Optegra Birmingham Eye Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Patient safety was a clear priority throughout the service. Staff worked within established systems and processes to identify, monitor and manage risks. Appropriate checks were completed before procedures to help ensure the correct patient received the correct treatment.

Medicines were managed safely and staff understood their responsibilities for safeguarding people from abuse, neglect and discrimination. Patients underwent comprehensive pre-operative assessments and staff followed established pathways to ensure treatment remained appropriate to patients' individual needs and clinical circumstances.

At our last assessment we rated this key question good. At this assessment the rating has remained as good. 

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff and leaders listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Learning was shared with staff. 

Leaders and staff understood the importance of reporting incidents and learning when things went wrong. The service reviewed incidents through its governance processes and shared learning across teams. We saw evidence that incidents and near misses were discussed at regional training events attended by all staff. Learning was identified in relation to consent processes, documentation, theatre planning, communication, patient pathways and escalation processes.

Staff were supported to learn from incidents. Following a patient safety incident, the service completed a structured review involving senior clinical, operational and governance staff. The review identified contributory factors, immediate learning and areas for improvement. The service developed detailed action plans with named leads and timescales, including actions to strengthen patient pathway processes, clarify responsibilities and improve theatre planning arrangements. Records demonstrated actions were monitored and progressed to completion.

The service demonstrated openness and transparency when incidents occurred. Patients were informed when things went wrong and the principles of Duty of Candour were applied where appropriate. Learning from incidents was shared through governance arrangements and wider organisational learning processes to help reduce the risk of recurrence.

Staff told us they felt supported by leaders and described an open culture where concerns could be raised and discussed. Staff spoke positively about leadership visibility, regular opportunities to discuss performance and development, and the support available to raise issues affecting patient care and service delivery. Leaders encouraged reflection and learning to support continuous improvement and the delivery of safe care.

The service worked with patients and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when responsibility for patient care moved between different areas of a service and between providers.

The service had systems and processes to support the safe management of patients throughout their care journey. Patients underwent pre-operative assessments to determine their suitability for surgery and identify any risks which may affect treatment.

Staff understood how to identify and respond to risks. Staff described occasions where surgery was postponed when patients were found to be unsuitable for treatment at the time of assessment. For example, staff told us they had identified a patient with significantly elevated blood pressure during assessment and advised them to seek urgent medical review before surgery could safely proceed.

Staff followed established pathways to support the delivery of safe care. During our observations, we saw staff undertake safety checks and participate in theatre briefings before surgery. Staff completed the World Health Organization (WHO) Surgical Safety Checklist and undertook multiple checks to verify patient identity, procedure details and lens selection, helping to reduce the risk of error.

The service had clear arrangements for managing patients who required urgent assessment or treatment that could not be provided by the hospital. Staff understood the referral and escalation processes and could describe how they would support patients to access appropriate care. For example, one staff member told us they identified a patient with significantly raised blood pressure during a pre-operative assessment. The planned surgery was postponed, and the patient was advised to attend the local emergency department. Staff also provided a letter outlining the concerns identified to support continuity of care.

Patients were able to access advice and support following surgery. Staff told us concerns were assessed promptly and escalated appropriately and described how they arranged timely clinical review and ongoing care to ensure patients received the support they needed.

The service worked with patients and healthcare partners where required, to understand how best to keep people safe, what it meant for individuals and the best way to achieve that. Staff concentrated on protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff understood their responsibilities for safeguarding people from abuse and avoidable harm. Staff we spoke with were able to describe how safeguarding concerns would be identified, escalated and reported. They understood the need to raise concerns promptly and knew how to access advice and support when required.

Safeguarding training compliance was monitored by the service and was generally high during 2025/26. Training records showed 100% compliance for Safeguarding Children Level 1 and PREVENT training, and high compliance for Safeguarding Adults Level 2. More recent safeguarding training data for 2026/27 also demonstrated high levels of compliance across safeguarding modules. Safeguarding Adults Level 3 training was identified as a requirement for relevant managerial and clinical staff. Records showed that all staff requiring this training had completed it, with the exception of one manager whose training remained outstanding at the time of our assessment.

Staff demonstrated an awareness of safeguarding processes and the need to protect people who may be vulnerable. Staff gave examples of recognising concerns and taking appropriate action to protect people. This included identifying a patient who was reluctant to leave the hospital following treatment, prompting further consideration of the person's circumstances and support needs. Staff followed safeguarding procedures and escalated the concern appropriately, including seeking advice from safeguarding leads and involving relevant professionals to ensure the patient received the support they needed.

Staff told us they felt supported to raise safeguarding concerns and were confident concerns would be acted upon appropriately. Leaders promoted a culture where staff were encouraged to seek advice and escalate concerns when necessary.

The service worked with patients to understand and manage risks by thinking holistically. Staff provided care to meet patient’s needs which was safe, supportive and enabled patients to do the things that mattered to them.

Staff involved patients in managing risks associated with their care and treatment. Patients were supported to make informed decisions about their treatment through discussions during pre-operative assessments and consultations. Staff took time to explain procedures, discuss relevant risks and answer questions before surgery.

Where risks or concerns were identified, staff involved patients in decisions about their care and explained any actions required to maintain their safety. This helped ensure patients understood their treatment plan and any factors which may affect their surgery or recovery.

During our observations, we saw staff involve patients in safety checks throughout their surgical journey. Staff confirmed key information with patients prior to surgery and maintained communication throughout procedures, ensuring patients remained informed and able to raise any concerns.

Patients we spoke with were positive about the information and support they received. They told us staff explained procedures clearly, answered their questions and helped them understand what to expect before and after surgery. Patients felt involved in decisions about their care and knew how to access advice if they had concerns following treatment.

