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Optegra Manchester Eye Hospital Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 23 November 2017

Optegra Eye Hospital Manchester facilities include; a patient lounge, sub waiting areas with the capacity for 50 patients, six consultation rooms, two treatment rooms, one refractive eye theatre, a refractive patient preparation room, a refractive patient recovery room, a preoperative ward, a post-operative ward, seven diagnostic rooms and one ophthalmic operating theatre.

The hospital provides surgery and outpatient services for adults. The hospital does not offer treatment to under 18 year olds. We inspected surgery and outpatients.

We inspected this hospital using our comprehensive inspection methodology. We carried out the announced part of the inspection on 19 and 20 July 2017, along with an unannounced visit to the hospital on 28 July 2017.

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 provider understood and complied with the Mental Capacity Act 2005.

The main services provided by this hospital were ophthalmic consultations and diagnostics, disease management and treatment. Treatments included surgical and medical treatments. There were no inpatient stays at this hospital, all patients were treated as day cases and were discharged the same day.

The surgery and outpatient services worked closely together with staff working between disciplines. Where our findings on surgery for example, management arrangements also apply to outpatient services, we do not repeat the information, but cross-refer to the surgery core service.

We rated this service as Requires Improvement overall.

We found areas of good practice in surgery:

  • The hospital audited the outcomes of every patient who had surgery at the hospital. The hospital measured outcomes hospital wide and individually for each consultant.
  • The hospital proactively forward planned surgical and clinic sessions and used data to identify the number of patients waiting for treatment and procedures. The NHS Family Test (FFT) results reflected this by comments from the patients.
  • Patient outcomes survey showed 80% of patients said that they strongly agreed with the statement; I would recommend treatment to family and friends.
  • Patients we spoke with stated that their pain was monitored and treated appropriately.
  • The needs of diabetic patients were assessed pre-operatively and post-operatively. Staff were aware of the needs of diabetic patients and acted appropriately if the patients blood sugar levels were low.
  • The hospital had an eye sciences department, whose role was to collate data on Refractive Lens exchange (RLE), cataract surgery and laser surgery. The eye sciences team collected data for all Optegra hospitals across the UK.
  • Regular Medical Advisory Committee (MAC) meetings were held at the hospital where the eye sciences report would be discussed to enable the hospital to bench mark against other Optegra hospitals and other eye hospitals.
  • The hospital collected comparative outcomes by clinician and used this for competency and revalidation purposes as well as for quality improvement processes through the MAC and clinical governance processes.
  • The hospital provided a 24 hour helpline for advice to patients outside of normal working hours. Consultants were available during normal working hours to review patients if staff felt medical input was required.
  • Staff were familiar with the necessary minimum one week cooling off period for certain procedures and we saw that these periods were observed.
  • Patients we spoke with said they felt involved in decisions about their care and treatment and that treatment plans were clear and understood. They said that staff took time to involve them and explain things in a way that they understood.
  • The services were delivered in pleasant and appropriate premises, with excellent facilities for patients and staff.

We found areas that required improvement in surgery:

  • We observed patients being prepared for cataract surgery in the anaesthetic room and then instructed to transfer from the bed and walk into the operating theatre. We observed patients who were disorientated due to sedation, or walking without their glasses. We saw that several patients required support from theatre staff in order to safely make the transfer
  • At the unannounced part of the inspection we found that a new standard operating procedure had been completed with regards to the safety of patients walking into the operating theatre, we did not receive assurance that this process had been risk assessed and deemed to be safe practice.
  • The hospital was not able to evidence individual competency for specific tasks such as the dispensing of medicines to take home, nurse led discharge and pre-operative assessments.
  • We found that confirmation of consent for surgery was not shared with the wider surgical team as part of the WHO safer surgery checklist procedures as would be expected.
  • The hospital had a World Health Organization (WHO) Surgical Safety Checklist Policy in place. However, upon observing this process we found that the hospital was not compliant with this policy, or the overarching principles of the WHO surgical safety checklist and the National Patient Safety Agency (NPSA) five steps to safer surgery guidance.
  • The hospital did not carry out observational or documentation audits of safer surgery safeguards therefore they could not identify staff compliance or highlight areas that needed improvements.
  • The duty of candour was not embedded and appropriately applied by senior staff.
  • Actions recommended as a result of an investigation identified failings within surgical safety processes, some of the recommendations had still not been implemented in full.

