5 & 6 January 2022
During a routine inspection
We carried out a comprehensive inspection of Exeter Eye LLP @ Admiral House on 5 and 6 January 2022. The service was last inspected in January 2018 and was rated as requires improvement.
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.
Admiral House is owned by another organisation (further referred to as the host hospital) and 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. Types of surgery carried out include cataract removal, lens replacement and laser capsulotomy treatment. Ophthalmic (eye) surgical procedures are undertaken as day cases. They also provide ophthalmic consultations, diagnosis, treatment and management of long-term ophthalmic conditions.
Surgery is the main service provided. Our findings on surgery, for example, management arrangements also apply to other services, therefore, we have not repeated the information, but cross-referred to the surgery service.
At this inspection we inspected our five key questions: safe, effective, caring, responsive and well led. Before the inspection we reviewed information we had about the location, including information we received and intelligence available. The inspection was announced due to being immediately after the New Year and to check they would be offering their full range of services.
We rated safe, caring and responsive as good in surgery and outpatients. Effective was rated as good in surgery but is not rated in outpatients. Well led was rated as requires improvement in surgery and outpatients.
Our rating of this location since the last inspection had improved. We rated it as good because:
- The service had enough staff to care for patients and keep them safe. Staff had training in most key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Patients were assessed for their suitability for surgery. Staff kept good care records. They managed medicines well. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
- Staff provided good care and treatment and gave them pain relief when they needed it during surgery. Managers monitored the effectiveness of the service. Staff worked well together for the benefit of patients. Patients had access to good information about key conditions relating to eyes. Out of hours service for patient who had undergone surgery or treatment was available seven days a week.
- Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to patients.
- The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for treatment.
- Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged with patients to plan and manage services and all staff were committed to improving services continually.
However:
- The main leader was not able to fulfil the role of registered manager due to time constraints and other working commitments. They had also not completed additional training for their other lead roles.
- Governance arrangement had improved since our last inspection but there were still areas where improvements were needed. Assessment of risks was still reactive and had also not identified potential risks to the service provision.
- The safeguarding lead did not have the required level of safeguarding training to provide support and guidance to staff. The service vulnerable adults’ policy was not up to date with the latest legislation. This was identified at our last inspection. The safety briefing in theatre did not always take place without the distraction of the radio playing in the background which could mean not all staff would have been able to hear the important information.
- There was no system to monitor or record when all staff had completed training and when it was next due.
- There was no list of when audits would be completed to monitor the quality of service provision.
- When new staff were considered for a post not all references were obtained from other employers who did not work for Exeter Eye LLP.