Moorfields Eye Hospital NHS Foundation Trust
Evidence appendix 162 City Road Date of inspection visit: London 14 November to 6 December 2018 EC1V 2PD Date of publication: Tel: 12 March 2019 https://www.moorfields.nhs.uk
This evidence appendix provides the supporting evidence that enabled us to come to our judgements of the quality of service provided by this trust. It is based on a combination of information provided to us by the trust, nationally available data, what we found when we inspected, and information given to us from patients, the public and other organisations. For a summary of our inspection findings, see the inspection report for this trust.
Facts and data about this trust
Moorfields is the largest ophthalmic centre in Europe and the largest research academic teaching provider in the world. The trust operates from 31 sites and provides secondary care services to local populations as well as tertiary services to London and the South East of England. It also provides some national services, such as ocular oncology. In addition to its NHS work the trust has private facilities in two locations as well as three commercial facilities in UAE which are regulated by the local health system.
The trust has a tripartite mission of providing excellent clinical care, research and education.
Clinical care The trust measures and audits its core outcome for all specialties. These results show that outcomes are excellent compared to other NHS trusts, and in some specialties the best outcomes internationally. The trust has established a service improvement team to support frontline staff in improving services for patients.
Research The trust is a Biomedical Research Centre and Clinical Research Facility and is regarded as the top academic ophthalmic research unit in the world. Pioneering stem cell research is helping people with sight loss gain vision. The trust has a research collaboration which will allow artificial Page 1 intelligence to support diagnosis of key eye disease allowing detection sooner and improvement patient management.
Education Moorfields is a teaching and learning organisation with 50% of ophthalmic consultants in the UK having had an element of their training at Moorfields. There is an alumni day for medical, nursing and other allied health professionals which is a learning event open to external ophthalmology specialists to learn.
(Source: Acute Routine Provider Information Return- Context acute)
Acute hospital sites at the trust
A list of the acute hospitals at the trust is below.
Name of acute hospital site Address
162 City Road Moorfields Eye Hospital (City Road Campus) London EC1V 2PD
Kimbolton Road, Moorfields Community Eye Clinic at Bedford Hospital Bedford, (North) MK40 2AW
Kempston Road, Moorfields Eye Centre at Bedford Hospital (South) Bedford, MK42 9DJ 530 London Road, Thornton Heath, Moorfields Eye Centre at Croydon University Hospital Surrey, CR7 7YE Darenth Wood Road, Dartford, Moorfields Eye Unit at Darent Valley Hospital Kent, DA2 8DA Uxbridge Road, Southall, Moorfields Eye Centre at Ealing Hospital Middlesex, UB1 3HW Bancroft Road, Mile End, Moorfields Eye Unit at Mile End London, E1 4DG Watford Road, Harrow, Moorfields Eye Centre at Northwick Park Hospital Middlesex, HA1 3UJ
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Barnet Road, Potters Bar, Moorfields Eye Unit at Potters Bar Community Hospital Hertfordshire, EN6 2RY Roehampton Lane, Moorfields Eye Unit at Queen Mary's Hospital (community Roehampton, hospital) London, SW15 5PN St Ann's Road, Moorfields Eye Unit at St Ann's Hospital Tottenham, N15 3TH London Road, Cheam, Moorfields at St. Anthony’s Hospital Sutton, Surrey, SM3 9DW Blackshaw Road, Tooting, Moorfields Duke Elder Eye Unit at St George’s Hospital London, SW17 0QT
*There are also several community clinics and locations that provide ophthalmology services.
(Source: Routine Provider Information Return- Sites tab)
Since the last inspection the trust has restructured its NHS services into three divisions supported by an access directorate. The divisions are; Moorfields North division, Moorfields South division and Moorfields City Road division. Moorfields North division include Moorfields at Bedford, Moorfields East and Moorfields West. Moorfields South division includes Moorfields at St George’s and Moorfields South at Croydon. Moorfields City Road division compromises outpatients, surgery, a dedicated facility for children and young people and an emergency department. Most of the teaching and research activities are based at City Road.
The last comprehensive inspection of the trust was in May 2016, report published in January 2017, and we found some concerns in the surgery and outpatient services we inspected at Moorfields Eye Hospital (MEH) City Road, Bedford and Moorfields South at St George’s. As a result we took regulatory action, which included serving requirement notices. At this inspection we visited the same locations to follow up on progress against the actions and found improvements had been made.
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Is this organisation well-led?
Leadership
Board Members
Of the executive board members at the trust, 17.0% were Black Minority Ethnic (BME) and 33.0% were female.
Of the non-executive board members 14.0% were BME and 43.0% were female.
Staff group BME % Female %
Executive directors 17.0% 33.0%
Non-executive directors 14.0% 43.0%
All board members 15.0% 38.0%
(Source: Routine Provider Information Request (RPIR) – Board Diversity tab)
The trust had an established executive and non- executive team. The chief executive (CE) had been in post since April 2016. Following the 2016 inspection a new chair was appointed in September 2016 along with three new non-executive directors (2016/17). Two of the non-executive posts were newly created. The chair had been a non-executive director In other NHS trusts prior to joining the trust. The non-executive directors included an experienced foundation trust chairman, a commercial lawyer, a finance professional, an architect and clinicians.
The previous medical director had been in post for several years and had recently retired at the time of this inspection. A new medical director was appointed in June 2018 and had been working as a consultant at the trust. The director of workforce and organisational development had been in post since June 2018. The chief finance officer was appointed in August 2018 and had only been in post a few weeks during the inspection. However, he had previously worked at the trust, held the same position at two other NHS trusts and already had a good grasp of some of the potential financial challenges.
The chair of the audit & risk committee was an experienced finance professional whose career included senior treasury and financial management roles for a number of FTSE companies.
Non-executive directors joining the trust had an induction and were paired with an executive director. Board strategy and development days were also in place.
The board received an integrated performance report (IPR) highlighting a series of metrics regarded as the key indicators of trust performance. The report covered a variety of organisational activities within operations, quality and safety, workforce, finance, research, commercial and private patients.
