City Health Campus

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This means we looked for evidence that people’s care, treatment and support achieved good outcomes and promoted a good quality of life, based on best available evidence.

At our last assessment we rated this key question Good. At this assessment the rating has remained Good.

We have not awarded this service a score for Effective.

Find out about when we will not publish a key question score and what we look at when we assess Effective.

We scored the service as 3. The evidence showed a good standard. The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

We reviewed 5 electronic patient records during the inspection. Records were complete. up-to-date, personalised, and recorded patients’ individual needs, for example a patient living with dementia’s power of attorney information. Medical staff told us they undertook daily ward rounds where patients had the opportunity to discuss their care.

We scored the service as 3. The evidence showed a good standard. The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Staff participated in clinical audit, benchmarking and quality improvement initiatives. The service undertook a wide range of ophthalmology specific audits including but not limited to patient outcomes with a particular glaucoma implant over time, the long term outcomes of tubes in uveitic glaucoma and the anatomical and symptomatic outcomes of dacrocystorhinsotomies, a surgical procedure to create a new tear drainage pathway between the eye and the nose. The service participated in national benchmarking through the National Ophthalmic Database audit. Posterior capsular rupture rate and vision loss after cataract surgery were both within expected limits.

Staff monitored theatre utilisation rates, which were on average 84.2% in the 12 months before the inspection, very near the 85% target set by NHS England and Getting it Right First Time. Staff also monitored return to theatre rates, which were 0.13% for the 12 months prior to the inspection. There were 270 on the day cancellations of surgery in the 12 months before the inspection, 110 of which were hospital cancellations for clinical reasons, such as a pre-existing medical condition. 98 were hospital cancellations for non-clinical reasons, such as lack of staff availability, and 61 were cancelled by patients. Staff told us that on the day cancellations were escalated to the service manager via the daily ‘sitrep’.

We observed completion of World Health Organisation (WHO) safer surgery checklists in line with guidance. Staff audited WHO checklists, and completion of all 3 sections of the checklist was consistently high at 97.3%, 97.8% and 97.8% in July, August and September 2025, respectively. In the same period, an average of 83.5% of theatre lists had both a brief and debrief undertaken.

100% of theatre, medical staff and ward staff were up to date with appraisals, and 90% of the directorate management were up to date.

We scored the service as 2. The evidence showed some shortfalls. The service did not always work well across teams and services to support people.

We viewed minutes of monthly staff meetings on eye ward and saw records from daily huddles where information was shared between staff. Theatre staff told us that they had weekly team meetings, and any issues encountered on the day were discussed at the end of the list. Ward staff were encouraged to spend time observing in theatre and were provided with a booklet to support their learning.

However, staff told us, and we saw examples of incident reports where staff could not access support for patients from the mental health liaison team as they did not work cross-site. Staff also said they struggled to get input from physiotherapy, occupational therapy and dietetics.

We scored the service as 3. The evidence showed a good standard. The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

Staff supported patients to live healthier lives. They could refer patients to eye care liaison officers (ECLOs) for both practical and emotional support around living with sight loss, and referral to external partners. The ECLO we spoke with said they currently supported around 130 patients per month and aimed to make referral to them a mandatory part of the patient pathway.

We scored the service as 3. The evidence showed a good standard. The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Patient observations were recorded using a standardised tool in theatre and on the ward. We did not see any evidence of patient deterioration that would warrant intervention and/or escalation in the records we reviewed. However, all patient episodes were documented and any changes recorded. Staff could access blood test results and imaging through 1 electronic system.

We scored the service as 3. The evidence showed a good standard. The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Consent was accurately recorded in all patients records we reviewed and appropriately signed by patients or their legal power of attorney. Staff re-checked consent forms in theatre before procedures and explained to patients what they were doing. Most of the patients we spoke with said that staff explained things to them in a way they could understand.