Optegra Eye Hospital Uttoxeter

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• 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

This is the first assessment for this service. This key question has been rated as 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.

We scored the service as 3. 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.

Staff knew and understood the provider’s vision and values and how they were applied in the work of their team. The provider’s statement of purpose was ‘to be the most trusted eye care provider.’ This was underpinned by a set of four values; ‘we are safe’, ‘we are focussed’, ‘we move fast’ and ‘we are brave’. Values and strategic objectives were clearly displayed on notice boards across the hospital. They had been cascaded to staff across the services and all staff we spoke with had a good understanding of these. Objectives were also incorporated into individual staff appraisals.

The provider’s senior leadership team communicated the provider’s vision and values to the frontline staff and set an example. Optegra’s vision was focused on their recovery plan. Optegra were undertaking a small number of initials, second eyes, and urgent patients to ensure that those with the highest clinical needs were appropriately seen and treated.

Staff had the opportunity to contribute to discussions about the strategy for their service, especially where the service was changing. Optegra’s strategy for 2025/26, was to continue to strengthen clinical quality through their internal inspection programme and by working collaboratively with external partners. Optegra would also continue to embed continuous learning through the patient safety incident response framework, learning from patient safety
events and seeking feedback from those who used their services.

Staff could explain how they were working to deliver high quality care. All the staff we spoke with were highly motivated and positive about their work. They told us there was a friendly and open culture and that they received good support from their colleagues and managers.

Staff and people who used the service were empowered to share any concerns about the care at the service. All the staff we spoke with were aware of their role in reporting any concerns and they told us they would report concerns in accordance with the service’s whistleblowing policy. Managers and staff worked closely with local hospitals, commissioners and other healthcare partners to support patients.

We scored the service as 3. 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 relevant skills and abilities to manage the services effectively. They understood the risks to the service and had clear oversight on patient safety, governance and performance issues through daily involvement and quality monitoring. The overall responsibility for the hospital was with the registered manager, who was also supported by the regional head of clinical services. The registered manager also had responsibility for another of the provider’s hospitals.

Leaders had a good understanding of the services they managed. They could explain clearly how the teams were working to provide high quality care. Leaders were visible in the service and approachable for patients and staff. A safety and quality huddle took place at the start of each day. This was attended by the registered manager and senior leaders. There were also safety huddles and team briefings in the day so that staff received all relevant information and knew which area each of the staff were allocated to. Also any additional tasks given on shift such as the checking of the resuscitation trolley and fridge temperatures.

All staff we spoke with told us they understood the reporting structures clearly and described their line manager as approachable, visible and providing good support.

There was strong collaboration, and support and a common focus on improving the quality and sustainability of care and patients’ experiences. The culture of the service centred on the needs and experience of the patients who used services. Leadership development opportunities were available, including opportunities for staff to develop within the service and additional training was available.

We scored the service as 3. 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.

The hospital had Freedom to Speak Up (FTSU) Guardians. FTSU Guardians recorded any concerns on the hospital system, and these were reported back to the National Guardians office. Staff were aware of who the FTSU Guardians were and how to access them if they needed.

Openness and honesty were encouraged at all levels within the organisation, leaders and staff understood the importance of being able to raise concerns without fear of retribution. There was a culture of speaking up. Leaders supported staff to raise concerns. Managers and staff had access to feedback from patients, carers and staff and used it to make improvements.

There was a whistleblowing policy and staff were aware of the process to follow if they wished to raise any concerns. There were elements of strong leadership which supported a constructive culture among staff, and this had a positive impact on overall staff wellbeing.

Patients and carers were involved in decision-making about changes to the service and patients and staff could meet with members of the provider’s senior leadership team and governors to give feedback.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. Staff worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

There were effective policies and processes to ensure the appointment and employment of staff was inclusive and fair. These included directions to ensure all staff were treated equally regardless of age, gender, ethnicity, sexuality and religious beliefs.

Managers were able to provide reasonable adjustments for staff members to help them carry out their role. Staff working at the hospital could access additional support, such as counselling or emotional support through the corporate provider’s occupational health team if needed.

Optegra had an employee-led diversity and inclusion group, “BeYou”. Optegra were committed to grow, with new members joining, with a regular programme of events and communications delivered throughout the year. The aim of these groups was to promote an inclusive working environment where all employees felt respected, supported, and empowered to bring their authentic selves to work. “BeYou” played a key role in supporting Optegra’s wider equality, diversity, and inclusion objectives and contributed to fostering a positive and inclusive organisational culture. The provider undertook equality monitoring of staff within the service to ensure it was diverse in its make-up and representative of the patient group.

We scored the service as 3. The evidence showed a good standard. The service had clear responsibilities, roles, systems of accountability and good governance. Leaders used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

There were clear governance structures that provided oversight of performance against safety measures. Governance was overseen by the corporate governance and risk committee, which acted as the link between site-level operational delivery and the board of directors. In addition, a Medical Advisory Committee provided a clinical leadership by offering expert advice and guidance from consultants, ensuring that clinical perspectives were incorporated into strategic and operational decision-making. The hospital participated in medical advisory committee (MAC) meetings every 3 months led by the MAC chair. MAC meetings were attended by the site
management team and surgical specialty lead consultants. Recent meeting minutes showed the MAC undertook reviews of new and updated guidance, consultants’ performance, practicing privileges reviews as well as a review of governance and key risks.

