on a second check. Thisresulted in no harm and we observed action had beentaken to prevent it from occurring again.

Incidents

The service managed patient safety incidents well.Staff recognised incidents and near misses andreported them appropriately. Managers investigatedincidents and shared lessons learned with the wholeteam and the wider service. Managers ensured thatactions from patient safety alerts were implementedand monitored.

Safety alerts were managed and monitored by the directorof clinical services. During our inspection we observed arecent safety alert had been sent out and appropriateaction had been taken by the hospital manager.

Guidance for staff to follow in relation to reporting andmanaging incidents was documented within the seriousuntoward incident policy and the critical incident policy.The serious untoward incident policy includedresponsibilities around duty of candour and we observedthis was due to be reviewed April 2019.

Incidents and near misses were reported on the electronicreporting system and the hospital manager wasresponsible for review and if required, investigating.

The service had reported no serious incidents or neverevents reported from July 2018 to June 2019.

Surgery

Surgery

Good –––


Never events are serious incidents that are whollypreventable as guidance or safety recommendations thatprovide strong systematic barriers are available as at anational level and should have been implemented by allhealthcare providers.

Data provided prior to our inspection showed from July2018 and June 2019 the service reported 42 clinicalincidents, of those

• 38 resulted in no harm

• 4 low harm.

During the same reporting period, the service reported twonon-clinical incidents in relation to power failure.

Staff received feedback from investigation of incidents andlessons learned were shared.

Staff we spoke to were aware of the principles of duty ofcandour and had access to a recently revised policy. Theduty of candour is a regulatory duty that relates toopenness and transparency and requires providers ofhealth and social care services to notify patients (or otherrelevant persons) of certain ‘notifiable safety incidents ‘andprovide reasonable support to that person

Are surgery services effective?

Outstanding –

Evidence-based care and treatment

The service provided care and treatment based onnational guidance and best practice. Managerschecked to make sure staff followed guidance.

The service followed the Royal College of Ophthalmologists(RCOphth) standards.

There were policies and standard operating procedures inplace to support practice on the organisations intranet thatwas accessible to all staff.

The service carried out quarterly clinical audits thatcovered key topics. We were told any audits that were lessthan 90% compliant, had actions identified, and the auditwas repeated one month later.

The clinical audit process was undergoing a national reviewas part of a recently drafted clinical governance strategy.

The service provided an audit matrix that included handhygiene, clinical room audit, infection control, fridgetemperatures and emergency equipment in theatre. Datashowed compliance above 90% on audits performed fromJanuary to July 2019 apart from two audits in April (theatretrolley, emergency drawer and IOP Drawer) that reported acompliance of 80%.

The services referral to treatment target was six to sevenweeks. Activity was monitored through the operationsmeeting and the hospital manager reviewed activity on adaily basis and actioned or escalated any issues.

Nutrition and hydration

Staff offered patients enough food and drink to meettheir needs and maintain their health.

Hot and cold drinks and biscuits were available in waitingareas free of charge for patients and those accompanyingthem.

Pain relief

Staff assessed and monitored patients regularly to seeif they were in pain and gave pain relief in a timelyway.

Patients were administered local anaesthetic and painrelief during their procedure.

Following surgery, patients were asked about theirexperience including pain and comfort and this was fedinto the patient reported outcome measures (PROMS).

Data provided showed from July 2018 to June 2019 2220patients were asked about pain. Of those, 2135 of patientsreported no pain, 78 reported mild pain, six reportedmoderate pain and one patient reported severe pain. Wewere told the hospital manager received an email alert ifpatient’s pain was recorded as moderate or above and thehospital manager would then go and speak to the patient.The area manager confirmed the severe pain was recordedin error. However, if they identified any concerns such as aheadache they would ask the surgeon to review.

Patients were provided with a leaflet which gave advice onexpected post-surgery symptoms and guidance if excessiveor increased pain is experienced. During our inspection, wealso observed staff discuss the contents of the booklet tothe patient.

Patient outcomes

Surgery

Surgery

Good –––


Staff monitored the effectiveness of care andtreatment. They used the findings to makeimprovements and achieved outcomes for patientsthat were consistently better than the nationalaverage.

The service submitted data for inclusion in the NationalOphthalmic Database Audit (NODA).