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The IPR used a number of mechanisms to put performance into context, showing achievement against target, in comparison to previous periods and as a trend. Remedial action plans were included for areas of strategic objectives that are off-plan.
As at month six 2018/19 the trust delivered a surplus of £1.9m, £781k ahead of plan. The trust was forecasting to deliver a £6.7m surplus in 2018/19, in line with its plan.
At month six 2018/19 the trust had delivered £2.8m efficiencies year to date (planned £3.1m) and was forecasting £7.8m, in line with plan, for the full year. The planned level of efficiencies represented 3.4% of relevant operating expenditure.
Financial performance had been consistently strong with cash and revenue plans being delivered in line with plans in 2015/16, 2016/17, 2017/18 and 2018/19 year to date. In 2017/18 the trust delivered a surplus for reinvestment into their NHS services.
Leadership in the divisions had been strengthened since the last inspection and staff had oversight of their divisions’ performance and the quality and safety of care. The divisions were led by a divisional director (a clinician), divisional head of nursing and divisional manager. The design of the structure was intended to promote frontline clinical decision making and enabled senior staff to have more time to have oversight of their divisions’ performance and the quality and safety of care.
Each of the three divisions were supported by a range of corporate services covering quality and safety, human resources, governance, strategy and business development and finance. The newly established access directorate was responsible for business continuity and included, along with others, the booking centre and admissions department.
During the core service inspection staff spoke positively about their local managers, divisional leads and the restructure.
The trust had leads for safeguarding children and adults. The director of nursing and allied health professions (AHPS) was the infection prevention and control (IPC) executive lead and was supported by a lead (IPC) matron.
Care and treatment for patients with mental health needs were in development.
Medicines optimisation within the trust were well led. The chief pharmacist had been in post for over a year and was in the process of defining medicines optimisation in house with regards to being a specialist hospital and tailoring the local sustainable and transformation plan (STP) for the trust
During interviews with a range of executive and non-executive directors we heard a consistent message about collective responsibility with appropriate challenge between executive and non- executive directors. They were all aware of the strengths of the trust and the challenges it faced. It was clear from interviews that there was a real drive for improvement led by chair and chief executive.
An external review of the trust in August 2017 found the changes at board level were ‘positive’ and had enhanced the ‘rigour and discipline’ along with the cohesion and quality of debate at trust
Page 5 board and committee meetings. This reflected our findings during the inspection.
Senior managers, clinicians, executives and non-executives we spoke with were positive about the changes and how they would help the trust move forward.
Vision and strategy The trust had published a five-year strategy covering the period 2017 – 2022, building on its original ‘Vision of Excellence’ published in 2012.
The strategy set out four ambitions: 1. We will pioneer patient-centred care with exceptional clinical outcomes and excellent patient experience. 2. We will be at the leading edge of research, making new discoveries with our partners and patients. 3. We will innovate by sharing our knowledge and developing tomorrow’s experts. 4. We will collaborate to shape national policy.
Four enablers were identified: 1. We will attract, retain and develop great people 2. We will have an infrastructure and culture that supports innovation 3. We will have a sustainable financial model 4. We will be enterprising to support and fund our ambitions
Key measures had been identified for both the ambitions and enablers. The trust identified five strategic priorities for 2018/19: • New models of care • Service improvement • Project Oriel • Workforce planning • Commercial.
At quarter one 2018/19 the first three strategic priorities were rated by the trust as ‘Green’ with the last two rated ‘Amber’.
Underpinning the trust’s overarching strategy was the quality strategy, ‘Our journey to excellence’ 2017-2022. The strategy was developed in consultation with patients, staff and external stakeholders such as The Royal National Institute of Blind People and The Royal College of Ophthalmologists. It outlined the approach the trust would take and its key aims. The key aims included enabling people to feel they could make a difference, working with patients as partners, becoming a learning organisation, creating a quality governance framework and improving patient pathways. Fit for purpose estate and use of technological developments were also part of the strategy.
The strategies reflected the trust’s core belief that ‘Peoples sight matters’ and the importance of collaborating with patients, staff and partners to develop the best eye care.
The trust had a joint education strategy with University College London Institute of Ophthalmology. It included seven strategic principles and actions to track and measure progress. Page 6
The nursing strategy, ‘Focussing on the future’ (2018-2022) had been reviewed in light of the trusts’ strategy and the nursing workforce project. Nursing staff had been involved in the development of the strategy which had three key objectives covering careers, education and culture.
The trust had a draft workforce strategy which focussed on three areas capacity and capability, leadership, staff engagement and improving value. The strategy would support the trust in achieving its vision.
Following the 2016 inspection the trust had developed a strategy for children and young people which were informed by national guidance.
In addition to the strategies the trust had a comprehensive operation plan for 2018/19.
Culture
Staff Diversity
Within the trust’s Focus on Inclusion report it was reported that Moorfields Eye Hospital NHS Foundation Trust employed 2,102 people, of which:
• 68% are women
• 78% are aged between 25 and 54, and 19% are aged over 55.
• Across the trust 51% of staff were from Black Minority and Ethnic Communities.
• 1% of staff have disclosed that they consider themselves to have a disability, 94% of staff have told us they don’t consider themselves to have a disability with the remainder either unknown or have chosen not to disclose
• 52% of staff have disclosed as Heterosexual and 1% as Lesbian, Gay or Bisexual with the remainder unknown or chose not to disclose.
• 32% of staff considers themselves Christian, 5% as Atheists and 3% choosing to define their religion as ‘Other’
• 47% chose not to disclose their religion or belief
(Source: Moorfields Eye Hospital- Focus on Inclusion 2018)
The trust provided the following breakdowns of medical and dental and nursing and midwifery staff by Ethnic group.
