Optegra Manchester Eye Hospital NewApproachComprehensive ... ·...

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 Requires improvement –––

Are services safe? Requires improvement –––

Are services effective? Good –––

Are services caring? Good –––

Are services responsive? Good –––

Are services well-led? Requires improvement –––

Overall summary

Optegra Eye Hospital Manchester facilities include; apatient lounge, sub waiting areas with the capacity for 50patients, six consultation rooms, two treatment rooms,one refractive eye theatre, a refractive patient preparationroom, a refractive patient recovery room, a preoperativeward, a post-operative ward, seven diagnostic rooms andone ophthalmic operating theatre.

The hospital provides surgery and outpatient services foradults. The hospital does not offer treatment to under 18year olds. We inspected surgery and outpatients.

OptOpteegrgraa ManchestManchesterer EyeEyeHospitHospitalalQuality Report

One Didsbury Point2 The AvenueDidsburyM20 2EYTel: 0808 250 9331Website: www.Optegra.com

Date of inspection visit: 19, 20, 28 July 2017Date of publication: 23/11/2017

1 Optegra Manchester Eye Hospital Quality Report 23/11/2017

We inspected this hospital using our comprehensiveinspection methodology. We carried out the announcedpart of the inspection on 19 and 20 July 2017, along withan unannounced visit to the hospital on 28 July 2017.

To get to the heart of patients experiences of care andtreatment, we ask the same five questions of all services:are they safe, effective, caring, responsive to people'sneeds, and well-led? Where we have a legal duty to do sowe rate services performance against each key questionas outstanding, good, requires improvement orinadequate.

Throughout the inspection, we took account of whatpeople told us and how the provider understood andcomplied with the Mental Capacity Act 2005.

The main services provided by this hospital wereophthalmic consultations and diagnostics, diseasemanagement and treatment. Treatments includedsurgical and medical treatments. There were no inpatientstays at this hospital, all patients were treated as daycases and were discharged the same day.

The surgery and outpatient services worked closelytogether with staff working between disciplines. Whereour findings on surgery for example, managementarrangements also apply to outpatient services, we donot repeat the information, but cross-refer to the surgerycore service.

We rated this service as Requires Improvement overall.

We found areas of good practice in surgery:

• The hospital audited the outcomes of every patientwho had surgery at the hospital. The hospitalmeasured outcomes hospital wide and individually foreach consultant.

• The hospital proactively forward planned surgical andclinic sessions and used data to identify the number ofpatients waiting for treatment and procedures. TheNHS Family Test (FFT) results reflected this bycomments from the patients.

• Patient outcomes survey showed 80% of patients saidthat they strongly agreed with the statement; I wouldrecommend treatment to family and friends.

• Patients we spoke with stated that their pain wasmonitored and treated appropriately.

• The needs of diabetic patients were assessedpre-operatively and post-operatively. Staff were awareof the needs of diabetic patients and actedappropriately if the patients blood sugar levels werelow.

• The hospital had an eye sciences department, whoserole was to collate data on Refractive Lens exchange(RLE), cataract surgery and laser surgery. The eyesciences team collected data for all Optegra hospitalsacross the UK.

• Regular Medical Advisory Committee (MAC) meetingswere held at the hospital where the eye sciencesreport would be discussed to enable the hospital tobench mark against other Optegra hospitals and othereye hospitals.

• The hospital collected comparative outcomes byclinician and used this for competency andrevalidation purposes as well as for qualityimprovement processes through the MAC and clinicalgovernance processes.

• The hospital provided a 24 hour helpline for advice topatients outside of normal working hours. Consultantswere available during normal working hours to reviewpatients if staff felt medical input was required.

• Staff were familiar with the necessary minimum oneweek cooling off period for certain procedures and wesaw that these periods were observed.

• Patients we spoke with said they felt involved indecisions about their care and treatment and thattreatment plans were clear and understood. They saidthat staff took time to involve them and explain thingsin a way that they understood.

• The services were delivered in pleasant andappropriate premises, with excellent facilities forpatients and staff.

We found areas that required improvement in surgery:

• We observed patients being prepared for cataractsurgery in the anaesthetic room and then instructed totransfer from the bed and walk into the operatingtheatre. We observed patients who were disorientateddue to sedation, or walking without their glasses. Wesaw that several patients required support fromtheatre staff in order to safely make the transfer

• At the unannounced part of the inspection we foundthat a new standard operating procedure had been

Summary of findings


completed with regards to the safety of patientswalking into the operating theatre, we did not receiveassurance that this process had been risk assessedand deemed to be safe practice.

• The hospital was not able to evidence individualcompetency for specific tasks such as the dispensingof medicines to take home, nurse led discharge andpre-operative assessments.

• We found that confirmation of consent for surgery wasnot shared with the wider surgical team as part of theWHO safer surgery checklist procedures as would beexpected.

• The hospital had a World Health Organization (WHO)Surgical Safety Checklist Policy in place. However,upon observing this process we found that thehospital was not compliant with this policy, or theoverarching principles of the WHO surgical safetychecklist and the National Patient Safety Agency(NPSA) five steps to safer surgery guidance.

• The hospital did not carry out observational ordocumentation audits of safer surgery safeguardstherefore they could not identify staff compliance orhighlight areas that needed improvements.

• The duty of candour was not embedded andappropriately applied by senior staff.

• Actions recommended as a result of an investigationidentified failings within surgical safety processes,some of the recommendations had still not beenimplemented in full.

We found good practice in relation to outpatients anddiagnostics:

• The hospital managed staffing effectively and servicesalways had enough staff with the appropriate skills,experience and training to keep patients safe and tomeet their care needs.

• Consultants and staff told us they believed that theyhad access to the latest equipment and if newequipment was needed this was readily provided.

• The hospital had a good maintenance scheduled thatchecked the equipment available and made sure thatroutine maintenance was in place within theOutpatient Department (OPD).

• Records were comprehensive and contained referralletters and clinic letters that would be needed for anyconsultation.

• Care was delivered in line with national guidelines.

• Patient safety was maintained throughout. Patientsattended a clinical assessment prior to being seen bythe consultant, where any patients deemed unsuitablefor treatment were identified.

• The hospital supported student nurse placements inorder to assist both the development of student nurseskills and their own staff members.

• The hospital offered a range of appointments whichmeant that patients could attend at times suitable forthem. A satellite clinic offered outpatientappointments, so patients did not have to travel as far.

• Patients living with Age Related Macular Degeneration(AMD) were a priority for treatment. This was becausethat once diagnosed, delays in treatment could bedetrimental to patients sight.

• All staff spoken with in OPD told us that they felt verywell supported and enjoyed working at the hospital.They told us that there had been recent changes in theleadership but they were confident that the newmanagement team understood the hospital and itsstaff.

We found areas that required improvement inoutpatients and diagnostics:

• The medicines management policy stated that staffneeded to dispense medicines using a standardoperating procedure. A standard operating procedurewas not in place at the time of the inspection, but wasbeing developed. This meant that staff did not havethe guidance they needed in order to make sure thatthey dispensed medicines in a consistently safemanner.

• At the announced part of the inspection we saw thatthe staff members within the ward were giving outmedicines to take home in a manner that did notalways maintain the safety of patients.

• Prescriptions concerning eye drops did not containinformation regarding the quantity required; thereforestaff could not make this decision safely.

• Pain relief was discussed with patients on discharge,however these discussions were not recorded inpatients notes in order to determine and record thatthe best advice and support had been given.

• The hospital had not carried out training andcompetency assessments around the nursedispensing of medicines for outpatients which wascontrary to the hospital medicines managementpolicy.

Summary of findings


• Discharge information we reviewed did notconsistently include relevant information aboutmedicines. Patients were given verbal information, onwhen and how to take the prescribed medicine.However this was not recorded in the patients recordsin order to make sure that this information wasconsistent and fully understood by the patient.

• We observed that there was an inconsistent approachfrom staff greeting patients. The majority introducedthemselves to patients in order to set them at easeothers did not.

• Patient information leaflets in different formats suchas braille, large print or other languages were notreadily available on site.

• The outpatient department displayed their complaintsleaflet that informed patients of how to complain.However this was available only in one format and onelanguage.

• The results from the 2017 staff survey highlighteddissatisfaction amongst staff. We were told that thisled to an internal review at corporate level followed bymajor changes in staffing at Manchester eye hospital. Anew clinical manager was installed and the Optegranational clinical advisor was consulted to seekimprovements.

We found good practice in relation to both surgery andoutpatient and diagnostics:

• There were systems in place to keep people safe andsafeguarded from harm. The hospital had proceduresto investigate and learn from incidents. Staff wereconfident on how to raise incidents.

• The environment was visibly clean and well presented,procedures were in place to prevent the spread ofinfection and equipment was well maintained andappropriate for the services provided.

• The hospital was responsive to patients who requiredadditional support, such as patients living with hearingor language difficulties.

• The hospital had robust arrangements in place forobtaining consent for patients having surgery or otherprocedures at the hospital. The mental capacity of apatient to consent to treatment was reviewed duringconsultation and the pre-operative assessment stage.For those who did not have capacity, a best interestsdiscussion took place to decide the best course ofaction for the safety of the patient.

• The hospital received six complaints between May2016 and April 2017. It had a complaints systemprocess in place and supported patients who hadconcerns about the service.

• Optegra, which included Optegra Manchester, hadachieved number one in category for Trust Pilot. Theyhad been voted by the public as Best in category foreye treatment and rated 9.6 out of 10 based on 1,479reviews.

We found areas that required improvement in surgeryand outpatients and diagnostics:

• The hospital risk register did not show a date for whenthe risk was expected to be resolved.

• The hospitals staff survey was carried out in December2016 indicated staff felt unsupported by managers.

• Forty-five percent of staff felt that they did not have jobsecurity.

Following this inspection, we told the provider that itmust take some actions to comply with the regulationsand it should take some actions to help the serviceimprove. We also issued the provider with tworequirement notices that affected Optegra Eye HospitalManchester. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals

Summary of findings


Our judgements about each of the main services

Service Rating Summary of each main service

Surgery

Requires improvement –––

Surgery and outpatients and diagnostic imagingwere the only activities at the hospital.Surgery was the main activity of the hospital.Where our findings relate to both activities, we donot repeat the information but cross-refer to thesurgery section. Staffing was managed jointly withoutpatients and diagnostic imaging.We rated surgery overall as RequiresImprovement, because it required someimprovements in safety and being well led, thoughit was found to be good for effective, caring andresponsive.

Outpatientsanddiagnosticimaging

Good –––

Surgery and outpatients and diagnostic imagingwere the only activities at the hospital.Surgery was the main activity of the hospital.Where our findings relate to both activities, we donot repeat the information but cross-refer to thesurgery section. Staffing was managed jointly withoutpatients and diagnostic imaging.We rated outpatients and diagnostic imagingoverall as good, because it was safe, caring andresponsive, though it was found to be requiresimprovement in well-led. We did not rate theservice for being effective.

Summary of findings


Contents

PageSummary of this inspectionBackground to Optegra Manchester Eye Hospital 8

Our inspection team 8

Information about Optegra Manchester Eye Hospital 8

The five questions we ask about services and what we found 10

Detailed findings from this inspectionOverview of ratings 14

Outstanding practice 40

Areas for improvement 40

Action we have told the provider to take 41

Summary of findings


Optegra Manchester EyeHospital

Services we looked atSurgery; Outpatients and diagnostic imaging

OptegraManchesterEyeHospital



Background to Optegra Manchester Eye Hospital

Optegra Eye Hospital Manchester opened in February2011 and has subsequently treated both private and NHSophthalmic adult patients across a full range of subspecialities. The service primarily serves the communitiesof the Greater Manchester area, North and East Cheshireand East Lancashire for its NHS patients.

Optegra Eye Hospital Manchester is part of a worldwideorganisation. The service also has a satellite clinic inAltrincham, Cheshire, which provides clinic onlyappointments, for refractive lens exchange (RLE) initialconsultations.

The service is registered to provide the followingregulated activities:

• Treatment of disease, disorder or injury• Surgical procedures• Diagnostic and screening procedures

The service has a registered manager who has been inpost since 2011. The current registered manager is alsothe director of this service and another Optegra EyeService.

Our inspection team

The team that inspected the service comprised a CQClead inspector, Caroline Williams and three other CQCinspectors. The inspection team was overseen byAmanda Stanford, Head of Hospital Inspection.

Information about Optegra Manchester Eye Hospital

The service is open Monday to Saturday includingevenings and a variety of appointment times and optionsare available. Normal working hours are Monday 8am to8pm, Tuesday to Thursday 8am to 6pm, Friday 8am to8pm and Saturday 8am to 3pm.