Data submitted by the provider showed the service hadachieved significantly better outcomes for patientscompared to national standards for the 2,472 patients whohad cataract surgery performed from July 2018 to June2019:

• the adjusted posterior capsular rupture rate was 0.3% (National 1.1%)

• the visual acuity loss rate was 0.4% (National < 0.9%)

• 6/12 vision or better 96.82% (national target >95%)

• refractive outcome within 1D 93.16% (RCOphth >85%).

Outcomes were benchmarked across the organisation, aswell as externally, that identified good practice and areasfor support and focus.

The provided submitted data to The European Registry ofQuality Outcomes for Cataract and Refractive Surgery(EUREQUO). This was a database for providers, tobenchmark outcomes across Europe.

Competent staff

The service made sure staff were competent for theirroles. Managers appraised staff’s work performanceand held supervision meetings with them to providesupport and development.

Staff were experienced, qualified and had the right skillsand knowledge to meet the needs of patients.

New starters attended a corporate two day induction thatwas delivered at the providers headquarters. The inductionincluded shadowing a patient through their journey.

Managers made sure staff received any specialist trainingand induction for their role.

The service had a skills matrix with role allocatedcompetencies for each member of staff to complete forexample training in specific equipment and administeringeye drops.

The training was facilitated by a designated training teamat the providers headquarters.

During our inspection we observed staff being supportedthrough their competencies. Staff told us there was abuddying up system and there was always someonearound to ask any questions if they needed any advice.

Newly appointed surgeons had a period of supervisedpractice under a lead surgeon. The service monitoredquarterly comparative complications, infection rates andpatient bedside manner for surgeons using a RAG ratingtool. Any concerns were managed directly.

Surgeons and optometrists performance was monitoredand reviewed at governance and medical advisorycommittee meetings that focussed on outcomes as well aspatient experiences.

Staff told us they felt supported to develop their roles andskills.

Data showed all staff had received their annual appraisal.

Multidisciplinary working

Doctors, nurses and other healthcare professionalsworked together as a team to benefit patients. Theysupported each other to provide good care. Theservice engaged with external stakeholders toenhance the patient experience.

During our inspection we observed good interaction and apositive working environment with all staff and patients.

Effective working with external stakeholders, commissions,opticians and GP’s.

Multidisciplinary daily morning huddles and debriefs wereheld in the hospital led by the clinical lead on the day,normally the registered manager to plan and review theday's activities collectively.

Seven-day services

Key services were available seven days a weekincluding a 24-hour advice line to support timelypatient care. Additional appointments werescheduled at weekends to meet patient demand.

The service was opened six days a week and the areamanager told us this could be extended to seven days.However, this had never been required.

Surgery

Surgery

Good –––


Post-operative patients had access to a 24-hour, seven dayon-call service for advice and assistance. The phone callswere triaged by nurses and optometrists.

There was an on-call team consisting of a consultant andregistered nurse who could see the patient at a hospital forreview or treatment.

Health promotion

Staff gave patients practical support and advice tolead healthier lives.

Patients were given discharge advice both verbally andwritten leaflets that included advice about keeping the eyeclean as well as driving or operating machinery.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

Staff supported patients to make informed decisionsabout their care and treatment. They followednational guidance to gain patients’ consent. Theyknew how to support patients who lacked capacity tomake their own decisions or were experiencingmental ill health.

The provider had a Mental Capacity Act policy and aconsent policy that provided guidance for staff to follow.

Data provided showed from January 2018 all clinical staffand non-clinical staff had attended training in the mentalcapacity act that. Data provided stated staff were expectedto attend the training three yearly unless there was achange in legislation.

We were told senior optoms, two trained staff and twohealth care technicians were scheduled to attend a ‘bestinterest decision course’ in December 2019.

If patients lacked capacity to make their own decisions staffassessed care in the best interests of patients and involvedtheir representatives and other healthcare professionalsappropriately. This included referring back to the NHS forcare and treatment, including an independent mentalcapacity advisor (IMCA) where appropriate.

The service used a two-stage consent process. Thisincluding an initial consent being taken at thepre-assessment stage and a second stage by the consultanton the day of surgery.

Staff made sure patients consented to treatment based onall the information available.

Written consent was obtained prior to surgery and weobserved consent clearly documented in the four recordswe reviewed.

