Royal Eye Infirmary

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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

This means 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. Staff were not aware or following trust policies in relation to medicines, 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.

We scored the service as a 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 and reported safety events. Lessons were learnt to continually identify and embed good practice.

Staff knew the process to report incidents and understood duty of candour. We were provided with an example of a recent incident and the feedback received and learning shared. Learning was also shared via the ophthalmology learning bulletins.

The service line safety and quality assurance report identified an improved incident reporting culture. In the last 12 months there had been 24 incidents reported for urgent care. There were 3 which resulted in harm, loss or damage, 5 near miss due to intervention, and 16 with no harm, loss or damage. There was 1 where duty of candour was applied.

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.

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’s referral and admission processes ensured all essential information about the patient was received to determine if the patient’s needs could safely be met. We observed the pathway for patients during our inspection.

Patients were referred via healthcare professionals and healthcare services, for example GPs, 111 and opticians. We observed other healthcare professionals phoning or emailing for advice. Referral processes and standard operation procedures were available to support people to refer to the Royal Eye Infirmary for urgent eye care.

Ophthalmic trained nurses initially triaged referrals via a telephone consultation and provided advice or arranged for an appointment to see a clinician. An Royal Eye Infirmary Urgent Care Triage Guide was used for triage, but was overdue a review, dated February 2025.

There were 12 slots for patients to be seen by clinicians, sometimes these slots were overbooked with agreement with the clinician. The capacity did not always meet the demand, and people could not be seen the same day and were booked in line with their clinical lead.

On arrival patients were triaged by nurses before seeing a junior or senior clinician for decisions about their care and treatment. Electronic notes were accessible, this meant clinicians were able to review information for patients. Patients were booked in for follow up appointments where required or assigned to relevant care pathways for example outpatients or surgery.

Staff involved all the necessary healthcare and social care services to ensure patients had continuity of safe care, both within the service and post-discharge.

We scored the service as 2. The evidence showed some shortfalls. Safeguarding training data provided was not always accurate. 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 knew how to identify adults and children at risk of, or suffering, significant harm. Staff knew how to make a safeguarding referral and told us they would discuss with their manager if they needed support. There was also support available from the trust safeguarding lead.

Safeguarding alerts could be placed on the electronic system. This informed staff to review another trust electronic system to see the detail of the alert. We were told by management this process will be improved with the introduction of a trust wide electronic system.

Safeguarding training data was not always accurate. Staff received training in safeguarding adults and safeguarding children, trained to specific levels depending on their role. Training records for outpatients and urgent and emergency staff, and Royal Eye Infirmary medical staff showed most staff required to complete adults and children level 2 had up-to-date training. 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.

Children and young people were not always kept separate to adults when using urgent care. Some children were seen in the children and young people designated outpatients’ area or could wait in this waiting area. This was a dynamic risk assessment of the suitability dependent on what was happening in urgent care at the time of visit.

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.

We scored the service as 2. The evidence showed some shortfalls. 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. However, staff were not always up to date with basic life support training.

The service worked with patients to understand and manage risks. Staff communicated with patients, so they understood their care and treatment, including finding effective ways to communicate with patients with communication difficulties.

We spoke to patients and observed their care during our assessment, patients felt listened to and had risks explained, and were involved in decisions about their care and treatment.

Staff enabled patients to give feedback on the service they received.

Patients tended to be medically stable in the department, however if they deteriorated in the department, staff had access to a resus trolley and 999 would be called to transport the patient to the main hospital site.

Theatres were onsite if emergency ophthalmic procedures were necessary. See Surgery ASG report.

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.

We scored the service as 2. The evidence showed some shortfalls. The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

Equipment was mostly well maintained and serviced regularly. Staff received training to use equipment. We observed staff using equipment safely. However, we did find some items which were stored in a cupboard which we were told were not in use. These had not been serviced, and it was not clear they were not to be used.

Consumable items and cleaning products were stored securely. However, in the cleaning cupboard there were items on the floor, they were not elevated, for example on shelves, which posed an infection risk.

Fire safety equipment was available, however across the Royal Eye Infirmary site the fire extinguishers had missed being serviced in September 2025. After our onsite assessment, the trust told us that fire extinguishers had been serviced by 27 October 2025. Fire exits in the urgent care service were clear and free from obstructions.

