Optical Express - Southampton (The Avenue) Hospital

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• 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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination. We also checked people’s liberty was protected where this was in their best interests and in line with legislation.

At our last assessment we rated this key question good. At this assessment the rating has remained safe. This meant people were safe and protected from avoidable harm. However, there were some shortfalls where the service did not always work well with people to understand and manage risks.

The service was in breach of regulation for people’s safe care and treatment.

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.

We scored the service as 2. The evidence showed some shortfalls. When safety incidents occurred, these were not investigated well. Lessons were not always timely to continuously identify and embed good practice. However, staff had a proactive and positive culture of safety.

There were 9 incidents reported in the financial year 2024/2025. The summary report for these incidents showed leaders identified learning outcomes for 3 incidents, with most records showing staff had followed the correct processes. Leaders supported shared multidisciplinary learning when they identified shortfalls in practice, but these did not fully address the areas of concern. Incident records did not always show leaders had considered whether duty of candour was required and there was no record keeping of the decision-making process.

There was 1 incident where the patient received the incorrect treatment targets as staff had misidentified the patient. Although safety checks were completed, these were not performed well or in line with the service’s own policy. The patient was asked to confirm incorrect personal details by staff, such as their name. Following this, the patient confirmed the incorrect name and date of birth details. This occurred despite the services’ policy which stated, ‘patients must tell the team what their name and date of birth is and not confirm their identity with a ‘yes or no’ answer.’

Although the correct laser eye procedure was undertaken, the patient was treated with treatment targets they had not consented to. Despite this, the procedure and treatment targets were very similar for the mistaken patient, so the patient received a satisfactory visual outcome. Leaders were assured the patient achieved an excellent outcome but did not tell the patient about this incident as there was no impact on vision or wellbeing. Leaders did not include the patient in the incident investigation process.

An investigation by senior leaders found shortfalls in practice where staff had not followed policy. Action was taken to address the shortfalls immediately. The investigation records identified medium and long term actions to share learning, but there were no specific timeframes for these. Following onsite inspection activity, senior leaders delivered targeted wider learning with local and national teams on positive patient identification. This was detailed and addressed all the learning actions identified in the investigation record.

However, staff raised concerns with managers and understood how to report incidents. The service had a positive culture where staff reported feeling able to ask questions and raise concerns openly. Staff could describe when incidents had led to leaders fulfilling duty of candour and examples of learning shared because of these. 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.

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service ensured patients were booked to be 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. To support this, leaders reviewed the operating list against consent forms weekly to identify booking errors. This meant staff were able to resolve issues in advance and reduce the number of cancellations or rescheduling.

Staff could describe the process of how to refer a patient for specialist treatment if there were complications following surgery. There were detailed policies and documents available to staff to support an internal referral and emergency triage. The internal referral system enabled clinical staff, such as optometrists and consultant ophthalmologists, to access a second opinion service quickly. When a patient needed postoperative care or treatment unavailable at the service, they were included in the decision-making process. Once consent was gained, an appointment was arranged with an external provider, and a designated staff member would liaise with patients on arrangements. The service had a standardised patient record sharing process for this circumstance and staff followed up to make sure patients had reached a satisfactory outcome.

We scored the service as 3. 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 levels 1 to 3 and safeguarding children level 1. This training was updated every 3 years.

Staff were knowledgeable about which patient groups were at heightened risk of abuse for their service type. They showed an increased level of awareness about how to recognise abuse or neglect for patients living with dementia, those who did not speak English as a first language and domestic violence. Staff could describe when and how they had reported safeguarding concerns, while considering confidentiality and risk of harm. There was a focus on ensuring the patient voice was heard in all discussions. The service had 3 designated safeguarding leads nationally to support staff when needed.

We scored the service as 2. 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 safely.