During our inspection, we observed practice of obtainingconsent and noted staff checked patients understanding oftheir reason for attendance.

There was an interpreter service available to help withconsent for patients whose first language was not English,these were pre-booked to provide either face to face ortelephone support. Staff told us, they would not use familymembers for interpretation.

Are surgery services caring?

Good –––

Compassionate care

Staff treated patients with compassion and kindness,respected their privacy and dignity, and took accountof their individual needs.

Staff took time to interact with patients and those close tothem in a respectful and considerate way.

Patients said staff treated them well and with kindness andone patient told us they experienced back problems andstaff had taken the time to ensure they were comfortableon the operating table and had placed a pillow under theirlegs.

Compliments were recorded on the organisationselectronic reporting system shared at clinical governancemeetings.

We observed seven patients, during consultations withdifferent staff members and observed all introducedthemselves to the patient and explained all care andtreatment.

Patients were respected and their privacy and dignity wasmaintained. We observed staff communicating withpatients and their families in a respectful and consideratemanner.

Surgery

Surgery

Good –––


Engaged signs were on consulting room doors to show apatient was in a consultation. However, we observed thisdid not always stop staff knocking and walking in.

On the day of our inspection, staff told us a patient whohad previous surgery on one eye was booked in toattended for pre-operative assessment for the other.However, they believed they were coming in for surgery onthat day. Staff told us the patient and family weredistressed due to ongoing health concerns andarrangements were made for the patient to have surgery onthe same day.

The service submitted feedback data to the NHS Friendsand Family Test. Between February 2019 and July 2019,between 99% and 100 % of patients would recommend theservice, with a response rate ranging from 86% to 95%.

Emotional support

Staff provided emotional support to patients, familiesand carers to minimise their distress. Theyunderstood patients’ personal, cultural and religiousneeds.

Staff gave patients and those close to them help, emotionalsupport and advice when they needed it.

One patient told us they felt anxious prior to attending forsurgery. However, just by talking to the staff they told us feltmuch calmer and had the opportunity to ask questionsthat were worrying them.

During our inspection, we observed patients being offereda ‘hand holder’ during their procedure and staff gavereassurance throughout their procedure.

On the organisations website we observed there werevideos of previous patient who described their experienceof the patient journey.

Understanding and involvement of patients and thoseclose to them

Staff supported and involved patients, families andcarers to understand their condition and makedecisions about their care and treatment.

Staff made sure patients and those close to themunderstood their care and treatment.

Staff talked with patients, families and carers in a way theycould understand.

Patients and their families could give feedback on theservice and their treatment and staff supported them to dothis.

During our inspection, we observed staff explain clearly tothe patient what to expect at each stage the process andoffered reassurance. Staff ensured patients werecomfortable and did not feel rushed.

Patients we spoke with felt fully informed about what toexpect prior, during and following their procedure.

During our inspection we observed the receptionistchaperone a patient to a family members car as the familymember had very young children with them.

A chaperone policy had recently been introduced thatexplained staff roles and responsibilities and arrangementsfor a chaperone and hand holders were available duringtheir procedure. However, we did not see any signs in anyof the areas we visited explaining a chaperone service wasavailable. During our inspection, patients had attendedtheir appointments with their family.

Are surgery services responsive?

Good –––

Service delivery to meet the needs of local people

The service planned and provided care in a way thatmet the needs of local people and the communitiesserved. It also worked with others in the wider systemand local organisations to plan and deliver care.

Managers planned and organised services, so they met thechanging needs of the local population.

The service treated adult patients only, over the age of 18years and only elective patients according to theparameters set by their local commissioners.

Facilities and premises were appropriate for the servicesbeing delivered. However, reception staff told us they hadto assist staff from another provider to access their meetingrooms by pressing a buzzer located at the reception desk toopen the door and on occasions this impacted on theirtime assisting patients.

Surgery

Surgery

Good –––


There were two waiting areas with the larger waiting areaand reception desk located in open space, with staff fromanother provider passing to access their meeting rooms.There was also a smaller private waiting area that couldonly be accessed by Spamedica staff.

The hospital manager told us they had received nocomplaints from patients in relation to waiting for theirsurgery in the open waiting area and that patients hadexpressed a preference to waiting in the larger area ratherthan the smaller one. This was confirmed with the fivepatients we asked.