During the inspection we visited; consulting rooms,treatment rooms, refractive theatre, refractive patientpreparation room, refractive patient recovery room,pre-operative ward, post-operative ward, diagnosticrooms, ophthalmic and operating theatre. We spoke with27 members of staff including; registered nurses,reception staff, operating department practitioners, andsenior managers. We spoke with 11 patients. We alsoreceived nine ‘‘tell us about your care’ comment cardswhich patients had completed prior and during ourinspection. During our inspection, we reviewed three setsof patient records.

There were no special reviews or investigations of theservice ongoing by the CQC at any time during the 12months before this inspection. The hsopital had been

inspected on two previous occasions by the CQC, bothannounced inspections; 25 February 2013 and 10 October2013 and on both inspections, was found to meet allstandards of quality and safety it was inspected against.

Activity (May 2016 to April 2017):

• In the reporting period 1 May 2016 to 30 April 2017there were 432 refractive intra ocular lens surgeryperformed, 110 refractive laser eye surgery, 33refractive laser eye surgery , and 2969 other surgicalprocedures including vitreous retina procedures (VR).

• 25 Ophthalmologists worked at the service underpractising privileges. Optegra Manchester employed 12registered nurses, five Optometrists and two healthcare technicians.

In the reporting period between May 2016 and April 2017the service reported;

• No Never events (see section on incidents)• Two clinical incidents; one no harm and one low harm• Six complaints

Summaryofthisinspection

Summary of this inspection


Services provided at the service under service levelagreement:

• Clinical and or non-clinical waste removal• Interpreting services

• Grounds Maintenance• Laundry• Maintenance of medical equipment• Pathology and histology




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 safe as Requires Improvement because:

• Staff were not clear on what constitutes a serious incident. Wefound that incidents were investigated and actions applied,however in the two serious incidents we looked at some of therecommendations had still not been implemented in full.

• We found despite the previous issues with surgical safetyprocesses, the surgical safety processes were still not beingundertaken in line with best practice.

• The duty of candour was not embedded and appropriatelyapplied by senior staff. They were aware of being open andhonest when things went wrong; however patients involved inthe two serious incidents were not informed about mistakes atthe earliest opportunity.

• There were systems in place for the safe storage, use andadministration of medicines; however, the controlled drugsbook was not audited at local level and we found there weresome administrative errors.

• We saw good use of personal protective equipment (PPE) onthe ward and in the operating theatre. However, we alsowitnessed poor compliance as none of the staff wore gloves orPPE whilst in the anaesthetic room which led to the operatingtheatre.

• The hospital had appropriate processes and policies in place toassess patient risk, but we found the staff did not always followthe safety checklist guidance.

• The hospital had a World Health Organization (WHO) SurgicalSafety Checklist Policy in place. However, upon observing thisprocess we found that the hospital was not compliant with thispolicy, or the overarching principles of the WHO surgical safetychecklist and the National Patient Safety Agency (NPSA) fivesteps to safer surgery guidance.

• The hospital did not undertake observational ordocumentation audits of the safer surgery processes. Theytherefore could not provide assurance that action was beingtaken to reduce the risk to patients undergoing surgery.

However;

• Staff understood their responsibilities to raise concerns, torecord safely incidents, concerns and near misses and to reportthem internally and externally.





• Patient records both hardcopy and electronic, were accurate,complete, legible, stored correctly and kept people safe.

• The environment and equipment were visibly clean andmaintained to a good standard throughout the hospital.

• Cleaning rotas were in place and audited regularly. We initiallyfound that some of this documentation was unclear, thusmaking monitoring more difficult. We saw this had beenimproved by staff during our unannounced inspection.

Are services effective?We rated effective as good because:

• Patient outcomes were closely monitored and the hospitalaudited 100% of all surgical performance. This was for thehospital as a whole and the outcomes for each individualsurgeon.

• The policies we reviewed cited and included relevant bestpractice guidance such as National Institute for Health and CareExcellence (NICE) guidance for the treatment of Glaucoma andMacular diseases.

• One hundred percent of staff had received an appraisal withinthe last 12 months.

• The hospital supported student nurse placements in order toassist both the development of student nurse skills and theirown staff members exposure to different practice and views

• Regular team meetings enhanced shared learning and builtteam collaborative working.

• Processes were in place for obtaining appropriate consent andfor assessing patient capacity and making best interestdecisions where appropriate

• Patients we spoke with stated that their pain was monitoredand treated appropriately.

• Diabetic patients were assessed pre-operatively andpost-operatively. Staff we spoke with were aware of the needsof diabetic patients and acted appropriately if the patientsblood sugar levels were low.

However:

• Staff were dispensing medicines, the policy outlined that thiswas an extended nursing role. We found that specific trainingand assessment of competency to undertake this specific taskhad not been undertaken.

Good –––

Are services caring?We rated caring as good because:

Good –––




• We saw positive interaction from staff in clinic rooms andwaiting areas, consistently throughout the inspection. Staffwere kind towards patients, joking and smiling with them andputting their mind at ease.

• Feedback from people who used the service was consistentlypositive. This was reflected in the NHS Friends and Family test(FFT) scores; 100% of the patients said that they were likely torecommend the service. The response rate was 51% whichequated to 132 responses.

• During our observations we saw staff reassuring patients andgiving them time to understand the treatment they were due tohave.

Are services responsive?We rated responsive as good because:

• The service had varied and flexible opening times, so patientscould access the services at a time that suited them. Staffwould make sure that patients got an appointment of theirchoice, sometimes on the day of referral.

• The service had some consultations and clinics in a satelliteclinic to promote easier access to patients living further awayfrom the main site.

• Patients living with Age Related Macular Degeneration (AMD)were a priority for treatment. This was because once diagnoseddelays in treatment could be detrimental.

• The service achieved the NHS indicator of 18 weeks referral toconsultant led treatment. At the time of our inspection the waitwas three to five weeks for NHS patients. Private patients hadan average referral to treatment time (RTT) of two to five weeks.

• The service provided pre-planned services only. Therefore theywere in full control of the numbers of patients they couldaccommodate at any given period.

• The service had partnerships with a range of qualifiedoptometrists across the UK; these partners could refer patientsfor treatment if they found conditions that could benefit fromtreatment.

• The service recognised people who required additional supportto communicate and provided assistance in hearing andtranslation.

However:

• We were told that the service did not monitor waiting times forindividual patients once they arrived for their appointment.

Good –––

Are services well-led?We rated well-led as requires improvement because:





• The hospital risk register did not show a date for when the riskwas expected to be resolved.

• There was a lack of supervision and support for staff and lack ofoversight in the management of day to day activities within theoutpatients and surgery departments. This was due to anabsence of lower tier managers or team supervisors.

• The staff survey indicated that staff felt unsupported anddissatisfied with managers.

• Forty-five percent of staff felt that they did not have job security.• Optegra values were not embedded in the organisation and the

strategy was not well understood by staff.

However:

• There had been recent changes in leadership. Staff told us thatthey felt optimistic about the future, saw improvements in theway they were supported and were enjoying working in thehospital. They were confident that the new management teamunderstood the service and the staff.

• There was an effective governance framework to supportdelivery of the strategy and good quality care.

• Staff were clear about their roles and understood what theywere accountable for.

• The eye services monitored performance and produced aclinical outcomes report which reviewed complication ratesand clinical outcomes data for laser vision correction, RLE andcataract procedures performed at that hospital.

• Optegra, which included Optegra Manchester, had achievednumber one in category for Trust Pilot (a website whichpublishes reviews from customers for online businesses). Theyhad been voted by the public as Best in category for eyetreatment and rated 9.6 out of 10 based on 1,479 reviews.




Overview of ratings

Our ratings for this location are:

Safe Effective Caring Responsive Well-led Overall

Surgery Requiresimprovement Good Good Good Requires

improvementRequires

improvement

Outpatients anddiagnostic imaging Good N/A Good Good Requires

improvement Good

Overall Requiresimprovement Good Good Good Requires

improvementRequires

improvement

Detailed findings from this inspection


Safe Requires improvement –––

Effective Good –––

Caring Good –––

Responsive Good –––

Well-led Requires improvement –––

Are surgery services safe?


The main service provided by this hospital was surgery.Where our findings on out patients and diagnostic imaging,for example, management arrangements, also apply toother services, we do not repeat the information butcross-refer to the surgery section.

We rated safe as requires improvement.

Incidents

• The hospital had a standard operational procedure formanaging and reporting incidents, this was an Optegracorporate policy. Incidents were reported via anelectronic system which all staff had access to. The staffwe spoke with at the time of our inspection knew how toaccess the system and what incidents they shouldreport.

• The incident policy stated that the hospital was boundby the procedures relating to the ‘National Frameworkfor Reporting and Learning from Serious Incidents’ andthe ‘Strategic Executive Information System (STEIS)’ asdirected by the Department of Health and NHS Englandand other external reporting requirements.

• The hospital had two serious incidents during thereporting period 31 May 2016 and 30 April 2017; theystated they had no ‘never events’. Never Events areserious, largely preventable patient safety incidents thatshould not occur if existing national guidance or safetyrecommendations have been implemented byhealthcare providers.

• When we reviewed these incidents; one involved awrong type of lens being implanted and the other

involved the incorrect prescription being programmedand delivered by the laser. We found that both weregraded incorrectly as low and no harm, they were both‘never events’ and as such are considered seriousincidents which should be reported to CQC. The hospitaldid not grade, nor follow up these incidents in line withtheir own incident reporting policy. Furthermore, wealso determined that the patients involved in these twoincidents were not informed about mistakes at theearliest opportunity.

• The failure to report an incident to CQC is a breach ofthe Care Quality Commission (Registration) Regulations2009 (part 4).

• We reviewed the root cause analysis investigations forthese two incidents. We saw that the investigationidentified failings within surgical safety processes andactions were recommended to help to prevent similaroccurrences. We found that some of thoserecommendations had still not been implemented infull for example the use of a white board and teambriefings. This suggested the organisation did notalways learn from incidents or when things went wrong.

• Furthermore, on inspection we found despite theprevious issues with surgical safety processes which hadcontributed to the serious incidents, the surgical safetyprocesses were still not being undertaken in line withbest practice.

• The hospital reported 16 incidents in the period 20 July2016 to 19 July 2017. These involved incidents such as afall, administration errors, medicine errors andequipment issues. The incident report document didnot indicate the level of harm caused by these incidents;however it did show what actions were taken and howlearning was shared from these events.

Surgery

Surgery



• Issues that may affect clinical effectiveness werediscussed at the Medical Advisory Committee (MAC)meetings and the clinical governance meetings.Meetings with various location clinical services managerwere undertaken to share learning across branches.Minutes were recorded and shared amongst staff toraise awareness and learning from incidents.

• Safety huddles were conducted daily; important safetyissues and incidents were communicated at thesemeetings to highlight significant concerns or potentialsafety issues.

• The duty of candour is a regulatory duty that relates toopenness and transparency and requires providers ofhealth and social care services to notify patients (orother relevant persons) of certain ‘notifiable safetyincidents’ and provide reasonable support to thatperson.

• We found that managers in the hospital were aware ofthe duty of candour requirements and had receivedtraining and we found that although other staff wereless familiar with the legislative requirements, they wereaware of the principles of being open and honest withpatients.

• The hospital stated they did not experience an incidentwhich fitted the criteria for duty of candour processes,and so had not been obligated to implement duty ofcandour processes. However, we considered that bothof the serious incidents above should have beenidentified as meeting the criteria of a ‘notifiable safetyincident’, but due to the incorrect grading had not beentreated as such. We found that the patient was notinformed about the mistake in their treatment untilthree weeks after it had occurred.

Clinical Quality Dashboard or equivalent (how doesthe service monitor safety and use results)

• A clinical quality report was produced quarterly, whichsummarised performance in key areas, for example;unplanned re-admissions, transfers to other hospitalsand infection control. This was shared within thehospital to provide an oversight of results andachievements.

• The report was used to monitor improvements inperformance over time and to benchmark with otherlocations in the organisation

Cleanliness, infection control and hygiene

• During our inspection we found the ward and theatresareas were visibly clean and tidy. Cleaning wasundertaken by an external contractor through a servicelevel agreement. We saw that cleaning rotas were inplace and that these were audited regularly. Howeverwe found that some of this documentation was unclear,thus making monitoring more difficult. We raised thiswith managers and when we returned for theunannounced inspection the documentation had beenimproved.

• The hospital had an infection control policy in place andthis was accessible to staff. The infection control lead forthe hospital was the clinical services manager. Infectionprevention and control was classed as a component ofmandatory training for clinical staff.

