Royal Eye Infirmary

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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

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

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

However, the service was in breach of regulation, there was no audit process to ensure records and consent were consistently meeting standard.

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.

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.

The service worked within the trust’s overall vision, strategy and values. The vision was to provide outstanding integrated care. The service had a long-term clinical strategy to improve performance. Leaders were aware of the challenges with outpatient waiting lists and were focused in bringing waiting times down and providing safe care.

All staff and leaders followed the trust’s values and behaviours. Leaders told us they reviewed complaints from people using the service and staff feedback to understand how staff followed values and behaviours. Records showed values and behaviours were discussed at appraisals. Leaders said they aimed to listen, learn and improve.

Senior leaders told us they had seen an improving culture and were looking for ways to communicate better with staff to get more ideas to improve the culture. Staff told us there were challenges when communicating with different staff groups within the service when changes to the service were being considered. However, they said they were supported by senior leaders to resolve issues.

Staff understood the challenges to the service. Most staff described the service as running at maximum capacity and understood the pressures of waiting lists. However, staff said they enjoyed working at the service.

Survey results showed that staff felt positive about how colleagues treated each other and there was respect and kindness. Records showed that staff had not experienced unwanted behaviour from members of the public or colleagues.

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.

At the time of our assessment the service was going through an organisational restructure. Leaders said this was a challenging time but felt supported by colleagues and the wider team. Leaders told us they had access to development opportunities and gave examples of how the trust supported them to attain new qualifications to support the leadership of the service.

Leaders understood the pressures to deliver outpatient care. At the time of our assessment there were significant outpatients waiting lists across the healthcare system. Leaders understood the need to reduce waiting lists as this would decrease risks for people waiting for care and treatment. Leaders understood the need to promote early detection of eye conditions in children and young people to enable them to manage their conditions.

Leaders were experienced working in healthcare and understood their workforce and the challenges staff faced when performing their duties. They talked about the pressure staff were experiencing. They understood and there was the impact on staff’s wellbeing.

Leaders said they have been developing processes for managers of all levels to come together to address service pressures. Records showed teams were sharing performance information.

During our assessment of the service, staff told us leaders were visible across the service.

Survey results showed staff felt valued by their immediate manager. Records also showed 95% of staff did not experience bullying or harassment form managers. This was better than the trust average.

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 service had access to an up-to-date freedom to speak up policy supported by a variety of other policies and procedures designed to enable people to raise concerns.

Managers had access to feedback from people. They had access to feedback from patients and staff and used feedback to investigate concerns. Managers understood the importance of staff being able to raise concerns without fear of retribution.

During our assessment, staff gave us of examples of how they were supported by managers after raising concerns.

Staff survey results for 2024 showed 58% of staff at the Royal Eye Infirmary felt able to speak up about concerns and 32% felt the organisation would address any concerns. This was below the average for the trust. However, during the assessment, staff we spoke with told us they were able to raise concerns via the formal freedom to speak up process. In the 12 months prior to our assessment staff raised 18 concerns through the freedom to speak up process. They also said they could approach managers to raise concerns.

The trust’s freedom to speak up team held an engagement event at the Royal Eye Infirmary in March 2025 to promote speaking up.

The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The service was part of the trust’s equality, diversity and inclusion strategy which had 3 aims and objectives to help address challenges in the workplace. The trust had processes to monitor and report on gender, ethnicity and disability pay gaps. The trust had a variety of staff networks and support groups with the aim of making a positive difference in the workplace.

The services at the Royal Eye Infirmary were included in the trusts reporting for workforce race equality standards (WRES).

Staff survey results from 2024 showed most staff felt the organisation made reasonable adjustments to enable them to carry out their work.

Staff received training in equality, diversity and human rights.

The evidence showed significant shortfalls. The service did not have clear systems to identify issues in a timely way. However, the service had clear responsibilities, roles, systems of accountability.

The service did not always have complete audit programmes to manage the safety and quality. During our assessment we did not find concerns in the completion of records or consent. However, the service did not have a process to monitor the standards of record keeping or that consent was obtained correctly. This means the service could not be assured that actual practice was in line with best practice.

Systems and processes did not always identify issues in a timely way. Processes did not identify fire safety issues, laser safety issues or infection prevention control issues. However, the governance processes for the Royal Eye Infirmary were being reviewed and improved.

There was a dedicated governance role that supported the implementation of key governance processes that were previously not available. The service had developed a meeting structure which gave senior leaders and managers regular opportunities to discuss operational, quality and safety issues. They were 12 months into going live with a new framework which focussed on risk, incidents, and complaints. The governance lead recognised they needed to integrate and separate out different areas of the Royal Eye Infirmary, and bring their own unique reports into governance, and be able to drill down into different areas

The service had a clear structure to support the delivery of the children and young people’s service. At the time of our assessment all services provided from the Royal Eye Infirmary were led by a service line clinical director, operational manager and matron. They were responsible for monitoring the safety and quality of the service.

The service had clear staff job descriptions. Each job role had specific roles and responsibilities and set out the expectations. Staff understood their roles and who to report to in the service.

The service regularly reviewed risks. They maintained a risk register to evaluate and mitigate risks that posed a threat to the safety and quality of service provision. There was a named person responsible for completing each action. Managers and staff were aware of risks that were reflected on the risk register. Significant risks such as wait times were identified and escalated to board.

The service had an up-to-date business continuity plan should a major event interrupt the provision of care and treatment.

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.

The service worked with other providers in the integrated care system (ICS) to review performance and share learning. Leaders told us “Being part of the ICS enabled work with neighbouring units and get good advice and learning from them.”. Records showed services sharing performance and learning.

The service had regular engagement with charities linked to the Royal Eye Infirmary. Staff told us they had really good support from charities, and this enabled them to improve equipment for people using the service. Records showed the service working with charities and communities to make improvements to care provision.

The service was involved in local Plymouth networks to promote and support children receiving care and treatment for eye conditions. Records show that the service was working with independent health providers to promote the identification of eye conditions that required referral to the paediatric ophthalmology services.

The evidence showed some shortfalls. The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

The service did not have a culture of learning, improvement and innovation. Research and innovation were not part of core activity. There were no quality improvement initiatives.

We were told demand outstrips capacity and leaders were working to support workforce with the stressors of the workload. Therefore, this did not allow sufficient time for further learning, improvement and innovation linked to clinical audit and research. There was some participation in clinical audit that evaluated services. These were presented at the bi-monthly medical education sessions. However, there was no oversight of these audits via the clinical governance meeting. There was an action within the service’s governance improvement plan to improve oversight of audits and to help them to learn and improve the service. This action had yet to be started.

During the 12 months prior to our assessment, the service provided diagnostic support to 6 research projects allied to other services within and external to the trust. In the previous 12 months the service had run 4 research projects.

For the Royal Eye Infirmary, it was known the demand was going to increase by 20% over the next 10 years. The service was exploring how best to manage this. For example, weekend hours and different set ups for the future, such as virtual services.

The service was preparing for the trust-wide launch of a new IT system designed to provide a single comprehensive electronic health record for patients by replacing older systems and paper records.

The service worked in collaboration with other NHS trusts in researching care and treatment of eye conditions.