Patients confirmed they were given a choice ofappointment to suit their needs.

During July 2018 to June 2019 there were:

• 2,839 visits in the operating theatre

• There were 4,002 day case episodes of care recorded atthe hospital.

• There were 5,097 outpatient total attendances.

Information was available on the organisations websiteincluding how to get to the location via public transport orcar. Car parking facilities were available.

The service was routinely open six days per week, and wewere told extra lists could be added if there was anincreased demand.

The provider website included patient stories that could beviewed at home.

Meeting people’s individual needs

The service was inclusive and took account ofpatients’ individual needs and preferences. Staffmade reasonable adjustments to help patients accessservices. They coordinated care with other servicesand providers.

The hospital manager confirmed free patient and carertransport was offered to patients who lived more than tenmiles away. Drivers collected patients from their home witha reminder the day before of the expected time.

The service could accommodate bariatric patients up tothe weight of 250kg who were able to transferindependently on the theatre table. The area manager toldus the organisation were looking at the possibility ofproviding additional resources to be able to offer the

service out to people who required additional support,such as hoisting onto the theatre table and confirmed thedirector of clinical services had recently met with anexternal company to discuss trialling a mobile hoist to usein theatres. Lifts and disabled toilets were clearlysignposted and available along with wheelchairs, which wewere informed were suitable for bariatric patients.

There were 17 members of staff who worked across thisand another location who were dementia champions andhad completed dementia training.

For patients whose first language was not English,aninterpreter service was available either face to face or bytelephone. These were pre-booked when needed.

Written information was available in languages other thanEnglish, although the organisations website did not includea translation facility.

Leaflets could be accessed in formats such as larger print,however; there was no pictorial leaflets for patients with alearning disability or limited reading skills.

Access and flow

People could access the service when they needed itand received the right care promptly. Waiting timesfrom referral to treatment and arrangements to treatpatients were in line with the national standard.

Managers monitored waiting times and made sure patientscould access services when needed and received treatmentwithin agreed timeframes and targets.

Referrals were received by phone and we were told patientswere contacted within 48 hours to book an appointment.

Following confirmation of their appointment, patients weresent out written details of their appointment, this was thenfollowed up by a telephone call reminder 48 hours prior totheir attendance.

Patients were offered a choice of appointment, includingweekends. The services referral to treatment target was sixto seven weeks. Between July 2018 and June 2019, theaverage waiting time from referral to pre-assessment clinicwas 26 days. For the same time period, the average waitingtime between pre-assessment clinic and surgery was 25days.

Waiting times from time of arrival to departure througheach stage of the patient journey were monitored as part of

Surgery

Surgery

Good –––


key performance indicators to monitor and action if thereare areas that need addressing. Data provided showedduring July 2018 and June 2019 patients waited on averagebetween 16 and 23 minutes to be seen in thepre-assessment clinic and on average patients waited onaverage 17 minutes to be treated for YAG and 36 minutesfor cataract treatment.

During our inspection we observed a stand withinformation relating to a delay in waiting times. Staff toldus this would be displayed within the waiting area forpatients to see if there was an excessive delay.

The service had recently introduced a standard operatingpolicy for the management of patients who did not attendtheir appointments this included contacting the patientand their next of kin and sending a letter out with a furtherappointment.

Data provided showed during July 2018 to June 2019, 39procedures were cancelled due to non-clinical reasons, ofthose 4 were offered another appointment within 28 days.

The area manager told that the appointments werecancelled due to a failure of the uninterrupted powersupply (UPS) across the location that was managed byanother organisation and confirmed patients weretransferred and seen at another location in Merseyside.

We were told following the incident, an uninterruptedpower supply had been sought specifically for the serviceas an extra contingency in case of failure again across thebuilding.

During July 2018 to June 2019 there were 62 procedurescancelled due to clinical reasons, of those

• 39 received surgery on another day

• one was referred back to the optometrist

• 25 were referred back to their GP

For the same reporting period, data provided prior toinspection showed there were no unplanned returns totheatre.

Learning from complaints and concerns

It was easy for people to give feedback and raiseconcerns about care received. The service treated

concerns and complaints seriously, investigated themand shared lessons learned with all staff. The serviceincluded patients in the investigation of theircomplaint.