• Infection control audits were undertaken periodically toassess compliance with infection control practices andprocedures. A recent audit of the theatres environmentfound them to be 97% compliant. An action plan wasimplemented to further improve this and actions werecompleted.

• Staff appeared to comply with best practice in relationto uniform standards and theatre dress codes.

• There was adequate access to hand gels handwashingsinks on entry to clinical areas and also at the point ofcare.

• We observed good compliance with hand hygiene anduse of personal protective equipment (PPE) used on theward and in the operating theatre. Hospital audits ofhand decontamination found they were 100%compliant.

• We witnessed failure to comply with hospital policy andbest practice concerning infection control in theanaesthetic room which led to the operating theatre.None of the staff we witnessed wore gloves or PPEwhilst in the anaesthetic room. We observed thecannulation of a patient and the administering of localanaesthetic injections and the cleansing of the surgicalsite without the use of PPE.

• Furthermore, despite using a ‘sterile pack’ for cleaningand injecting of the surgical site, staff did not weargloves and so contaminated the sterile field with theirhands. We raised this with the hospital managers andthey stated that this had been raised with staff and staffhad been reminded that they must comply with the useof PPE and infection control practices.

Surgery

Surgery



• We were advised that the hospital had no healthcareassociated infections during the period May 2016 toApril 2017.

Environment and equipment

• We found that the clinical areas were well maintained,free from clutter and provided a suitable environmentfor dealing with patients.

• Waste and clinical specimens were handled anddisposed of in a way that kept people safe. Thisincluded safe sorting, storage, labelling and handling.

• The hospital used single-use, sterile instruments asappropriate. The single use instruments we saw werewithin their expiry dates. The hospital had arrangementsfor the sterilisation of reusable instruments which werecontracted out and monitored through a service levelagreement with an external provider.

• Emergency and resuscitation equipment was accessiblein the theatre area. Records indicated that equipmentand consumables were checked in line with hospitalpolicy. We checked a sample of consumables and thesewere in good order and in date.

• The resuscitation trolley was equipped with adefibrillator, oxygen and portable suction and we sawthat emergency drugs were stored appropriately intamper evident bags. It was noted however, that thistrolley was not able to be sealed and so not all the itemswere ‘tamper evident’, in particular, it would not beevident if fluids had been tampered with. Staff told usthat a new fully sealable and tamper evident trolley wason order, which was the same as the one as in theoutpatients department, this would rectify this issue.The situation had been risk assessed and it was decidedthat the first trolley should be placed in the more publicarea of outpatients and the older trolley remain in theoperating theatres which was a more restricted areawith less patient throughput.

• The hospital had a range of refractive eye treatmentsusing the following equipment on site LensAR Infinityphaco; Intralase Femto second Schwind excimer;Schwind excimer and Constellation (VR). We were toldthat manufacturers’ instructions were followed for themaintenance of these machines.

• A designated member of staff was responsible foroverseeing and ensuring the maintenance, safetychecks and servicing of equipment was undertaken

effectively and that an accurate asset register wasmaintained for all equipment in the hospital. Wechecked a sample of items in the asset register and sawthat these had up to date servicing records.

• The traceability for implants used in surgical procedureswas maintained by retaining the bar codes with uniquetraceable reference numbers. These were recorded inpatients’ medical records. Patients were given a card tokeep which contained the barcodes and uniquereference numbers for their own lens implants.

• Airflow was maintained in the theatre with 15 changes ofair per hour, which was in line with the Royal College ofOphthalmologists ophthalmic services guidance ontheatres, the airflow system was tested and servicedannually and we saw evidence of its compliance withrequired standards.

• The laser room was a large, visibly clean, clinical spacewith a clinical trolley. The trolley held the laser roomchecks book and we saw that the room temperatureand humidity checks were carried out and dated, timedand signed accordingly. Rooms used for lasers wereappropriately equipped, were lockable and hadappropriate warning notices and signage.

• Each time the laser was used the temperature andcalibration was recorded.

• A laser refractive information booklet was accessible tostaff on the clinical trolley. The book included; the safeuse of Mitomycin –C, prompt cards for latex allergies,MRSA patient information and management ofhypoglycaemia (which is low blood sugar).

• Local rules were displayed in the laser room and we sawthat staff had signed the register to confirm they hadread and understood the local rules. All signatures wereup to date.

Medicines

• The hospital had a medicine management andadministration policy in place. This was readilyaccessible to staff via the organisation’s electronicsystem.

• We saw accurate records were kept when medicineswere administered and records included the patient’sallergy status.

• The hospital had a service level agreement in place witha pharmacy; this also involved the provision of

Surgery

Surgery



medicines management audits by this externalcontractor. We saw evidence that audits of stock,storage and medicines recording were undertaken at aminimum of three monthly intervals.

• Medicines were stored securely and there wereprocesses to ensure they remained suitable for use.Fridge temperatures were checked and recorded dailyto ensure that certain medicines that requiredrefrigeration remained suitable for use and roomtemperatures were checked by the hospitalmaintenance staff.

• Staff were aware of the procedures to follow iftemperatures became out of range and would contactthe pharmacist to confirm drugs remained fit for useshould this occur.

• We checked a sample of medicines and found these tobe in date. We were advised that the external pharmacychecked expiry dates, stock reconciliations andprovided stock top ups. We also found all emergencymedicines were in date. The sample of controlled drugswe checked was found to correspond to the details inthe register.

• Local audits such as the weekly checks of controlleddrugs were being completed and documented howeverrecords management checks as described in theOptegra policy were not being completed. We foundthat there were some administrative errors in thecontrolled drugs book which would not have beenpicked up on external audits, but which would havebeen noted on local checks. We raised this withmanagers who wrote and implemented a new standardoperating procedure ensuring a weekly managementcheck was introduced.

• We saw that nurses were administering someprescription medicines (eye drops) to patients prior totheir procedure. We were told that this was done under‘patient group directions’ (PGD). This is where a ‘groupprescription’ for a particular medicine is pre-authorisedunder strict conditions and must follow strict guidance.

• When we checked the PGD we found that contrary toguidance that the PGDs were not signed by a doctor anda pharmacist. We saw that although nurses had signedthe document, the authorising signatures were missingin the majority of cases. With regards to the actualprescriptions we found there were no indications (why

they were being given) on some and one of the eyedrops was instructed to be given immediately prior totreatment when in fact it takes 60 to 90 minutes tobecome most effective.

• We found that following surgery nurses were dispensingprescribed medicines from the hospital stock supplies.Whilst the Nursing and Midwifery Council gives provisionfor this practice as being within nurses’ scope ofpractice, he guidelines state that this must be in thecourse of the business of a hospital, and in accordancewith a registered prescriber’s written instructions andcovered by a standard operating procedure. It alsostates that the patient has the legal right to expect thatthe dispensing will be carried out with the samereasonable skill and care that would be expected from apharmacist.

• During our inspection we found that this was not thecase as there was no standard operating procedure inplace, and the labelling of the medicines did notdescribe the total amount of medicine supplied and anyadditional advice such as ‘causes drowsiness’. Thereforenurses were acting outside of their scope of practice.

• We raised these issues with managers and they statedthey would implement actions to correct these issuesimmediately. When we returned for the unannouncedpart of the inspection, we found that a new standardoperational procedure had been implemented and newmedicine labels had been introduced.

Records

• We saw that the hospital had both hardcopy and someelectronic patient records. The hardcopy files hadcolour-coded covers to identify which patients wereNHS and which were private patients. This was done sothat the correct care advice and referrals could bemade.

• The electronic records contained copies of informationsent to private patients regarding the costs of theirtreatment in order to provide the patient with relevantinformation.

• For surgical patients this involved a physical filecontaining key records such as the WHO surgical safetychecklist, medicine administration records, consentforms and pre-operative assessments.

• Patient risks were assessed and documented on pre-opassessment charts. The details were entered into the

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computer system, which took the nurse throughstandard sets of questions and assessments. The resultswere then printed and placed in the patient noteshighlighting relevant aspects for that patient.

• Patient records included information such as thepatient’s medical history, previous medicines,consultation notes, treatment plans and follow-upnotes.

• The records included information specific to thetreatment needed such as the recommended type andprescription of lens to be implanted during surgerybased on various test readings.

• The serial number of the implanted lens was logged onthe patient’s records, as was any other equipment usedduring surgery. This meant there was an audit trailavailable that if there were any later issues withimplants the patient could be tracked.

• The hospital retained all copies of the patient recordsand supplied patient information as needed to externalprofessionals.

• The patient liaison staff we spoke with told us theymade sure records were available for patients who wereattending for surgery by checking the ward staff hadthese records before surgery took place. We confirmedthis during the inspection and observed that recordswere made available as needed throughout thedepartment. The record then went with the patient intosurgery so a contemporaneous record of treatmentcould be maintained.

• We reviewed a total of 18 patient records. The recordsheld details of the patient’s full medical history in thehospital, including medicine records, diagnosis andtreatment history. We also saw that the recordscontained observations immediately after surgery in theward area where patients rested in comfortable chairs.

• Staff told us and records available confirmed that in thethree months before the inspection there was nooccasion in which patients had received treatmentwithout relevant records.

• The records we checked appeared comprehensive andcomplete. We noted that the handwriting by somemedical staff was barely legible and did not meet bestpractice standards. Entries were not always timed,dated and stated the author’s full name anddesignation; we found that notes often just contained adoctors initials. Notes by other members of staffappeared to conform to best practice standards.

Safeguarding

• The hospital had a safeguarding policy in place and thiswas in date, had been reviewed and revised regularlyand was accessible to staff.

• The hospital had a separate, on-site, safeguarding leadthat was able to provide advice when necessary. Therewas a national corporate safeguarding lead that wasalso available to provide advice and oversight.

• Safeguarding vulnerable adults and children wasincluded in the hospital mandatory trainingprogramme. Although the hospital did not treatchildren, they completed child protection training toensure they were aware to recognise and respond topotential safeguarding issues concerning childrenassociated to their patients.

• At the time of our inspection, we found that 87% of alleligible staff in the hospital had completed safeguardingadults and children training.

• Staff we spoke with were familiar with their obligationsregarding safeguarding and knew what they should do ifthey had concerns about a patient or their family.

Mandatory training

• The hospital had a mandatory training policy. Staff wererequired to undertake a range of general and rolespecific mandatory training modules which were bothonline and in person. This was in line with the policy andthe mandatory training schedule, which set out thefrequency that each module was to be repeated.

• General subjects included basic life support,safeguarding children and vulnerable adults, the mentalcapacity act and deprivation of liberty safeguards(DoLS), infection prevention and control, equality anddiversity and manual handling

• Mandatory training completion rates across the wholehospital were at 84% at the time of our inspection. Thehospital did not set a target for this training.

Assessing and responding to patient risk (theatres,ward care and post-operative care)

• Managers told us that the hospital did not have aspecific admission or exclusion criteria for patients.They stated that they assessed the suitability of eachcase on its own merits. They stated they generallyaccepted patients who classed as level 2 or 3 within theAmerican Society of Anaesthesiologists (ASA) PhysicalStatus classification system. However, this was only if

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they assessed that they could safely meet their medicalneeds. This assessment was undertaken through a‘triage’ process upon referral, through the outpatientconsultation and through pre-operative assessmentprocesses.

• The service did not routinely weigh patients and so didnot calculate body mass index (BMI), therefore did notuse BMI as an exclusion criteria. As they did not weighpatients, they could not determine if maximum weightrestriction for certain pieces of equipment were beingobserved.

• We were told that due to the fact that the ophthalmicsurgery is only conducted under a local anaesthetic andis of short duration, the risk of venousthromboembolism is minimal; however a general riskassessment that might highlight if any precautionsmight be required is taken as part of the pre-assessmentprocess.

• A staff briefing was held prior to each surgical session.This was attended by all staff involved in the surgery intheatre. The meeting reviewed a brief summary of eachpatient undergoing surgery and highlighted any specificissues or concerns, such as any notable past medicalhistory or comorbidities, any changes to the theatre listor specific equipment required for a particular case.

• The hospital had a ‘World Health Organization (WHO)Surgical Safety Checklist Policy’ in place. However, uponobserving this process we found that the hospital wasnot compliant with this policy, or the overarchingprinciples of the WHO surgical safety checklist and theNational Patient Safety Agency (NPSA) ‘five steps to safersurgery’ guidance.

• We observed several departures from WHO and NPSAguidance and the hospital’s own policy. Namely; staffdid not introduce themselves to each other by nameand role at the briefing, they stated that they alreadyknew each other. Later at the ‘time out’ phase theyfailed to introduce themselves by name and role again.They also did not record information on a visible wipeclean board as per their policy.

