City Health Campus

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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. At our last assessment we rated this key question Good. At this assessment the rating has remained Good. There was a breach of regulation around completion of mandatory 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 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 could give examples of incidents they had reported or would report, and most said that they received feedback on incident reports. Themes of incidents reported in the 12 months prior to the inspection included theatre lists starting late, cancelled operations, communication failure between staff and equipment failure. Staff and leaders understood the duty of candour and wrote to patients when serious incidents occurred, giving an apology and explanation of what went wrong. We saw evidence of learning from incidents shared in team meetings and divisional clinical governance meetings.

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.

Most referrals were received and processed by a central referral team. Urgent referrals were sent directly to a service manager for urgent booking and were pre-triaged by clinicians.

There were systems in place to ensure safety after surgery. Clinicians listed the requirement for an overnight stay on electronic decision to admit forms. High risk patients such as those with brittle glaucoma undergoing tube surgery at risk of a significant pressure spike in the eye always required an inpatient stay. Patients who did not fulfil the service’s safe day case criteria, such as those requiring general anaesthetic without support at home, remained an inpatient overnight. Furthermore, patients who live a long distance from the service and required next day review stayed as an inpatient. Paediatric patients were transferred to a children’s ward at Midland Metropolitan University Hospital if they needed an overnight stay.

As of August 2025, there was a backlog across the Ophthalmology service of 11,532 overdue follow-up appointments, which had been significantly reduced from 16,254 since June 2025. This was rated as the top risk on the service’s risk register. However, there was just 1 reported incident of patient harm due to a delay or failure to monitor or follow up a patient related to surgery in the 12 months prior to the inspection. There were some failsafes in place to prevent patients being lost to follow up post-surgery. A failsafe officer for glaucoma was in post from July 2025, and a tracker introduced to ensure glaucoma filtration surgery patients received 4 weekly follow-up appointments over a 12 week period, as a greater risk of harm to these patients from missed follow-up had been identified. Ward clerks arranged follow-up appointments the day after surgery and printed a letter for all patients requiring this. Leaders aimed to expand the failsafe officer role to medical retina and cornea sub-specialities. Another high risk on the register was the risk of operations not being performed at the right time due to capacity and staff inexperience in booking lists. As a result, patients were red,amber,green risk stratified, with standard operating procedures to support this.

We saw copies of discharge letters shared with patient’s GPs in the records we viewed.

We scored the service as 3. The evidence showed a good standard. 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 were mostly trained in safeguarding. At the time of inspection, only 23.33% of theatre staff and 33% of ward staff had completed safeguarding children level 3 training, and 0% of theatre staff and 4.8% of ward staff had completed safeguarding vulnerable adults level 3 training. However, leaders told us that level 3 training for staff below band 7 had become mandatory 16 days prior to the inspection, and the training included a face to face element that staff needed to book onto. Staff knew how to make a safeguarding alert and did that when appropriate. Staff gave examples of concerns they would or have reported, with an appreciation of specific issues that might affect people living with sight loss. There were several noticeboards with safeguarding information on, including contact details for the trust safeguarding team and contacts for domestic violence support.

There was a separate ward area for children with fob access. Paediatric staff we spoke with felt well supported to deal with safeguarding concerns. They had access to the child protection information sharing system and felt confident that they could seek support from the main paediatric department at Midland Metropolitan University Hospital (MMUH) and safeguarding team. Children were transferred to MMUH if they needed an overnight stay.

Doors to ward and theatre areas were secure, and inspectors were appropriately challenged by staff when walking onto the pre-assessment area which was not physically secured.

We scored the service as 3. The evidence showed a good standard. 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.

Patients were spoke with largely said staff communicated with them so that they understood their care and treatment. Medical staff told us they undertook daily ward rounds where patients had the opportunity to discuss their care. We saw a poster for the ‘call for concern’ service, which patients or their loved ones could use if they felt they or their relative were deteriorating and required escalation. Staff enabled patients to give feedback on the service they received through the friends and family test survey.

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.

Although the estate was aged, it appeared to be well-maintained in general. A patient-led assessment of the care environment audit was carried out on eye ward in April 2025, and a 95% score was achieved. However, the main doors to Sheldon block were not working correctly at the time of the inspection. Staff were worried about the potential effect on site security this could have, particularly at night, as security presence was ‘roving’ between sites. Staff on the eye ward noted concerns about the environment in their daily huddle and the faulty doors to Sheldon block, as well as a leak in the storeroom had been recorded several times.

Staff completed daily checks of emergency equipment via a quick response code, and emergency trolleys were securely tagged. We found a packet of paediatric defibrillator electrodes which were past their expiration date in the eye ward emergency trolley, which staff replaced on the day. Staff told us there was a dedicated equipment technician, and they were very responsive. Train the trainer programmes were in place for staff training on hoists, blood glucose monitoring and pregnancy testing.

Most equipment in theatre was single use. Staff rinsed reusable equipment immediately after use, before sending it for sterilisation.

Sharps boxes were appropriately built and filled, with temporary closures on where appropriate. However, the sharps skip in the dirty utility room on eye ward was not properly secured. This was rectified on the day.

There were policies and a flow chart in place for action in the event of a fire. However, staff told us that there was no longer a fire response team on site as referenced in the flow chart, and while security took responsibility for the first 100 days after the closure of the acute hospital at the site, staff were unsure who were responsible after this time.