We found good practice in relation to outpatients and diagnostics:

  • The hospital managed staffing effectively and services always had enough staff with the appropriate skills, experience and training to keep patients safe and to meet their care needs.
  • Consultants and staff told us they believed that they had access to the latest equipment and if new equipment was needed this was readily provided.
  • The hospital had a good maintenance scheduled that checked the equipment available and made sure that routine maintenance was in place within the Outpatient Department (OPD).
  • Records were comprehensive and contained referral letters and clinic letters that would be needed for any consultation.
  • Care was delivered in line with national guidelines.
  • Patient safety was maintained throughout. Patients attended a clinical assessment prior to being seen by the consultant, where any patients deemed unsuitable for treatment were identified.
  • The hospital supported student nurse placements in order to assist both the development of student nurse skills and their own staff members.
  • The hospital offered a range of appointments which meant that patients could attend at times suitable for them. A satellite clinic offered outpatient appointments, so patients did not have to travel as far.
  • Patients living with Age Related Macular Degeneration (AMD) were a priority for treatment. This was because that once diagnosed, delays in treatment could be detrimental to patients sight.
  • All staff spoken with in OPD told us that they felt very well supported and enjoyed working at the hospital. They told us that there had been recent changes in the leadership but they were confident that the new management team understood the hospital and its staff.

We found areas that required improvement in outpatients and diagnostics:

  • The medicines management policy stated that staff needed to dispense medicines using a standard operating procedure. A standard operating procedure was not in place at the time of the inspection, but was being developed. This meant that staff did not have the guidance they needed in order to make sure that they dispensed medicines in a consistently safe manner.
  • At the announced part of the inspection we saw that the staff members within the ward were giving out medicines to take home in a manner that did not always maintain the safety of patients.
  • Prescriptions concerning eye drops did not contain information regarding the quantity required; therefore staff could not make this decision safely.
  • Pain relief was discussed with patients on discharge, however these discussions were not recorded in patients notes in order to determine and record that the best advice and support had been given.
  • The hospital had not carried out training and competency assessments around the nurse dispensing of medicines for outpatients which was contrary to the hospital medicines management policy.
  • Discharge information we reviewed did not consistently include relevant information about medicines. Patients were given verbal information, on when and how to take the prescribed medicine. However this was not recorded in the patients records in order to make sure that this information was consistent and fully understood by the patient.
  • We observed that there was an inconsistent approach from staff greeting patients. The majority introduced themselves to patients in order to set them at ease others did not.
  • Patient information leaflets in different formats such as braille, large print or other languages were not readily available on site.
  • The outpatient department displayed their complaints leaflet that informed patients of how to complain. However this was available only in one format and one language.
  • The results from the 2017 staff survey highlighted dissatisfaction amongst staff. We were told that this led to an internal review at corporate level followed by major changes in staffing at Manchester eye hospital. A new clinical manager was installed and the Optegra national clinical advisor was consulted to seek improvements.

We found good practice in relation to both surgery and outpatient and diagnostics:

  • There were systems in place to keep people safe and safeguarded from harm. The hospital had procedures to investigate and learn from incidents. Staff were confident on how to raise incidents.
  • The environment was visibly clean and well presented, procedures were in place to prevent the spread of infection and equipment was well maintained and appropriate for the services provided.
  • The hospital was responsive to patients who required additional support, such as patients living with hearing or language difficulties.
  • The hospital had robust arrangements in place for obtaining consent for patients having surgery or other procedures at the hospital. The mental capacity of a patient to consent to treatment was reviewed during consultation and the pre-operative assessment stage. For those who did not have capacity, a best interests discussion took place to decide the best course of action for the safety of the patient.
  • The hospital received six complaints between May 2016 and April 2017. It had a complaints system process in place and supported patients who had concerns about the service.
  • Optegra, which included Optegra Manchester, had achieved number one in category for Trust Pilot. They had been voted by the public as Best in category for eye treatment and rated 9.6 out of 10 based on 1,479 reviews.

