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 safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. Leaders had systems for identifying and responding to deteriorating patients on the departments, in the operating theatre and recovery. Patients received treatment and care to reduce the risk of avoidable harm, such as pressure damage, blood clots or falls. There were safety processes arranged before surgical procedures and operations started, with staff working together to ensure the right patient had the correct operation. Medicines were managed safely. Patients were safe from neglect, abuse and discrimination.

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 patients 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, trip hazards were not always identified, and staff did not always receive up-to-date training.

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.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff and leaders listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Learning was shared with staff.

The service had systems and processes to investigate incidents and near misses. There were up-to-date policies to support incident investigations. The Royal Eye Infirmary reported incidents through an incident reporting system. All patient safety events were then automatically uploaded to the Learning from Patient Safety Events (LFPSE)

In the 12 months prior to our assessment, there were 37 incidents reported. Learning form incidents was shared with staff. Staff confirmed feedback from incidents was shared with them.

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.

Staff raised concerns and reported incidents and near misses in line with provider policy. We saw evidence of incidents having been investigated, and sufficient action taken to reduce the risk of recurrence. Staff had the opportunity to discuss learning through regular safety meetings.

There had been 1 reported never event in the preceding year. Never Events are serious, preventable safety incidents which should not occur if the available preventative measures are followed. They include things like wrong site surgery.

Staff understood the duty of candour. They were open and transparent and gave patients and families a full explanation if and when things went wrong. Records showed in the 12 months prior to our assessment, the service performed duty of candour 31 times for incidents considered moderate or high harm.

The Royal Eye Infirmary staff survey records for 2024, showed staff felt encouraged to report incidents and near misses. They also felt the provider took action to prevent recurrence.

The service worked with patients and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when responsibility for patient care moved between different areas of a service and between providers.

There was an admission criterion for patients. These criteria reflected the service’s limitations and were designed to minimise patient‑safety risks by excluding individuals whose needs could not be safely met. For example, patient with multiple comorbidities who were assessed as high risk and requiring general anaesthesia would be seen at Derriford Hospital. The service was not available at night or on weekends. Outside of the service opening hours, an on-call service was provided at Derriford hospital.

Staff had access to patient information enabling them to plan care. Records had clear flags to highlight a patient’s needs. We observed staff following good practice during pre-operation checks. The service carried out the World Health Organisation (WHO) surgical safety check list to avoid harm. We observed staff completing the process.

The transfer of patients from the operating theatre to recovery was managed safely, with the anaesthetist retaining responsibility for determining the readiness for transfer. Suitably skilled and qualified staff accompanied patients in all areas.

When overall responsibility for the care and treatment of a patient moved to a different service provider, there was effective communication, which allowed for seamless transfer.

We observed staff providing patients with discharge information to help them manage post-surgery recovery.

The evidence showed some shortfalls. Safeguarding training data provided was not always accurate. 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.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff received adult and children's safeguarding training. Data showed 98% of staff were up-to-date with safeguarding adults training, and all staff were up-to-date with safeguarding children training level 2. However, the trust was in the process of reviewing safeguarding level 3 training in line with changes to the intercollegiate document for all band 6 to be level 3 trained. However, not all staff at the Royal Eye Infirmary who were required to have safeguarding level 3 training were up to date. The data provided showed some staff roles, for example consultants, were not required to have safeguarding level 3, which is inaccurate.

There were current safeguarding policies, and these reflected the national guidance for adults and children, including visitors.

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.

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 74% 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 would start a process to deliver this training.

The service worked with patients to understand and manage risks through pre-procedure assessments. Treatment and care met patients' needs in a way which was safe and supportive and enabled them to do the things that mattered to them.

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. Staff understood what their role was in an emergency. There were processes to identify sepsis.

We observed patient safety checks where allergies were noted.

Patients were provided with information on discharge about the surgery they had and what to do in after care. They were provided with information on what to do if they have issues post discharge.

The service did not always detect and control potential risks in the care environment. Leaders and staff did not make sure the equipment, facilities and technology supported the delivery of safe care. Risks were not fully mitigated.

