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East Point Vision @ James Paget University Hospital Good

The provider of this service changed - see old profile

Inspection Summary


Overall summary & rating

Good

Updated 7 December 2017

East Point Vision (EPV) opened in 2016; and is located in Gorleston. EPV is a private patient ophthalmic service, which operates from consulting rooms based in the local NHS foundation trust.

The service is set over two floors and has a reception area, one consulting room, a diagnostic area, an operating theatre and pre and post treatment areas. All five partners are full time NHS consultant ophthalmologists.

The service provides ophthalmic health screening care and surgery to privately funded patients. This includes outpatient investigations for glaucoma, diabetic retinopathy, macular degeneration disease and invasive procedures such as non-laser cataract surgery, intravitreal implants and vitreoretinal surgery.

We inspected this service using our comprehensive inspection methodology. We have reported our inspection findings against the two core services of Surgery and Outpatients as these incorporated the activity undertaken by the provider. We carried out the announced part of the inspection on the 4 September 2017, along with an unannounced visit to the provider on the 18 September 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.

The main service provided by this hospital was non-laser cataract surgery. Where our findings on surgery– for example, management arrangements – also apply to other services, we do not repeat the information but cross-refer to the surgery core service.

We rated this service as good overall because;

  • Patients were treated with care and kindness.

  • Patients were provided with an out of hours contact number for any concerns or advice required post treatment.

  • The service managed staffing effectively and had processes in place to ensure that staff had the appropriate skills, experience and training to keep patients safe and to meet their care needs.

  • Patient feedback was collected, analysed and used to make improvements/changes to the service.

  • Results from the patient feedback survey undertaken by the provider indicated patients were satisfied with the care they received.

  • All clinical and non-clinical areas were visibly clean and well maintained.

  • There were effective processes in place to ensure that medicines were stored and checked appropriately.

  • The results of local audit demonstrated positive outcomes for patients.

However

  • We found there were eight days in a three-month period in which the daily checks for the blood glucose monitoring equipment was not checked.

  • The provider did not have a process in place to meet the needs of patients with complex needs

Following this inspection, we told the provider that it should make improvements, even though a regulation had not been breached, to help the service improve.

Heidi Smoult

Deputy Chief Inspector of Hospitals

Inspection areas

Safe

Good

Updated 7 December 2017

We rated safe as good because:

  • The service had a sound track record for safety. There was one clinical incident, and no non-clinical or never events reported between April 2016 and March 2017.

  • In the period between April 2016 to March 2017 there were no reported intra-operative complications of PCR(Posterior capsule rupture).

  • During the reporting period, there were no incidences of hospital-acquired infections.

  • The provider used a locally adapted World Health Organization (WHO) surgical safety checklist for cataract surgery. This was a process for ensuring that a number of safety checks were completed including patients’ identity, completed consent, allergies, identifying and marking the operated eye for surgery prior to the procedure.

  • Staff recognised how to respond to patient risk and there were arrangements to identify and care for deteriorating patients.

  • Staff were aware of their responsibility to safeguard vulnerable adults from abuse. There were clear internal processes to support staff to raise concerns.

  • The registered manager and staff were aware of their responsibilities in relation to duty of candour. The duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that person.

  • There was an ‘out of hours’ emergency call system providing patients with a 24 hour mobile number following their discharge.

  • Patient records were well maintained, legible and up to date. We saw that they were stored securely and noted regular auditing took place.

  • Audit data revealed compliance with hand hygiene practice and general cleanliness audits demonstrated a clean environment.

However, we also found the following issues that the service provider needs to improve:

  • We found there were eight days in a three-month period in which the daily checks for the blood glucose monitoring equipment was not checked.

  • The provider did not have a process in place to meet the needs of patients with complex need.

Effective

Good

Updated 7 December 2017

We rated effective as good because:

  • There were effective procedures in place to ensure medical staff were appraised, competent and revalidated. This was monitored through the East Point Vision’s Medical Advisory Committee (MAC).

  • East Point Vision (EPV) had a service level agreement (SLA) with the local NHS trust, which detailed arrangements for sharing policies and procedures developed by the trust. We saw that EPV monitored these policies to ensure that these were in date and updated to reflect best practice.

  • EPV did not participate in national audits. This was due to the low patient volume, which meant national benchmarking could not be achieved. However, the service did undertake some local audit and measured patients’ outcomes through patient feedback. There had been no negative outcomes recorded with all patients reporting an improvement in their condition following treatment.

  • Consent was consistently well recorded and audited.

  • Staff were aware of the requirements of the Mental Capacity Act and Deprivation of Liberty safeguards.

Caring

Good

Updated 7 December 2017

We rated caring as good because:

  • Patient’s privacy and dignity were maintained and they were well respected at all times. We saw positive interactions between staff and patients.

  • The service received consistently positive feedback from patients. We reviewed feedback from April 2016 to March 2017 and found that out of eight individually test areas, patients scored the service as excellent.

  • The satisfaction survey also demonstrated that 100% of patients would recommend the service.

  • Patients we spoke with were complimentary about the service. One patient was very complimentary about the staff ‘they are lovely’. One patient had written on the comment card, ‘the care received was first class’.

Responsive

Good

Updated 7 December 2017

We rated responsive as good because:

  • Access to the service was seamless and without delay. Outpatient appointments were offered immediately upon referral and were usually attended within two weeks. Surgical appointments were available within a month or sooner for all patients’.

  • There was no cancellation of procedures between April 2016 to March 2017.

  • There was an effective complaints procedure in place.

Well-led

Good

Updated 7 December 2017

We rated well-led as good because:

  • The service had a clear vision and staff were aware of this.

  • The leadership team was proactive and approachable. Staff told us that they felt comfortable in raising concerns and that they had confidence these would be taken forward.

  • Staff felt there was an open and honest culture within the service.

  • There was informal cross-organisational learning and sharing of data between EPV and the local NHS trust.

  • There was a governance framework in place, with the local NHS trust providing EPV with assurances on a quarterly basis on mandatory training, audits and incidents.

  • All EPV ophthalmologists were able to access continuous audit data on operative complications and outcomes on all NHS procedures.

  • Data relating to EPV was submitted to the Private Healthcare Information Network (PHIN) that publishes independent, trustworthy information to help patients make informed treatment choices.

Checks on specific services

Surgery

Good

Updated 7 December 2017

Surgery was the main activity of the hospital. Where our findings on surgery also apply to other services, we do not repeat the information but cross-refer to the surgery section.

We rated surgery as good overall. We found:

  • There were processes in place to ensure that staffing levels met the needs of patients.
  • Staff had the appropriate training, experience and qualifications for their roles.
  • We observed that patients were treated with dignity, respect and kindness.
  • There were processes in place to ensure that medicines were stored and managed correctly in line with organisational policies and legal requirements.
  • Local audits were conducted to identify best practice and areas for improvement.
  • Patients were provided with a 24-hour contact number post treatment or surgery.

However we found;

  • There were eight days in a three-month period in which the daily checks for the blood glucose monitoring equipment was not checked.
  • The provider did not have a process in place to meet the needs of patients with complex needs

Outpatients

Good

Updated 7 December 2017

We rated outpatients and diagnostic imaging as good overall.

  • Staff had the appropriate training, experience and qualifications for their roles
  • There was a system for reporting and recording significant events.
  • All clinical and non-clinical areas were visibly clean and well maintained.
  • The outpatient clinic achieved a 100% compliance on a ‘Glo and Tell’ handwashing audit.