• The ‘sign in’ phase involving the checking of thepatient’s allergies, confirmation of consent, surgical sitemarking and patients’ understanding of procedure wasconducted in the absence of the surgeon and otherteam members. This was not in keeping with the WHOprinciples and was not complaint with the Optegra

policy which states that the sign in must be done beforeinduction of any anaesthesia whether that be topical,sedation or general anaesthetic; it also states theconsultant must be present at ‘sign In’.

• We observed that the ‘sign out’ procedure wasconducted in line with best practice. We were told bystaff that debriefs were conducted at the end of lists butdid not observe a debrief session during the inspection.

• We were told by managers that the hospital did notcarry out any observational or documentation audits ofthe surgical safety process. Managers stated that theyplanned to implement an audit programme as part ofthe review of surgical processes.

• Upon arrival for their procedures the patients wereadmitted by a nurse. They had their observationsrecorded, including blood pressure, pulse and oxygensaturations. A temperature was taken if indicated.Patients’ known allergies were recorded in their recordsand they were given a red wristband to alert the surgicalteam that they had an allergy. Their health and pastmedical history was reviewed and they were asked ifanything had changed since their pre-operativeassessment. They were also reviewed by the surgeonand anaesthetist where relevant to ensure theyremained were suitable for surgery.

• We observed patients being prepared for cataractsurgery in the anaesthetic room. Patients had theirglasses removed, eye openers inserted, localanaesthetic injected and the surgery site cleaned withsolution. Some patients were also administeredsedation medicines. Patients were then instructed totransfer from the bed and walk into the operatingtheatre. We observed that a patient who had receivedsedation was very disorientated and unsteady and theystumbled whilst making the transfer. Furthermore weobserved that even patients who had not receivedsedation appeared disorientated having hadinterference to their eyes, then getting up withoutglasses. We saw that several patients required supportfrom theatre staff in order to safely make the transfer.

• We raised this issue with managers who stated theywould review and risk assess this practice. When wereturned for the unannounced part of the inspection wefound that a new standard operating procedure hadbeen completed, but there was no risk assessment onthis process. The standard operating procedure statedthat patient under sedation should receive oxygentherapy and be monitored throughout. Patients we

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observed were not monitored by oxygen saturationsand pulse, nor did they receive oxygen therapy duringthe period they remained in the anaesthetic room. Thismeant the process was not compliant with theprocedure in place. We did not receive assurance thatthis process had been risk assessed and deemed to besafe practice.

• During the surgical procedure within the operatingtheatre, the patient’s pulse rate and oxygen saturationswere monitored and displayed on a screen for teammembers to observe.

• A staff de-briefing session was carried out at the end ofeach surgical session to share any good practice andhighlight any learning which could be shared. Patientswho became acutely ill were transferred by ambulanceto the nearest NHS acute hospital. This had happenedon two occasions in the reporting period 31 May 2016 to30 April 2017.

• The hospital provided a 24 hour advice line whichpatients could telephone following their surgery.However, they were advised to seek emergency medicalassistance for more serious matters following discharge.

• The hospital had an on-site laser protection supervisor;this individual had received the appropriate training andcompetency assessments. We found that 83% of eligiblestaff had completed ‘laser safety core of knowledge’training.

• The hospital had an anaphylaxis policy in place with astandard operating procedure of what should be donein the event of an incident; this was readily accessibleand familiar to staff.

Nursing and support staffing

• Due to the nature of the service provided and the size ofthe surgery department, it did not use a formalisedstaffing acuity tool. The clinical services managerassessed and anticipated the numbers of staff requiredbased on the number and type of procedures that werebeing undertaken for that session. This information wasthen used to plan and schedule the appropriatenumbers of nursing staff required.

• The clinical service manager was responsible forensuring an effective mix of skills and ensuringcompetence of staff was maintained.

• The operating theatre team comprised of a surgeon, ascrub practitioner, a circulating practitioner and a nurseresponsible for monitoring the patient. An anaesthetistmight also be present if a patient was sedated for theprocedure.

• Patients were recovered in the ward area where at leastone registered nurse was present.

• Our observations determined that there weresatisfactory numbers of staff on duty to maintain patientsafety. Staff and patients reported there were sufficientstaff available.

• Handovers were conducted as necessary whereincoming staff were taking over during the course of apatient’s treatment, or there was a need to transfer thecare of a patient to another nurse. However, this did nothappen very often as most staff worked long days.

• The hospital had its own ‘bank’ of staff that could becalled upon when required. These individuals hadexperience and knowledge of the hospital and werecurrent or former Optegra staff. The hospital had notused any agency staff in the reporting period 31 May2016 to 30 April 2017.

• Sickness rates were recorded at hospital level only. Theaverage rate of sickness between May 2016 and April2017 was 4.6% for nurses, 0.7% for health caretechnicians and 1.1% for other clinicians.

• The hospital had 0% vacancies for all staff members.

Medical staffing

• The hospital did not directly employ any medical staffbut had 25 ophthalmologist consultants who workedacross surgery and outpatients under the practisingprivileges scheme.

• Medical oversight was maintained by the Optegranational medical director from whom advice could besought on corporate medical matters. Local medicalsupervision was available from the medical advisorycommittee chair that through the committee reviewedand monitored clinical practices across the hospital.

• Medical advice was always available for advice andconsultation during opening hours. Input from thepatient’s own consultant was available by telephone ifneeded. Cover was provided by another consultant withthe same sub speciality for any period of absence orleave by individual consultants.

• We saw evidence that a robust process operated for thegranting of practising privileges. All appropriate checks

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such as disclosure and barring service (DBS), GeneralMedical Council (GMC) and specialist registration andhealth screening were carried out before practisingprivileges were granted.

• Although the service did not accept emergencies, aconsultant or doctor was available during usual openinghours to review patients who might be experiencingdifficulties post-operatively.

Emergency awareness and training

• A business continuity plan was in place which coveredpotential risks such as dealing with crisis eventmanagement, bomb threats, IT system and hardwarefailures, clinical equipment failure, utilities failure. A riskmanagement policy was also in place coveringnon-clinical risks, such as fire etc.

• Staff had received fire safety training as part of themandatory training package.

• Evacuation procedures were in place and emergencysimulation exercises were practised periodically.

• The hospital had recently undertaken a practise cardiacarrest exercise to check that the processes wereeffective and embedded for staff.

Are surgery services effective?

Good –––

We rated effective as good.

Evidence-based care and treatment

• The hospital followed national guidance and bestpractice by the Royal College of Ophthalmologists andNational Institute For Health and Clinical Excellence(NICE) in relation to patient care pathways, cataract,medical retina, glaucoma, cornea and vitreoretinalprocedures.

• The clinical services manager in conjunction with theclinical governance committee was responsible forensuring that the hospital was kept up to date andaware of how new guidance affected clinical practice.

• The hospital had a comprehensive range of localpolicies and procedures. These were reviewed andupdated regularly and reflected current best practiceand evidence based guidance. However, we foundevidence that the hospital was not compliant withelements of their own internal and corporate policies

such as medicines management in relation to thedispensing of medicines on discharge and patient groupdirections. We also found they failed to adhere to someelements of their WHO surgical safety policy andinfection control policy. See relevant sections above.

• The hospital participated in some local and corporateaudits, which were used to benchmark performanceagainst other Optegra hospitals nationally andinternationally.

Pain relief

• Pain relief was administered in the form of anaestheticeye drops prior to surgery or procedures. Patients wereasked about pain levels during and after procedures.

• Staff could seek advice and input from surgeons wherepatients complained of pain after surgery in therecovery area.

• Patients were advised on pain relief during dischargediscussions and advised on recovering at home. Theywere given a 24 hour helpline number but we told if thepain was severe they should go to their local accidentand emergency department.

• Patients we spoke with stated that their pain wasmonitored and treated appropriately.

Nutrition and hydration

• Due to the nature of the surgical services offered, therewere no specific nutritional or hydration facilities inplace. However, nursing staff offered drinks and snacksto patients pre and post operatively.

• The needs of diabetic patients was assessedpre-operatively and post-operatively. If they were insulindependent and required to fast for a procedure, forexample if they were receiving sedation, the consultantor anaesthetist was able to advise on the number ofunits of insulin they should take beforehand in order tohelp prevent a drop in blood sugar levels.

• Staff we spoke with were aware of the needs of diabeticpatients and would offer appropriate snacks or drinks topatients if their blood sugar levels were low.

Patient outcomes

• We spoke to the head of Eye sciences, whose role was tocollate data on Refractive Lens exchange (RLE), cataractsurgery and laser surgery. The eye sciences teamcollected data for all Optegra hospitals each quarter andpresented the data across the UK. Data collected wouldinclude operative details; pre-operative, post-operative

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and clinical outcomes. For example the results showedOptegra Manchester scored 100% for the number oftreatments undertaken and the percentage oftreatments with no recorded operative complicationsover the past four quarters, compared to 99% in the restof the UK Optegra hospitals.

• The Medical Advisory Committee (MAC) meeting held atOptegra Manchester would receive the eye sciencesreport to enable them to bench mark against otherOptegra hospitals and other eye hospitals. Numbers ofprocedures each month are monitored and outlierschecked.

• Eye Sciences have recently started to audit the Optegrahospitals outside the UK, which include Poland, Chinaand Germany. Bi-weekly calls are held to shareinformation nationally.

Competent staff

• Any new doctor applying to work at the hospital wouldbe discussed at the MAC. They would look at thepracticing rights and background to consider theirsuitability. They would ensure that the doctor’sappraisal was up to date and if their skill was required atthe hospital.

• All new staff completed an induction programme on theinternet, which included; health and safety, access tosystems, mandatory training, human resources andpolicies and procedures. Staff would have a six monthprobationary period.

• An informative induction booklet was issued to newstaff which informed them of; the fire evacuationprocedures, emergency contingencies, local contactnumbers, health and safety policy statements andcontractor rules.

• Any new procedures brought to the hospital by doctorswere also discussed at the MAC and if considered, theythen had to be signed off by the medical director, as safeto be used.

• If a doctor had not practised at the hospital for 12months or more the MAC would consider removingthem from the list.

• The registered manager ensured that consultantsurgeons and other staff from the NHS working at thehospital had practising privileges. We reviewed fivepersonal files of surgeons and all checks were in order.These included, amongst others; practicing privilegesinterview forms, ophthalmic surgery certificates anddisclosure and barring service (DBS) checks.

• The hospital collected comparative outcomes byclinician and used this for competency and revalidationpurposes as well as for quality improvement processesthrough the MAC and clinical governance processes.

• The hospital’s annual appraisal programme ran fromJuly to July each year, as our visit was undertaken inJuly 2017 we found that the annual appraisals for 2017were ‘due’ for completion. During the inspection we sawthat 100% of staff had received an appraisal within thelast 12 months from July 2016 to July 2017.

• The clinical services manager had a system foridentifying which staff were competent to work in whichareas of the hospital, such as those who could act asscrub nurse, co-ordinator or undertake cannulation, IVadministration etc. However, was not able to evidenceindividual competency for specific tasks such as thedispensing of medicines to take home, nurse leddischarging and pre-operative assessments which maybe considered as extended practices for nurses.

• This meant that there was a lack of assurance thatnurses were competent to perform these roles. Wespoke to managers about this on inspection and theyadvised us they would be working on a new system toevidence these as a priority in the coming months.

Multidisciplinary working

• During our inspection we saw good multidisciplinaryteamwork between disciplines within the hospital.There appeared to be a sense of respect and recognitionof the value and input of all team members.

• A number of staff were able to work across the hospitalcovering surgery and outpatients duties. This meantthat staff were able to demonstrate an understanding ofdifferent roles and better collaboration with colleagues.In turn, this led to continuity for patients on longer-termtreatment pathways.

• Within theatres staff stated that teams worked welltogether and all members of the team had a voice. Staffsaid that all grades of staff were able to have theiropinions heard.

• The hospital had effective external workingrelationships through service level agreements withexternal contractors to facilitate the effective running ofthe hospital. This included the provision of pharmacyservices, clinical waste management and disposal,laundry, cleaning and estates management.

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• The hospital had effective relationships with communityeye practitioners such as optometrists, opticians andcommunity nurses.

Access to information

• Patient records were both electronic and paper based.All staff had access to full details of a patient’s pastmedical history, medicines, allergies, referral letters,consent information, clinic notes, pre-assessmentnotes, and consultants’ operation notes.

• Paper records were kept on site for three months beforebeing archived to an external storage facility.Documents could be recalled should they be neededafter being archived.

