Royal Eye Infirmary

On this page

• 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 people were protected from abuse and avoidable harm.

This is the first assessment for this service. This key question has been rated requires improvement. This meant some aspects of the service were not always safe and there was limited assurance about safety. There was an increased risk that people could be harmed.

The service was in breach of regulation for people’s safe care and treatment as fire safety was not always followed, laser safety was not always followed, staff did not always receive up-to-date training, and infection prevention controls were not always followed.

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.

Quality Statement Score: 3

The evidence showed a good standard. The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated safety events. Lessons were learnt to continually identify and embed good practice.

The service had systems and processes to investigate incidents and near misses. There were up-to-date policies to support incident investigations.

Staff understood what needed to be reported as an incident. They told us it was important to report all incidents to keep people safe. We reviewed incidents and found staff reported these and leaders investigated them.

The Royal Eye Infirmary reported incidents through Learning from Patient Safety Events (LFPSE) for the specialty listed as ophthalmology. There were 87 reported incidents between 10 September 2024 to 9 September 2025. Of these incidents, 15 related to delays or patients being lost to follow-up resulting in deterioration and permanent harm to patients’ sight. There were 201 reported incidents between 1 October 2024 to 30 September 2025 at all levels of harm or no harm for the combined services assessed involving adults and paediatric patients. Incident review meetings were undertaken where moderate or severe harm had been reported or was suspected to have occurred. Between 1 September 2024 and 12 September 2025 there had been 25 moderate to severe levels of physical harm related to delays or patients being lost to follow up resulting in deterioration or permanent harm to adult patients’ sight. The service carried out reviews of incidents for patients on waiting lists and developed plans to improve performance.

Records showed the service followed duty of candour (being open and honest when things go wrong). In the 12 months prior to our assessment, the service had performed duty of candour 26 times for incidents in outpatients and Royal Eye Infirmary administration. Staff understood the importance of professional duty of candour. Leaders involved in incident investigations understood their responsibilities in following statutory duty of candour requirements.

The Royal Eye Infirmary staff survey records for 2024 (outpatient and urgent and emergency care combined staff), showed staff felt more able to raise concerns about unsafe clinical practice compared to the 2023 survey. Staff survey results showed 80% of staff felt the service ensured errors, near misses or incidents were not repeated. This was significantly higher than the trust average.

Learning from incidents was identified by leaders and shared with all staff through various communication methods.

The evidence showed 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.

People were referred to the service by GPs, health visitors, local opticians or other healthcare professionals.

The service had processes and guidance to book patients on to the correct pathways. A central booking team used information to send booking letters. Patient records showed correct recording of patient information and conditions.

During our assessment, staff told us some clinics were turned to virtual clinics without prior notice to the people attending appointments. At virtual clinics, people would have tests completed which were later reviewed by clinicians.

The service carried out reviews of patients on waiting lists to ensure patients were scheduled to receive the correct care and treatment.

The evidence showed some shortfalls. Safeguarding training data provided was not always accurate. There was no advertising of the availability of chaperones should people require this. However, 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.

The service had up-to-date policies and procedures to keep people safe from abuse or improper treatment. Staff followed processes to report concerns.

Staff understood their responsibilities to keep people safe from abuse or improper treatment. Staff knew how to identify and raise safeguarding concerns. They knew who to contact for safeguarding advice.

The service carried out appropriate recruitment checks. This included checks with the Disclosure and Barring Service (DBS) for both adults and children barred lists. There was a process to review identified risk in recruitment checks.

Staff received training to understand threats from terrorism or extremism and support people susceptible to radicalisation.

During the assessment of the service, patients told us they felt safe.

We saw there was no safeguarding or chaperone information displayed in waiting areas and clinical areas. Staff told us they can offer a chaperone if requested.

Staff received training in safeguarding adults and safeguarding children to a specific level depending on their role. Training records for outpatients and urgent and emergency staff showed most staff who were required to complete adults and children level 2 had up-to-date training. However, completion for level 3 safeguarding adults was 60% (10 staff were required to complete training), and safeguarding children was 62% (8 staff were required to complete training). Staff said that safeguarding training supported them to do their jobs.

The evidence showed some shortfalls. Staff were not always up-to-date with basic life support training. Staff had not received paediatric life support training. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff received training to support people having a medical emergency. Records showed 76% of staff were up to date for level 2 adult basic life support training. Staff did not have paediatric basic life support training. The service told us the resuscitation team will start a process to deliver this training.

Staff communicated clearly with people about their care and treatment. During our assessment we observed staff communicating in a clear way so people could understand their care and treatment. Staff discussed treatment options and risks with people.

There were processes to manage a person having a medical emergency. The location was separate to the trust’s main hospital. In an emergency, staff provided life support and called for an emergency ambulance to transport the person to the main hospital.

Resuscitation trolleys were located throughout the outpatient department. Staff regularly checked trolleys and ensured they were fully equipped. The resuscitation trolleys were easily accessible to staff if required.

The evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care.

