Optimax Laser Eye Clinics - Southampton

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

At our last assessment we rated this key question requires improvement. At this assessment the rating has changed to good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

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 evidence showed a good standard. 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 people and their communities.

Leaders and staff had a united vision and organisational culture. They worked together to achieve this. All staff understood how they contributed to the organisations’ work to positively impact on the lives of patients and the services’ overall business goals and values. Staff felt the service was supportive of diversity and inclusiveness.

The wider provider had 3 core values: clinical excellence, patient centred service and trust and responsibility. They were centred around ensuring every patient had the best possible experience of their services, and the best possible outcome. The wider provider promoted a shared clinical vision through a range of internal and external engagement events, such as a refractive teaching programme for doctors and annual staff events.

At the time of the inspection, the service was considering how they could better serve the needs of people in their local community.

The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Leaders had the experience, capacity, capability and integrity to ensure the organisational vision could be delivered, and risks were managed. The CQC Registered Manager held overall responsibility for the services at this location. An area manager supported the Registered Manager and had the skills, knowledge and experience to perform their roles.

Leadership development opportunities were available, including opportunities for staff not currently in a leadership role. Leaders were knowledgeable about issues and priorities for the quality of services and could access appropriate support and development in their role. There were processes for providing all staff at every level with the development they needed, including yearly appraisals and career development opportunities.

Leaders at every level were visible and led by example. Staff told us leaders were approachable and supportive. Members of the senior leadership team were visible, and staff told us they listened to staff.

Leaders held regular staff meetings where staff told us they could safely voice their views and were listened to and valued.

Leaders attended regional and national meetings with the senior leadership team where they received updates, discussed governance, performance and shared learning.

The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

There was a culture of speaking up where staff felt able to actively raise concerns. Staff told us they thought they would be supported to raise concerns without fear of detriment; they had not however had to do this. There were posters displayed in staff areas which encouraged staff to raise concerns internally or access local speaking up policy.

No concerns had been raised by staff in the year prior to our inspection.

The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Staff felt they were treated fairly. Staff we spoke with reported they had not experienced bullying or harassment because of their protected characteristics. They also reported being able to work flexibly when the service’s needs allowed for this. Reasonable adjustments considered accommodations for religious needs.

The provider was not required to report on gender pay gap or workforce race and equality statistics. Equality impact assessments were undertaken at central provider level and were not recorded in individual policies. Although there were processes for identifying workforce inequalities reviewed though line management and human resources, there was no strategy for monitoring and addressing these if concerns arose.

The evidence showed some shortfalls. The service did not always have effective systems of accountability and good governance. However, leaders acted quickly when concerns were raised and addressed these fully.

There were gaps in governance procedures identified by the inspection team, in the rollout of improvements and changes to the service. Despite clearly defined governance systems and structures, the inspection team identified improvements had not always been made in line with best practice guidelines. Although there were agreed procurement processes, these provided limited assurance that only suitable equipment was ordered. Additionally, translation and interpretation arrangements provided limited assurance that patients with communication barriers were safeguarded from harm and abuse. In response to identified gaps in governance procedures, senior leaders responded immediately to revise systems and processes to address shortfalls. This included consideration of how to monitor the effectiveness of the improvements made, which meant similar shortfalls were unlikely to repeat. The service were highly responsive and made significant improvements for all concerns we identified. For example, senior leaders shared a formalised procurement policy and associated processes drafted within 1 week of the first onsite assessment. This was designed well to prevent similar incidents of incorrect medical device ordering.

Leaders showed they had made significant improvements where there had been breaches identified at the previous inspection.

The service maintained a risk register and this was reviewed by the Registered Manager every 3 months. Risks such as the lack of handwashing sinks matched those described to us by staff during the inspection. The service had plans for emergencies such as loss of power. Essential equipment, such as medical devices were connected to the circuit which had a backup generator in place. Records were stored securely in all areas of the service.

Many of the support services such as clinical governance, human resources and medical staff oversight was managed at provider level. The Registered Manager ran the service on a day-to-day basis. They were responsible for auditing performance, delivering the service and ensuring things ran smoothly. Leaders at all levels of the organisation worked well together to make improvements to patient care.

There were effective systems for managing and acting upon external alerts. Leaders received safety alerts from the central provider and shared relevant information with staff. This occurred in team meetings, structured email bulletins and monthly learning webinars. We reviewed a manufacturer field safety notice which showed leaders at central provider level reviewed and acted on concerns within 2 working days.

The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Staff and leaders collaborated with all relevant external stakeholders. Senior leaders at provider level were active in regional, national, and international professional networks.

There was shared learning and collaborative improvement within and across these various provider networks. Senior leaders described how these networks collected data to identify new ideas and worked together to assess whether new technologies or processes could improve outcomes for patients.

They had developed a wide range of relationships with public and private health providers that promoted shared care for patients with complex eye needs.

The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.

Leaders demonstrated a commitment to improvement. Performance was used to promote learning and learning was shared across the organisation. Communication records showed senior leaders took action to improve the service. This was coordinated to ensure relevant staff at all levels of the organisation were aware of their responsibilities and what needed to be done to achieve this.

Clinical outcomes data at the service was collected by a central team at provider level. Outcomes data was continuously analysed and used to inform innovative services such as a laser eye surgery forecast. This provided patients with likely outcomes following treatment, using live data of visual results and satisfaction levels of patients with similar demographics.

The provider had recently increased the frequency of case review webinars to run every 2 months. This was expected to create a regular forum to discuss clinical cases as part of the refractive teaching programme.