• Staff had access to the information required toundertake their role. They had access to a range ofpolicies, standard operating procedures and opensource material via the computer system.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

• A corporate consent policy was in place at the hospital.The policy was compliant with Mental Capacity Act andDeprivation of Liberty Safeguards legislation. The policyset out staff responsibilities for seeking and obtaininginformed consent, including the type of consent (verbalor written) needed for different procedures undertakenat the hospital.

• Training on Mental Capacity Act and Deprivation ofLiberty Safeguards legislation formed part of thesafeguarding vulnerable person’s mandatory trainingmodule.

• The hospital had never had cause to seek a deprivationof liberty authorisation.

• The responsibility for consent to procedures wasundertaken by consultants, this took place atconsultation or immediately prior to the procedure. Allpatient records we looked at had completed and signedconsent forms.

• We found that confirmation of consent for surgery wasnot shared with the wider surgical team as part of theWHO safer surgery checklist procedures as would beexpected.

• The capacity of a person to consent to treatment wasreviewed by consultants and staff nurses duringconsultation and the pre-operative assessment stage.For those patients who lacked capacity a decision wasmade whether their needs could be accommodated

based on the type of treatment they sought. For some,the hospital acknowledged a general anaesthetic wasnecessary which could not be accommodated at thishospital, therefore they were referred back to the NHSacute service.

• We saw evidence of consideration of the capacity of apatient and their consent for treatment. We saw thatappropriate actions were taken; best interest decisionswere made with input of the family and healthcareprofessionals, a consent form four was completedtogether and evidence of the power of attorney forhealth issues was obtained.

• For certain elective procedures such as some of thosebeing undertaken at this hospital, best practiceguidance suggests that practitioners should allow aminimum of one week between the date of consultationwhere they agreed to a procedure and the date theprocedure is undertaken. This allows the patient a‘cooling off’ period during which they can consider theirdecision and change their mind if they wish to. The staffwe spoke with were familiar with cooling off periods andwe saw that minimum cooling off periods of at least oneweek were observed.

Are surgery services caring?

Good –––

We rated caring as good.

Compassionate care

• All staff, including reception staff and non-clinical staff,were highly compassionate and respectful to everypatient who used the service.

• We witnessed that the privacy and dignity of patientswas maintained at all times.

• The NHS Friends and Family test (FFT) results reflectedthis by comments from the patients; 100% of thepatients said that they were extremely likely torecommend the service. The England average being94%. The response rate was 51% which equated to 132responses.

• One additional comment made by a patient in the freetext box on the FFT was ‘I was treated in a kind andcaring way and (this) made me feel less anxious’.

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• We spoke to 11 patients and their families during ourvisit and all patients we spoke to, spoke positively abouttheir care; ‘Excellent’, ‘Very, very, good’ and a number ofpatients said the service was fantastic and there wasnothing they would change.

• Out of the 11 comment cards we viewed from patients,nine spoke positively with regards to the care they hadreceived. One patient wrote; ‘All staff's attitude and careare of the highest standard.’ One family member madecomment about the ‘compassion’ shown to her and herfather by the patient liaison staff member.

Understanding and involvement of patients and thoseclose to them

• Patients we spoke with said they felt involved indecisions about their care and treatment and thattreatment plans were clear and understood. They saidthat staff took time to involve them and explain things ina way that they understood.

• Consultants ensured that patients had realisticexpectations of their procedure and treatment beforeconsent was obtained. Patients were afforded ‘coolingoff’ periods to ensure that they had fully understoodand considered all the information available.

• During surgical procedures staff explained what washappening during each stage of the procedure andchecked on the patient’s welfare.

• Staff ensured that patients had the support they neededfollowing a procedure and involved those close topatients to ensure they were supported when theyreturned home.

• We observed staff taking time to explain follow up careand instructions to patients and to answer theirquestions following surgery. This included how tocorrectly insert eye-drops at home, they also advised ontake home medicine details and after-care such asbathing and cleaning the eye.

Emotional support

• Staff demonstrated empathy and understanding aboutthe emotional impact that sight problems might haveon patients. They provided emotional support topatients and would refer them to sight supportorganisations and charities if they felt the patient wouldbenefit from this.

• Staff provided reassurance to patients who wereundergoing procedures. They supported nervous or

anxious patients by putting them at ease and calmlyexplained the procedure. They identified patients whomight be nervous during pre-operative assessmentsand considered if they might benefit from sedation.

Are surgery services responsive?

Good –––

We rated responsive as good.

Service planning and delivery to meet the needs oflocal people

• The services were delivered in pleasant and appropriatepremises, with excellent facilities for patients and staff.

• The hospital assessed the requirements of their privateand insured patients, the requirements of the localclinical commissioning groups and their potentialpatients when designing, furnishing and equipping thepremises. The needs of all groups were taken intoaccount when planning and arranging the hospital’sservices.

• Managers told us that the hospital did not have aspecific admission or exclusion criteria for patients.They were also unclear about the nature of theiragreement with the clinical commissioning groupsabout which patients they could not accept. They statedthey were unable to accept some patients living withdementia or learning disabilities as they could not safelyaccommodate their needs but this was not formalisedinto a contract or policy. They could not provide detailsof the number of patients they had deemed unsuitablefor treatment due to the hospital being unable to meettheir needs.

• The service provided pre-planned services only.Therefore they were in full control of the numbers ofpatients they could accommodate at any given period.The service proactively forward planned surgical andclinic sessions and used data to identify number ofpatients waiting for treatment and procedures.

• They had the ability to decrease or increase the numberof surgical sessions and clinical appointments requiredto meet the needs of patients and to maintain flexibilityat busy periods.

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• If a surgeon had planned time off then theatre list wouldnot be compiled for those days and in turn if increasednumbers of patients were waiting extra sessions couldbe organised.

• The hospital was planning to open its second operatingtheatre; this was to ease demands for the currentoperating theatre. The utilisation of the theatre wasoversubscribed and very much in demand during sometheatre sessions and was in response to requests byconsultants. There was no planned date for the openingof the second operating theatre.

• The second theatre would enable the hospital toaccommodate more surgical sessions, reduce waitingtimes, in particular waiting times for private patientsand treat greater numbers of patients generally.

• The hospital was open from Monday to Friday between8am and 8pm and on Saturday between 8am and 3pm.

• The service provided a 24 hour helpline for advice topatients outside of normal working hours. Consultantswere available during normal working hours to reviewpatients if staff felt medical input was required.

Access and flow

• Patients were able to access the service via a range ofmeans. Self-paying and insured patients were able toself-refer without a GP or optician’s referral. Four localNHS clinical commissioning groups (CCG)commissioned services from the hospital forappropriate NHS patients.

• As part of the quality data required by NHS contracts thehospital was required to meet the 18 week Referral totreatment (RTT) pathway. The hospital had no breachesof this requirement.

• During the period 31 May 2016 to 30 April 2017, theaverage NHS RTT was three to five weeks andappointments were offered to fit around patient choiceand availability. We were told this was achievable as theservice offered all diagnostics at the time of the initialconsultant appointment and also because they treatedunder local anaesthetic as a day case.

• Private patients, who include those on the refractivetreatment pathways for laser, had an average RTT of twoto five weeks subject to laser and refractive consultantavailability. All patient treatment is scheduled in thesame way regardless of being NHS or private patientand medically urgent patients, are treated as soon aspossible as a priority.

• NHS patients followed the NHS patient pathway whichincluded an assessment of suitability and triage by aclinician. These patients required a GP or optometristreferral. For some procedures NHS patients couldchoose this service through the NHS e-referralprogramme (formally known a ‘choose and book’).Optegra Manchester had also supported two local CCG’swith waiting list initiatives, enabling NHS patients to beseen in timely manner.

• Private patients could arrange a free no obligationconsultation with ophthalmologists to discuss potentialtreatments and procedures. They could also attend‘open evenings’ where consultants gave a presentationand discussed the various treatments on offer.

• Patients were offered a choice of appointments to suittheir circumstances. The hospital was open until 8pmduring weekdays and opened on a Saturday until 4pm.

• The hospital had partnerships with a range of qualifiedoptometrists across the UK; these partners could referpatients for treatment if they found conditions thatcould benefit from treatment.

Patient flow

• The hospital did not provide an emergency eye surgeryservice. They provided for elective and pre-plannedprocedures only. Any emergency cases were referred tothe appropriate emergency eye care services.

• Discharges following surgery were undertaken by nursesfollowing assessments of the patient’s recovery andfitness to go home. If nurses had any concerns theycould seek a review by the surgeon involved.

• Discharge letters were completed and copies were sentto the patient’s GP and or optometrist/optician, with acopy being supplied to the patient. This letter outlined;the procedure that had been completed, theirprescription and details of any treatment plan orpost-operative care and follow up.

• Patients were advised regarding post-operative care,how to use the medicines provided and given details ofthe 24 hour helpline should they have concernsfollowing discharge.

• Follow up appointments were arranged as outpatientsat clinic for reviews and dressing changes.

• The hospital cancelled seven operations during theperiod 20 July 2016 to 19 July 2017. This was due to a

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theatre list being arranged when the surgeon was onleave. The patients all had their procedure rescheduledwithin 28 days and most were rearranged for thefollowing day.

Meeting people’s individual needs

• The hospital provided surgery for both private and NHSpatients and the patient mix for the last 12 months was65% NHS patients and 35% privately funded. From whatwe observed, both patients were treated equally.

• There were no special considerations for bariatricpatients and as patients were not routinely weighed,they did not have a system in place to ensure that theoperating tables were adequate. We spoke to themanagement team and it was not something thehospital had considered.

• Patient language and interpretation needs were coveredin the hospital’s policy on Equality, inclusion and humanrights. Staff could access language and interpretationservices and information could be made available inappropriate formats. The policy had information for stafffor using interpretation services.

• A loop system was in place for hearing aid users.• The hospital was accessible for those patients with

mobility problems and wheel chair users. There weredesignated disabled car parking spaces and step freeaccess to the hospital. There were designated disabledbathroom facilities on site.

• Optegra’s information pack which was sent out toindividuals prior to coming in for a procedure was of asmall print. We were told that this was not available in alarge print, or in another format, e.g. audio. We raisedthis with the management team as we felt that inparticular pre-operative patients would struggle to readthis information, management agreed and spoke ofimproving the packs.

• If patients were found to be particularly worried orconcerned at initial consultation or pre-operation stagethen the hospital would invite them for a trial visit. Thiswould comprise of the patient walking through thepathway, including getting on and off the trolley, whichhelped if their concerns were due to mobility issues. Thehospital found this extremely helpful and believed theymay lose worried patients if they did not invite patientsfor this extra visit.

• The hospital combined online learning with workshopsto discuss key issues and share learning with regards todementia awareness and safeguarding vulnerableadults.

• Following surgery patients were provided with writteninformation explaining follow-up care. The patientswere given contact details of who to call if they had anyconcerns. Patients were also offered a follow-upappointment the day after surgery to check on theirprogress.

Learning from complaints and concerns

• The hospital had a complaints policy in place, this wasin date, reviewed and updated regularly and wasaccessible to staff.

• We looked at the hospital’s complaints tracker whichshowed they had received six complaints between May2016 and April 2017. We found that all of the complaintshad been acknowledged within Optegra’s stated time oftwo working days. A written response following aninvestigation was evident and the patient informedwithin 20 working days of receiving the compliant.

• Only two of the complaints out of the six had beenclosed. The oldest complaint on the tracker still activewas for January 2016; however we saw evidence thatthe patient had been kept informed.

• The process at the hospital was to refer any complaintsto the director of the hospital, who would review andescalate to the operations director if they could notresolve it.

• Details of complaints were shared within thegovernance structure at the Medical AdvisoryCommittee (MAC) and integrated governance meetings.Informal complaints were shared at the daily huddle.

• A patient was advised that they may refer theircomplaint to the independent sector complaintsAdjudication service (ISCAS) for an independent review.Details of how to do this were in the Optegra ‘Feedback,comments & complaints’ booklet.

Are surgery services well-led?


We rated well-led as Requires Improvement.

Surgery

Surgery



Leadership / culture of service related to this coreservice

• There had been recent changes in the managementteam and an interim clinical manager and a newhospital manager had been appointed. They were verypositive about the future. Likewise staff we spoke withwere optimistic about the new management structure.

• The management team were introducing a team leaderfor surgery which was welcomed by staff.

• Feedback from staff members produced a mixedpicture. Some staff members felt supported, described agood work/life balance and being valued. Whereasothers reported they had no received support theydeserved over the last 12 months.

• The hospital had an Equality, inclusion and humanrights policy in place. The policy outlined that everymanager employed by Optegra was responsible forpromoting equality inclusion and human rights in theirsphere of management and for preventing unduediscrimination in practice. The policy had clear aims andobjectives.