We found areas that required improvement in surgery and outpatients and diagnostics:

  • The hospital risk register did not show a date for when the risk was expected to be resolved.
  • The hospitals staff survey was carried out in December 2016 indicated staff felt unsupported by managers.
  • Forty-five percent of staff felt that they did not have job security.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and it should take some actions to help the service improve. We also issued the provider with two requirement notices that affected Optegra Eye Hospital Manchester. Details are at the end of the report.

Ellen Armistead

Deputy Chief Inspector of Hospitals

Inspection areas

Safe

Requires improvement

Updated 23 November 2017

We rated safe as Requires Improvement because:

  • Staff were not clear on what constitutes a serious incident. We found that incidents were investigated and actions applied, however in the two serious incidents we looked at some of the recommendations had still not been implemented in full.
  • We found despite the previous issues with surgical safety processes, the surgical safety processes were still not being undertaken in line with best practice.
  • The duty of candour was not embedded and appropriately applied by senior staff. They were aware of being open and honest when things went wrong; however patients involved in the two serious incidents were not informed about mistakes at the earliest opportunity.
  • There were systems in place for the safe storage, use and administration of medicines; however, the controlled drugs book was not audited at local level and we found there were some administrative errors.
  • We saw good use of personal protective equipment (PPE) on the ward and in the operating theatre. However, we also witnessed poor compliance as none of the staff wore gloves or PPE whilst in the anaesthetic room which led to the operating theatre.
  • The hospital had appropriate processes and policies in place to assess patient risk, but we found the staff did not always follow the safety checklist guidance.
  • The hospital had a World Health Organization (WHO) Surgical Safety Checklist Policy in place. However, upon observing this process we found that the hospital was not compliant with this policy, or the overarching principles of the WHO surgical safety checklist and the National Patient Safety Agency (NPSA) five steps to safer surgery guidance.
  • The hospital did not undertake observational or documentation audits of the safer surgery processes. They therefore could not provide assurance that action was being taken to reduce the risk to patients undergoing surgery.

However;

  • Staff understood their responsibilities to raise concerns, to record safely incidents, concerns and near misses and to report them internally and externally.
  • Patient records both hardcopy and electronic, were accurate, complete, legible, stored correctly and kept people safe.
  • The environment and equipment were visibly clean and maintained to a good standard throughout the hospital.
  • Cleaning rotas were in place and audited regularly. We initially found that some of this documentation was unclear, thus making monitoring more difficult. We saw this had been improved by staff during our unannounced inspection.

Effective

Good

Updated 23 November 2017

We rated effective as good because:

  • Patient outcomes were closely monitored and the hospital audited 100% of all surgical performance. This was for the hospital as a whole and the outcomes for each individual surgeon.
  • The policies we reviewed cited and included relevant best practice guidance such as National Institute for Health and Care Excellence (NICE) guidance for the treatment of Glaucoma and Macular diseases.
  • One hundred percent of staff had received an appraisal within the last 12 months.
  • The hospital supported student nurse placements in order to assist both the development of student nurse skills and their own staff members exposure to different practice and views
  • Regular team meetings enhanced shared learning and built team collaborative working.
  • Processes were in place for obtaining appropriate consent and for assessing patient capacity and making best interest decisions where appropriate
  • Patients we spoke with stated that their pain was monitored and treated appropriately.
  • Diabetic patients were assessed pre-operatively and post-operatively. Staff we spoke with were aware of the needs of diabetic patients and acted appropriately if the patients blood sugar levels were low.

However:

  • Staff were dispensing medicines, the policy outlined that this was an extended nursing role. We found that specific training and assessment of competency to undertake this specific task had not been undertaken.