Medical and dental Qualified nursing Ethnic group staff (%) staff (%) White 45.2% 28.5% BME 45.2% 64.9%
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Unknown / Not Stated 9.6% 6.6%
(Source: Routine Provider Information Request (RPIR) – Diversity tab)
NHS Staff Survey 2017 – results better than average of acute specialist trusts
The trust has 19 key findings that exceeded the average for acute specialist trusts in the 2017 NHS Staff Survey:
Key Finding Trust Score National Average
Appraisals & support for development
KF12. Quality of appraisals 3.45 3.16 KF13. Quality of non-mandatory training, learning or 4.12 4.08 development Errors & incidents *KF28. % witnessing potentially harmful errors, near 25 27 misses or incidents in last month KF30. Fairness and effectiveness of procedures for 3.91 3.80 reporting errors, near misses and incidents KF31. Staff confidence and security in reporting unsafe 3.87 3.71 clinical practice Health and wellbeing *KF17. % feeling unwell due to work related stress in 33 35 last 12 months *KF18. % attending work in last 3 months despite feeling 48 50 unwell because they felt pressure KF19. Org and management interest in and action on 3.82 3.73 health and wellbeing Working patterns *KF16. % working extra hours 70 75
Job satisfaction KF4. Staff motivation at work 4.08 3.94 KF8. Staff satisfaction with level of responsibility and 3.97 3.93 involvement KF14. Staff satisfaction with resourcing and support 3.55 3.41
Managers KF5. Recognition and value of staff by managers and 3.62 3.53 the organisation Page 8
KF6. % reporting good communication between senior 43 35 management and staff KF10. Support from immediate managers 3.90 3.81
Patient care & experience KF2. Staff satisfaction with the quality of work and care 4.23 4.02 they are able to deliver KF3. % agreeing that their role makes a difference to 93 91 patients / service users KF32. Effective use of patient / service user feedback 3.89 3.83
Violence, harassment & bullying *KF22. % experiencing physical violence from patients, 4 7 relatives or the public in last 12 months
*Lower scores are better NHS Staff Survey 2017 – results worse than average of acute specialist trusts
The trust has five key findings worse than the average for acute specialist trusts in the 2017 NHS Staff Survey:
Key Finding Trust Score National Average
Equality and diversity *KF20. % experiencing discrimination at work in last 12 16 9 months KF21. % believing the organisation provides equal 80 88 opportunities for career progression / promotion Violence, harassment & bullying *KF23. % experiencing physical violence from staff in 2 1 last 12 months *KF25. % experiencing harassment, bullying or abuse 25 21 from patients, relatives or the public in last 12 months *KF26. % experiencing harassment, bullying or abuse 29 23 from staff in last 12 months
*Lower scores are better
(Source: NHS Staff Survey 2017- link)
The findings of the staff survey were generally reflective of what we found during the inspection. Staff were happy and proud to work for the trust. The exception to this was staff experiencing bullying and harassment and violence; staff did not raise this as an issue with us. The trust believed that higher incidents of bullying and harassment from patients and visitors was likely to occur in walk in accident and emergency services
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The trust provided us with a revised action plan following the 2017 staff survey. We could see in May 2018, that the trust had introduced a new approach to challenge poor behaviour, the ‘Bullying and Harassment resolution Pathway’ and staff had access to leadership development programmes. The trust had also commissioned further analysis of staff group variation of staff experience by site and professional group
Workforce race equality standard
The scores presented below are the un-weighted question level score for question Q17b and un- weighted scores for Key Findings 25, 26, and 21, split between white and black and minority ethnic (BME) staff, as required for the Workforce Race Equality Standard.
Note that for question 17b, the percentage featured is that of “Yes” responses to the question. Key Finding and question numbers have changed since 2014.
To preserve the anonymity of individual staff, a score is replaced with a dash if the staff group in question contributed fewer than 11 responses to that score.
Of the four questions above, the following two questions showed a statistically significant difference in score between white and BME staff:
• KF21. Percentage of staff believing that the trust provides equal opportunities for career progression or promotion • Q17b. In the last 12 months have you personally experienced discrimination at work from a manager / team leader or other colleagues?
(Source: NHS Staff Survey 2017- link)
An external review, March 2018, of the trust’s equality and diversity (E&D) processes provided a rating of amber-green. This meant there was ‘significant assurance with minor improvements’. The review covered the general and specific requirements outlined in the Public Sector Equality Duty Page 10
(PSED) and the requirements set out by NHS England to complete the Equality Delivery System (EDS2).
Areas of good practice included the trust having a policy and compliance with NHS England requirements to complete and publish the Equality Delivery System (EDS2). The trust had a strategy for inclusion and objectives for equality and diversity for the next four years.
Areas for improvement included the trust having a clear framework for reporting on equality and diversity and progress against equality and diversity action plans. The trust had developed an action plan in response to the audit.
The Director of Work Force was the executive lead for E&D. The latest update, August 2018, on the trust’s WRES action plan showed that work was being progressed but, some actions had not been taken forward due to resource issues. Since the last inspection the trust had established three staff networks, MoorAbility (staff with a disability), BeMoor (BAME staff) and MoorPride (LGBT staff). Of these MoorAbility was the longest established network and MoorPride the most recent. Feedback from staff about the networks indicated that although the networks were still evolving the trust was supportive and had recognised concerns that had been raised by staff in relation to equality and diversity. It was putting effective structures in place for it to become a more inclusive organisation. They were able to provide us with information about improvements in staff experience. For example the percentage of BAME staff entering disciplinary procedure: used to be 2.56% likely and was down to 01.6% in 2018. Some areas, such as a higher percentage of white people being shortlisted for interviews, were a work in progress with plans in development. From the information provided by the trust and through interviews with staff it was clear the trust was committed to being an inclusive organisation and saw it as integral to the success of the trust.