Vision and strategy for this core service

• Optegra's vision was ‘To ensure Optegra UK is a marketleading profitable provider of first choice, famous forPatient service and eye care excellence because we lookafter our colleagues, who look after our Patients’. Thevalues were found on the website, but not displayedaround the hospital.

• One member of staff we spoke to could not recite thevalues but knew where to access them on the intranet.

• The Hospital director said that the vision for OptegraManchester was to continue with outstanding patientcare and all the staff were aware that this was thehospital’s priority.

Governance, risk management and qualitymeasurement (and service overall if this is the mainservice provided)

• The hospital held Clinical service managers (CSM)meetings quarterly, which were attended by UK clinicallead and head of clinical governance and risk, togetherwith all CSM’s from UK Optegra hospitals. Key areasdiscussed were; medicine management, infection,control, safe guarding, clinical incidents and health andsafety. Incidents are shared between Optegra hospitalsfor learning. The CSM meetings ensured commonality

across the hospitals, shared pathways, documentationand encourages staff recognition of their relationshipwith Optegra. We looked at four sets of minutes from theCSM meeting to evidence the shared learning.

• The service carried out a number of audits, however wesaw no evidence of staff members monitoringcompliance of the WHO surgical safety check list, ormaking observational checks to ensure the safety ofpatients.

• We identified a number of concerns in relation to; poorstaff adherence to the WHO surgical safety checklistguidelines, lack of policies and staff competenciesaround dispensing and labelling of medicines, poorunderstanding by staff of incident grading and reportingof serious incidents and never events. Therefore wewere not reassured that risk management and qualitymonitoring was robust

• The hospital’s 2017 staff survey indicated that stafflacked confidence in the management and their abilityto implement changes.

• Eye sciences did not bench mark outside Optegra, butlooked at and consider international data and reviewedpublished papers reflecting outcomes for cataractprocedures.

• The risk register accurately reflected all the risks withinthe hospital. The risk register described the cause andconsequence of this risk. We saw from the risk registerthat the type of risks were categorised as; Financial,quality or operational.

• However, the risk register did not show a date for whenthe risk was expected to be resolved. We were told thatthe risk register was under review and they were lookingat making the risk register more ‘reader friendly’ andwhether the risk was still ongoing, would be clearer.

• An Integrated governance steering group was heldquarterly and attended by Optegra UK seniormanagement team, including hospital Directors,function heads, eye Sciences, Medical director andOptegra UK Managing Director. At the meetings theoutputs from the hospital level governance groups werereviewed to ensure consistency, monitor trends andadherence to policy and outcomes data, complaintsand serious incidents were also reviewed. We sawevidence of this by reviewing the minutes to the lastthree meetings.

• A Medical Advisory Committee (MAC) was held fourtimes a year and attended by the chair, an optometrist,clinical nurse, consultant and a spread of

Surgery

Surgery



sub-specialities for glaucoma, refractive eye surgery,cataract, cornea and retinal. We looked at the minutesof the last three meetings, which showed they were wellattended.

• At the MAC safety issues, adverse events, infections,complaints and incidents were discussed and learningtaken from critical incidents and events. Local andNational incidents were discussed at the meeting. If amember of staff could not attend the meeting, theminutes would be distributed for their attention.

Public and staff engagement

• The service had a website where full information couldbe obtained about the treatments available for patients.It was very comprehensive including information aboutcosts and finance.

• Optegra, which included Optegra Manchester, hadachieved number one in category for ‘Trustpilot’ (awebsite which publishes reviews from customers foronline businesses). They had been voted by the publicas ‘Best in category’ for eye treatment and rated 9.6 outof 10 based on 1,479 reviews. We had sight of thecomments made regarding Optegra Manchester, whichincluded comments such as; “I would not hesitate torecommend Optegra”. “A relaxing and comfortableexperience”. First class premises, first class facilities, firstclass staff.”

• The hospital used the NHS Friends and family test tofind out the views of patients who used the service. Howmany surveys sent out to patients varied; betweenFebruary and April 2016, 90 surveys were sent out with aresponse rate of 59%. Between January and February2017, 66 surveys were sent out to patients, with a 61%response rate.

• The hospital’s staff survey in December 2016 highlighteddissatisfaction amongst staff. Approximately 56% ofclinical staff stated that they strongly disagreed withstatements such as; their line managers were availablewhen needed, consulted them about decisions thatwould affect them and that the manager made itpriority to spend 1:1 time with them. However, 69% feltthere was a strong sense of belonging in their team.

• Forty-five percent of staff felt that they did not have jobsecurity. 50% of clinical staff & 40% of managersdisagreed that there was a ‘no blame culture’ and thatpeople felt free to speak their mind.

• Fifty percent of patient services staff and 62% ofmanagers said they had not attended a communicationmeeting.

• We raised the issues from the staff survey with themanagement team, concerning the poor figures onmanagement related questions. As a result of the figuresOptegra carried out an internal review, after whichmajor changes in staffing were carried out. The clinicalmanager was replaced with a clinical manager fromanother Optegra branch and the UK clinical advisorbrought in.

• Two years ago the Eye sciences developed a patientquestionnaire for those who had undergone cataractsurgery, laser vision correction or, refractive lensexchange at Optegra. The questionnaire was developedto be delivered by a touch screen tablet with theguidance of the patient liaison, or a paper version wasavailable.

• We looked at the electronic patient reported outcomessurvey for the recording period of June 2014 to June2017. 499 cataract patients responded to the survey and80% of patients said that they strongly agreed with thestatement; ‘I would recommend treatment to family andfriends”. 40 RLE patients completed the survey and 80%of patients said they strongly agreed with the statement“I feel my quality of life has improved followingtreatment”. Only five respondents were patients whohad received laser vision correction.

• Staff ‘Huddles’ took place daily at 10am whererepresentatives of all departments were present. Staffwere informed of who the lead was in theatre that day,visitors to the hospital, rolls and responsibilities of staffand other relevant information that needed sharing.

• Optegra had a staff recognition scheme whereby staffcould nominate individuals and teams. In December2016 the clinical team at Optegra Manchester had beennominated for ‘Colleague Recognition’ for outstandingcommitment and professionalism to their work withcolleagues and patients. An individual was alsonominated in March 2017 having been new to thecompany the employee was nominated for taking onextra responsibilities in such a short time frame.

• The hospital held open evenings periodically when thepublic were invited to view the facilities and ask anyquestions regarding the process and procedures.

• The Optegra website advertised a free no obligationquote, to test the patient’s suitability for Refractive eyesurgery. This was only available to private patients.

Surgery

Surgery



• The clinical manager had recently left and the newmanager had been brought in from head office and waskeen to boost morale amongst the staff. A strategy dayhad been arranged for all the staff to attend and wasdue to be primarily a social and team building event.

• There was also a change in director at the hospital andthe new director due to take over had already booked innew monthly, senior management team meetings, forMonday lunch times, to be attended by the patientservices manager, lead ophthalmologist and clinicalmanager in order to share information and learning.

• There was currently no patient forum in place at thehospital. Patient forums are usually open to any patientor relative to discuss any concerns or anxieties they mayhave about the hospital and treatment. We spoke to themanagement team who said this was something theyintended to start and planned for these to take placeevery three months.

• The hospital was actively involved in two local charitiesand certificates of the fund raising totals were displayedon the walls of the manager’s office.

Innovation, improvement and sustainability

• The hospital was interested in further expansion andhad recently secured a contract with a local NHS trustfor taking all newly diagnosed age related maculardegeneration glaucoma (AMD) patients. This means arapidly growing cohort of patients and the hospitaldirector told us this was the right pathway for the futureof the hospital.

• A new monthly hospital-wide meeting had recently beenput in place. The meeting was to discuss any relevantclinical governance issues and was to be attended by allstaff.

• The management team told us that they would like toreconfigure the hospital waiting room. Currently allpatients sit together in one central area, until calledthrough. They planned to segregate areas for patients tomake it clear to staff which patients are for whichappointments and procedures. They also believed thiswould be beneficial for patients to sit with similarpatients.

• Improvement on waiting times was on the managementteam’s agenda for future improvements. For example,current waiting times for private patients fromconsultation to operation were 12 weeks and theopening of a second theatre would improve this.

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Safe Good –––

Effective

Caring Good –––

Responsive Good –––

Well-led Requires improvement –––

Are outpatients and diagnostic imagingservices safe?

Good –––

We rated safe as Safe as good.

Incidents

• The service had a policy for incident reporting andinvestigation. We reviewed the policy and saw that itidentified what to report as an incident and encouragedstaff to report accidents or near misses related to safetyconcerns and practice.

• All staff spoken with in the Outpatient Department(OPD) told us they were supported to raise any potentialrisks or concerns. They were confident that they weremade aware of how to raise incidents. Staff also told usthey were informed of learning as a result of incidentinvestigations that assisted in improving the servicesperformance.

• Information provided to us by the service showed thatthere were no Never Events in relation to OPD reportedin either the Manchester or the Altrincham site in thelast year.

• Never events are serious incidents that are entirelypreventable as guidance, or safety recommendationsproviding strong systemic protective barriers, areavailable at a national level, and should have beenimplemented by all healthcare providers.

• Records available recorded that there were fewincidents reported in OPD as such there were no clearpatterns that could have identified areas ofimprovement for the service to monitor.

• Staff working in the OPD told us that daily huddles(small meetings for staff on duty) were in place and atthese any new learning was discussed. They told us thatthey found this useful in order to make sure that theywere kept up to date with any changes. Additionallyincidents and learning outcomes were discussed at staffmeetings.

• We were shown copies of emails that staff had receivedin relation to safety alerts produced from externalorganisations. Staff told us that they were kept up todate by Optegra when alerts were made about the latestsafety findings. We were also informed by staff thatthese were discussed at team meetings and they foundthis information of use.

• Staff we spoke with understood their responsibilitiesregarding duty of candour. The duty of candour requiresstaff to be open and transparent with people about thecare and treatment they receive. There had been noincidents in relation to OPD that required a duty ofcandour response.

Cleanliness, infection control and hygiene

• On reviewing the environment we saw that all areaswere visibly clean. Protective equipment to assist in thereduction of the spread of infection such as gloves wereavailable and observed to be used appropriately. Allbins were hands free or pedal bins, soap in bathroomswas liquid soap and there was access throughout theservice to hand sanitiser. These aspects were in place toassist in the prevention of the spread of infection viatouch. Additionally the service provided training onhand hygiene and audits took place to ensure that staffadhered to the best practice guidelines of hand hygiene.


Outpatients and diagnosticimaging

Good –––


• We observed staff practice throughout the inspectionand saw that staff washed their hands appropriately andused protective equipment as needed. Staff practiceassisted in reducing any risks of the spread of infectionwithin the service.

• Throughout the service we observed that there were“sharps” boxes these were used for the safe disposal ofitems such as used needles and denatured (destroyed)controlled drugs as needed. The service had a contractwith an external organisation for the removal andreplacement of sharps boxes in order to make sure thatthese were safely dealt with.

• All furniture throughout the service at both sites wasobserved to be easily cleaned. We were shown copies ofcleaning schedules available in some areas, such asbathrooms, which recorded that these areas werechecked throughout their usage in order to maintaintheir cleanliness.

• Throughout the inspection we observed the cleaningteam attended to any spills rapidly. Patients and theirrelatives were complimentary about the cleanlinessthey observed within the service. One person told us“the environment was clean and safe”, another said “Ilike how clean and fresh it looks”.

• We looked at the infection, prevention and controlpolicy dated January 2015, this included information onstaff training and the disposal of clinical waste tosupport staff in maintaining good hygiene.

• The policy was supported by a senior staff member whohad an additional lead role as infection, prevention andcontrol. Staff members spoken with were aware of whoto access for advice regarding any infection controlquestions they may have.

Environment and equipment

• The service had two sites; in Manchester and a smallerclinic in Altrincham. We saw that both buildings wereaccessible to patients and their relatives. We looked atclinical areas in both sites including examination rooms,consultation rooms and the area described as the wardat the Manchester site. They were observed to containequipment that was suitable to the diagnosis, treatmentand recovery of patients. Consultants and staff told usthey believed that they had access to the latestequipment and if new equipment was needed this wasreadily provided.

• Records available indicated that the service had anongoing maintenance schedule that checked the

equipment available and made sure that routinemaintenance was in place within the OPD. Anyequipment or areas of the environment that needed tobe repaired or replaced was actioned rapidly in order tomaintain the safety of patients.

• We checked the resuscitation trolley located on themain corridor outside the theatre area. The trolley wasavailable for both theatre staff and the OPD area staff.Daily checks were observed to be in place to make surethat all equipment was within expiry date and testedthat it functioned safely.

