Optimax Laser Eye Clinics - Southampton

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

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good.

This meant people were safe and protected from avoidable harm.

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 evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

The service had a positive culture where staff reported feeling able to ask questions and raise concerns openly. Staff could describe when incidents had occurred and gave examples of learning shared because of these. There were 11 incidents reported in 2025. Of these, there were 5 incident reports and 6 near miss events. Leaders supported shared multidisciplinary learning when they identified shortfalls in practice. Investigations were undertaken in line with just culture processes.

The service had no serious incidents in the 12 months prior to inspection. We reviewed 3 incident reports and 3 near miss events which had been correctly categorised and acted upon in line with the provider’s policy. The number of incidents reported was proportionate to the service activity, but did not meet the expected provider target proportion of 7 near miss incidents to 3 incident reports. In response, senior leaders at provider level encouraged services to increase reporting of near miss incidents. This showed the culture of the provider and service promoted prevention of harm, to improve patient safety.

Incident records showed leaders had considered whether duty of candour was required and there was detailed record keeping of the decision-making process. Duty of candour is the legal and ethical obligation for healthcare services and staff to be open and honest with patients and their families when something goes wrong with their care.

The service operated within the network of 18 services under a central provider in the UK. Staff received feedback from investigation of incidents, from the service they worked in and other locations. Staff met to discuss feedback at local team meetings and virtual regional meetings, which led to service improvements and shared learning. This included the rollout of standardised and audited team brief for laser only surgery lists following a near miss event at a different location.

The evidence showed an exceptional standard. The service always worked with people and healthcare partners to design, establish and maintain safe systems of care, in which safety was always well managed and monitored. They made sure there was always continuity of care, including when people moved between different services.

The service ensured patients were always operated on by the consultant ophthalmologist who consented them for the procedure. This exceeded best practice guidelines for informed consent and showed high standards of continuity of care.

When patients were referred outside of the service for urgent care or treatment, staff recorded all correspondence to the electronic patient record. The service followed up on whether patients received the care and treatment they needed. The treating surgeon and clinic manager always followed up to make sure patients had reached a satisfactory outcome. This process was centrally managed and audited, ensuring learning could be identified and shared across teams if needed. All external referrals were recorded and submitted on a GOS18 form. A GOS18 referral is an official NHS form and pathway used by optometrists and ophthalmic surgeons to refer patients for acute care and share information with GP. Staff were well informed of which emergency conditions required a pre-alert phone call to ensure timely triage by the receiving service. Between June 2025 and 2026, the service had undertaken 1 urgent external referral and 1 non urgent external referral. Both patients went on to receive specialist care and treatment not available at this location.

Teams worked effectively with external professionals for the benefit of patients. There were detailed and up to date policies and documents available to staff to support internal referral, urgent and non-urgent external referrals. Between June 2025 and 2026, the service had submitted 16 internal referrals mostly related to a dissatisfactory outcome. Most patients chose to receive further corrective treatment when this was clinically necessary.

The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

All staff had the right knowledge, skills and training to recognise and act on safeguarding concerns. There was 100% compliance with all modules of safeguarding training, including safeguarding adults and children levels 1 to 2. This training was updated every year for permanent staff and every 3 years for staff employed under practicing privileges. Additionally, the clinic manager had received safeguarding adults and children level 3 training every 2 years.

Staff knew how to identify adults and children at risk of, or suffering, significant harm. The service did not submit any safeguarding referrals to the local authority in the last year. However, staff understood how to raise and escalate safeguarding concerns. The service had 2 designated safeguarding leads at central provider level, to support staff when needed.

Staff followed safe procedures for children visiting the service. The service did not provide treatment for patients under the age of 18 years.

The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Emergency equipment for resuscitation and airway management was not always managed well. Although there was a range of standardised resuscitation equipment and these were checked weekly, the contents of the resuscitation trolley did not fully match the inventory checklist. The central provider had recently updated risk assessments and policies to include new equipment such as laryngeal forceps but had not updated the inventory checklist yet. Additionally, the resuscitation trolley was stored in a controlled access environment but was not designed to be tamper proof. This meant people could access equipment on the trolley between the weekly checks, without this being recognised by the service. Furthermore, an adrenaline auto injector was observed stored in the operating theatre instead of the resuscitation trolley. Adrenaline autoinjectors are used for emergency treatment of serious allergic reactions, such as anaphylaxis. Resuscitation Council UK recommends resuscitation trolley should contain all drugs and equipment recommended for immediate access in the event of an emergency and all resuscitation drugs must be stored in tamper-evident containers. This meant there was a risk of delayed treatment and harm, if drugs or equipment had been misplaced or tampered with. When we raised this with leaders, they ensured the adrenaline autoinjector was stored in the resuscitation trolley, introduced tamper proof seals for resuscitation trolleys across all locations and updated checklists to fully reflect required equipment. During the second onsite assessment, we confirmed these improvements had been made.

However, specialist equipment and medication for endophthalmitis and anterior vitrectomy was immediately available when needed for an emergency. Leaders ensured staff were competent in managing and responding to these incidents through mandatory competency-based assessments and training drills.

All staff received life support training aligned to their specific roles and provider policy. When surgical lists were booked, the service ensured there were always a minimum of 2 members of staff trained in Intermediate Life Support (ILS). This meant patients having surgery were always cared for by staff who were skilled in managing deteriorating patients until transfer to an acute hospital.

