Moorfields Eye Hospital

Moorfields Eye Hospital City Road is part of Moorfields Eye Hospital NHS Foundation Trust. The trust has 32 centres in and outside of London. It provides a networked satellite model of care at Moorfields Eye Hospital City Road and across three geographical networks: Moorfields North, Moorfields South and Moorfields East. Services provided include surgery, outpatients and professional support to other eye services managed by other organisations.

Moorfields Eye Hospital City Road is located in central London. The hospital provides comprehensive general and specialist outpatient, diagnostic and surgical services for the local population and for those from further afield who require more specialist treatments not available elsewhere. Islington Clinical Commissioning Group is the lead NHS commissioner of services provided by the trust, with over 28 key associates to the contract. As well as providing clinical services it is the trust headquarters.

Our key findings were as follows:

• There was an open and transparent approach to incident reporting. Staff were encouraged to report incidents but feedback and learning from incidents was variable..

• Medicines were managed safely with relevant checks carried out.

• Care and treatment was delivered in line with best practice and staff had ready access to and followed protocols and guidelines driven by national guidelines and best practice. Medical staff contributed to the development of national standard setting and guidance.

• Patients had access to new and innovative treatments through participation in research studies. At the time of our inspection there were a significant number of studies underway, including: six adnexal, nine age related macular degeneration, three cataract, nine corneal external disease, three diabetic retinopathy, eight glaucoma

• There was good multidisciplinary team working involving staff from a range of specialities including and orthoptists and optometrists.

• Staff were aware of the signs of potential and actual abuse and knew the action to take to protect children and adults.

• Patient risk was assessed but, the full five steps to safer surgery had not been fully Implemented and embedded in operating theatre practice.

• Patient outcomes were monitored and benchmarked nationally and internationally. The hospital provided information to the World Association of Eye Hospitals’ (WAEH), which compiled an annual report demonstrating the numbers of attendances and interventions in comparison with other eye hospitals globally.

• Patients had their pain regularly assessed and managed effectively. Child friendly pain assessment tools were used.

• For patients who were having surgery a range of sandwiches and drinks were available following their procedure. Following surgery c hildren were offered drinks, a choice of sandwiches, cereals and ice cream.

• Staff had access to on-going training and development and the uptake of appraisals was good.

• We found caring was good in all the services we inspected and in services for children and young people it was outstanding.

• Patients described staff as caring, kind and compassionate. Staff tried to reassure patients and put them at ease prior to their surgery. In services for children and young people all staff engaged with children and their parents to reduce their anxiety and reassure them;” they turned a scary place into a friendly place.”

• Patients and their families told us staff spent time explaining their assessments and treatment options. They didn’t feel “rushed” and had time to ask questions..

• Psychological and emotional support was provided by staff and the integrated patient support team also gave practical advice and information on services outside the hospital.

• The process for managing and responding to complaints was well developed. Where possible staff tried to resolve patient concerns immediately. We saw evidence that the findings from investigations were shared with the patient along with an apology.

• Most services had good governance and risk management processes to monitor and evaluate care.

• Staff told us they were proud to work for the trust and most felt valued. They were aware of the trust’s values.

• The hospital provided updates to staff using a range of methods including weekly newsletters and ‘In your shoes’ session where staff were given feedback about patient experience and contributed to discussion about improving the patient experience.

• Staff in the A&E and pharmacy department staff raised concerns about bullying and harassment and the hospital had taken a range of actions to address the problems in these areas.

• The environment in the accident and emergency department (A&E) did not meet the needs of children and young people or protect patient’s privacy. There were also problems with the ventilation in the A&E and limited storage space for patient records.

• Areas we inspected were clean but, space in the outpatients department  was limited and there was insufficient seating for the number of patients attending clinics.

• The availability of medical records was an on-going issue and temporary notes were used until the records could be located.

• We found omissions in some patient records including staff signatures and record entry dates.

• There was a general laser risk assessment however, these were not dated. Laser safety guidelines on the intranet were dated October 1999 and although more up to date guidelines were available staff were not aware of them..

• The hospital had taken some action to cope with the increasing demand on services; extra consultants had been employed to work in the A&E and audits had been carried out to identify urgent and non urgent attendances and make GPs aware of the services provided by the A&E to reduce inappropriate referrals. Extra clinics were being held in the evenings and on Saturdays to cope with the busy caseloads in the OPD.

• There were delays with patient flow in some services. In surgery there was significant variation in the number of children undergoing surgery on different days of the week. Outpatient clinics often over ran and patient waiting times were not monitored.

• Many staff spoke positively about the leadership of their service, although some staff in the outpatients department lacked confidence in the management because of the lack of action to address some of the on-going problems.

We saw several areas of outstanding practice including:

• Staff’s sensitivity to the needs of children, young people and their families was outstanding.

• Play staff were able to engage with children on a one to one basis to provide age appropriate activities and distraction when they became anxious. This input was available in all areas of the RDCEC including A&E and outpatients clinics.

• The written information provided for children and young people was of very high quality. An internet resource had been designed for children and young people, giving information about eye conditions. It was divided into three different age groups and also had an animated eye, a virtual children’s eye hospital and other interactive features suitable for children.

However, there were also areas of poor practice where the trust needs to make improvements.

Importantly, the trust must:

• Ensure the World Health Organisation (WHO) surgical safety checklist  is consistently implemented for all surgical procedures including the five steps of team brief, sign in, time out, sign out, and debriefing.
• Ensure adequate audit and monitoring systems are in place to monitor performance and compliance of the five steps to safer surgery safer surgery checklist to guide improvement.
• Ensure that the quality and safety of the outpatients service are fully monitored, including patient waiting times and clinic finish times.
• Ensure that risks relating to patient waiting times are fully mitigated.
• Ensure that patient records are fully and legibly completed, including staff signatures, record entry dates and documentation errors correctly marked.

In addition the trust should:

• Look for ways to improve patient privacy in the OPD, accident and emergency department and day case wards.
• Address the lack of storage space for patients’ notes in ED and the administrative office and remove barriers to evacuation.
• Consider implementing the business plan for an electronic record system and scanning of casualty cards. This will free up space within the administration office and eliminate the risk of trips.
• Repair the ventilation system within the emergency department.
• Improve the waiting area for children and young people in the main accident and emergency department.
• Ensure all staff complete all aspects of mandatory training.
• Ensure all staff are aware of the incident reporting process.
• Ensure all staff have knowledge and awareness of the duty of candour principles.
• Review and update, as appropriate, risk assessments and guidelines for lasers and ensure staff are competent to use them.
• Ensure staff have the correct training and implement formalised systems to monitor and record staff training information for paediatrics within the theatre department.
• Improve the availability and storage of medical records.
• Work to reduce the number of operations cancelled due to theatre cancellations.
• Develop a strategy for services for children and young people and consider how reporting about plans, priorities and the quality and safety of the service could be improved.
• Improve the uptake of appraisals and ensure all staff are aware of their responsibilities in relation to the Mental Capacity Act 2005.
• Consider how documentary information and signage could be improved for people with visual impairment
• Ensure all staff are aware of the electronic flagging system for vulnerable patients, such as those living with dementia or a learning disability in the outpatients department.
• Ensure that the environment of the outpatient department is routinely monitored and appropriate actions are taken to ensure patient safety, comfort and welfare.
• Ensure emergency buzzers are available in radiology.

Professor Sir Mike Richards

Chief Inspector of Hospitals