Prior to the inspection the trust had revised its process for Freedom to speak up. Initially the Freedom to speak up guardians (FTSUG) were executive and non-executive directors at the trust. The trust found the system was not effective and carried out discussions with various staff groups and the executive team. Some of the problems identified included accessibility of the FTSUG. The trust reviewed the speak up/whistleblowing policy and asked staff to volunteer to become FTSUGs. At the time of the inspection the trust had five FTSUGs from different staff groups: medical, nursing, optometry and management. It was intended that the FTSUGs would have external supervision to support their development and one of them would take the lead for organising meetings and drafting reports. All of the FTSUGs had attended the national training and support was provided by the director of workforce and organisational development, director of quality and safety and company secretary. They would meet with the chair and chief executive on a monthly basis to review themes arising. The FTSUGs told us that staff were beginning to recognise them and raise concerns with them and they believed the culture in the trust enabled staff to do this.
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Friends and Family test
The Friends and Family Test was launched in April 2013. It asks people who use services whether they would recommend the services they have used, giving the opportunity to feedback on their experiences of care and treatment.
The trust scored above the England average for recommending the trust as a place to receive care from September 2017 to August 2018.
(Source: Friends and Family Test)
General Medical Council – National Training Scheme Survey
In the 2018 General Medical Council Survey the trusts scores were in the middle 50% of all scores for all 18 questions in the survey.
(Source: General Medical Council National Training Scheme Survey)
The trust had a Guardian of safe working hours (GSWH). The role had three objectives; • Oversight of the exception system. • Being visible to and listening to trainees. • Ensuring systems were in place to promote safety and quality for patients, with patient care being the ultimate goal.
The GSWH was clear that exception reports were not about blame but, a safeguarding exercise. Working hours had to be observed and that it should not be down to trainees to ask if they could leave, consultants were responsible to tell them they could leave when their shift had finished.
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Trainee doctors were informed about exception reporting when they joined the trust and this was followed by a discussion with GSWH two months later.
Exception reports were reviewed at the trust board every six months. The most recent were 15 from Moorfields South at St George’s. These had been followed up and there were now more staff on the rota.
The trust had quarterly junior doctors meeting which were generally well attended as they were held on a study day.
During the core service inspection staff told us they felt able to raise concerns and that the trust was open to hearing their opinions and ideas for improvement.
The medical director was the named lead for duty of candour and the trust had a duty of candour policy. We reviewed the investigations of five serious incidents and found the duty of candour policy had been followed.
Since the last inspection the trust had introduced Schwartz rounds. These were support sessions for staff who have had to manage difficult and stressful challenging situations.
Governance
Board Assurance Framework
The trust had identified eight objectives: four are ambitions that represent the impact the trust aims to have and four are enablers that represent what the trust believes it needs to do to achieve its ambitions.
Ambitions
• We will pioneer patient-centred care with exceptional clinical outcomes and excellent patient experience • We will be at the leading edge of research, making new discoveries with our partners and patients • We will innovate by sharing our knowledge and developing tomorrow’s experts • We will collaborate to shape national policy
Enablers
• We will attract, retain and develop great people • We will have an infrastructure and culture that supports innovation • We are able to deliver a sustainable financial model • We will be enterprising to support and fund our ambitions
The trust provided their Board Assurance Framework, which details eight risks that may have an adverse affect on the trust achieving their strategic objectives. A summary of these is below.
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CQC Like- Risk Target Risk description Impact Domain link lihood Score Score
Effective, Tariff 12 (4x3) Well Led If there are central changes to the tariff Impact and Financial and market forces factor which have a likelihood disproportionate impact on MEH as a can both single specialty trust then this will have be 5 3 15 a significant adverse impact on the mitigated long term financial viability of the through organisation. new models of care Effective, Project Oriel 10 (5x2) Well Led If the key assumptions behind Project Impact will Infrastructure Oriel are not achieved then there may always be be insufficient capital and resources 5 3 15 high, available leading to a failure to deliver likelihood the project objectives and a significant can be reputational risk to the trust. mitigated Effective, Commercial growth Responsive, If the growth in commercial activities is 8 (4X2) Well Led not to plan then there will not be Will be Enterprise sufficient revenue generated leading to able to pressure on trust finances elsewhere 5 3 15 mitigate and a lack of ability to effectively the impact compete in the market and provide and high quality services to scale. likelihood
All domains CQC Compliance Care If the trust fails to comply with the CQC 8 (4x2) fundamental standards and if actions Robust arising from the CQC visit are not planning implemented at sufficient pace then will allow clinical standards may not be met 5 3 15 the trust to leading to significant patient harm, mitigate deterioration in patient outcomes, a the impact failure to maintain a CQC rating of and 'good' and a serious reputational risk to likelihood the trust. Effective, Commissioner turbulence 8 (4x2) Well Led If there is continued or increased Impact and Financial turbulence in the commissioning likelihood landscape then this will lead to 5 3 15 can both increasing pressure on services, more be notices of termination and tendering of mitigated services leading to loss of contracts
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and income, a significant impact on staff and serious reputational risk.
Responsive, Staff engagement 6 (3x2) Well Led If engagement with staff is ineffective Both and inconsistent then they will have a impact and lack of confidence in the organisation likelihood leading to poor staff retention and can be morale, deterioration in the quality of mitigated 4 3 12 patient care and a risk to the trust's with reputation as an employer of choice. improved engageme nt and communic ation Safe, Workforce planning 9 (3x3) Responsive, If the trust does not have a robust Currently Well Led workforce plan in place then there will the largest Workforce be staff shortages and skill gaps risk facing leading to insufficient numbers of staff the NHS, available in key areas and a some 4 3 12 subsequent impact on the quality of mitigation patient care, pressure on staff, staff can be and financial planning. done but facing national problems Safe, Learning the lessons 8 (4x2) Responsive, If the trust fails to identify or address Both Well Led poor clinical practice then there could consequen be multiple serious incidents leading to ce and significant patient harm, regulatory likelihood intervention or damage to reputation. can be 5 2 10 mitigated but always need to factor in human error
(Source: Trust Board Assurance Framework)
There were six sub-committees of the board; quality and safety, audit and risk, remuneration and nominations, finance, strategy and commercial, capital scrutiny and people. There was also the
Page 15 trust management executive (TME). The TME was where the divisions reported into about their performance and quality and safety.