The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

We observed a manual suction device for airway management was stored on the resuscitation trolley and did not appear to carry a UKCA, CE mark or registration under the Medicines and Healthcare products Regulatory Agency (MHRA). There was a risk of harm to patients if used as unregulated equipment carries a risk of device failure as it has not undergone essential mandatory safety testing. However, the service confirmed this device had not been used for any patients. When we raised this concern with the service, leaders confirmed they had removed the equipment from use and replaced this with an equivalent product from a medical device supplier.

Ventilation maintenance and servicing records showed there remained actions for the service to undertake to ensure safe air movement in one of the diagnostic imaging rooms where mould was identified. However, cleaning and maintenance arrangements for the surgical theatre were managed well.

However, staff reported faulty equipment to managers, and these were recorded in an equipment log. This was kept up to date by leaders, who recorded actions taken in response to this. Records showed medical devices underwent routine electrical testing and servicing yearly. This meant patients could be assured equipment used at this location was safe for use.

The service maintained a purpose-built ophthalmic clinic and theatre environment designed for laser, refractive and intraocular procedures which met the needs of patients. The operating theatre had signage for laser surgery above main entry points. Staff could describe the safety precautions used for managing safe use of lasers. Laser safety audits were undertaken monthly. Between March and April 2026, the clinic was fully compliant with laser safety checks such as usage reports and daily calibration tests. Records indicated staff had performed these well, with clear records to show when any additional action had been undertaken. Staff had access to the relevant type of laser protection goggles when using tier 4 laser equipment and used this when needed.

The service managed clinical waste and laundry well. There were scheduled weekly and monthly waste and laundry collection services according to the type of waste. This included safe disposal of cytotoxic waste such as mitomycin-c and sharps bins. Clinical waste and surgical instruments requiring decontamination were safely secured for transport in line with contractor’s arrangements and provider policy. However, we observed 1 sharps bin which did not have the safety closure engaged while not in use. When this was raised with leaders, they resolved this immediately.

The service stored and managed medical devices and single use disposable equipment well. All hazardous items, including surgical skin scrub and cleaning products, were now stored in lockable cupboards or cabinets. Storerooms were tidy and well maintained, with all items stored in or on purpose-built shelves. Audits of routine temperature and humidity monitoring showed the environment had been well maintained for equipment requiring consistent storage conditions.

The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were enough staff, with the right skills, knowledge and training to deliver safe care and treatment. All staff had met their mandatory training requirements. Staff were knowledgeable and had the right training and experience. Records showed staff received structured supervision and observation sessions including competency assessments and mentor shadowing.

Monthly staff rotas between April and June 2026 showed the service consistently staffed operating theatre lists, admissions and discharge above their own minimum staffing standards. There were a minimum of 2 registered staff and 1 non registered staff for operating theatre lists. Staffing levels met or exceeded the best practice standards for safe staffing levels from the Association of Perioperative Practitioners (AfPP).

The service recruited staff safely. Leaders checked that staff continued to be suitable to work with patients, by maintaining a yearly professional registration review for all healthcare professionals.

The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The inspection team did not always observe a high standard of hand hygiene during the onsite assessment. Staff did not always wash their hands or use hand gel in line with standard infection prevention and control precautions. There was limited access to handwashing sinks, especially in areas such as consultation rooms. However, alcohol-based hand gel was available in all areas. This was recognised as a risk by leaders and had been escalated to the central provider team. There were plans in place to refurbish the service, including the addition of handwashing sinks throughout. Despite this, local hand hygiene audits over the last 3 months showed staff undertook hand hygiene well.

During the onsite assessment, the inspection team observed a bottle of ultrasound transmission gel on the resuscitation trolley, for use in an emergency. However, the product was not designed for use as a sterile product. There was a risk of contamination if used for invasive procedures such as airway management. When this was raised with leaders, the ultrasound transmission gel was removed from the resuscitation trolley immediately and replaced with a sterile product.

During our inspection, we found multi-use medicinal products were not always managed in line with manufacturers' guidelines. A bottle of surgical skin scrub used for handwashing was not labelled with the date it had been opened. This presented a risk of contamination if the product exceeded the recommended safe usage period. Following feedback, the service took immediate action to address this. New labelling systems were ordered and implemented, supporting staff adherence to expected safe practice. During the second onsite assessment, staff were using these labels well.

The service had formalised arrangements with a local NHS trust for the management and processing of clinical specimens. While this service had not been recently used, staff were trained to handle specimens safely and there were guidelines to support staff to ensure safe transport of fresh specimens within expected timeframes.

Records showed the service managed the risk of legionella well. Leaders ensured annual water microbial tests were only undertaken by accredited companies. Staff completed weekly audits including water temperature checks and outlet flushing.

The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happen.

Patients were given information on how to self-administer eye drops following surgery with clear instructions. All patients were discharged with standardised data sheets for respective medicines even when these were dispensed from a partial box. This met best practice guidelines on patient information leaflets.

Medical gases for laser eye surgery, such as helium, were stored and managed safely. Areas where medicines were used or held, were temperature controlled and managed well. Staff had access to up-to-date policies and processes for safe management of medicines and medicines dispensing.

Staff monitored patient’s pain levels during surgical procedures and adjusted pain relief when this was needed.

The service managed the use of off label medicines well. Leaders were able to describe how to safely manage off licence usage of medicines commonly used in refractive eye surgery. The service used Mitomycin C for specific surgical procedures when there was an increased risk of the cornea becoming clouded. There were standard processes for informed consent, record keeping, safe handling, safe administration and disposal of these medicines, in line with best practice guidelines.