Caring

Good

Updated 23 November 2017

We rated caring as good because:

  • We saw positive interaction from staff in clinic rooms and waiting areas, consistently throughout the inspection. Staff were kind towards patients, joking and smiling with them and putting their mind at ease.
  • Feedback from people who used the service was consistently positive. This was reflected in the NHS Friends and Family test (FFT) scores; 100% of the patients said that they were likely to recommend the service. The response rate was 51% which equated to 132 responses.
  • During our observations we saw staff reassuring patients and giving them time to understand the treatment they were due to have.

Responsive

Good

Updated 23 November 2017

We rated responsive as good because:

  • The service had varied and flexible opening times, so patients could access the services at a time that suited them. Staff would make sure that patients got an appointment of their choice, sometimes on the day of referral.
  • The service had some consultations and clinics in a satellite clinic to promote easier access to patients living further away from the main site.
  • Patients living with Age Related Macular Degeneration (AMD) were a priority for treatment. This was because once diagnosed delays in treatment could be detrimental.
  • The service achieved the NHS indicator of 18 weeks referral to consultant led treatment. At the time of our inspection the wait was three to five weeks for NHS patients. Private patients had an average referral to treatment time (RTT) of two to five weeks.
  • The service provided pre-planned services only. Therefore they were in full control of the numbers of patients they could accommodate at any given period.
  • The service had partnerships with a range of qualified optometrists across the UK; these partners could refer patients for treatment if they found conditions that could benefit from treatment.
  • The service recognised people who required additional support to communicate and provided assistance in hearing and translation.

However:

  • We were told that the service did not monitor waiting times for individual patients once they arrived for their appointment.

Well-led

Requires improvement

Updated 23 November 2017

We rated well-led as requires improvement because:

  • The hospital risk register did not show a date for when the risk was expected to be resolved.
  • There was a lack of supervision and support for staff and lack of oversight in the management of day to day activities within the outpatients and surgery departments. This was due to an absence of lower tier managers or team supervisors.
  • The staff survey indicated that staff felt unsupported and dissatisfied with managers.
  • Forty-five percent of staff felt that they did not have job security.
  • Optegra values were not embedded in the organisation and the strategy was not well understood by staff.

However:

  • There had been recent changes in leadership. Staff told us that they felt optimistic about the future, saw improvements in the way they were supported and were enjoying working in the hospital. They were confident that the new management team understood the service and the staff.
  • There was an effective governance framework to support delivery of the strategy and good quality care.
  • Staff were clear about their roles and understood what they were accountable for.
  • The eye services monitored performance and produced a clinical outcomes report which reviewed complication rates and clinical outcomes data for laser vision correction, RLE and cataract procedures performed at that hospital.
  • Optegra, which included Optegra Manchester, had achieved number one in category for Trust Pilot (a website which publishes reviews from customers for online businesses). They had been voted by the public as Best in category for eye treatment and rated 9.6 out of 10 based on 1,479 reviews.
Checks on specific services

Outpatients and diagnostic imaging

Good

Updated 23 November 2017

Surgery and outpatients and diagnostic imaging were the only activities at the hospital.

Surgery was the main activity of the hospital. Where our findings relate to both activities, we do not repeat the information but cross-refer to the surgery section. Staffing was managed jointly with outpatients and diagnostic imaging.

We rated outpatients and diagnostic imaging overall as good, because it was safe, caring and responsive, though it was found to be requires improvement in well-led. We did not rate the service for being effective.

Surgery

Requires improvement

Updated 23 November 2017

Surgery and outpatients and diagnostic imaging were the only activities at the hospital.

Surgery was the main activity of the hospital. Where our findings relate to both activities, we do not repeat the information but cross-refer to the surgery section. Staffing was managed jointly with outpatients and diagnostic imaging.

We rated surgery overall as Requires Improvement

,

because it required some improvements in safety and being well led, though it was found to be good for effective, caring and responsive.