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Inspection carried out on 20, 21 and 27 September 2017

During a routine inspection

Optical Express – Exeter Clinic provided laser eye surgery for adults who pay privately for their care and treatment. No NHS funded work was completed at this clinic.Optical Express Exeter (hereafter known as ‘the clinic’) was operated by Optical Express Limited (hereafter known as ‘Optical Express’). The regulated activities at this location were diagnostic and screening procedures; and treatment of disease, disorder or injury and surgical procedures.

The clinic was situated on the first floor of a multi-occupied office building in Exeter city centre.  The entrance to the clinic was on the first floor of this shared building. The first floor was accessed by stairs or a lift. At the time of our inspection, the service provided refractive eye surgery for day case adult patients. Part of the practice provided a general optometry service which falls outside the scope of registration.There were no inpatient facilities.

All surgery was carried out using topical anaesthesia. Refractive eye surgery was undertaken on approximately one day per month. On the day of surgery the patients were treated by a regional surgery team who moved between all locations within the South West dependent on demand at the various locations. This team consisted of the registered manager who was based in Exeter, plus staff who were based in other clinics but covered the Exeter clinic on surgery days. A separate team of optometrists and patient advisors in the general optometry service saw surgery patients prior to surgery. This team completed the patient’s initial measurements and topography scans. Topography scanning is a non-invasive medical imaging technique for mapping the surface curvature of the cornea, the outer structure of the eye. Optometrists completed a consultation regarding suitability for surgery that included a discussion of fees terms and conditions. This same team saw patients after their surgery for follow up aftercare appointments. The surgical team and the optometry team worked under separate line management and clinical governance structures.

Patients referred themselves to the clinic for initial consultation. Patients were accepted for surgery if they met admissions criteria and if the optometrist and surgeon agreed that surgery was a viable treatment option.

During August 2016 to July 2017, there were a total of 1950 patient activities including 752 pre-surgery consultations, 268 eye treatments/surgical procedures and 930 aftercare appointments. We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 20 and 21 September 2017 along with an unannounced visit to the clinic on 28 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? 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 regulate refractive eye surgery services, but we do not currently have a legal duty to rate them. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary.

We found the following areas of good practice:

  • There had been no instances of healthcare associated infection during the 12 months preceding our inspection. We saw that staff washed their hands and cleaned equipment thoroughly.
  • There were systems to ensure that lasers were used safely. The environment was designed and maintained for the use of lasers. Staff were trained to operate lasers and laser equipment was maintained.
  • Patients were assessed for their suitability for surgery using current treatment criteria. There was a clear procedure for obtaining patient consent. There were adequate systems for follow up of post-surgery patients.
  • Optical Express had an independent medical advisory board that reviewed treatment protocols to ensure these were based on current evidence. Clinicians were supported to maintain up to date clinical skills and competencies.
  • Optical Express presented analyses of their clinical outcomes data to conferences hosted by the European Society of Cataract and Refractive Surgeons and the American Society of Cataract and Refractive Surgeons.
  • Staff built effective relationships with patients. Surgeons talked to patients during surgery to help patients to feel at ease. Patients told us they felt comfortable and safe with staff.
  • The surgery team and the optometry team showed compassion towards patients. Staff listened to patients and showed respect for patients’ dignity.
  • The service offered flexibility around appointment times and dates and locations. There was no waiting list for surgery. Surgery was rarely cancelled.
  • Optical Express encouraged feedback from patients. Staff told us they felt supported, and valued by their peers and their managers. Staff enjoyed their work. Leaders were well respected.

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

  • There was a system for sharing learning from incidents at other locations, but this did not include discussion at team meetings.
  • Staff did not always date the administration record for individual patient medicines.
  • In the 12 months preceding our inspection, 14% of surgeon consent appointments were carried out less than seven days prior to the day of treatment. This did not comply with the Royal College of Ophthalmologists professional standards for refractive surgery.
  • Not all reasonable adjustments were made so that disabled people could use the service on an equal basis to others. People with a hearing impairment were required to provide their own sign language interpreter and patients with mobility impairment were required to provide their own moving and handling equipment and a carer for surgery day. Staff did not always plan to meet individual needs effectively on the day of surgery.
  • At a local level, the

    registered manager did not have a continual oversight of the entire patient journey.

    The optometry team and the surgery team were separated and there were no clear processes for the integration of quality information at a local level.

  • Minutes of meetings did not provide a complete record of governance processes at a local or corporate level. The risk register was a collection of risk assessments rather than a live tool to monitor current risks to patient care or service delivery. The mitigation of risks such as non-compliance with guidance issued by the Royal College of Ophthalmologists was not clearly identified, mitigated and monitored.

  • There were no staff surveys. There were no team meetings for the optometry team. There were no joint team meetings for the optometry and surgery staff who looked after patients on the surgery pathway.

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 two requirement notice(s) that affected the refractive eye service. Details are at the end of the report.

Amanda Stanford

Deputy Chief Inspector of Hospitals