The six sub-committees were all chaired by the CE, chair or a NED. The chair of the finance committee was also the chair of the audit and risk committee. We discussed this potential conflict of interest and were told that the chair was aware and although they would have preferred for another director to chair one of the committees until that happened felt the NED was the best person to chair both of them. The principal duties of the sub-committees were clear and relevant.
The trust had adults and children safeguarding committees which were chaired by the director of nursing and AHPs who was the executive lead for safeguarding. Both committees met bi-monthly. Membership of the committee included heads of nursing, the safeguarding team and the lead clinical commissioning group designated nurse. The committees reported to the trust board through the clinical governance committee and quality and safety committee. Initially we were concerned about the low level of safeguarding referrals made, however following a discussion with the director of nursing and AHPs and safeguarding leads we were more reassured. As a tertiary referral centre many of the children and adults seen at the trust may already be known to social services and they are already involved in their care. The referring service would have already made the referral and if there was any doubt the trust’s safeguarding team followed it up with the relevant local authority.
The trust had two data sets for safeguarding. One captured referrals regarding care and support needs and the other captured referrals regarding potential abuse or neglect. The way the trust captured data allowed for more in depth analysis of activity and provided comprehensive assurance to the safeguarding committee.
The 2017/18 annual safeguarding report assured the trust board that the Child Protection Information Sharing (CP-IS) project had been implemented. CP-IS enables clinicians in unscheduled care setting to identify vulnerable children. During the inspection staff told us that the system was not working due to IT problems and they had been waiting three months for the problems to be resolved. The director of nursing and AHPs and the CE told us that the system was in place but, that work was underway to fully embed it by February 2019.
In terms of medicines management the chief pharmacist reported to the medical director for medicine management issues and to the director of clinical support for all other issues. The trust had a medicines safety group (MSG chaired by Medicines Safety Officer) and a Non-Medical Supply of Meds Group. Both of these fed into the drugs and therapeutics medicines management Group (DTMMC) chaired by a consultant with quarterly meetings. The trust had its own pharmacy teams at three of the host sites and service levels agreements with the others which also included a third party contractor. Systems for monitoring incidents and key performance indicators were standard across all sites.
As an NHS foundation trust the trust had a membership council. The trust had over 20,000 members. The membership council was made up of elected and nominated members, known as governors, from staff, patients and people who lived in the communities it served. We met with six of the governors. They had either worked at the trust or been a patient and some of them lived outside of London. As part of their governance arrangements they had a code of conduct. The governors told us there was a real commitment from the trust to engage with them and hear their views and ideas and they were involved in developing the strategy. They carried out visits to
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In the core service inspections we found there were effective governance systems which staff could describe to us. The trust had introduced half day clinical governance study days for all staff to attend. They covered updates from the CE and improvements, innovations, learning from incidents and staff also had the opportunity to ask questions.
The trust external auditor’s final report to the audit committee for the year ended 31 March 2018, did not identify any significant issues with the trust’s internal control processes.
Management of risk, issues and performance
Finances Overview
Historical data Projections Previous Last Financial This Financial Next Financial Financial metrics Financial Year Year (2017/18) Year (2018/19) Year (2019/20) (2016/17) Income £222.0m £221.9m £222.2m £228.5m
Surplus (deficit) £2.6m £5.7m £1.3m £1.4m
Full Costs £219.4m £216.1m £220.9m £227.1m Budget (or budget £2.0m (£0.2m) £1.3m £1.4m deficit)
(Source: Routine Provider Information Request (RPIR) – Finances Overview tab)
Trust corporate risk register
The trust provided a document detailing their 19 highest profile risks. Each of these have a current risk score of 12 or higher.
Risk Risk Risk Last Risk Description Ref score score review IF the growth in commercial activities is not to plan THEN there will not be sufficient revenue generated 1 Aug 1 LEADING TO pressure on trust finances elsewhere, 15 8 2018 regulatory impact and a deterioration in the trust's cash position. IF the key assumptions behind Project Oriel are not achieved THEN there may be insufficient capital (human, financial etc.) 1 Aug 2 15 8 available 2018 LEADING TO failure to deliver the project objectives
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If the trust fails to comply with the CQC fundamental standards and if actions arising from the CQC visit are not implemented at sufficient pace then clinical standards may 1 Aug 3 15 8 not be met leading to significant patient harm, deterioration in 2018 patient outcomes, a failure to maintain a CQC rating of 'good' and a serious reputational risk to the trust. If there are central changes to the tariff and market forces factor which have a disproportionate impact on MEH as a 1 Aug 4 15 12 single specialty trust then this will have a significant adverse 2018 impact on the long term financial viability of the organisation. If there is continued or increased turbulence in the commissioning landscape then this will lead to increasing 1 Aug 5 pressure on services, more notices of termination and 15 8 2018 tendering of services leading to loss of contracts and income, a significant impact on staff and serious reputational risk. If the trust does not have in place a robust plan for recruitment and retention then there may be staff shortages and skill gaps leading to insufficient numbers of staff available 1 Aug 6 12 6 in key areas and a subsequent impact on quality of care, risk 2018 of patient harm, adverse impact on staff morale and an increase in agency spend If engagement with staff is ineffective and inconsistent then they will have a lack of confidence in the organisation's 1 Aug 7 approach to workforce issues leading to poor staff retention 12 8 2018 and morale, deterioration in the quality of patient care and a risk to the trust's reputation as an employer of choice. IF there is a major IT failure THEN access to the trusts IT systems could be disrupted 1 Aug 9 12 6 LEADING TO poor patient care, a reduction in income or 2018 damage to the trust's reputation IF there is poor environment, practices or behaviour THEN outpatient clinics may not be managed effectively 1 Aug 10 12 9 LEADING to poor patient experience, low staff morale or 2018 damage to reputation IF data quality is poor THEN this could reduce the ability of the trust to manage its 1 Aug 11 activities 12 6 2018 LEADING TO poor patient care, a reduction in income or damage to the trust's reputation IF a financial surplus at the required level is not maintained THEN there may be a shortage of available funds 1 Aug 12 LEADING TO a reduction in or cancellation of major capital 12 10 2018 projects (e.g. Oriel), regulatory intervention or cash flow issues IF policies and standards are not consistent across the 1 Aug 13 network 12 9 2018 THEN operating models and service quality may vary