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 were overdue for their next scheduled safety check.. 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 fire extinguishers had been serviced by 27 October 2025.

Fire evacuation routes were not kept clear. There were items stored underneath the stairwells leading to the outpatient’s area on the first floor, 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 environment was not always managed in a safe way. There were exposed trailing cables in theatre presenting a trip hazard. During our assessment we saw a near miss trip those exposed trailing cables.

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 design of the environment followed national guidance around the built environment. Where required, areas were secure and protected patients. Access was restricted by swipe card locks.

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

The service made sure there were adequate numbers of qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care, which met patient’s individual needs.

The service planned staffing rotas in advance. Records showed there were enough staff scheduled to care for patients.

The service monitored vacancy, turnover and absence rates. The general trend across the clinical service showed allied health professionals and nursing staff had a reducing level of absence in the 12-month period.

Staff survey results for 2024 showed 45% of staff had felt unwell due to work related stress in the previous 12 months. In the 12 months prior to our assessment the service reported 23% of absence were due to stress or other mental health conditions.

Managers monitored the use of agency and locum cover. In the 12 months prior to our assessment, medical cover varied between 0.25 to 0.9 whole time equivalent (measurement indicating the workload of an employed person). Nursing staff agency use varied between 0.12 to 2.46 whole time equivalent.

Staff survey results for 2024 showed 27% of staff felt there was enough staff at the service to enable them to do their job properly. During our assessment, staff said they had enough resources to carry out safe care and treatment

Managers supported staff to develop through constructive recorded, annual appraisals of their work and regular clinical supervision. If poor staff performance was identified, this was dealt with in a supportive way, with a view to improvement. Records showed all staff had received an appraisal by September 2025.

The service had an induction process for new members of staff.

Surgical procedures and clinical decisions were carried out by doctors with appropriate seniority and speciality training. Staff told us they always have access to medical cover.

Patients spoken with felt their needs were met in a timely way.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading by following policies. Infection prevention and control data was collected and reviewed. Where required, actions were taken to improve shortcomings.

Theatres and recovery areas were visibly clean, free from clutter and had suitable furnishings which were clean and well-maintained. People told us the environment was clean and tidy.

The theatre environment followed national guidance, with separate areas to enable flow from clean storage, preparation through to an area for dirty equipment and waste management. There was storage for equipment including sterile packs, uniforms and linen.

Surgical instrumentation was managed off site at Derriford Hospital, which involved the processing of items, delivery of these and collection after use for cleaning and sterilising. Staff checked the condition of sterile packs before they were opened and prior to use.

There was an up-to-date provider infection prevention and control policy and supporting guidance which was accessible to staff. The provider’s policies and procedures reflected national guidance. Staff could access expert advice from an infection prevention control lead.

The service carried out audits to monitor compliance to policies. For example, hand hygiene and peripheral cannula insertion audits showed 100% compliance.

We observed staff cleaning equipment after patient contact.

We saw staff were following infection control principles including compliant handwashing and the use of personal protective equipment (PPE). We saw staff following the trust’s uniform policy. Staff were bare below the elbows to enable effective hand washing.

The environment was built in line with healthcare building guidance. The service had hand washing facilities and hand sanitiser stations to support hand hygiene

There was appropriate testing of water outlets and air exchange systems in theatres.

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

Staff received training in preventing the spread of infections. Records showed 89% of staff were up-to-date with the training.

The service made sure that medicines and treatments were safe and met patient’s needs, capacities and preferences. Staff involved patient in planning, including when changes happened.

The service had safe systems for the appropriate and safe handling of medicines. However, some records of medicines checks were missing. For example, we saw daily checks of the emergency trolley were sometimes missing. A review of the trolley showed all content was correct and in date. These checks are important to ensure medicines required in an emergency are always available when needed.

There were processes were to ensure patient received the medicines they needed. The main pharmacy at Derriford hospital provided oversight of medicines and undertook audits to ensure medicines were managed appropriately.