South West Eye Surgeons LLP provides a range of specialist eye care for adults, children and young people at CESP (Bristol) LLP – Bristol Eye Hospital (the hospital). Services for children and young people made up 2% of the services provided in the reporting period, this has been included in the surgical core service report.
The service is currently registered with the CQC as CESP (Bristol) LLP – Bristol Eye Hospital but is in the process of changing its name. Work is undertaken under the provider parent name of South West Eye Surgeons LLP.
The service mainly provides private care to patients; however, they have an arrangement with the local clinical commissioning group to provide NHS patients treatment as part of a waiting list initiative. This accounts for 10% of their total patients in the reporting period of March 2016 to April 2017.
We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 3 July 2017, along with an unannounced visit to the hospital on 20 July 2017.
To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.
Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.
We rated this service as inadequate overall.
Safe and well led were rated as inadequate, effective was rated as requires improvement and caring and responsive were rated as good.
-
There were limited systems and processes to provide oversight of the quality and safety of the services provided. The provider relied on the systems and processes of the hospital they carried out the surgical procedures in, but did not gain assurance from the hospital of this.
-
There was limited use of systems to record and report safety concerns. Although there was an incident reporting system in place, staff were not aware of this and said they reported incidents using the hospitals reporting system rather than the provider’s system. No incidents had been reported using the provider’s reporting system and as such no investigations had taken place, learning identified or feedback provided to staff.
-
Safeguarding was not given sufficient priority. There was no evidence of training undertaken by staff and systems were not clear, although staff knew how to report a safeguarding concern.
-
Information about safety was not always comprehensive or timely. Safety concerns were not identified. There was no safety dashboard in place, no safety audits carried out, for example, on compliance with infection control practices, or the World Health Organisation surgical safety checklist. However, practice seen on inspection indicated good practice.
-
The monitoring of the safety systems implemented at the hospital was not robust. Senior staff held monthly meetings but these were unrecorded. There was no environmental audit in place.The provider had no assurance that the maintenance of facilities, environment and equipment they used in the delivery of care was safe or if there were any risks posed to patients as a result of this.
-
There was no oversight of the mandatory training or employment checks for the trained nurses and consultants that they employed or engaged under practising privileges. Although all staff employed worked within a local NHS trust and were known to the partners, there was no evidence of training undertaken by staff or evidence of employment checks being carried out.
-
Medicines were not always prescribed prior to being administered to patients and there were no patient group directions in place to cover this.
-
Records were not always maintained of medical photography.
-
There was limited assurance that patients’ care and treatment reflected current evidence based practice because the provider relied upon the hospital undertaking this work. There was no evidence that this was monitored by the provider.
-
There was no evidence of how the provider and senior managers monitored and used current evidence based guidance, standards, best practice and legislation to develop the service.
-
The outcomes of patient’s care and treatment were not always monitored regularly. Participation in internal and external audits and benchmarking was limited. The service did not submit data to the Royal College of Surgeons, Patient Reported Outcome Measures (Q-PROMS) or the Private Healthcare Information Network (PHIN).
-
There was limited oversight that staff had the right training, only carried out surgery they were skilled for and had the correct employment checks.
-
There was no evidence to show that staff received regular appraisal from the provider, or training and development opportunities.
-
Patient concerns raised during the feedback survey were not clearly actioned. The executive committee meetings did not have complaints as a standard agenda item.
-
There was limited awareness of the organisational vision and values.
-
The arrangements for governance and performance management did not operate effectively. There was no recent review of the governance arrangements, the strategy, plans or the information used to monitor performance at Bristol Eye Hospital.
-
Quality did not receive sufficient coverage in executive meetings and was not documented in other relevant meetings. There was no evidence of performance monitoring or of assurance gained about the quality and safety of the service.
-
Leaders did not have the necessary experience or support to lead effectively. Leaders were not always clear about their roles and their accountability for quality.
-
The service level agreement between the provider and the local NHS trust was dated 2007 and was not monitored or reviewed regularly.
However, we found some good practice:
-
Although staff were using the wrong reporting system, they said they felt able to report incidents and that there was a good reporting culture. Most staff understood their responsibilities under the duty of candour, although there was no evidence of the need to do so.
-
Medicines were stored securely.
-
We observed good hand hygiene practice in clinical areas and patients confirmed this.
-
During the reporting period, there were no incidences of hospital-acquired infection.
-
Patient records were secured, well maintained and clear to follow.
-
We observed good compliance with the World Health Organisations (WHO) surgical safety checklist.
-
There were sufficient staff on duty at the time of our inspection to meet patients’ needs. There were also arrangements in place to ensure that children and young people were cared for by suitably qualified and experienced staff.
-
Outcomes that were measured for ophthalmic surgery were good. Posterior rupture rates were below the national benchmark and as such were better than expected.
-
There had been no unplanned transfers of care to other hospitals and no unplanned readmissions.
-
Consultants and nursing staff understood the relevant consent and decision-making requirements of legislation and guidance. There was evidence that consent practices were in line with guidance and best practice.
-
Patients were given the opportunity to take a period of reflection following a consent discussion and prior to surgery.
-
Feedback from people who use the service, those who are close to them and stakeholders was positive about the way staff treated people.
-
Patients were involved and encouraged to be partners in their care and in making decisions about their treatment and support.
-
There were transparent and easy to understand pricing structures.
-
Staff responded compassionately when patients needed help.
-
Services were planned and delivered in a way that met the needs of the local population.
-
Patients reported they had timely access to initial assessment, diagnosis and treatment. However, the provider did not monitor this.
-
Care and treatment was only cancelled when necessary. Only one patient had their procedure cancelled between April 2016 and March 2017 and they were offered another appointment within 28 days.
-
There was equal access to people who were visually impaired and had physical disabilities.
-
Information was provided pre-operatively on how to make a complaint or raise a concern.
-
Patient information could be provided in large print and Braille format.
-
There was clear communication between multidisciplinary teams and administrative staff and external partners.
-
No complaints had been made to the service.
-
The organisation actively sought the views of patients and staff about the quality of the service provided.
Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with one warning notice and four requirement notices that affected surgery. Details are at the end of the report.
Amanda Stanford
Deputy Chief Inspector of Hospitals (hospitals directorate)