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LEADING TO poor patient care, a reduction in income or damage to the trust's reputation
IF service level agreements across the network are not in place or properly managed 1 Aug 14 THEN service standards may be inconsistent 12 8 2018 LEADING TO poor patient care, a reduction in income or damage to the trust's reputation IF there are no written safeguarding arrangements between Moorfields and the local safeguarding teams. 1 Aug 15 THEN there may be inconsistency across the network 12 6 2018 LEADING TO poor patient care, reputational damage and potential regulatory intervention If the trust is unable to provide an adequate level of assurance to comply with the General Data Protections by 1 Aug 16 May 2018 then this cause information governance breaches 12 6 2018 leading to regulatory intervention, considerable fines, reputational risk and improper use of personal data. If the issues relating to ventilation in Moorfields North theatres are not addressed then this will cause infection control and 1 Aug 17 capacity issues leading to a reduction in the quality of patient 12 6 2018 care, patient harm, inability to work to full capacity and an impact on trust income. If the trust fails to achieve cost improvement targets then this leads to pressure on budgets affecting staff morale and 1 Aug 18 12 8 patient care, inviting increased scrutiny from regulators and 2018 commissioners If there is deterioration in patient and carer experience then this will lead to patients choosing to be treated elsewhere and 1 Aug 19 12 6 a significant reputational risk to the trust plus a corresponding 2018 loss of income. There is also potential for patient harm. If there is not sufficient mental health liaison in place then patients who present in crisis with acute and severe mental 1 Aug 20 12 4 health problems will not be supported to access appropriate 2018 mental health services and could harm themselves or others
(Source: Trust Corporate Risk Register – August 2018)
The audit & risk committee reviewed the board assurance framework (BAF) on a quarterly basis and the board received a bi-annual highlight report.
The BAF described risks to delivering the strategy, alongside plans to mitigate those risks. The BAF covered potential external risks to finances (tariff changes and commissioner turbulence) as well as internal risks.
The format of the trust BAF was under review and in future would include a separate template for each of the eight risks, allowing a more detailed analysis of each risk including mitigating actions, trends and executive commentary.
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During the inspection executive and no-executive directors were well sighted on the key risks for the trust.
The trust was fully aware that the estate/infrastructure, at its own sites and host sites, needed to be improved and would require significant investment. Project Oriel was the trust’s proposal to relocate all services from Moorfields Eye Hospital City Road to a new site, bringing together clinical care, research and education expertise in one flexible, fully integrated facility. This project had been discussed and documented for several years but, the trust had secured funding for the proposal. Following the well-led inspection the trust announced the architect firm that had been appointed to design the new centre.
Concerns about the estate at Moorfields at St George’s had been identified at the 2016 inspection. The trust was in the process of upgrading them and we saw improvements at this inspection.
Workforce planning was a key risk for the trust and was rated amber/yellow on the corporate risk register. In June 2018 vacancies for nursing staff and allied health professionals was 16% against a trust target of 10%. The trust was aware of the locations/areas affected and had taken action. Discussions with executives with indicated they were looking at how they could develop their own staff and the trust had a recruitment programme. The workforce strategy was in the final stages of approval at the time of the inspection. Consultant job planning was being progressed but, had yet to be completed.
For medicines management, risks included prescribing and dispensing for the wrong eye. This was a problem because the IT system defaulted to the previous version of patient details, therefore the risk of needing to manually input eye details each time. This was being mitigated by dispensing screening the information and an upgrade to the IT system to solve the issue.
In most of the services we inspected we found comprehensive up to date risk registers that reflected the specific risks for that service. For example at Moorfields at St George’s lack of space for administrative staff and overcrowded clinics were on the risk register with dates of when they had last been reviewed.
The trust had taken some action to mitigate risks to patients with mental health problems. It had developed a mental health crisis protocol and was developing a service level agreement (SLA) with a mental health trust to provide training for staff.
The trust had an emergency response policy and business continuity plans along with a building maintenance programme. Senior leaders received briefings from the emergency planning lead as required. An external review had rated the trust as good for emergency preparedness resilience and response (EPRR). Information management The board received holistic information on quality and sustainability. Board papers covered finance, quality, strategic and performance updates. Minutes of the audit committee, finance and performance committee and quality and clinical governance committee were shared with board attendees. The integrated performance report provided updates on key performance indicators and covered a range of organisational activities within operations, workforce, finance, quality and safety, Page 20 commercial and private patients and research. Remedial action plans for strategic objectives were part of the report and were rag rated. Each division had a divisional board and monthly performance reviews which covered quality and safety, workforce, finance and performance in all the locations/sites within the division. Within the divisions service speciality meetings were also held. The trust was aware of its performance and staff we interviewed, during both the core service and well-led inspection, were able to share with us specific information about their division’s performance and the quality and safety of care. The trust was improving how it collected data about cataract outcomes and complications and was introducing an electronic clinical audit system. Staff had access to the IT equipment and systems needed to do their work. There was a mixture of electronic and paper systems being used in the trust. The trust had implementation plans to roll out a new electronic medical record (EMR). The system would give staff real time access to patient records across all of the specialities.
The trust had introduced an e-rostering system that included a safe staffing tool.
From 1st August 2016 onwards, all organisations that provided NHS care and / or publicly-funded adult social care were legally required to follow the Accessible Information Standard (AIS). The standard sets out a specific, consistent approach to identifying, recording, flagging, sharing and meeting the information and communication support needs of patients, service users, carers and parents with a disability, impairment or sensory loss. To meet the standard the trust had an AIS project group supported by a patient forum that provided ideas and suggestions from a patient and carer perspective. In addition it had installed an e-learning package for staff and developed a system to identify patients who may require information in different formats.