Staff disposed of clinical waste safely.

Environmental audits were completed monthly. However, issues we identified on inspection with the safe environment had not been picked up in these audits.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received up to date training.

The multidisciplinary team included nurses, doctors, advanced clinical practitioners, orthoptists and optometrists. Staff told us there were enough staff to fill the rooms but not enough rooms to meet the demand of the service. The service did not collect and review data to evidence this demand and aid review of their capacity and staffing.

There were 3 rooms available for clinicians in urgent care, this included a senior in room 1, a junior or second senior in room 2 and an advanced care practitioner or optometrist in room 3. On review of the rota for September 2025, this showed 2 rooms were regularly staffed, the third room was not always in use. On Fridays there was just 1 senior doctor available. An on-call consultant was always available on site should advice be needed and they could see an additional 4 patients if required. Additionally, the consultant was on call at all times.

Medical staff worked across the Royal Eye Infirmary and did their allocated sessions in urgent care. There were not enough slots available to cover all urgent referrals to see a clinician. Some slots were already prebooked with follow-up patients to be seen. The clinical lead told us this was a point for improvement where follow up appointments resulted in overbooking clinics. We saw an example during the inspection where a walk-in patient was unable to be seen on the same day. However, the triage nurses checked with a clinician and the patient was suitable to be seen within 24 hours and was therefore booked for the next day. Staff told us they tried to find a solution so not to turn people away and see them in a timely manner. There was no data collected to capture how quickly people were seen or when people were turned away. This resulted in the service being unable to analyse data to make rapid improvements where needed.

Nursing and clinical services staff worked across the outpatient and urgent care departments. There were no nursing vacancies and 7.68% vacancy for additional clinical services at the time of our inspection. There was a small to zero turnover of staff in the last year.

Nursing staff were predominantly band 6 Nurse Practitioners working in urgent care. Each shift had 2 qualified nurses and 2 or 3 trainees or band 4/5. There were currently 3 trainees and a further 3 being employed. Staff reflected it can sometimes be difficult to support trainees due to high workload. There were 2 regular bank staff used to fill nursing gaps due to unplanned absence and holiday cover.

There was no clinical educator available to staff. Staff said they would like a clinical educator as this was a specialist area and would benefit from their input.

Staff received mandatory training to support them to perform their jobs and staff told us they were provided with time to complete their mandatory training. However, there was not a clear oversight of training position. The training data provided was not always clear and we were provided with different documents reporting different data. There were some gaps identified by the trust in compliance with mandatory training for staff across the Royal Eye Infirmary. 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 only 12% of staff had completed the second part which was face-to-face.

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

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 maintained equipment well and were observed to clean equipment between patient contact. All areas of the department were observed to be clean, had required furnishings and were well-maintained.

Staff mostly adhered to infection control principles, including handwashing, being bare below elbow and use of personal protective equipment. However, we found some staff used alcohol hand gel but did not regularly use the hand basin to wash their hands. In one nursing room, there was no access to a hand basin and staff told us they would wash their hands in the neighbouring rooms. We discussed this with the nursing lead and they informed us the room should not be used to see patients. Following our inspection, we were told the room was locked so it would not be used to see patients, and there were plans to repurpose this room to a triage call handling room.

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

There was a programme of infection, prevention and control audits, to include the hand hygiene audit and environment audit. Records showed the service was performing to expected standards.

We scored the service as 1. The evidence showed shortfalls in the management of medicines processes. The service did not always ensure staff were aware of and followed trust policies in relation to medicines. Not all staff had completed training in medicines.

The service had safe systems and processes for the appropriate and safe handling of medicines, however we saw staff did not always follow these. 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.

We saw staff were not always aware of trust policies in relation to medicines. For example, staff did not undertake second checks of medicines issued to patients To Take Away (TTA), this was against trust policy and could result in errors.

Staff issuing medicines as part of a process called Patient Group Directions (PGDs) could not access the electronic documentation to support them to do this. This meant there was a risk staff were not following the most up to date practice in relation to medicines.

A box of medicines to be used in case of the diabetic emergency hypoglycemia was available in the department. This box was not being checked as required on a weekly basis. There was no trust policy to support this box. This meant there was a risk the medicines contained in the box may not be suitable for use in case of an emergency.

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.