During our assessment of the service, we saw fire safety processes not being followed. Fire extinguishers in the outpatient’s areas and across the location had not been safety checked as scheduled. All extinguishers were due for safety checks before the end of September 2025 but had not been checked by the time of our assessment on 15 to 16 October 2025. After our onsite assessment, the trust told us that that fire extinguishers had been serviced by 27 October 2025.

Fire evacuation routes were not kept clear. Underneath the stairwells leading to the outpatient’s area on the first floor, there were items stored which could have been a potential fuel source for a fire. Wheelchairs were stored in these areas which could be an obstacle in evacuating the building. Records showed the service carried out a fire safety check in July 2025 where items were found to be stored in the rear stairwell, the service noted these items should be moved. Fire regulation requires stairwells to be clear to prevent obstruction and remove potential fuel for a fire.

The use of lasers was not always managed appropriately. There were clear laser warning signs and safety procedures in use. However, there were gaps in the risk assessments in the use of lasers. Records showed the service had identified gaps in safety processes prior to our assessment and had started to address these issues.

The service had enough suitable equipment to help staff safely care for people. Staff were trained to use equipment. During our assessment we saw staff using equipment safely and as intended. Staff completed regular stock checks to ensure items were available when needed.

The service had a process to manage the safety of equipment. Faulty equipment was identified and removed from service. We saw portable electronic equipment had been safety tested.

Leaders said the service was running at capacity and was limited by physical space to expand the service.

The evidence showed some shortfalls. Staff were not up-to date on all training. The service made sure there were enough qualified, and experienced staff, who received effective support. They worked together well to provide safe care that met people’s individual needs.

Staff received mandatory training to support them to care for people. The trust had identified the need for all patient facing staff to complete learning disability and autism training. Records showed most staff had completed the online training. However, records showed that only 12% of staff had completed the second part which was face-to-face.

The service planned staffing in outpatients combined with urgent and emergency care. Leaders carried out reviews of staffing levels against service demand and created business proposals to plan for the future.

Staff received yearly appraisals supported by up-to-date policies and guidance. Managers monitored appraisal compliance. Records showed most staff had received an appraisal. Managers understood the reasons for uncompleted appraisals and had plans to complete these. However, staff survey results for 2024 showed only 8% of staff felt appraisals helped them to perform their job and 25% felt able to access clinical supervision opportunities. Both were below the trust average.

Sickness rates averaged around 8.5% and nursing staff was 5.2% which was higher than the service’s target of 4%. Staff told us that sickness had a significant impact on their ability to bring waiting lists down. Managers monitored themes of sickness and took action to reduce occurrences where possible.

The service had a stable overall staff turnover rate in the 12 months prior to our assessment. However, macular treatment waiting lists were negatively impacted by turnover. The service had trained staff in other areas of the Royal Eye Infirmary to provide care and treatment.

We reviewed staff recruitment files and found the service was completing necessary recruitment checks.

Managers used appraisals and supervision to monitor and improve performance. There were policies to manage conduct and support performance improvements.

The service had regular team meetings to ensure staff were kept up-to-date with service performance.

People using the service told us staff were skilled and competent in delivering care.

The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Stock was not always stored correctly. During the assessment, we observed that stock was being stored directly on the floor in the cleaning room and storeroom. These items were at higher risk of becoming contaminated.

The service had processes to manage the disposal of waste. The management of sharps bins was safe. Waste was disposed of in suitable segregated bins. However, during the assessment we observed 1 clinical waste bag loose on the floor in the sluice.

The service carried out a programme of environment audits. However, the cleaning room sink had the presence of rust. The presence of rust makes effective cleaning difficult and increase the risk of cross-contamination.

The service was visibly clean and tidy. Fixtures and fittings were well-maintained. Records showed regular cleaning was being performed.

The service had hand washing facilities and hand sanitiser stations to support hand hygiene. All consultation rooms had suitable hand washing sinks. During our assessment we observed staff washing their hands in line with best practice. Staff were bare below the elbow and uniforms were visibly clean to help prevent the spread of infection. Records showed the service monitored hand hygiene and staff were following good practice.

Staff had access to personal protective equipment (PPE). Each consultation room had a PPE station suitably stocked. We observed staff using PPE in line with best practice.

Staff completed water safety checks to prevent the spread of water-based bacteria.

The service had processes to identify patient infection risks. Alerts were put on to the patient record and staff could identify these alerts.

During our assessment, people we spoke with felt the service was clean and tidy.

Staff received training in preventing the spread of infections.

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

The service had safe systems for the appropriate and safe handling of medicines.

There were processes to ensure people received the medicines they needed. The main pharmacy at Derriford Hospital provided oversight of medicines and undertook audits to ensure medicines were managed appropriately. However, at times there were not always the right staff members available to carry out medicines related tasks. For instance, when ‘to take away’ medicine packs, are issued, such as post laser treatment, there were not always the right members of staff available to carry out this task. This meant patients had to take prescriptions to be dispensed via an external pharmacy based on the main Derriford site following an agreed operational policy. Staff told us that patients were not always happy with this option due to the distance of the pharmacy from the Royal Eye Infirmary site.

The trust had medicines management level 1 training for nurses, 18 nursing staff were required to complete this training and 4 had not completed it. There was level 2 training for medical staff, 35 medical staff were required to complete the training and 10 had not completed it.