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

This means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first inspection for this newly registered service. This key question has been rated Requires Improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of regulation for good governance, the governance processes did not help support how to assess, monitor and improve the quality and safety of the urgent care service.

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 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 told us the vision of the service was to treat everyone as quickly as possible and safely, and to continue to bring waiting time down. They aimed to listen, learn and improve. There was also a desire to improve staff sickness and welfare and make it a better place to work.

Staff understood the challenges to the service, but it was not always clear what was being done to improve or manage this. For example, with demand outstripping capacity within urgent care.

We scored the service as 2. The evidence showed some shortfalls. There was not a cohesive leadership team for urgent care.

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.

The Royal Eye Infirmary leadership team consisted of a triumvirate of service line clinical director, operational manager and matron. They were responsible for monitoring the safety and quality of the service. There had been changes in leadership and people were adjusting to new people and different styles of leadership.

The urgent care department had a nursing and clinical lead. There was a band 7 post out to advert to help support the running of the department. Leadership in the department was not joined up. There were difficult dynamics within the leadership team which staff reflected was impacting on them. This was being managed by the Royal Eye Infirmary leadership team to seek a resolution.

Leaders said they were visible in the service. The clinical lead worked 1 session clinically a week in urgent care. The nursing lead spent time in the area. Staff told us these leaders were visible, however they were not all aware of the Royal Eye Infirmary matron who was new to the service and worked across different trust locations.

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 this impacted on staff’s wellbeing.

We scored the service as 3. 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.

There were trust processes for people to speak up. Patients and their carers could send a complaint. Staff could speak with freedom to speak up.

Staff were aware of the trust’s freedom to speak up champions and there was a freedom to speak up champion within the Royal Eye Infirmary imaging team. Listening events were held with urgent care and outpatient staff.

There were opportunities for patients and their carers to provide feedback on the service.

We scored the service as 3. 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.

Data was captured at care group level not at local service line level.

There were trust processes to support workforce equality, diversity and inclusion. Staff provided examples of where they were able to work flexibly to meet personal circumstances.

Managers told us about reasonable adjustments they were able to arrange for staff members to carry out their roles. Staff survey results from 2024 showed most staff felt the organisation made reasonable adjustments to enable them to carry out their work.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have clear responsibilities, roles, systems of accountability or good governance. They did not act on the best information about risk, performance and outcomes.

Governance at Royal Eye Infirmary was embedding, 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 Royal Eye Infirmary, and bring their own unique reports into governance, and be able to drill down into different areas. There was a clear governance meeting structure.

We found for urgent care the governance structure did not focus on outcomes, audit and regular review of practice for urgent and emergency eye care. There was no clinical audit for urgent ophthalmic care and outcomes were not monitored for lessons to be learned from patients with poor outcomes. Key governance metrics for emergency eye care were not being used.

Relationship difficulties within the leadership team had resulted in a significant gap in governance. The clinical lead did not attend any urgent care governance meetings and did not receive updates on complaints or incidents for the urgent care department. There were no meetings held between the nursing and clinical lead.

The service did not complete audit programmes or use recommended audit tools for reviewing records and consent. The trust told us this was no longer mandated to complete. During our review of records, we found for nursing consultations in urgent care, where a patient did not see a doctor, a discharge letter was not automatically sent to the GP from the system. This had not been picked up and improvements made due to the lack of audits.

Audits being completed were not always effective at identifying issues. For example, areas we identified on inspection under safe environment, were not picked up in the environmental audits.

A risk register was maintained for Royal Eye Infirmary, this included risks for the working environment and building, staffing, and ophthalmic specialties. There were no specific risks for urgent care. The risks staff told us about, for example demand and capacity, were not considered on the risk register.

We scored the service as 3. 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.

In July 2025 healthwatch staff and 2 volunteers visited the Royal Eye Infirmary on 3 separate occasions to gather feedback on experience and impact of recent service improvements. Healthwatch have offered to work with Royal Eye Infirmary to support recommendations and improvements outlined in their reports and to offer assistance with reviewing patient communications for clarity and accessibility and to help strengthen understanding of the needs of people using the service. Healthwatch said the Royal Eye Infirmary were receptive to this offer.

The Royal Eye Infirmary is part of One Devon, this allows them to work with neighbouring units and get good advice and learning, and share their own successes.

The clinical lead recognised they could be better connected with partnerships and communities to help develop the urgent care service.

We scored the service as 2. 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. There was no participation in audits to help them to learn and improve the service. 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 time for further learning, improvement and innovation.

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.