• Emergency medicines were available on theresuscitation trolley were stored within an anti-tamperbag and checked that they remained within their expirydate.

Medicines

• We saw that medicines were stored appropriately inOPD within lockable cupboards to preventinappropriate access. The service has identified that onearea of storage presented a risk to staff consistentlyhaving to bend to retrieve the medicines and had madearrangements to relocate the medicines safely.

• Patient records examined recorded patients currentmedicines, any allergies and a medical history weredetermined in order to make sure that any medicinesprescribed by the consultants were safe to be given andwould not react with the patients regular medicines.

• At the announced inspection we saw that staff withinthe ward were giving out medicines to take home in amanner that did not always maintain the safety ofpatients. This was because medicines given to thepatients did not include vital information they neededsuch as cautionary labels such as “may causedrowsiness” were not used.

• Staff told us that they had in the past recognised thatone bottle of a certain eye drops was not sufficient forpatients and gave them two. However when wereviewed the prescriptions we saw that they did notcontain the information that staff needed to make thisdecision safely.

• A copy of the medicines management policy wasreviewed. However this did not explore thearrangements in place to support staff to dispensemedicines for patients to take home. The policy alsostated that staff needed to dispense medicines using astandard operating procedure. We spoke to seniormanagement and nursing staff who confirmed that a



Good –––


standard operating procedure was being developed andwas not in place. This meant that staff did not have theguidance they needed in order to make sure that theydispensed medicines in a consistently safe manner.

• On our return to the service for the unannounced part ofthe inspection we saw that the service had taken actionto reduce some of the risks and had put into place theguidance that staff needed to assist them in givingmedicines safely.

• The service did not carry out its own audits formedicines but had contracted for an external pharmacyto do this. The audit system had not identified the issueswe found during our inspection.

• For our detailed findings on medicines for this coreservice, please see the Safe section in the Surgeryreport.

Records

• The electronic records available contained copies ofinformation sent to private patients regarding the costsof their treatment in order to provide the patient withrelevant information before they agreed to thetreatment.

• The patient liaison staff we spoke with told us that theymade sure that for each pre and post-operativetreatment patient records were available for theconsultants and returned to a secure storage when theconsultants finished their consultation.

• Records reviewed contained copies of any referral lettersand clinic letters that would be needed for anyconsultation. Additionally there were copies of posttreatment letters that were sent on behalf of patients toother relevant medical professionals.

• For our detailed findings on Records for this core serviceplease see the Safe section in the Surgery report.

Safeguarding

• Staff told us and records confirmed that OPD staff didnot raise or escalate any safeguarding concerns in theprevious 12 months.

• Information from the service showed that they do nottreat patients under the age of 18 years old. As such theOPD had limited contact with young people. Staffmembers told us that they were provided with onlinesafeguarding training for both adults and children. Theyprovided child safeguarding training as children canattend waiting areas with their relatives.

• Records showed that all staff with the OPD (100%) in theservice had completed safeguarding adults training aspart of their ongoing development.

• We saw that there were local and national safeguardingpolicies and procedures in place, which staff in theservice knew how to access and were able to giveexamples as to what a potential safeguarding concerncould be and how it would be dealt with.

• Staff told us that they had access to safeguardingsupport when required from a senior member of themanagement team who was allocated as thesafeguarding lead. Senior management confirmed thatthey had a safeguarding lead available within theservice that supported staff with any concerns.

• For our detailed findings on safeguarding for this coreservice, please see the Safe section in the Surgeryreport.

Mandatory training

• All staff in OPD we spoke with told us that they had hadcompleted their mandatory training before theinspection, this included fire, manual handling,safeguarding training and health and safety. Thistraining was done on line. They also told us they hadcompleted additional training in areas such as dementiacare and mental capacity. All staff we spoke with told usthat they had particularly enjoyed the dementia caretraining. Records available with the service showed thatstaff had completed mandatory training.

• All staff in OPD we spoke with told us that they had lifesupport training at immediate life support level (ILS) orabove records available confirmed that 100% of staffhad received training in this area.

• For our detailed findings on mandatory training for thiscore service, please see the Safe section in the Surgeryreport.

Nursing staffing

• Managers spoken with told us that the service did notuse a recognised patient acuity tool to determine howmany staff members were needed each day in the OPD.As appointments and surgery was planned in advancethe service was able to plan patient care in advance andco-ordinate staff to patient procedures andappointments.

• All the nursing staff we spoke with told us that theythought that there was sufficient staff available tomanage their workloads appropriately.



Good –––


• Records submitted before the inspection did not dividethe staffing levels into surgery and OPD. The servicesupplied information that stated the establishment (i.e.staff needed) was 6.4 whole time equivalent (WTE)nursing staff. The information further stated there werefour full time nursing staff and four part time nursingstaff.

• Additionally there were 12 bank staff that worked as andwhen they were needed. All bank staff worked regularlyin the service or had previously worked there. Theservice had not used any agency staff in the previous 12months. As such staff members employed wereexperienced in working in the service and familiar withthe job role.

• We saw that the staffing structure was flexible andnursing staff in OPD could support surgery if and whenrequired.

Medical staffing

• Information supplied by the service showed there werefive optometrists undertaking pre-operative checks andreferrals for surgery as needed. They all worked in thehospital under practicing privileges. Practicing privilegesare a process within independent healthcare whereby amedical practitioner is granted permission to work in anindependent hospital or clinic, in independent privatepractice, or within the provision of community services

• There was an optometrist employed by the service on apart time basis (0.8 WTE) who provided support andleadership to the other optometrists.

• For our detailed findings on medical staffing for this coreservice, please see the Safe section in the Surgeryreport.

Emergency awareness and training

• For our detailed findings on emergency awareness andtraining for this core service, please see the Safe sectionin the Surgery report.

Are outpatients and diagnostic imagingservices effective?

We did not rate effective.

Evidence-based care and treatment

• Records reviewed and discussions with managementdemonstrated that the service utilised both national

policies and procedures developed by Optegra as wellas local policies. Clinical guidance that wasincorporated in policy was reviewed at a companynational level as well as at local level to maintaincontinuity of care and support and develop consistentimplementation.

• The policies we reviewed cited and included relevantbest practice guidance such as National Institute forHealth and Care Excellence (NICE) guidance for thetreatment of Glaucoma and Macular diseases.

• Records and staff confirmed that when patients did notattend appointments or dropped out of treatment theywere reviewed and contacted to determine if they stillrequired the appointment.

• We saw that the service had a policy that patients starttheir treatment by a clinical assessment which involveda review by an optometrist prior to being seen by theconsultant. Where a patient was deemed unsuitable fortreatment an explanation in writing was provided tothem and this was undertaken in line with best practiceguidelines in order to maintain patient safety.

• For our detailed findings on Evidence based care andtreatment for this core service, please see the Effectivesection in the Surgery report.

Pain relief

• The outpatients department provided limited forms ofpain management and no formal pain screeningprocess. The only form of pain relief given at pre andpost-surgery consultations was anaesthetic eye drops

• We were informed by staff that patients were advised onpain relief during discharge discussions. However thesediscussions were not recorded in patients’ notes inorder to determine and record that the best advice andsupport had been given.

• Records available and staff discussion showed thatprivate patients were given a 24 hour helpline numberto contact if they needed pain relief. NHS patients weretold to contact their local NHS provision if needed. Allpatients were given discharge information that if thepain was severe they should go to their local accidentand emergency department. There were no incidentrecords available that showed any patients hadexperienced severe pain after discharge.

• Patients returning for after care appointments informedus that they had experienced little to no pain.

Nutrition and hydration



Good –––


• Due to the nature of the service, the OPD did notprovide food and drink specifically. We observed thatthere was a hot drink machine and biscuits available inthe reception area that patients were observed to freelyaccess. Patient’s relatives were also encouraged toaccess this provision.

Patient outcomes

• Records we reviewed showed that patients withnon-surgical conditions such as glaucoma weremonitored according to the service’s policy, patient’sindividual needs and the contract in place with the NHS.Information regarding patient monitoring and outcomeswas reported directly to the NHS in order to make surethat patient’s outcomes continued to be monitored.

• Optegra Manchester benchmarked itself against theother Optegra hospitals. The eye sciences departmentcompleted a report which was fed back, quarterly, to themedical advisory committee. The report covered; localbench marking, UK bench marking and Internationalbench marking. We were provided with a Clinicaloutcomes report which reviewed complication rates andclinical outcomes data for laser vision correction, RLEand cataract procedures performed at that hospital.Comparative data from the previous three quarters anda summary of patient outcomes data was also provided.

• For our detailed findings on Patient outcomes for thiscore service, please see the Effective section in theSurgery report.

Competent staff

• Staff told us they had good access to training regardingtheir professional development. Training recordsreflected a variety of training including additionaltraining above mandatory training such as dementia,stress awareness and equality and diversity.

• All nursing staff spoken with and records reviewedindicated that that 100% of staff had received anappraisal within the last 12 months. Staff told us thatthey found this of use and that there was ongoinginformal supervision that assisted them in identifyingareas of skill they wished to develop.

• We saw that nurses worked in both OPD and surgerywhen required. In general they remained within theirchosen work areas. Nursing staff and consultants alsoworked across both the Manchester and Altrinchamsites. The staff had a varied skill mix and often had extraroles in the organisation. An example of this was a

member of the nursing staff had taken responsibility forleading on infection control and another trained to actas the Laser Protection Advisor who has responsibilitiesin making sure that local laser safety was maintained.

• Management and staff told us that they supportedstudent nurse placements in order to assist both thedevelopment of student nurse skills and their own staffmember’s exposure to different practice and views. Theservice had supported a member of staff to developtheir skills to the point of being successful in gaining aplacement as a student nurse.

• We spoke with staff dispensing medicines and reviewedthe policy which outlined that this was an “extended”nursing role. Staff spoken with and managementconfirmed that specific training and assessment ofcompetency to undertake this specific task had notbeen undertaken. Management confirmed that thiswould be addressed as a priority.

• For our detailed findings on competent staff for this coreservice, please see the Effective section in the Surgeryreport.

Multidisciplinary working

• Records showed and staff confirmed that a teammeeting was held on a six monthly basis, whichincluded staff from across the disciplines. The purposeof the meeting was to enhance shared learning andbuild team collaborative working.

• All staff we spoke with told us that all the disciplinesworked well together and there was a mutual respect foreach other’s profession. They also stated that thoughtthey had good working relationships with other serviceproviders such as general practitioners (GP’s) andopticians. Patients’ records reflected that pre and posttreatment information was sent to patients relevantexternal medical professionals.

• Staff and management told us that the service alsoundertook a weekly lecture night when members of thepublic and other professionals were invited to attend inorder to share learning, build relationships and enhancepractice. This was also widely advertised on the services‘website and explained what topics were to be covered.

• For our detailed findings on Multidisciplinary workingfor this core service, please see the Effective section inthe Surgery report.

Access to information



Good –––


• We looked at how information needed for staff to deliversafe treatment was made available. We saw that patientfiles were made available for each appointment and forstaff to monitor patients after their surgery.

• Records showed that information was sent to relevantexternal professionals as required by the patients.

• Discharge information we reviewed did not consistentlyinclude relevant information about medicines. Patientswere given verbal information, on when and how to takethe prescribed medicine. However this was not recordedin the patients’ records in order to make sure that thisinformation was consistent and fully understood by thepatient.

Consent, Mental Capacity Act and Deprivation ofLiberty Safeguards

• Staff working in the outpatient departmentdemonstrated a clear understanding of how to gainpatient consent and the legal requirements of theMental Capacity Act 2005 and Deprivation of LibertySafeguards (DoLS). The staff members spoken with gaveexamples of when patients might lack the capacity tomake their own decisions and how this would bemanaged.

• We observed records that demonstrated the mentalcapacity of a patient to consent to treatment wasreviewed by consultants and staff nurses duringconsultation and the pre-operative assessment stage.

• For those patients who lacked capacity a decision wasmade whether their needs could be accommodatedbased on the type of treatment they sought. Where itwas determined that the patient did not have capacity abest interests discussion took place and if the treatmentwas in the patient’s best interest and could beaccommodated within the service arrangements weremade that maintained the patients safety and rights.

• For our detailed findings on Consent, Mental CapacityAct and DoLS please see the effective section in theSurgery report.

Are outpatients and diagnostic imagingservices caring?

Good –––

We rated caring as good.

Compassionate care

• We observed staff interaction with patients these werepositive in nature. Some patients return frequently tothe service and the familiarity of staff with individualpatients was observed as warm and welcoming.Patients spoken with told us that, “Staff are very caringand welcoming”, “I am listened to my view matters”, and“staff are very friendly and calm”.

