You are here

Exeter Eye LLP @ Admiral House Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 3 April 2018

Exeter Eye LLP @ Admiral House is operated by Exeter Eye LLP. The service provides ophthalmic surgery and outpatient clinics for private, adult patients from Admiral House in Exeter which is owned by another organisation called Exeter Medical (further referred to as the host hospital). Exeter Eye LLP rent rooms from the host hospital to provide their outpatient and diagnostic services. These include waiting areas, consultation rooms, a laser room and office space for secretarial staff. Exeter Eye LLP has an agreement with the host hospital to access theatre space, staff and equipment to carry out surgical procedures within Admiral House. Facilities include an anaesthetic room, recovery room and an operating theatre. The service has no overnight beds.

The service provides surgery and outpatient and diagnostic imaging services for privately funded ophthalmic patients. Types of surgery carried out include cataract removal, lens replacement and laser capsulotomy treatment.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 17 and 18 January 2018 along with an unannounced visit to the service on 1 February 2018.

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? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the service understood and complied with the Mental Capacity Act 2005.

The main service provided by this hospital was surgery. Where our findings on surgery – for example, management arrangements – also apply to other services, we do not repeat the information but cross-refer to the surgery core service.

See surgery section for main findings.

Services we rate

We rated this service as requires improvement overall.

  • There was limited oversight by the service that checks undertaken by the host hospital as part of their agreement were being completed. There were no formal reporting systems in place to gain assurance.
  • The provider advised us that records were not always stored in a way which maintained patient confidentiality.
  • Safeguarding adult processes were not always given sufficient priority.
  • There was no policy for mandatory training so there was no clear guidance on what essential training staff were expected to undertake. There were no records of staff compliance levels.
  • Staff competencies were not always regularly maintained and Exeter Eye LLP had limited oversight of the competency of staff employed as part of the agreement with the host hospital.
  • There was no protocol or training provided in relation to recognition, diagnosis or early management of sepsis.
  • Patient outcomes were not monitored by the service as a whole. Individual consultants audited their own outcomes but these were not submitted to any national audit.
  • Outcome data was not submitted to the Private Healthcare Information Network (PHIN).
  • Staff had not been provided with Mental Capacity Act training. The Exeter Eye LLP consent policy did not provide clear guidance for staff nor did it relate to relevant legislation.
  • There was no access to foreign language or sign language interpretation services should these be required. This included both verbal and written translation.
  • Governance arrangements were underdeveloped and not used as effectively as they could be to monitor the safety and quality of the service.
  • Not all Exeter Eye LLP policies provided relevant and specific guidance for staff.
  • Staff engagement was limited but undergoing a process of development.

However, we also found the following areas of good practice:

  • Staff were aware of the protocol for reporting incidents. The senior team ensured that actions were taken and lessons were learnt as a result of incidents reported. However, staff had not been provided with incident report training as required by the service’s incident reporting policy.
  • All areas we visited were visibly clean and well maintained.
  • Control measures for the use of laser equipment were good and all safety protocols were used effectively.
  • Medicines were stored securely and at recommended temperatures. There were checks on stock levels and fridge temperatures.
  • All patient records were complete, legible and up to date.
  • There were 24 hour arrangements for patient access to consultants following surgery undertaken by the service.
  • There was consistent use of the World Health Organisation surgical safety checklist and this was embedded in practice. Completion of the checklist was audited with positive results.
  • There was effective multidisciplinary working within the service and with the host hospital. Educational sessions were offered to optometrists and GPs and communication with GPs took place in a timely way.
  • Consent was assessed throughout the patient journey and recorded clearly.
  • Patients received compassionate care from staff. Staff were caring and took time to gather information about lifestyle and personal circumstance in order to provide the best care and treatment.
  • Staff involved patients as active partners in their care and were sensitive to the emotional needs of those using the service.
  • Patients were overwhelmingly positive about the service provided and the outcome of their treatment.
  • The service provided good continuity of care. Patients were seen by the same consultant throughout their treatment journey.
  • Patients were individually assessed for their suitability for treatment taking into account known risk factors.
  • The premises and facilities were designed to meet the needs of patients. The theatre and consulting rooms were all on ground level and accessible.
  • Patients did not wait long to receive treatment. There were no waiting times for surgery.
  • There had been no complaints received by the provider.
  • The service sought the views and experiences of patients and feedback was consistently positive.
  • Leaders were visible and accessible to staff. All staff were proud of the service and care they provided.
  • The service responded positively to opportunities for development.

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 notices that affected surgery and outpatients and diagnostic imaging services. Details are at the end of the report.

Amanda Stanford

Deputy Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 3 April 2018

We rated safe as requires improvement because:

We found the following areas of practice which required improvement:

  • There was limited oversight of the completion of safety processes such as medication management, infection and prevention control and staff training and competencies which were undertaken by the host hospital as part of a service level agreement.
  • The registered manager did not have easy organisational oversight of the quality of the services being provided.
  • Staff did not receive incident reporting training as required by the Exeter Eye LLP policy on incident reporting and management.
  • The provider idenfified that records were not always stored in a way that protected patient confidentiality. This risk was being managed.
  • Safeguarding adults was not always given sufficient priority. Policies were not updated in line with current legislation and the service was unclear on what level of training they expected staff to complete.
  • Mandatory training was not well defined by the service, there was no policy about what training was deemed necessary for staff to undertake and no checks were provided on compliance levels.
  • The service did not have a protocol or provided training in the recognition and management of sepsis.
  • There were not always the recommended number of theatre staff within surgery.

