NHS North Derbyshire Community Ophthalmology Service is operated by New Medical Systems Limited. The service at this location provides outpatients and surgery. The service provided the surgeon to conduct ophthalmic related surgical procedures however the theatre environment, additional theatre staff and day case waiting area, were provided by another provider (the ‘host’ provider). The service runs and delivers the ophthalmology outpatients element within their dedicated outpatient department. The outpatient department consists of three clinical rooms, an administrative area and a toilet.

We inspected both outpatients and surgery. We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 11 September 2017, along with an unannounced visit to the hospital on 20 September 2017.

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 provider understood and complied with the Mental Capacity Act 2005.

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

Services we rate

We rated this service as good overall.

• The service had processes in place which monitored safe care and treatment provided at this location.

• The service reported no never events, serious incidents, surgical site infections (SSIs) or healthcare associated infections (HCAIs) from April 2016 to March 2017.

• All staff had an awareness of the safeguarding policy and reporting procedure and felt confident in identifying a potential safeguarding incident and the steps they would need to take.

• Medicines were administered to patients in a way, which kept them safe from avoidable harm.

• The service had policies, procedures, and guidelines, which were based on current legislation, evidence-based care and treatment and nationally considered best practice. These were regularly reviewed at the medical advisory committee (MAC) meetings.

• The service submitted patient outcomes to the clinical commissioning groups (CCGs) as part of their contract.

• Local cataract audits demonstrated positive outcomes for 95% of the patients who underwent the procedure.

• The service followed robust processes when it came to seeking out consent from patients. We observed best practice with the quality of information patients received to enable them to make fully informed decisions. We also observed staff adhering to the two week cooling off for patients who underwent oculoplastics procedures.

• Staff had a strong focus on providing a caring, compassionate and professional service. We observed examples of respectful and dignified care during our inspection.

• The service had processes in place to arrange for additional clinical support to meet patient needs if identified during their consultations.

• The service exceeded the 85% target set in their contract for reviewing patients within eight weeks of being referred. The service regularly recorded a monthly compliance of 100% for meeting referral to treatment times.

• There was a vision and strategy for the service, which all staff were aware of. We observed the mission statement for the service displayed in the outpatient department.

• There were effective governance arrangements in place to monitor quality, performance and patient safety. There was clear evidence that information from all meetings was shared so all staff were aware.

• There was a risk register in place, which the service regularly reviewed. All risks had an owner and mitigating actions recorded.

However:

• The room where the class four laser was operated was not compliant with recommendations from the Medicines and Healthcare products Regulatory Advice (MHRA) guidance and did not have signage in place which complied with Health and Safety (Safety Signs and Signals) Regulations 1996 (11) and related standards. This was entered on to the services risk register; however, we were not assured this had been escalated to the provider risk register.

• There was no on site supervisor to ensure safe usage and adherence to local rules when the laser equipment was in use.

• Staff files did not all contain all the essential evidence within them. The human resources department managed this centrally, however the senior management at this location did not regularly review them to provide assurance all staff were fit and safe to work within the service.

• The outpatient department was compact and concerns were raised around the accessibility for disabled patients, and more importantly the ability to evacuate them safely and swiftly in a fire.

• Staff knowledge around clinical incidents was variable. We observed a near miss during a procedure, which staff did not consider, was a reportable clinical incident.

• We observed staff members not adhering to the surgical policies and procedures of the host provider whilst in the operating theatre.

• The service did not participate in national audits at the time of inspection; it was therefore not possible to benchmark its performance against other providers.

• The service used the World Health Organisations (WHO) surgical safety checklists for all surgical and minor procedures. We observed variable levels of compliance with these checklists and minimal auditing of compliance.

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 one requirement notice that affected the outpatient department. Details are at the end of the report.

Heidi Smoult

Deputy Chief Inspector of Hospitals