The service had a complaints policy that providedguidance for staff to follow in receipt of a verbal or writtencomplaint along with individual responsibilities andactions to take within set timelines.

The chief operating officer reviewed any investigation andthe hospital manager issued the final response letter to thepatient. The organisations electronic system included theinvestigation, relevant statements, documents and actionsor learnings. Trends and learning were shared at seniormeetings and cascaded to staff at daily huddles, email,newsletters and team meetings.

During our inspection we observed complaints leaflet inthe reception area and information on the website as howto complain to the service along with details of theParliamentary and Health Service Ombudsman (PHSO) ifthe complainant wasn’t satisfied with the response.

The hospital manager knew how to acknowledgecomplaints and patients received feedback from managersafter the investigation into their complaint.

Data provided showed the service received two complaintsduring August 2018 and July 2019 and were observed thesehad been investigated appropriately and neither had beenupheld.

Managers told us they shared feedback from complaintswith staff and learning was used to improve the service.

Are surgery services well-led?

Good –––

Leadership

Leaders had the skills and abilities to run the service.They understood and managed the priorities andissues the service faced. They were visible andapproachable in the service for patients and staff.They supported staff to develop their skills and takeon more senior roles.

Surgery

Surgery

Good –––


The organisation had a board that consisted of a chiefexecutive officer, chief operations officer, chiefimplementation officer, chief finance officer, medicaldirector and chief peoples officer.

The service was led by the experienced hospital managerwho had recently been promoted to area manager.However, they remained as hospital manager whilst thenewly recruited hospital manager was being inducted.

The recently recruited manager had worked at theorganisation for four years and told us they felt ‘massivelysupported’ in their transition from healthcare technician tohospital manager and told us senior managers visited thesite to offer support when the hospital manager was onannual leave.

There was a planned period of training, induction andmentorship. Both the recently recruited hospital managerand area manager told us they felt supported within theirrole by all levels of managers.

All staff we spoke to told us managers were visible andapproachable.

Vision and strategy

The service had a vision for what it wanted to achieveand a strategy to turn it into action, developed withall relevant stakeholders. The vision and strategywere focused on sustainability of services and alignedto local plans within the wider health economy.Leaders understood and knew how to apply them andmonitor progress.

The organisation vision and strategic objectives was everypatient, every time, no excuses, no exceptions. Their aimwas to deliver a world class service by excelling in the carestandards to ensure all patients are cared for safely andeffectively and to be the patients first choice for cataractassessment and surgery.

The organisation values were included in induction for allstaff.

Staff we asked were aware of the vision and strategicobjectives and told us the service was very ‘patientfocussed with emphasis on putting the patient first andpatient experience’.

Culture

Staff felt respected, supported and valued. They werefocused on the needs of patients receiving care. Theservice promoted equality and diversity in daily work,and provided opportunities for career development.The service had an open culture where patients, theirfamilies and staff could raise concerns without fear.

Staff felt fully supported by managers and we wereprovided with examples.

Staff told us they felt valued and were comfortable inraising concerns directly with their peers and manager andstaff shared examples of when this had happened.

Staff were proud of the department they worked in andproviding the service to patients.

During our inspection we observed positive workingrelationships and engagement with staff and patients.

Governance

Leaders operated effective governance processes,throughout the service and with partnerorganisations. Staff at all levels were clear about theirroles and accountabilities and had regularopportunities to meet, discuss and learn from theperformance of the service.

There was a process and policy in place to monitor andreview practising privileges for medical practitioners toensure standards were adhered and concerns escalated.This had been reviewed by the medical advisory committee(MAC). Surgeons were interviewed and their outcomes forpatients reviewed prior to forwarding recruitmentdocumentation. New applications were received with aprocess where individual applicants were reviewed andaccepted to supervised practice assessment, before havingpractising rights approved. The lead surgeon observed theapplicants during a trial operation list followed bysupervision with a limited number of patients initiallyincreasing to a maximum of 24.

The human resources team monitored individualconsultant files, checking registration with the GeneralMedical Council (GMC), professional indemnity, appraisalsand responsible officer reports. The MAC reviewed themonitoring processes with a responsible officer on theMAC.

Surgery

Surgery

Good –––


Following a recent inspection at another location, theprovider had recently updated the recruitment policy toreflect changes that included reference and health checksand were conducting risk assessments of medical staffemployed under practising privileges.

