This was a responsive unannounced inspection carried out as a result of information of concern provided to us via a single anonymous source relating to an operating theatre. These were related to the environment particular the efficacy of the air ventilation system, damage to the fabric of the room and potential privacy and dignity issues.

We saw the theatre (called a treatment room by CESP) was clean and bright. The air was constantly and filtered as soon as the equipment was switched on. Where equipment needed to be plugged in cables trailed behind the operating chair and did not cause a trip hazard. We saw some of the equipment used was operated wirelessly reducing the amount of cables in use in the room. There was an oxygen cylinder provided by the British Oxygen Company which did not look rusty. It was housed in a new cylinder stand.

The windows were double glazed and sealed. There were no issues with privacy as although the room was on the ground floor of the building there were sloping areas of grass that would need to be negotiated to see in the windows. The windows had a covering that obscured the view from outside.

There was some exposed wooden skirting board underneath windows and the scrub sink.

Exeter Eye LLP @ Admiral House is operated by Exeter Eye LLP. The service provides ophthalmic surgery and outpatient clinics for private, adult patients from Admiral House in Exeter which is owned by another organisation called Exeter Medical (further referred to as the host hospital). Exeter Eye LLP rent rooms from the host hospital to provide their outpatient and diagnostic services. These include waiting areas, consultation rooms, a laser room and office space for secretarial staff. Exeter Eye LLP has an agreement with the host hospital to access theatre space, staff and equipment to carry out surgical procedures within Admiral House. Facilities include an anaesthetic room, recovery room and an operating theatre. The service has no overnight beds.

The service provides surgery and outpatient and diagnostic imaging services for privately funded ophthalmic patients. Types of surgery carried out include cataract removal, lens replacement and laser capsulotomy treatment.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 17 and 18 January 2018 along with an unannounced visit to the service on 1 February 2018.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the service understood and complied with the Mental Capacity Act 2005.

The main service provided by this hospital was surgery. Where our findings on surgery – for example, management arrangements – also apply to other services, we do not repeat the information but cross-refer to the surgery core service.

See surgery section for main findings.

Services we rate

We rated this service as requires improvement overall.

• There was limited oversight by the service that checks undertaken by the host hospital as part of their agreement were being completed. There were no formal reporting systems in place to gain assurance.
• The provider advised us that records were not always stored in a way which maintained patient confidentiality.
• Safeguarding adult processes were not always given sufficient priority.
• There was no policy for mandatory training so there was no clear guidance on what essential training staff were expected to undertake. There were no records of staff compliance levels.
• Staff competencies were not always regularly maintained and Exeter Eye LLP had limited oversight of the competency of staff employed as part of the agreement with the host hospital.
• There was no protocol or training provided in relation to recognition, diagnosis or early management of sepsis.
• Patient outcomes were not monitored by the service as a whole. Individual consultants audited their own outcomes but these were not submitted to any national audit.
• Outcome data was not submitted to the Private Healthcare Information Network (PHIN).
• Staff had not been provided with Mental Capacity Act training. The Exeter Eye LLP consent policy did not provide clear guidance for staff nor did it relate to relevant legislation.
• There was no access to foreign language or sign language interpretation services should these be required. This included both verbal and written translation.
• Governance arrangements were underdeveloped and not used as effectively as they could be to monitor the safety and quality of the service.
• Not all Exeter Eye LLP policies provided relevant and specific guidance for staff.
• Staff engagement was limited but undergoing a process of development.

However, we also found the following areas of good practice:

• Staff were aware of the protocol for reporting incidents. The senior team ensured that actions were taken and lessons were learnt as a result of incidents reported. However, staff had not been provided with incident report training as required by the service’s incident reporting policy.
• All areas we visited were visibly clean and well maintained.
• Control measures for the use of laser equipment were good and all safety protocols were used effectively.
• Medicines were stored securely and at recommended temperatures. There were checks on stock levels and fridge temperatures.
• All patient records were complete, legible and up to date.
• There were 24 hour arrangements for patient access to consultants following surgery undertaken by the service.
• There was consistent use of the World Health Organisation surgical safety checklist and this was embedded in practice. Completion of the checklist was audited with positive results.
• There was effective multidisciplinary working within the service and with the host hospital. Educational sessions were offered to optometrists and GPs and communication with GPs took place in a timely way.
• Consent was assessed throughout the patient journey and recorded clearly.
• Patients received compassionate care from staff. Staff were caring and took time to gather information about lifestyle and personal circumstance in order to provide the best care and treatment.
• Staff involved patients as active partners in their care and were sensitive to the emotional needs of those using the service.
• Patients were overwhelmingly positive about the service provided and the outcome of their treatment.
• The service provided good continuity of care. Patients were seen by the same consultant throughout their treatment journey.
• Patients were individually assessed for their suitability for treatment taking into account known risk factors.
• The premises and facilities were designed to meet the needs of patients. The theatre and consulting rooms were all on ground level and accessible.
• Patients did not wait long to receive treatment. There were no waiting times for surgery.
• There had been no complaints received by the provider.
• The service sought the views and experiences of patients and feedback was consistently positive.
• Leaders were visible and accessible to staff. All staff were proud of the service and care they provided.
• The service responded positively to opportunities for development.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with two requirement notices that affected surgery and outpatients and diagnostic imaging services. Details are at the end of the report.

Amanda Stanford

Deputy Chief Inspector of Hospitals