Hospital passports to support patients living with a learning disability and cognitive impairment had been introduced and received praise from NHS England and Mencap.
Financial information provided to NHS Improvement had generally been consistent and reliable. Reporting of core financial information to the board was an appropriate balance in terms of actuals and projections, detail of costs and income categories, granularity of divisional information and links with operational drivers. A rolling 12-month cashflow was presented along with capital expenditure, better payment practice code performance and aged debt information. However, a full statement of financial position was not included in the finance report. Finance reports were the subject of discussion.
The board finance report included an underlying financial position, although this was the same as the overall financial position, and did not appear to reflect non-recurrent elements such as non- recurrent efficiencies. The finance report showed the ‘RAG’ status of efficiency schemes, although no definition was given for blue/green/amber/red status.
The trust had been working over the last 12 months towards implementing a costing system that complied with NHS Improvement’s costing transformation programme. The trust had appointed a new costing manager in January 2018 to deliver internal and external reports. The trust expected to be able to comply with the mandatory patient-level costing collection for designated acute providers in 2019.
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The medical director was the Caldicott Guardian. Information was available on the trust’s website for patients/carers telling them how information about them was collected, stored and used. It made reference to the Records Management Code of Practice for Health and Social Care 2016 and legislation related to protecting patient confidentiality. Engagement The trust had a patient participation strategy 2017-2022. The strategy outlined the key elements of patient participation; patient experience, patient engagement and patient involvement.
The trust engaged with patients/carers through the membership council and the AIS patient forum. It had also consulted with patients/carers about future plans by working with external organisations such as the Royal National Institute of Blind People (RNIB). However, the trust recognised that a more coherent structured approach was needed and hence the strategy. At the time of the inspection the trust was embedding the strategy. A governance structure and lines of accountability and assurance were approved by the trust board at its July 2018 meeting.
The trust used a range of mechanisms to engage with staff: communication systems such as the chief executive quarterly blog, intranet and newsletters were in place to ensure staff had access to up to date information, divisional service meetings/team meetings, governance study days and visits to sites/services.
The trust celebrated staff and volunteer achievements annually at the Moorfields stars awards. There were several awards for innovation, team of the year, star of the year, the patient choice award (individual and team) and volunteer of the year. In 2017 over 400 nominations were received, the highest number in the awards nine year history.
The trust had approximately 187 volunteers who were managed by the Friends of Moorfields charity. We met some of the volunteers, many were or had been patients, during the inspection and they told us they found the work rewarding and it gave them the opportunity to give something back to the trust.
Staff at all levels and across all groups were positive about how the CE and other members of the executive team engaged with them. We observed that the CE knew many of the staff across all groups by name.
In terms of external engagement, the trust had become more outward looking since the last inspection. Although it had always worked with external partners including other NHS trusts and clinical commissioning groups this had been strengthened and was more explicit at this inspection.
The trust worked very closely with University College of London Institute of Ophthalmology and they shared a joint director of education.
In 2014, Moorfields was one of 50 vanguards selected by NHS England to develop new care models as part of implementing the NHS Five Year Forward View. As part of this work the trust had developed a toolkit to help other organisations improve care and involve patients and carers to improve care.
The trust had led the establishment of the UK Ophthalmology Alliance, which brought together eye
Page 22 care professionals, patient groups and national ophthalmic bodies across the UK to improve efficiency and pathways, create quality standards, benchmark performance and provide support in areas where performance can be improved. The RNIB was closely involved in the work of the Alliance.
The trust worked closely with CCGs (Islington CCG was the lead for commissioning) and GPs and offered a professional development programme for GPs. The programme, delivered by consultant ophthalmologists, aimed to improve patient care and promote effective working relationships between trust and primary care professionals.
Two charities, Moorfields Eye Charity and Friends of Moorfields, supported the trust to achieve its key strategic aims: developing a world class integrated care and treatment centre and managing the trust’s volunteer programme.
The trust was an active member of the north central London sustainability and transformation plan (STP). A draft plan had been developed and was a work in progress while engagement with staff patients and other stakeholders taking place.
Learning, continuous improvement and innovation
The trust had systems to identify learning from incidents, complaints and safeguarding alerts to make improvements.
Complaints process overview
The trust was asked to comment on their targets for responding to complaints and current performance against these targets for the last 12 months.
Target Question In days performance What is your internal target for responding to complaints? 3 days 90% 25 working What is your target for completing a complaint 80% days If you have a slightly longer target for complex complaints 60 working 100% please indicate what that is here days Number of complaints resolved without formal process in the 1,684 - last 12 months?
(Source: Routine Provider Information Request (RPIR) – Complaints Process Overview tab)
Number of complaints made to the trust
The trust received 187 complaints from August 2017 to August 2018. Outpatient services received the most complaints with 108.
Number of Percentage of Core Service complaints total
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Outpatients 108 57.8% Surgery 29 15.5% Urgent and emergency care 26 13.9% Other 23 12.3% Diagnostics 1 0.5% Total 187 100.0%
(Source: Routine Provider Information Request (RPIR) – Complaints tab)
CQC received a low level of concerns from patients and staff. When we had received concerns the trust was able to provide information that reassured us that action was or had been taken to address the issue.
The complaints and patient advice and Liaison service (PALS) were based at City Road. Staff at other sites had information they could give to patients about how to contact them. If patients contacted the host site PALS service they were redirected to the Moorfields PALS.
The trust had a complaints policy which had been reviewed and updated at regular intervals. Along with the annual report information about complaints and concerns raised PALS information was reported six monthly to the quality and safety committee. Divisional teams received a weekly complaints summary and the outcome of all PALS enquiries and concerns along with social media feedback.