During our inspection we reviewed five staff files and foundevidence of a disclosure and barring check, health checks,references and employment history. However, there wasjust one reference in one surgeons file and we observed theprovider had completed a risk assessment.

There was a clear governance structure with clear roles andresponsibilities.

A director of clinical services had recently been appointedto focus on clinical leadership, quality and governancesupported by the quality assurance and risk manager(QARM). The director of clinical services reported to thechief operating officer.

As part of the organisations clinical governance strategythere was a planned review of the policies, procedures andprocesses and we observed some had not been reviewedwithin the documented date including consent policy,clinical governance policy and the compliance andretention of records policy that had last been reviewed inMay 2018 but did not have a documented date for nextreview.

The director of clinical services told us they were going tointroduce a new electronic system where policies would beuploaded, and it monitored which staff accessed alongwith the time to read each policy.

Significant incidents and themes were reported anddiscussed at the organisations national clinical governanceand clinical effectiveness bi-monthly meetings, medicaladvisory and health and safety committees.

We were told complaints were monitored by the executiveassistants, chief operating officer and director of clinicalservices. However, we observed complaints was not astandardised item on the agenda in the three clinicalgovernance meeting agenda’s we received.

The clinical audits were discussed at clinical governancemeetings. Changes to policy or practice were implementedby the clinical effectiveness group.

Monthly operations team meetings and clinical governancemeetings included representatives from all theorganisations locations. Regular agenda items werediscussed with actions identified.

Service level agreements between the provider andsuppliers were managed by the facilities team. We weretold the agreements along with dates for monitoring wereavailable on an internal system that could be accessed bythe hospital manager. We requested service levelagreements for the location and were provided with threein addition to one quote. We noted none of the service levelagreements were signed or dated by either party thereforeit was not clear if both parties had agreed to the service orif the contracts were indefinite.

There was a service level agreement in place with therecently recruited laser protection advisor (LPA). However,we observed this had not yet been signed. Local rules werein place that authorised operators of the YAG laser andsupport staff were required to read and sign. The areamanager told us only staff who had been in the YAG laserclinic since the recent introduction had signed the localrules. We observed these had been signed by sevenmembers of staff including the medical director, hospitalmanager and healthcare technicians.

Managing risks, issues and performance

Leaders and teams used systems to manageperformance effectively. They identified andescalated relevant risks and issues and identifiedactions to reduce their impact. They had plans to copewith unexpected events. Staff contributed todecision-making to help avoid financial pressurescompromising the quality of care.

Senior managers were committed to providing quality carefor patients. Surgical performance was monitored quarterlyon a dashboard that included outcomes of surgery andbedside manner using a RAG rated system.

The service had introduced a structure that encouragedparticipation from staff at all levels with meeting decisionscascaded to al staff and managers open to staffsuggestions.

The service had a business continuity plan that reflectedactions to take in response to untoward events effectingservice delivery such as equipment failure or cyber-attack.

Surgery

Surgery

Good –––


There was a process in place for any new risks added to therisk register to be escalated to senior managers.

The service had a risk register. We reviewed the risk registerand saw that each risk was accountable to the hospitalmanager. Control measures in place to reduce the riskalong with the date the risk was added and review date. Allrisks had been added in 2019 with the majoritydocumented as potential incidents or issues that mayoccur rather than a current actual risk. For example,‘sub-optimal treatment of any patient’, premisesunexpectedly not available and patients becoming unwellwithin their care.

Team meetings were held monthly at either one of the twolocations in Merseyside. The hospital manager told us theinvite was sent out to all staff and the agenda was open togive staff the opportunity to add anything they wished toraise or discuss.

We reviewed minutes from three team meetings andobserved in one of the minutes there was no recordeddate, location of the meeting, who attended and chairedthe meeting. All minutes consisted of a list of points thatwere discussed, and these included operational andgovernance issues, but we did not see evidence oftimelines against actions or of actions being completed.

Managing information

The service collected reliable data and analysed it.Staff could find the data they needed, in easilyaccessible formats, to understand performance, makedecisions and improvements. The informationsystems were integrated and secure. Data ornotifications were consistently submitted to externalorganisations as required.

Patient details were maintained initially using acombination of paper and electronic systems. Followingdischarge, paper records were scanned onto the electronicsystems. These were backed up in case of accidentalfailure.

