• Hospital
  • Independent hospital

Leicestershire Consultant Eye Surgeons LLP @ The Stoneygate Eye Hospital Also known as CESP

Overall: Requires improvement read more about inspection ratings

The Stoneygate Eye Hospital, 376 London Road, Leicester, Leicestershire, LE2 2PN (0116) 270 8033

Provided and run by:
Leicestershire Consultant Eye Surgeons LLP

Latest inspection summary

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Background to this inspection

Updated 21 November 2017

Stoneygate Eye Hospital is operated by Leicestershire Consultant Eye Surgeons LLP. The hospital opened in 2013. It is a privately-run eye hospital in Leicester. The hospital primarily serves the communities of the Leicester, Leicestershire and Rutland areas. It also accepts patient referrals from outside this area. There are nine eye surgeons and a practice manager/registered manager along with nursing and administrative staff.

The registered manager has been in post since 2013. The hospital’s regulated activities are surgery, treatment of diseases, disorder and infections and diagnostic and screening procedures. This was the first CQC inspection at Stoneygate Eye Hospital. It took place on the 5th and 6th September 2017 followed by an unannounced inspection on the 19th September 2017.

Overall inspection

Requires improvement

Updated 21 November 2017

Stoneygate Eye Hospital is operated by Leicestershire Consultant Eye Surgeons Limited Liability Partnership (LLP).

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection between 5 and 6 September 2017, along with an unannounced visit on 19 September 2017.

The hospital provides surgery, services for children and young people, and outpatient clinics. We inspected surgery, outpatients and services for children and young people. The main service is surgery. Following our visit in September 2017 it ceased offering children’s services in outpatients and surgery and we have not rated this service due to the very low numbers of children treated, and insufficient evidence.

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 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 hospital as requires improvement overall.

We found the following issues that the service provider needs to improve:

  • Managers did not share learning from incidents with all staff.
  • Staff did not always ensure medicines and eye drops were stored securely.
  • Staff did not always ensure patient records were stored securely for example, leaving records on desks in open consulting rooms.
  • Four out of five patient records we reviewed in outpatients were either not legible, signed, or dated in line with general medical council (GMC) standards
  • The service did not monitor the effectiveness of pain relief or document levels of pain in patient records.
  • Despite using patient outcome forms the hospital did not audit them to measure clinical effectiveness.
  • Managers did not use competency frameworks to assess staff competency in undertaking their duties.
  • Nursing staff did not receive regular one to one meetings or team meetings which meant there was no ongoing formal support process for them.
  • Patients sometimes experienced long waits once they had arrived in clinic to see a consultant or for their treatment.
  • Outpatient services did not have written materials available in other languages for patients whose first language was not English. This included pre-appointment information.
  • The hospital had a vision but no medium to long term strategy plan with clear aims and objectives. There were no strategic plans to support the development of quality, safety or performance.
  • The hospital did not have fully developed arrangements to manage risk or performance, and lacked quality, safety or performance dashboard for the full range of its activities
  • Policies were not tailored to the needs of the hospital
  • Management resources were stretched

We found the following areas of good practice:

  • Clinicians recorded and analysed any clinical or non-clinical incidents and learned from them. Clinicians acted in line with the duty of candour
  • Track record of incidents and infection control compared with similar organisations
  • Theatres, diagnostic rooms and consulting rooms were visibly clean and well equipped
  • Theatres were staffed with nurses and support staff in line with good practice
  • Clinicians assessed patient risks before operations and theatre teams used the World Health Organisation (WHO) Surgical Safety Checklist for Cataract Surgery, and five steps to safer surgery checklist
  • Appropriate emergency back up arrangements were in place
  • Surgery was based on national guidance and conducted clinical audits. Clinicians kept upto date with best practice.
  • Technology was used to monitor patient’s conditions accurately so that clinicians could give the best advice possible
  • The service contributed to the Royal College of Ophthalmology expected outcomes audit on cataracts and its results were better than the national average for acuity, with a low complication rates.
  • Patients we spoke with found the staff to be reassuring and compassionate and we observed this during operations
  • After patients had an operation, nurses explained to them in a very understandable way how they could self-care.
  • Patients had a choice of clinic and surgery times including evenings
  • Consultants used an interactive display screen which covered a range of languages, to illustrate and explain procedures to patients
  • Patients did not have to wait very long for NHS cataract surgery – when we inspected they were waiting approximately nine weeks from referral to surgery
  • The service responded to patient views. They installed a larger waiting area, different seating and alternative refreshments in response to patient feedback.
  • The hospital had a track record of technical and clinical innovation.

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 three requirement notice(s) that affected outpatients and surgery. Details are at the end of the report.

Heidi Smoult

Deputy Chief Inspector of Hospitals (Central)

Services for children & young people

Insufficient evidence to rate

Updated 21 November 2017

Children and young people’s services were a very small proportion of hospital activity, and the service operated on only one child in 2016 – 2017, and 17 children had outpatient appointments at the hospital during this time. The hospital ceased its children’s services in September 2017. We have not rated this service due to the small numbers of children involved and insufficient evidence.

Outpatients and diagnostic imaging

Requires improvement

Updated 21 November 2017

Few patients visited the hospital for outpatients services only. The main service was surgery. Where arrangements were the same, we have reported findings in the surgery section. There were 4,002 outpatient attendances in the reporting period Apr 2016 to March 2017. Of these, 81% were NHS funded and 19% were private or self-funded patients.

We rated outpatient services as requires improvement because medicines and records were not always stored securely. Medicines management was not robust. Patient records were not in line with general medical council (GMC) standards. The hospital did not have a full range of written materials in large print for patients with visual impairments or for patients whose first language was not English. There was no strategy for the hospital and quality and performance only recorded for NHS contracted services.

However, we saw positive and compassionate patent interactions. Staff involved patients in their care and treatment and patients were positive about their care and treatment at the hospital. The hospital provided a flexible range of appointments and enabled patients to access appointments quickly.

Surgery

Requires improvement

Updated 21 November 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 this service as requires improvement overall because the service did not formally share learning from incidents with staff at all levels of the organisation.Changing facilities for theatre staff were not ideally located to minimise infection risk to patients, because clinicians had to walk through areas shared with other staff and the public.We found some resuscitation trolley items which had broken packaging or beyond their expiry date. Staff were unclear who to contact about this.The hospital did not have robust arrangements for medicines management and did not store medicines in a safe and appropriate manner Safeguarding arrangements did not include female genital mutilation (FGM)

There was a lack of governance arrangements such as medium term strategic planning, comprehensive risk management, which meant that risks such as medicines management and out of date resuscitation materials had not been identified.