There were regular meetings covering aspects of governance. There were several groups and committees that held meetings either monthly or every 3 months and reported to the senior management team. This included the medicines management committee, resuscitation meeting, infection prevention and control meeting, age-related macular degeneration team meetings, staff training meetings and clinical staff meetings. Each meeting had a standardised agenda and action logs to monitor improvements to the services.

Meeting minutes for 2025 showed discussions around incidents, complaints, audits, performance, risks and changes to guidance were routinely discussed. There were action plans which were followed up at subsequent meetings. Leaders shared updates and learning with staff through a range of communications. Policies and procedures reflected this, and leaders benchmarked their performance against other services to measure outcomes of care and
treatment.

There were systems to monitor the quality of the care. The governance system monitored the quality of care provided, patient feedback, staff performance and changes to best practice guidance. Staff at all levels were clear about their roles and accountabilities and had regular opportunities to meet, discuss and learn from the performance of the service.

Staff undertook or participated in local clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed. Leaders undertook a range of reviews on audits to monitor performance. Leaders and managers discussed the results of audits at governance meetings, which was shared with the executive teams and appropriate staff for learning.

Staff understood the arrangements for working with other teams, both within the provider and externally, to meet the needs of the patients. There were regular communication and oversight from the corporate provider. The senior management team and departmental leads routinely reported governance, performance and risks to the corporate provider. Senior managers and departmental managers participated in regular peer meetings to share learning and
benchmarking with the provider’s other hospitals across the region and nationally and against eye sciences benchmarking.

Managers carried out daily and weekly informal meetings to review key risks and performance. Senior managers also held daily and weekly informal meetings to discuss day to day issues and a hospital-wide quality and a safety huddle was held daily to manage patient risks and cascade governance information to staff. Practising privileges for consultants were reviewed annually and consultants were required to submit updated appraisals, GMC registration information and indemnity insurance information to the hospital on an annual basis. Individuals working under practising privileges received reminders to submit required documentation annually. Individuals who did not submit the required information within required timelines would have their practising privileges removed or suspended.

Key risks relating to the surgical services were incorporated into the hospital-wide risk register. The risk register showed key risks were identified with control measures. Risks had a review date and an accountable staff member responsible for managing that risk. There were 4 overdue actions and 1 risk registered overdue for review. Compliance for reviewing risks was between 85% and 97%. We did not see an action plan for mitigating overdue risks for review.

Staff knew how to record and escalate key risks on the risk register. A risk scoring system was used to identify and escalate key risks to the senior management team and corporate provider. Key risks and risk register entries were reviewed at routine clinical governance, medical advisory committee and senior management team meetings. Staff meetings took place to discuss day-to-day issues and to share information on performance, complaints, incidents and audit results.

Team managers had access to information to support them with their management role. This included information on the performance of the service, staffing and patient care. Information relating to performance against key quality, safety and performance objectives was monitored and cascaded to staff through team meetings, safety huddles, performance dashboards and newsletters.

We scored the service as 3. 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.

Directorate leaders engaged with external stakeholders such as commissioners. Patients and staff could meet with members of the provider’s senior leadership team and commissioners to give feedback if they wish to.

Staff worked in partnership with other agencies on project work and research with the aim of improving the quality of care. The service continually reviewed the needs of the local population and implemented changes in care provision to meet the population’s changing needs.

Staff and leaders were open and transparent, and they collaborated with all relevant external stakeholders. The service maintained an open channel of communication with community partners, ensuring their services remained inclusive, culturally sensitive, and responsive to local needs. The registered manager told us they routinely engaged with the public to promote services through the provider’s website, through local events and using social media.

Staff routinely engaged with other healthcare professionals, such as GPs, and those involved in patients care and treatment. Staff also held meetings with local commissioners regarding performance around care and treatment provided for NHS patients.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. Leaders encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Staff were given the time and support to develop opportunities for improvements and innovation and this led to changes in care delivery. Staff told us they received good support and regular communication from the local management team and the wider organisation. Staff at the hospital participated in hospital-level and team meetings and meetings with peers across the provider’s other locations. Staff engagement also took place through emails, daily huddles, newsletters and through other general information and correspondence that was displayed on notice boards.

Innovations were taking place in the service. The hospital was committed to providing a service that was continually evolving and improving because of learning or research. To strengthen support for staff wellbeing, Optegra ran a Mental Health First Aiders (MHFA) programme. Trained MHFA representatives were available on all sites to provide immediate support to colleagues experiencing mental health concerns or emotional distress. Staff used quality improvement methods and knew how to apply them. Mental Health First Aiders offered confidential advice, initial support, and signposting to appropriate external services where needed. This initiative formed a part of Optegra’s broader commitment to creating a psychologically safe and supportive workplace environment.

Staff had opportunities to participate in research. Staff told us that Optegra continued to share research findings, and the audits from their outcomes data with the wider professional and scientific community. Staff participated in national audits relevant to the service and learned from them. Over the last 12 months, work was shared at international congresses, educational and industry meetings including European Society of Cataract and Refractive Surgeons, United Kingdom and Ireland Society of Cataract and Refractive Surgeons and The British Society for
Refractive Surgery. Optegra Eye Sciences participated in research collaborations with industry and academic partners. Furthermore, the provider attended several research collaborations aimed at advancing ophthalmic care. These studies included evaluating new intraocular lens designs, the use of artificial intelligence in clinical workflow and patient experience, and the efficacy of new treatment options for both wet and dry age-related macular degeneration.