We observed the service did not meet national standards for National Safety Standards for Invasive Procedures 2 (NatSSIPS2) 8 steps to safer surgery. The wall mounted count board used to record accountable items was not being used on the day of surgery. However, staff were using mobile count boards. The mobile count board did not include all the expected relevant information unlike the wall mounted count board. Accountable items checks must be performed to ensure that items used, such as needles and swabs, are removed intact and are not left in the wound. Although staff recorded patient identifiable information, procedure details, planned implant details and biometry, they did not include the type and number of accountable items used during surgery. Staff recognised this fell below the expected standard which did not follow the services’ own policy for accountable items checks. When the inspection team raised this concern with staff, they hand wrote the accountable items used. Staff explained the wall mounted count board they were expected to use, had been placed in a location not easily accessible or safe to use during surgery. Leaders were aware of this challenge but felt the temporary mobile count board was an appropriate mitigation. Following inspection, the count board was moved to an accessible location. Senior leaders said the actual practice was for staff to record only the additional items used during surgery and this was performed verbally but not recorded to the count board. The service’s policy, leaders’ expectations, and staff practice deviated from national standards. This meant patients may be at risk of harm due to retained items during surgery.

The inspection team observed poor adherence to accountable items checks, where scrub and circulating practitioners were not engaged in visual and verbal checks from start to finish. In line with NatSIPPS2 standards, accountable items checks must be performed at least twice, before surgery and before wound closure, to make sure items used during surgery are not unintentionally left inside the patient. Checks began while 1 team member was distracted with a separate task. This was most frequently observed for the final accountable items check at the end of surgery. This meant leaders could not be assured that staff were carrying out accountable items checks in line with best practice standards, despite confirmation of checks in care plans. Leaders felt this was not a concern, as the type and number of accountable items was expected to be routine for each procedure. This did not consider the risk of items breaking while in use or the possibility that further items could be used during surgery, because of damage or change in procedure. However, there was no evidence of patient harm. Leaders acknowledged this risk and were confident they had appropriate mitigations in place. Following the inspection leaders delivered simulation training on accountable items.

Some members of the surgical team did not actively engage with World Health Organisation (WHO) surgical safety checklists. The services’ own policy stated that all team members must stop to focus during the time out procedure. Despite this, the inspection team observed the operating surgeon continuing with surgical preparations and provided no verbal acknowledgement during the WHO timeout. There was no challenge provided by other team members. WHO audit data from March 2025 showed for 4 out of 5 procedures, the WHO time out did not occur before incision or site preparation. Additional comments from the auditor indicated the theatre team had stopped to engage in the process, but the operating surgeon did not. Senior leaders provided additional evidence showing the auditor had addressed and escalated poor compliance.

Also, during final implant checks, immediately prior to the implant entering the sterile field, we observed the operating surgeon did not engage in the stop moment to formally verify the visual and verbal check of the implant. This did not meet NatSSIPS2 standards and could increase the risk of a patient receiving the wrong implant. Leaders said this was a known challenge which had already been escalated to senior leadership at provider level. They indicated there was an improvement plan to monitor and resolve this as part of the appraisal process. Following inspection, leaders addressed concerns of poor compliance with the operating surgeon. Records showed improvement in the subsequent months. Additional training was delivered to encourage and support theatre staff to challenge poor practice.

Despite leaders taking action to address several areas falling short of expected compliance with national standards, further work was needed to ensure the service met the standards and this was sustainable.

Patients were informed about the risks of surgery during consultation with both the optometrist and the ophthalmic surgeon and provided with an information booklet to review in their own time. At discharge, patients were given further instructional leaflets on how to self-administer new medications and how to recognise when to ask for help if their condition deteriorated. This was tailored to individual patient needs.

Records such as care plans and operating theatre lists showed that staff documented individual risks well. Allergies and other risks like blood thinning medication or diabetes status were consistently recorded by optometrists.

Emergency equipment for resuscitation and airway management was checked by staff daily and were well maintained. Specialist equipment and medication for emergency anterior vitrectomy was immediately available, when staff were asked for it. Staff received extra training and competency assessments for rare complications of surgery. These were detailed and role specific, covering topics like anatomy and physiology, step by step guides and escalation processes. This meant leaders could be assured staff responded swiftly and appropriately when patients were at risk of deterioration.

The service ensured there were enough staff trained to an appropriate level of life support, depending on their responsibilities. When patients with a higher risk of breathing complications needed anaesthesia, the service ensured there was always at least 1 staff member trained in advanced life support. This meant patients having intravenous sedation or regional anaesthesia were always cared for by staff who were skilled in managing and treating breathing difficulties.

We scored the service as 3. The evidence showed mostly a good standard. The service detected and control potential risks in the care environment. They mainly ensured equipment, facilities and technology supported the delivery of safe care.