We scored the service as 2. The evidence showed some shortfalls. The service generally made sure there were enough qualified, skilled and experienced staff. They generally made sure staff received effective support, supervision and development but staff did not always receive the required mandatory training.

Managers calculated the minimum number and grade of staff required for safe staffing which was generally met in a review of rosters from the 3 months prior to the inspection. There was 11.6% vacancy rate across band 2 to band 8 theatre staff at the time of inspection and 6% vacancy rate on the eye ward, however a new starter had been recently recruited which would take the rate to 3.5%. The total turnover rate for registered nursing staff across Ophthalmology in the 12 months before the inspection was 3.7%. Nursing leaders we spoke attributed low nursing turnover to there being good opportunities and a clear pathway for progression. Staff we spoke with agreed that there were development opportunities if they wanted them. We viewed a band 2 development pathway document which assisted theatre support workers into a band 3 role, and potentially beyond.

There was a higher turnover rate for medical staffing at 69.3%, although this included resident doctors and fellows who rotated through the service every 6 to 12 months. The service did not have accurate figures for permanent staff turnover. There was an 8.2 WTE medical staffing vacancy, including 5.3 WTE Consultant vacancy. Consultants operated an on-call roster for out of hours cover. A Consultant we spoke with said that for their first 6 weeks in post, they carried out on-calls with a ‘buddy’, and that while the frequency of on-calls was not too high, at around 1 in 30, the workload was high on-call. Sickness rates were variable across staffing groups, ranging from 1.4% for additional professional, scientific and technical staff to 6.5% for the additional clinical services group. The service did not use agency staff, and bank shifts were covered by regular staff to ensure staff had the right skills and experience. The service treated paediatric patients from 1 year old. On days where paediatric surgery lists were running, there were generally 2 paediatric nurses on shift.

Staff mostly received and were up to date with mandatory training. However, at the time of inspection, 0% of ward staff and 2.4% of theatre staff had received tier 2 Oliver McGowan training on learning disability and autism. Leaders told us that this training learning required a whole day off site and there were very limited opportunities for booking. Completion of non-patient moving and handling training and basic life support training were also below target for theatre staff at 71.4% and 72.5%, respectively.

We scored the service as 2. The evidence showed some shortfalls. The service did not always assess or manage the risk of infection. They did work to detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

The environment was aged but visibly clean, and equipment had ‘I am clean’ stickers with the day’s date on. Domestic staff carried out a cleanliness audit, and eye ward received the highest rating of 5 stars. The result of a cleanliness audit carried out in theatres in September 2025 was a pass at 99%. Theatre matrons undertook weekly checklists to ensure their clinical areas were clean and tidy, and cleaning schedules were completed and actioned. Staff carried out infection prevention and control (IPC) audits. Scores for the 3 months prior to the inspection were all 100% for theatre. Eye ward scored 98.3% in July 2025, 96.2% in August and 98.2% in September.

We observed that staff adhered to ‘bare below the elbow’ policy, and patient doors had signs to advise staff whether routine or enhanced IPC precautions were in place. Staff carried out monthly hand hygiene audits. A score of 100% was achieved on eye ward in August 2025, however in September this fell to 89.5%, with a repeat score of 95%, followed by a drop to 73.3% in October, with a repeat score of 95%. On eye ward we observed 2 doctors entering patient side rooms without sanitising their hands. We observed one of the doctors then examine a patient with a scope, as they had not closed the door or drawn a curtain, before leaving the patient’s room without washing or sanitising their hands. Hand hygiene scores for theatres were more consistent at 97% in July 2025, 98% in September and 98% in October.

We scored the service as 2. The evidence showed some shortfalls. The service did not always make sure that medicines and treatments were safe and met people’s needs.

Staff generally followed good practice in medicines management and did it in line with national guidance. Staff told us that there was a dedicated pharmacist for the service, and that medications on eye ward were topped up daily due to a high turnover. Medicines, including controlled drugs (CDs), were stored and secured appropriately on the eye ward.

We saw that CD count checks were consistently carried out twice daily by 2 staff. However, the latest CD audit for eye ward from August 2025 showed 90% compliance and was red, amber, green rated as red due to issues including ‘reg flag’ errors including the controlled drugs book not being correctly amended, and unavailability of the correct syringes and bungs for measurement and dosing of liquid CDs. An action plan had been produced to address the issues. Latest CD audit results for Theatre 1 and 2 were both 96%.

Registered staff on eye ward had electronic keys which provided an audit trail of who accessed medicines and when. Medicines in the anaesthetic room were stored appropriately and locked away when staff were not present. Medicines fridge temperatures in the anaesthetic room and on eye ward were consistently checked and recorded. All drugs checked were in date. However, oxygen cylinders were not appropriately stored on eye ward. This was fed back to staff on the day. Pharmacy conducted Safe Storage and Handling of Medicines (SSHM) audits every 6 months. The latest results showed 95% compliance for Theatre 2, 3, 4, theatre recovery and eye ward. Staff also conducted a monthly ‘mini’ SSHM audit on eye ward. The September 2025 result was 95%.

Staff appropriately recorded medications and allergies in patient records. Staff told us that waiting for ‘to take home’ (TTO) medications was often a source of delays to discharge. A patient we spoke with told us they had been waiting a couple of hours for their TTO eye drops.