The service detected and controlled potential risks in the care environment. Leaders and staff took steps to make sure equipment, facilities and technology supported the delivery of safe care. Where they were unable to do so, they mitigated the risks. 

The service provided an environment that was suitable for the delivery of ophthalmic surgery. During our inspection, clinical areas were visibly clean and well maintained. We observed staff following processes designed to maintain a safe environment and reduce risks to patients. Access to clinical areas was restricted using swipe card entry systems.

The service had systems in place to monitor the safety of the environment and equipment. Records demonstrated planned preventative maintenance schedules were in place for medical equipment, specialist ophthalmic equipment and building infrastructure.

The service monitored the environment through regular audits. A workplace environment audit completed in July 2026 achieved an overall score of 87%. Where areas for improvement were identified, these were reviewed through the provider's governance processes.

During our observations in theatre, we saw staff undertake equipment checks and participate in safety briefings before surgery commenced. Staff calibrated equipment prior to procedures and completed checks to ensure equipment was available and functioning as intended.

We observed emergency equipment was available and accessible. During our inspection, we identified inconsistencies in the completion of resuscitation trolley checks. While staff were able to describe their responsibilities for maintaining equipment used to support patient care, checks had not always been completed consistently. Leaders responded promptly and took immediate action to address the issues identified and provide assurance that emergency equipment remained safe and ready for use.

The service had enough staff with the appropriate skills, experience and qualifications to provide safe care and treatment. Staff worked across a range of professional groups including consultants, optometrists, nurses and healthcare technicians. During our inspection, we observed sufficient staff available to support patients throughout their care journey.

Workforce data from August 2026 showed an establishment of 21.5 whole-time equivalent (WTE) staff, with 18.5 WTE posts filled, giving an overall fill rate of 89.1%. There were no vacancies for consultants or optometrists. At the time of our inspection there was 1 nursing vacancy and 2 healthcare technician vacancies. The provider was actively recruiting to these posts and used 3.2 WTE bank staff and 0.8 WTE agency staff in July 2026 to support service delivery whilst recruitment was ongoing.

Staff told us they worked across a number of locations within the region. Staff and leaders recognised that this could present challenges, particularly within theatre teams where staff were not always working with familiar colleagues. Leaders had implemented induction, training and competency assessment processes to support staff to work safely across locations and had not identified any incidents relating to these arrangements at the time of our assessment. Staff told us the same arrangements applied to bank staff, who were required to complete appropriate induction and competency processes before working within the service.

The service monitored staff training, competency and development. Mandatory training compliance was 98% in June 2026 and 95% in July 2026. Clinical competency compliance was 100% during both months. Performance and development review compliance was also 100% in June and July 2026.

Staff spoke positively about opportunities for learning and development. Staff gave examples of developing skills across different patient pathways and described how colleagues shared knowledge and experience to support each other's development.

The service supported staff to respond effectively to emergencies. Regular emergency response drills and call bell testing were undertaken. A medical emergency simulation completed in August 2026 demonstrated a clinical member of staff responded within 16 seconds and the resuscitation trolley arrived within 59 seconds.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading by following policies. Infection and prevention and control data was collected and reviewed. Where required, actions were taken to improve shortcomings. 

The service had systems and processes in place to prevent and control infection. During our inspection, clinical areas were visibly clean, and staff demonstrated good infection prevention and control practices.

We observed staff following appropriate infection prevention and control procedures in theatre. Staff maintained the sterile field, demonstrated appropriate scrub techniques and segregated waste appropriately. Staff adhered to the provider's bare below the elbows policy and used personal protective equipment appropriately.

The service monitored infection prevention and control through regular audit activity. A decontamination and clinical waste audit completed in July 2026 achieved a compliance score of 100%. A scrub procedures hygiene audit completed in May 2026 also achieved a compliance score of 100%. Hand hygiene was monitored through regular audit, with the most recent audit completed in August 2026 achieving a compliance score of 100%.

The service also completed an environmental hygiene audit in June 2026, which achieved a compliant score of 95%. Where areas for improvement were identified, actions were implemented and completed to support good infection prevention and control standards.

Staff understood their responsibilities for preventing and controlling infection and demonstrated good practice throughout the inspection. Leaders maintained oversight of infection prevention and control arrangements through regular monitoring and audit activity.

The service made sure that medicines and treatments were safe and met patient’s needs, capacities and preferences. Staff involved patients in planning, including when changes happened.

The service had systems and processes to support the safe management of medicines. There was a medicines management policy which provided staff with guidance on the ordering, storage, prescribing, administration and disposal of medicines.

Staff followed processes to ensure medicines were prescribed, administered and stored safely. During our observations in theatre, medicines drawn up for procedures were clearly labelled and staff completed appropriate checks before administration. Staff also confirmed patient allergies at multiple stages of the patient journey and used visual alerts to identify patients with known allergies.

The service had appropriate arrangements to ensure only suitably trained and competent staff administered eye drops. Staff completed role-specific training and competency assessments before undertaking this activity, and records showed 91% compliance with eye drop administration competencies.

The service monitored medicines management through regular audit. A medicines management monthly audit completed in June 2026 achieved a compliance score of 100%. An external medicines management audit completed in March 2026 identified areas of good practice and highlighted opportunities for improvement relating to medicines storage, stock management and temperature monitoring. Leaders monitored actions through governance processes to support ongoing improvement.

Medicines were stored securely in restricted-access areas and there were clear arrangements for the ordering, receipt and disposal of medicines. Staff demonstrated an understanding of their responsibilities for medicines management and leaders maintained oversight through policy, audit and governance processes.