• We saw positive interaction from staff in clinic roomsand waiting areas, consistently throughout theinspection. Staff were kind towards patients, joking andsmiling with them and putting their mind at ease.

• Patients spoken with told us that that they were treatedwith dignity and respect by all staff members. Allpatients we spoke with said they found the staff polite,friendly and approachable.

• We observed that staff respected patient confidentialityand ensured discussion took place in treatment rooms.At reception patients were not asked to provideconfidential information such as name and address.

• Staff told us and we observed that patients’ relativeswere supported to attend appointments and thisoccurred several times whilst we observed staff supportto patients. Staff told us relatives were welcomed andsupported to attend with their family member.

• We observed that there was an inconsistent approachfrom staff greeting patients. The majority introducedthemselves to patients in order to set them at easeothers did not.

• The majority of time we saw that patient’s dignity wasrespected and maintained. We did observe on oneoccasion a patient could be observed lying on anexamination couch from the main corridor. We broughtthis matter to the attention of a senior member of themanagement team who immediately addressed this byclosing the door.

• For our detailed findings on compassionate care for thiscore service please see the Caring section in the Surgeryreport.

Understanding and involvement of patients and thoseclose to them

• All patients and relatives we spoke with told us that careand treatments were explained to them and theirrelatives. Patients told us they felt involved in their care



Good –––


and their appointments were not rushed. Commentsincluded, “it was all well explained to me”, and “All thestaff give the impression of really wanting to help andsupport you”.

• During our observations we saw staff reassuring patientsand giving them time to understand the treatment theywere due to have.

Emotional support

• We spoke with patients and their relatives who told usthey felt supported and staff members were warm andwelcoming. Records showed and was confirmed bypatients that they were given verbal information andsupport regarding their treatment.

• Patients told us that the staff put them at ease onarrival.

• Records showed that many of the patients had adiagnosis of long term conditions such as Age relatedMacular Degeneration (AMD) where the patients’ centralvision deteriorates or glaucoma where the optic nerve isdamaged by the pressure of the fluid inside the eye.Both these conditions can cause significant sight loss.We saw that information on support groups such asRNIB who provide advice to people with sight loss wasavailable.

• Throughout our visit we observed staff givingreassurance to patients with additional support givenwhen it was required, especially if patients wereapprehensive.

Are outpatients and diagnostic imagingservices responsive?

Good –––

We rated responsive as good.

Service planning and delivery to meet the needs oflocal people

• All patients we spoke to felt comfortable in the waitingareas at the hospital, where drinks facilities, magazinesand information leaflets were close to hand. One patientsaid that ‘after surgery they always come round with adrink and a biscuit.’

• We spoke with patients and staff who confirmed that allappointments are planned in advance. As such, theservice was able plan clinic sessions and use

appointment information to identify number of patientswho would be attending each day. They had the abilityto decrease or increase the number of clinicalappointments required to meet the needs of patientsand to maintain flexibility of staff.

• Records and discussion with senior managementidentified that the service had ongoing relationshipswith four Clinical Commissioning Groups (CCG’s) whocommissioned their services. The CCG’s had activemonitored contracts with the service for NHS patients toreceive treatment.

• The service had opening times of; Monday to Thursdayfrom 8am to 8pm, Friday 8am to 6pm and Saturday 8amto 4pm in order to meet patients’ needs. There were twolocations; one at Manchester and one at Altrincham toprovide additional services for patients in thecommunity.

• We were informed by management and staff that one ofthe developments for the future was to have a secondoperating theatre it had been anticipated that thiswould need additional facilities for patients both preand post theatre and action had been taken to providethis additional support.

• For our detailed findings on Service planning anddelivery to meet the needs of local people for this coreservice please see the Responsive section in the Surgeryreport

Access and flow

• Patients were able to arrange OPD appointments via arange of means. Self-paying and insured patients wereable to self-refer without a GP or optician’s referral.

• Management and staff spoken with confirmed that theservice did not monitor waiting times, both prior to anappointment being arranged or when the patientarrived for their appointment. Patients told us that theydid not wait long before they got an appointmenthowever some patients spoken with told us that theydid wait for up to an hour before they were seen.

• We observed staff try to make sure that patients got anappointment of their choice, sometimes on the day ofreferral. We saw one patient call the hospital and wasoffered several different appointments. Another patientspoken with said they were pleased as to how fast theygot an appointment.



Good –––


• We were informed by staff and saw records thatconfirmed that patients living with Age related MacularDegeneration (AMD) were a priority for treatment. Thiswas because that once diagnosed delays in treatmentcould be detrimental to patients’ sight.

• Staff and patients confirmed that where patients did notattend any appointments the service contacted themwithin 48 hours to follow up and rearrange anappointment as needed.

• We spoke to a number of patients on inspection andfound that they had waited between ten and 14 days.

• One patient told us that after their first surgery theyrequested an extra appointment with theophthalmologist regarding the best treatment optionsand this was arranged quickly.

• We observed patients in the waiting room and thosespoken with told us they had not had to wait long beforebeing called for their appointment.

• For our detailed findings on Access and flow please seethe Responsive section in the Surgery report

Meeting people’s individual needs

• We observed that information was available to patientsabout who to contact if they had any concerns abouttheir care. Additionally there was a wide variety ofinformation leaflets available in both waiting areas. Weasked staff and patients if information was available indifferent formats such as braille, large print or otherlanguages. Staff and management confirmed thatdifferent formats were available if requested but werenot readily available on site. The availability ofinformation in formats to meet the needs of people withimpaired sight would benefit patients in theirunderstanding and involvement of the treatment theyare to receive.

• The waiting area was spacious with separate offices thatsupported staff and administrators and staff to haveprivate discussion if need be. The services also hadconfidential interview and clinic rooms, which enabledstaff and patients to have private discussions.

• The environment was observed to be pleasant but wesaw that there were limited adaptations to people livingwith dementia or a learning disability, such asappropriate signage. Staff spoken with andmanagement were not aware of a specific dementia orlearning disability strategy. However, training for staffwas available in dementia awareness, staff stated thatthey had enjoyed this training and found it of benefit.

• We observed staff worked closely with patients and sawthe same staff supported patients on their return to thehospital. Information was not easily available indifferent formats or languages but could be ordered inadvance if required. Staff we spoke with could not recallan occasion when information had been made availablein different formats or languages.

• Car parking was observed to be available at theManchester site but was limited at the Altrincham site.The lack of car parking spaces meant that patients andcarers sometimes needed to park on local roads or payfor car parking. There was a large car park withinwalking distance of the Altrincham site.

• For our detailed findings on Meeting people’s individualneeds please see the Responsive section in the Surgeryreport.

• We spoke with staff and patients who informed us thatthere was assistance for people who required additionalsupport to communicate such as a loop system to assistin hearing and translation service for patients whowould benefit from these services. We saw that loopsystem equipment was available in the majority of areasat both sites of Manchester and Altrincham.

Learning from complaints and concerns

• The hospital had a complaints policy in place, this wasin date, reviewed and updated regularly and wasaccessible to staff.

• The outpatient department displayed their complaintsleaflet that informed patients of how to complain.

• For our detailed findings on Learning from complaintsand concerns for this core service please see theResponsive section in the Surgery report.

Are outpatients and diagnostic imagingservices well-led?


We rated well-led as required improvement.

Leadership and culture of service

• There was no separate manager for the outpatientsdepartment. The Hospital manager also oversaw themanagement of this department.



Good –––


• Staff we spoke with who worked in OutpatientsDepartment (OPD) told us that they were aware thatproviding quality care and being a national leader wasimportant to the service. They spoke about their abilityto recruit the best staff including surgeons.

• Senior management told us that they invested in staffthrough training and awards for staff when theydelivered outstanding practice.

• All staff spoken with in OPD told us that they felt verywell supported and enjoyed working in the service. Theytold us that there had been recent changes in theleadership but they were confident that the newmanagement team understood the service and the staff.

• For our detailed findings on Leadership and culture ofservice please see the Well led section in the Surgeryreport

Vision and strategy for this core service

• The provider’s vision was ‘To ensure Optegra UK is amarket leading profitable provider of first choice,famous for Patient service and eye care excellencebecause we look after our colleagues, who look afterour Patients’. The values were found on the website, butnot displayed around the hospital

• All staff members we spoke with in OPD were aware ofthe vision and strategy of the service.

• For our detailed findings on Vision and strategy for thiscore service please see the Well led section in theSurgery report.

Governance, risk management and qualitymeasurement

• The risk register for the whole service covered risks fromboth surgery and OPD.

• All staff members we spoke with in OPD were aware ofthe governance arrangements. They described howmanagement checked the quality of the service andinformed them of where improvements needed to bemade.

• There was evidence of governance meetings, bothcorporately and locally, where managers discussed andreviewed risks and incidents. Staff we spoke and copiesof the minutes reflected that OPD staff attended theservice-wide meeting

• For our detailed findings on Governance, riskmanagement and quality measurement for this coreservice please see the Well led section in the Surgeryreport.

Public and staff engagement

• For our detailed findings on Public and staffengagement for this core service please see the Well ledsection in the Surgery report

Innovation, improvement and sustainability

• For our detailed findings on Innovation, improvementand sustainability for this core service please see theWell led section in the Surgery report.



Good –––


Areas for improvement

Action the provider MUST take to improve

• The provider must finalise, embed and adhere to aStandard operating procedure as referred to in themedicines management policy with regards to staffdispensing medicines.

• The provider must follow its own policies.• The provider must follow action plans and pass

learning onto staff when an investigation has beencompleted as a result of an incident.

• The provider must carry out audits in order to monitorthe effectiveness of the care and treatment deliveredto patients.

• The provider must ensure that all staff are competentto undertake the activities required to carry out theirrole.

• The provider must audit staff compliance with theirpolicies, including observational checks, to ensure thesafety of patients.

• The provider must implement the surgery check listthey have in place, in a manner that mitigates risks topatients.

• The hospital must ensure it identifies, grades andreports serious incidents and never events in line withits own policy and external reporting obligations.

• The hospital must ensure an effective process formanaging risks to the service which follows up andreviews actions in a timely way.

Action the provider SHOULD take to improve

• The provider should consider taking actions so that allpatients are given enough support and opportunity tobe fully involved in the planning of their own care.

• The provider should consider conducting furtheranalysis to understand the reasons for high staffturnover.

• The hospital should ensure they have in place atransparent patient admission and exclusion criteriapolicy which clearly describes who is they are or arenot able to treat at this facility.

• The hospital should ensure staff and managers arefully aware of the duty of candour processes, whichincidents these apply to and how these should beimplemented in practice.

• The hospital should ensure that any audits,identification of risks and the monitoring of quality arerobustly managed and actioned.

Outstandingpracticeandareasforimprovement

Outstanding practice and areasfor improvement


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

Regulated activity

Surgical procedures

Treatment of disease, disorder or injury

Regulation 12 HSCA (RA) Regulations 2014 Safe care andtreatment

Regulation 12 HSCA 2008 (Regulated Activities)Regulations 2014: Safe care and treatment

12.-(1) Care and treatment must be provided in a safeway for service users.

(b) doing all that is reasonably practicable to mitigateany such risks

(c) Ensuring that persons providing care or treatment toservice users have the qualifications, competence, skillsand experience to do so safely.

(g) the proper and safe management of medicines

The provider did not ensure the persons providing careor treatment to service users had the qualifications,competence, skills and experience to do so safely;

There was no Standard operating procedure as referredto in the medicines management policy with regards tostaff dispensing medicines.

Staff did not fully adhere with your own ‘World HealthOrganization (WHO) Surgical Safety Checklist’ policy.

Individual competencies were not in place for tasks suchas the dispensing of medicines to take home, nurse leddischarging and pre-operative assessments.

Regulated activity

Surgical procedures

Treatment of disease, disorder or injury

Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

Regulation

Regulation

This section is primarily information for the provider

Requirement noticesRequirementnotices


Regulation 17 HSCA 2008 (Regulated Activities)Regulations 2014: Good governance

17 17(2)(a)

Systems and process were not operated effectively toenable the provider to assess, monitor and mitigate therisks relating to the health, safety and welfare of serviceusers and others who may be at risk;

Actions recommended as a result of an investigationidentified failings within surgical safety processes, someof the recommendations had still not been implementedin full.

This is because:

The provider did not have effective systems in place toassess, monitor and improve the quality of the service.

There was no evidence of staff members monitoring thecompliance of the WHO Safety check list, or makingobservational checks to ensure the safety of patients.

This section is primarily information for the provider

Requirement noticesRequirementnotices


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