The Care Quality Commission
  • Hospital
  • Independent hospital

Leicestershire Consultant Eye Surgeons LLP @ The Stoneygate Eye Hospital Also known as CESP

Overall: Good read more about inspection ratings

The Stoneygate Eye Hospital, 376 London Road, Leicester, Leicestershire, LE2 2PN (0116) 270 8033

Provided and run by:
Leicestershire Consultant Eye Surgeons LLP

All Inspections

09 January 2024

During a routine inspection

Our rating of this location improved. We rated it as good because:

  • The service had enough staff to care for patients and keep them safe. Most staff had training in key skills, understood how to protect patients from abuse, and managed safety well, although we saw gaps in safeguarding training for 5 staff who’s training had expired. Staff were aware of how to report safeguarding concerns and the provider was arranging training. The service generally controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. The service managed safety incidents well and learned lessons from them.
  • Staff provided good care and treatment, gave patients enough to eat and drink and gave them pain relief when they needed it. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of patients, supported them to make decisions about their care, and had access to good information. Services were available 7 days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them to understand their conditions. They provided emotional support to patients, families and carers.
  • 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.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. 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 well with patients and the community to plan and manage services and all staff were committed to improving services continually.

However:

  • We found medicines in open cupboards in the laser room. Although the laser room had a keypad lock on the door, all staff had access to this room, therefore medicines were not stored securely and safely. There were medicines in plastic boxes for consultant clinics left on a worktop in the laser room, these were also not stored safely. Medicines were stored in the main storeroom in a locked cupboard, we found boxes of medicines on top of the locked cupboard as there was no room to store them, they were not stored safely, and all staff had access.
  • The store person was responsible for ordering and receiving drug deliveries and storage. The provider was not able to demonstrate the member of staff had been given appropriate training for this role.
  • Although the private prescription pads were stored in a locked cupboard and audits carried out on usage they were accessible for all staff and therefore not as secure as required.
  • There was carpet in the room that was used as a waiting area, recovery area and, discharge area for patients. This prevents effective cleaning and infection prevention and control and does not meet buildings guidance.
  • Policies were updated by individuals, but it was unclear if these were reviewed and approved by managers or at a governance meeting.
  • Some staff training was out of date and did not meet the providers target of 95% for safeguarding adults level 3.

5th and 6th September 2017

During a routine inspection

Stoneygate Eye Hospital is operated by Leicestershire Consultant Eye Surgeons Limited Liability Partnership (LLP).

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection between 5 and 6 September 2017, along with an unannounced visit on 19 September 2017.

The hospital provides surgery, services for children and young people, and outpatient clinics. We inspected surgery, outpatients and services for children and young people. The main service is surgery. Following our visit in September 2017 it ceased offering children’s services in outpatients and surgery and we have not rated this service due to the very low numbers of children treated, and insufficient evidence.

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 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.

We rated this hospital as requires improvement overall.

We found the following issues that the service provider needs to improve:

  • Managers did not share learning from incidents with all staff.
  • Staff did not always ensure medicines and eye drops were stored securely.
  • Staff did not always ensure patient records were stored securely for example, leaving records on desks in open consulting rooms.
  • Four out of five patient records we reviewed in outpatients were either not legible, signed, or dated in line with general medical council (GMC) standards
  • The service did not monitor the effectiveness of pain relief or document levels of pain in patient records.
  • Despite using patient outcome forms the hospital did not audit them to measure clinical effectiveness.
  • Managers did not use competency frameworks to assess staff competency in undertaking their duties.
  • Nursing staff did not receive regular one to one meetings or team meetings which meant there was no ongoing formal support process for them.
  • Patients sometimes experienced long waits once they had arrived in clinic to see a consultant or for their treatment.
  • Outpatient services did not have written materials available in other languages for patients whose first language was not English. This included pre-appointment information.
  • The hospital had a vision but no medium to long term strategy plan with clear aims and objectives. There were no strategic plans to support the development of quality, safety or performance.
  • The hospital did not have fully developed arrangements to manage risk or performance, and lacked quality, safety or performance dashboard for the full range of its activities
  • Policies were not tailored to the needs of the hospital
  • Management resources were stretched

We found the following areas of good practice:

  • Clinicians recorded and analysed any clinical or non-clinical incidents and learned from them. Clinicians acted in line with the duty of candour
  • Track record of incidents and infection control compared with similar organisations
  • Theatres, diagnostic rooms and consulting rooms were visibly clean and well equipped
  • Theatres were staffed with nurses and support staff in line with good practice
  • Clinicians assessed patient risks before operations and theatre teams used the World Health Organisation (WHO) Surgical Safety Checklist for Cataract Surgery, and five steps to safer surgery checklist
  • Appropriate emergency back up arrangements were in place
  • Surgery was based on national guidance and conducted clinical audits. Clinicians kept upto date with best practice.
  • Technology was used to monitor patient’s conditions accurately so that clinicians could give the best advice possible
  • The service contributed to the Royal College of Ophthalmology expected outcomes audit on cataracts and its results were better than the national average for acuity, with a low complication rates.
  • Patients we spoke with found the staff to be reassuring and compassionate and we observed this during operations
  • After patients had an operation, nurses explained to them in a very understandable way how they could self-care.
  • Patients had a choice of clinic and surgery times including evenings
  • Consultants used an interactive display screen which covered a range of languages, to illustrate and explain procedures to patients
  • Patients did not have to wait very long for NHS cataract surgery – when we inspected they were waiting approximately nine weeks from referral to surgery
  • The service responded to patient views. They installed a larger waiting area, different seating and alternative refreshments in response to patient feedback.
  • The hospital had a track record of technical and clinical innovation.

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 three requirement notice(s) that affected outpatients and surgery. Details are at the end of the report.

Heidi Smoult

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Deputy Chief Inspector of Hospitals (Central)