Staff and leaders could not demonstrate that some equipment was stored at temperatures that ensured it was safe to use. There were no records or audits of routine temperature monitoring in storerooms. These storerooms held equipment, medicines and fluids requiring storage at specific temperature ranges. This included medical devices, such as sterile gloves used during ophthalmic surgery. These required consistent storage conditions to remain safe for use. However, other medical devices such as laser equipment were stored within the operating theatre which was appropriately temperature monitored. Following the on-site assessment, leaders purchased and installed temperature monitoring in all storerooms and introduced a record log to audit this. This meant patients were no longer exposed to the risk of poorly stored equipment and medicines.

However, corridors and storerooms were kept clean and tidy, free of clutter. Staff undertook monthly stock checks as part of routine deep clean processes. Items were identified 3 months in advance of expiry and proactively managed.

Staff reported faulty equipment to managers, and these were recorded to an equipment log. This was kept up to date by leaders, who recorded actions taken in response to this. However, the equipment register did not include all equipment observed on the day of inspection such as defibrillator, portable heating units and a patient monitoring device.

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 all entry points. Staff could describe the safety precautions used for managing safe use of lasers. Laser safety audits were undertaken monthly. In January and February 2025 data we reviewed, the clinic was fully compliant with laser safety checks including protective equipment availability, access security and usage reports for each laser unit. Records indicate that staff had performed these well, with clear records to show when any additional action had been undertaken.

We scored the service as 3. 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. Recently appointed staff reported that they had received supportive and structured induction packages including competency assessments and mentor shadowing. They understood how their work affected other members of the team interacting at different points of the patient pathway.

April and May 2025 staff rotas showed the service consistently staffed operating theatre lists, admissions and discharge above their own minimum staffing standards. There were a minimum of 3 registered staff and 3 nonregistered staff for topical anaesthesia lists, with additional anaesthetist and anaesthetic practitioner staff for conscious sedation lists. Staffing levels were above 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 and ongoing 3 yearly criminal records check.

We scored the service as 3. The evidence showed a good standard. The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

Staff were observed to be ‘bare below the elbow’ and following best practice guidelines for hand washing. There were adequate supplies of personal protective equipment and single use scrub suits available. Staff were observed wiping down equipment after patient contact and between patients. Although there were multiple large pieces of equipment in the operating room, these were kept clean, well maintained and dust free.

The service used appropriate waste disposal methods depending on the type of waste. Cytotoxic medications were disposed of safely. Cytotoxic medications are used to cause cell damage for treatment of certain conditions and need to be safely managed to prevent harm to patients and staff. Sharps bins were securely assembled and labelled with relevant information.

Leaders used a standardised tool to monitor and manage infection prevention and control risks. Audits were conducted quarterly in 10 areas. This covered areas such as surgical instrument decontamination, air and water management and surgical site infection surveillance. Water management audits from January and May 2024 showed the service was safely managing microorganism risks. We also reviewed the water sampling independent analysis in June 2024, which showed water quality met good levels.

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs and preferences. They involved people in planning, including when changes happen.

Patients were counselled on what medications to continue taking or stop prior to surgery. 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.

Staff communicated effectively to ensure they had the correct information about individual patient’s needs to safely dispense medications for home use. Staff could explain what medicines might interact with certain conditions or allergies.

Medical gases, such as helium, were stored and managed safely. Empty and full cylinders were stored separately, ensuring these would not be easily mixed up.

Staff monitored patient’s pain levels during surgical procedures and adjusted pain relief when this was needed. Staff and leaders were able to describe how to safely manage off licence usage of medicines commonly used in refractive eye surgery. The service used ethanol and Mitomycin C for specific surgical procedures. There were standard processes for consent, record keeping, safe handling, administration and disposal of these medicines.

Most areas where medicines were used or held, were appropriately temperature controlled. Staff had access to up-to-date policies and processes for safe management of medicines. However, Balanced Salt Solution (BSS) and Trypan Blue dye, used during ophthalmic surgery were not stored well. These required consistent storage conditions to remain safe for use, between 2-25’C for the former and 2-30'C for the latter. Following the on-site assessment, leaders purchased and installed temperature monitoring in all storerooms and introduced a record log to audit this. This meant patients were no longer exposed to the risk of poorly stored medicines.