City Health Campus

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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.

At our last assessment we rated this key question Requires Improvement. At this assessment the rating has changed to Good.

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.

We scored the service as 3. The evidence showed a good standard. The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff understood the provider’s vision and strategy, and we saw posters promoting this on display throughout the service. A separate vision for surgical services was also presented to the inspection team, “To deliver high-quality, patient-centred, and efficient Surgical services by improving access, capacity, and operational effectiveness, while embracing innovation, digital transformation, and workforce well-being” with the aim to “reduce waiting lists, optimise resources, and enhance patient outcomes, aligning with (the trust’s) strategic goals and NHS national priorities.” Leaders had formulated plans to develop the service in line with these visions.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Service leaders had the skills, knowledge and experience to perform their roles, and staff spoke positively of them, saying that leaders were visible and supportive. Theatre staff told us that matrons carried out clinical shifts alongside them. Leaders had a good understanding of the services they managed and were aware of the challenges they faced. Leaders’ greatest areas of concern matched the highest risks on the service risk register.

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.

Staff we spoke with felt able to speak up to their leaders without fear of detriment. However, in the annual staff survey Ophthalmology staff scored ‘We each have a voice that counts’ slightly below the Trust average.

Patients and carers had opportunities to give feedback on the service. Friends and Family Test scores for day case ophthalmic surgery were 92.9% positive as of September 2025, and scores for ophthalmic inpatients were 96.6% positive. A surgical patient had commented that “The care I received for my operation to remove a cataract and fit a stent was excellent. Every member of staff I met was professional and so helpful”.

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.

The theatre team were awarded the equality, diversity and inclusion champion award at the trust’s 2025 allied health professional awards. There were several equality networks in the trust including the Black and Minority Ethnic Network, Muslim Liaison Group, Christian Network and People’s Experience Team. According to the 2025 Workplace Race Equality Standard data, staff from black and minority ethnic backgrounds made up 45% of the trust’s workforce, above local community representation. The provider undertook monitoring of staff salary by sex and ethnicity.

We scored the service as 2. The evidence showed some shortfalls. The service did not always have clear responsibilities, roles, systems of accountability or good governance.

Staff undertook or participated in clinical audits. The audits were sufficient to provide assurance and staff acted on the results when needed. There was some structure to ward and theatre team meetings, which staff minuted and recorded attendance. There were clear structures to clinical governance meetings and group board meetings at directorate level with discussion of risk, issues and performance. Staff maintained a risk register for the service. The service had business continuity plans in place for emergencies including adverse weather, as well as significant short staffing and IT failure which were reviewed annually. There were policies and a flow chart in place for action in the event of a fire. However, they did not reflect the current circumstances as staff told us that there was no longer a fire response team on the City Health Campus site as referenced in the flow chart. Staff were unsure of their roles and responsibilities.

Multiple electronic systems were in place in the service. Staff told us that some systems, such as the booking system and a patient record system, did not ‘speak’ with each other and therefore manual failsafe checks had to be carried out to ensure different systems had the same up-to-date information. Information governance systems included confidentiality of patient records. However, we found an unattended, unlocked computer with a staff member’s smartcard in on the pre-assessment unit which risked unauthorised access. We also found an unsecured records trolley on eye ward. This was fed back to staff on the day.

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.

Service staff met with representatives from Healthwatch monthly as part of a ‘Wayfinding Action Group’ which worked to action patient feedback. Open actions included introducing audio prompts into lifts and addressing a lack of information in patient letters.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research

The service had strong links with a local university, with faculty members on site, and facilities for skills training including a ‘wet lab’, and a cataract and vitreoretinal surgical simulator. Staff had opportunities to participate in research and clinical audit programmes.