25 October 2019
During an inspection looking at part of the service
The service is registered to provide the following regulated activities:
- Diagnostics and screening procedures
- Surgical procedures
- Treatment of disease, disorder or injury.
During the inspection, we visited outpatient and surgical areas. We spoke with 15 staff including registered nurses, health care technicians, reception staff, medical staff, and senior managers. We spoke with eight patients and six relatives. During our inspection, we reviewed five sets of patient records that covered cataract surgery, age-related macular degeneration (AMD) and YAG laser.
There were no special reviews or investigations of the hospital ongoing by the CQC at any time during the 12 months before this inspection. This service had been inspected following previous methodology.
Activity (July 2018 to June 2019)
- In the reporting period July 2018 to June 2019 there were 3 702 visits in the operating theatre
- There were 6 239 day case episodes of care recorded at the Hospital.
- There were 6 863 outpatient total attendances in the reporting period.
- All patients were NHS-funded.
There were a total of 17 surgeons who worked for the provider under practising privileges. Of these, seven had carried out between 10 and 99 episodes of care and 10 had carried out more than 100 episodes of care. There was one regular surgeon who worked at the location. The service employed 10 registered nurses, seven health care technicians, eight patient co-ordinators, as well as having its own bank staff. These were shared with another location that was buddied with them.
Track record on safety
- There were no never events
- There were a total of 40 clinical incidents of which 38 were classified as either no harm or low harm
- Two incidents were classified as moderate harm
- There were no serious injuries
There were no incidences of hospital acquired Meticillin-resistant Staphylococcus aureus (MRSA),
There were no incidences of hospital acquired Meticillin-sensitive staphylococcus aureus (MSSA)
There were no incidences of hospital acquired Clostridium difficile (C.diff)
There were no incidences of hospital acquired E-Coli
There were 6 complaints
Services provided at the hospital under service level agreement:
- Sterilisation
- Decontamination
- Out of hours call handlers
- Pathology
- Interpreter services
- Cleaning
- Clinical waste
- Confidential waste
- Pharmacy service