Staff could access information via the organisationsintranet and via emails. Staff we spoke with said thatmanagers were very responsive to any queries.

During our inspection we observed a notice boarddisplaying information including audit results, NationalOphthalmic Database Audit (NODA) results and patientfeedback.

Minutes from operational meetings included concernsabout data breaches across the organisation, such asletters being sent out with other patient letters and alsotheatre list in with these letters. The hospital managerconfirmed there had been no data breaches at thislocation.

The service submitted 100% of their data to benchmarkand monitor their clinical outcomes nationally.

During our inspection we observed information relating toGeneral Data Protection Regulation visible within staffareas.

Engagement

Leaders and staff actively and openly engaged withpatients, staff, the public and local organisations toplan and manage services. They collaborated withpartner organisations to help improve services forpatients.

We were told staff feedback was encouraged through sixmonthly staff surveys and forums. Hospital roadshowswere held where the board listened to staff concerns,sharing planned changes in response includingimprovements to the staff travel policy.

There was a whistleblowing and raising concerns policy,however, this was passed their review date of May 2019.

Education evenings and events for communityoptometrists were held to improve continued care andcross provider engagement to support ongoing patientcare in the community.

We were told the organisation liaised with local charities tosupport continued care in the community.

Staff received updates via the organisations intranet,weekly emails, monthly newsletters and team meetings.

The organisation had achieved gold for Investors in Peoplevalid until 2021.

Social events were held throughout the year to celebrateany success.

Surgery

Surgery

Good –––


Staff told us the company held corporate events where allstaff were invited and encouraged to engage with eachother and staff from other locations at the annual summerand Christmas social events. Staff told us they enjoyed theevents.

Staff told us there was positive engagement with theirpeers and managers and gave us examples of whenmanagers had supported them.

The service encouraged and gave patients the opportunityto feedback about their care and experience.

Learning, continuous improvement and innovation

All staff were committed to continually learning andimproving services. They had a good understanding ofquality improvement methods and the skills to usethem. Leaders encouraged innovation andparticipation in research.

During our inspection we observed an ‘endophthalmitisbox’ stored securely within the theatre. This allowed forimmediate access to all equipment including antibiotics totreat the serious sight threatening complication. Themedical director told us having all the equipment on siteensured patients received timely care. We were toldsurgeons had received training as this was a rarecomplication. The organisation had made a DVD forsurgeons to watch to refresh their knowledge. The medicaldirector told us they had received positive feedback fromstaff.

The medical director was passionate about their work.They had carried out research into social deprivation andthe impact it is has on cataracts. This has been presentedat ophthalmic conferences and was published in a nationaljournal for the medical profession.

The provider has been nominated for a national antibioticguardianship award for supporting the appropriate use ofantibiotics for cataract surgery.

The service had shared videos of cataract surgery withcolleagues that were accepted in the European Society ofcataract and refractive library.

The medical director was planning to introduce across theorganisation some additional simulation training sessionsfor surgeons to enhance skills.

By monitoring outcomes and patient satisfaction, theservice was committed to continuous improvement.

The organisation had introduced an optometryaccreditation scheme. This involved inviting localoptometrist to the location for a presentation aboutservices provided. Following any surgery, if routine,patients could be followed up by an accredited optometristrather than needing to visit the location.

Surgery

Surgery

Good –––


Outstanding practice

• The service achieved good outcomes that werecontinuously monitored with patients reporting apositive experience.

• The service had an endophthalmitis box on site incase of an emergency.

• Patients were provided with the organisations"patient stories" DVD where previous patientsdescribed their experience to help relieve anxiety.Videos were included in the organisations website.

• The service provided free transport to patients wholived within a set distance from the location.

• The service offered an accreditation scheme forcommunity optometrist.

Areas for improvement

Action the provider SHOULD take to improve

• The provider should ensure all patient records arestored securely at all times.

• The provider should ensure all policies are reviewedand reflect current guidance within agreed timelines.

• The provider should ensure that the safeguardingpolicy for children references current guidance.

• The provider should consider recording versioncontrol on all documents.

• The provider should consider alternative formats forleaflets and website information.

• The provider should consider posters to indicate achaperone is available.

• The provider should consider reviewing service levelagreements in line with best practice.

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


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