Optegra Birmingham Eye Hospital

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of patients who used services and wider communities.  We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

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

We have not awarded this service a score for Well-led.

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

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of patient and their communities.

Leaders promoted a positive and inclusive culture within the service. Staff told us leaders were visible, approachable and created an environment where people felt comfortable raising concerns, sharing ideas and discussing issues affecting the service.

Staff described an open-door culture and told us managers took time to listen to their views. Staff felt supported by leaders and were confident concerns would be acted upon appropriately. Staff also told us there were regular opportunities to discuss service developments, performance and improvement activities.

We observed positive working relationships across the service. Staff spoke respectfully about colleagues and leaders and described a culture based on teamwork, collaboration and mutual support. Staff told us they felt valued and were encouraged to contribute to the ongoing development of the service.

Staff described opportunities to develop their skills and experience and gave examples of sharing knowledge and learning across teams and locations. Leaders encouraged staff involvement in improvement activities and supported professional development across the service.

The service had leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders usually had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty and understood the impact their behaviours and leadership had on patient outcomes and experience.

Leaders were visible, approachable and supportive. Staff spoke positively about local leaders and told us they were available to provide guidance and support when needed.

Staff described an open and supportive leadership culture. Managers took time to listen to concerns, respond to feedback and support staff to carry out their roles effectively. Staff told us they felt comfortable approaching leaders for advice and support.

Leaders supported staff development and wellbeing. Staff told us they had regular opportunities to discuss their performance, development and career aspirations through one-to-one meetings and performance reviews. Staff gave examples of being supported to develop new skills and broaden their experience across different patient pathways.

Staff described a period of uncertainty when changes to commissioning arrangements and activity restrictions were first introduced. Staff told us this initially had an impact on morale and created uncertainty about the future of the service. However, staff spoke positively about the support provided by leaders during this period and told us leaders worked hard to support teams, communicate changes and restore stability within the service.

Leaders demonstrated an understanding of the operational challenges facing the service and responded to concerns raised by staff. For example, one member of staff told us they raised concerns regarding staffing levels on the day of our inspection. Leaders responded by arranging additional support from another location to help maintain service delivery and support the team.

We reviewed complaint investigations and found leaders responded openly and transparently when concerns were raised. Investigations were thorough and included reviews of records, discussions with staff and the identification of learning to support improvements in service delivery. Leaders acknowledged where improvements were required, apologised where appropriate and identified actions to reduce the likelihood of similar issues occurring in the future.

The service fostered a positive culture where patients and staff felt they could speak up and their voice would be heard.

Staff felt able to raise concerns, share feedback and suggest improvements. There was a culture where speaking up was encouraged, and concerns could be discussed openly.

Those we spoke with were aware of the arrangements in place to support speaking up and knew who their Freedom to Speak Up Guardian was. They told us they would feel comfortable using these arrangements if required.

Leaders were described as approachable and receptive to feedback. Individuals felt able to discuss issues affecting patient care or service delivery and were confident concerns would be listened to and acted upon appropriately.

The service valued diversity in their workforce. Staff worked towards an inclusive and fair culture by improving equality and equity for everyone.

The service promoted equality, diversity and inclusion within the workforce. There were policies which supported fair and inclusive working practices and ensured people were treated with dignity and respect.

Equality, diversity and human rights formed part of the mandatory training programme. This included supporting patients with a learning disability and understanding how to meet the needs of patients from different backgrounds and circumstances.

The provider supported an employee-led equality, diversity and inclusion network known as “BeYou”. The network promoted awareness and understanding of equality, diversity and inclusion across the organisation through regular communications, events and engagement activities. Leaders told us the network continued to grow and provided opportunities for colleagues to contribute to discussions, share experiences and support the development of a more inclusive workplace. The network formed part of the provider’s wider approach to promoting equality, diversity and inclusion across the organisation.

Leaders also monitored workforce equality information to understand the composition of the workforce and support an inclusive working environment. This helped provide assurance that employment practices were fair and supported a workforce that reflected the diverse communities served by the organisation.

The service had clear responsibilities, roles, systems of accountability and good governance. Staff used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

Leaders had governance structures in place to support the effective management of the service. A Medical Advisory Committee (MAC) provided oversight of clinical governance matters, including patient safety, incidents, complaints, clinical outcomes, regulatory updates and the introduction of new techniques and treatments.

Leaders maintained oversight of risks affecting the service. We reviewed the risk register and found risks were clearly documented, assigned to named leads and subject to regular review. Risks identified included staffing levels, patient safety processes and information systems. Actions and mitigating controls had been identified to reduce risk and support the safe delivery of care.

Performance and quality were monitored through a range of governance processes. Leaders reviewed information from incidents, complaints, audits, risks and performance measures to identify areas requiring action and support service improvement.

Leaders had recently introduced a monthly Responsible, Accountable, Consulted and Informed (RACI) tracker. This provided oversight of operational, clinical, governance, health and safety and performance responsibilities across the service. Responsibilities, actions and timescales were allocated to named individuals, supporting accountability and ownership of improvement activities.

Leaders demonstrated an awareness of the challenges affecting the service and used governance arrangements to monitor performance, manage risks and support the continued delivery of safe and effective care.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for patients. Staff shared information and learning with partners and collaborated for improvement.

The service worked collaboratively with external organisations and healthcare professionals to support patient care and local eye care pathways.

Leaders actively engaged with the wider eye care community through continuing professional development (CPD) events, educational workshops and knowledge-sharing activities for community optometrists. These activities supported professional development, collaboration and the delivery of evidence-based care.

The service maintained strong relationships with community optometrists and other healthcare providers. Between June and August 2026, representatives from the organisation engaged with 303 community optometry practices to share clinical updates, service developments and pathway information.

The service also worked in partnership with Aston University to support education and research initiatives, including opportunities for optometry students to gain insight into clinical practice.

These partnerships supported shared learning, professional development and effective working across the wider eye care community.

The service focused on continuous learning, innovation and improvement across the organisation and local system. Staff encouraged creative ways of delivering equality of experience, outcome and quality of life for patients. Staff actively contributed to safe, effective practice and research.

The service demonstrated a commitment to learning, continuous improvement and innovation. Leaders used information from incidents, complaints, audits and performance monitoring to identify opportunities to improve services and patient outcomes.

Leaders had recently introduced a monthly Responsible, Accountable, Consulted and Informed (RACI) tracker to strengthen oversight and accountability across the service. Leaders told us the tool would continue to evolve and be used to embed responsibilities more widely across teams and support ownership of improvement activities.

The service supported the introduction of new approaches and treatments where there were appropriate governance arrangements. This included the development of drop-free cataract surgery pathways and the introduction of Low-Level Light Therapy (LLLT) for selected patients with dry eye disease. Leaders ensured new treatments were supported by defined clinical pathways, training requirements and governance processes before implementation.

The service also promoted learning through engagement with the wider eye care community. Educational events, workshops and shadowing opportunities were provided to support knowledge sharing, professional development and the dissemination of good practice across the sector.

Leaders encouraged a culture of continuous improvement and supported opportunities to develop services in response to learning, innovation and emerging evidence.