However, we also found the following good practice:

  • Staff were aware of how to report incidents. The registered manager ensured that actions were taken and lessons were learnt and shared as results of incidents reported.
  • Staff were open and honest with patients when things went wrong and were aware of the duty of candour.
  • There were systems to minimise the risk of healthcare associated infection. The environment and facilities were suitable and visibly clean.
  • Control measures for the use of the non-invasive laser were well established and embedded. Precautions taken protected staff and patients.
  • Medicines were stored securely and at manufacturer recommended temperatures.
  • The team consistently followed World Health Organisation guidelines on the use of safer surgery checklists to minimise risk of harm to patients undergoing surgery. Use of the checklist was audited with positive results. It was clear during our inspection this process was embedded and all members of the team recognised and respected the importance of using these checklists.
  • Patients had access to 24 hour consultant cover following surgery. 

Effective

Good

Updated 3 April 2018

We rated effective as good because:

We found the following areas of good practice in surgery:

  • Consultant partners reviewed National Institute for Health and Care Excellence (NICE) guidelines and Medicines and Healthcare Products Regulatory Agency (MHRA) alerts.
  • Technology recommended by the Royal College of Ophthalmologists was available and used by the service.
  • The service managed the pain of patients well.
  • There was effective multidisciplinary working across Exeter Eye LLP and between the host hospital. Educational sessions were offered to optometrists and GPs outside the service.
  • All necessary patient information to deliver care and treatment.was accessible to staff.
  • Staff were aware of consent processes and provided patients with clear information to support decision making and informed consent.

However, we found the following evidence of practice that required improvement in surgery:

  • Surgical outcomes were not consistently audited and benchmarked by the service as a whole.
  • The consent policy used by Exeter Eye LLP did not reflect the Mental Capacity Act, 2005 and there was no evidence that staff employed by the service or the host hospital had undertaken this training.
  • Exeter Eye LLP had limited oversight of the qualifications, training and competencies of those staff working under service level agreements.

Caring

Good

Updated 3 April 2018

We found the following areas of good practice:

  • Staff cared for patients with compassion and took time to gather information about individual lifestyles and personal preferences to ensure good treatment outcomes.
  • Patients’ privacy and dignity was a priority for the service.
  • Staff supported patients to reduce anxiety, encouraged them to ask questions and provided detailed information to support decision making.
  • Staff showed genuine interest in the individuality of patients and establishing rapport.

Responsive

Good

Updated 3 April 2018

We found the following areas of good practice:

  • The service offered continuity of care which patients found important and reassuring. The same consultant would see the patient throughout their treatment journey.
  • Access to the service was good and patients did not wait long for appointments or treatment.
  • The service had received no complaints and patient feedback was overwhelmingly positive.

However, we found the following evidence of practice that required improvement:

  • The patient guide did not provide specific details on how to report a concern or complaint.
  • Exeter Eye LLP did not have the ability to provide translation services for those people requiring a foreign language or sign language interpreter.

Well-led

Requires improvement

Updated 3 April 2018

We rated well-led as requires improvement because:

We found the following areas of practice which required improvement:

  • Governance arrangements including risk management and quality measurement were underdeveloped. There was no clear audit system or formal reporting to the Medical Advisory Committee. This was especially the case in relation to safety and quality measures undertaken by the host hospital. Accountability was not clearly defined. Performance measures were not used effectively to identify any concerns with safety and to improve services.
  • The quality and relevancy of policies and procedures was variable. Relevant legislation and guidance was not always included and not all policies were specific or relevant to the service.
  • Processes for staff engagement were limited but action was being taken to improve this.

However, we also found the following good practice:

  • Leaders were visible as they carried out clinical duties alongside staff and were available.
  • Exeter Eye LLP maintained an oversight of risks and action plans were developed based on this.
  • The service engaged patients to seek feedback about the service.
  • Fee structures were clear and patients were informed of costs prior to undergoing any treatment or consultation.
Checks on specific services

Outpatients and diagnostic imaging

Requires improvement

Updated 3 April 2018

Outpatient and diagnostic imaging services were a smaller proportion of the service activity.

The main service was surgery. Where arrangements were the same, we have reported findings in the surgery section.

We rated this service as requires improvement for  safety and for being well led, although it was good for being caring and responsive. We do not rate the effectiveness of outpatient and diagnostic imaging services.

Surgery

Requires improvement

Updated 3 April 2018

Surgery, and outpatients and diagnostics were the only activities undertaken at this service.

Surgery was the main activity at the service.

Where our findings apply to other services, we do not repeat the information but cross-refer to the surgery section of the report.

We rated this service as requires improvement for safety and being well led, although it was good for being effective, caring and responsive to people’s needs.