In 2017/18 the trust received slightly fewer complaints than in 2016/17 and a slightly higher number of concerns through the PALS. The percentage of patients who complained was low when compared with the number of patients receiving care; for 2017/18 it was 0.02%. Clinical care customer care, communication, waiting times and the environment were the main themes of complaints. Although the number of complaints about clinical care had decreased there had been a small increase in the number related to customer care.
The trust was meeting the standard for acknowledging complaints within three working days but did not always meet the 25 day standard for providing a response. In some instances this was due to how the complaint was managed within the division and not the complexity of the complaint. To help improve this, the 25 day standard was included into the monthly integrated performance report.
The trust had made improvements in response to complaints. For example there were repeated complaints from patients at Moorfields at St George’s who had experienced difficulty in getting through via the phone. The trust had taken some action to remedy the situation and was looking at how it could be further improved. In optometry a new process had been established to ensure that there was not a repetition of an issue where a complainant had received the wrong lens in their glasses.
The complaints team shared information with the risk and safety team and the safeguarding team to ensure that where appropriate they could be investigated as an incident. In 2017/18 eleven complaints were referred to the serious incident panel for review but, they were not categorised as serious incidents.
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We reviewed the records of five people who had made complaints. We saw that where a relative or carer had contacted the trust consent had been sought from the patient to provide a response. The responses showed that effective investigations had been undertaken to answer all of the issues raised.
The trust had systems for investigating and learning from serious incidents and deaths. The policy and procedure for reporting incidents and serious incidents had been reviewed and updated in August 2018. The trust’s serious incident reporting and management group was responsible for ensuring there was an effective process to review complaints, incidents, claims and concerns raised based on a clear criteria. The group was chaired by the clinical lead for quality and safety who was a consultant ophthalmologist and met weekly. Representatives from nursing, quality and safety team, IT, estates and facilities, service directors and managers along with others attended the meetings. The meeting held on the first week of each month reviewed actions and learning arising from incident reporting.
Given the nature of the care provided by the trust the number of reviews of deaths was low. We reviewed five serious incident reports and found that all of the families had been sent a copy of the report and a letter of apology with an offer to meet with them. The reports demonstrated a comprehensive analysis of the information and that potential safeguarding issues were considered.
There was reference, in the integrated performance report, to a delay in closing some incidents but the trust had taken action to reduce the number and minimise this happening.
The trust participated in the ‘Opening the door to change’: a report commissioned by the Secretary of State for Health and Social Care to look at issues in NHS trusts that contributed to Never Events taking place. The trust had experienced Never Events related to incorrect intraocular lens insertion. It had investigated each incident and instituted a series of actions to minimise the risk of it recurring. The trust had consulted with external organisations such as the Health Safety Investigation Branch (HSIB) and worked with them to find better ways to address the problem.
The trust was a founding member of the University College London Partners (UCLP) which is the largest academic health science partnership in Europe.
In partnership with University College London the trust had established The London Project to Cure Blindness. The aim of the project was to see if sight loss caused by wet age-related macular degeneration (AMD) could be improved by using a stem cell –based treatment. In March 2018 the clinical trial were published and showed that patients who had received the stem cell treatment had regained their reading vision.
The trust had received funding to trial a blood test that could be performed at home to pick the early signs of diabetic eye disease.
Since the last inspection the trust has introduced emergency endophthalmitis boxes at trust sites. The boxes contained medications to treat bacterial endophthalmitis.
The trust had received a national award from a health care journal for patient safety. They had received first prize for the quality of an investigation and multidisciplinary response to a unique situation. Page 25
The trust’s ophthalmic outcomes were evidenced to be among the best in the world: 96% (>80% national standard) of patients had visual stability after injections for macular degeneration and 98% of patients (>90% national standard) have a successful outcome 12 months after surgery for the eye condition keratoconus.
The trust’s optometrists in partnership with UCL Institute of Ophthalmology had developed the advanced clinical optometry suite of qualifications.
In partnership with the UK Ophthalmology Alliance (UKOA) and the Royal National Institute of Blind People (RNIB) the trust launched a pioneering set of national patient standards designed to improve care for eye clinic patients. The standards make clear the importance of patient support and state that all eye clinics should have an Eye Clinic Liaison Officer (ECLO) and adhere to the RNIB ECLO Quality Framework.
Compliments
From August 2017 to August 2018, the trust received a total of 299 compliments. A breakdown by core service can be seen in the table below:
Core service Number of compliments Percentage of total Outpatients 142 47.5% Trust wide 56 18.7% Surgery 45 15.1% Urgent and emergency care 42 14.0% Not specified 10 3.3% Other 4 1.3% Total 299 100.0%
The trust has commented that “the compliments that they receive focus on the standard of clinical care provided, with patient’s treatment meeting expectations and clinical outcomes being positive. Patients also compliment the care provided by individual members of staff, highlighting their kindness, professionalism and caring attitude which helps patients feel they are being treated personally. Many people comment that caring staff and the calm environment reduces their anxiety.”
Compliments are shared either in-person or via email with the staff member or teams who have received praise. Divisional leadership teams are provided with a summary of feedback on a weekly basis. The chief executive personally responds to compliments received in writing or via social media to thank patients for their feedback and passes on this gratitude to staff members to thank them for providing such excellent patient care.
(Source: Routine Provider Information Request (RPIR) – Compliments)
Accreditations
NHS trusts are able to participate in a number of accreditation schemes whereby the services they provide are reviewed and a decision is made whether or not to award the service with an
Page 26 accreditation. A service will be accredited if they are able to demonstrate that they meet a certain standard of best practice in the given area. An accreditation usually carries an end date (or review date) whereby the service will need to be re-assessed in order to continue to be accredited.
At the time of data collection, the trust did not participate in any listed national service accreditation or peer-review schemes.
(Source: Routine Provider Information Request (RPIR) – Accreditations tab)
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Moorfields at St George’s
Evidence appendix Blackshaw Road, Date of inspection visit: Tooting, 14 to 6 December 2018 London, SW17 0QT Date of publication: 12 March 2019 Tel : 020 8725 0297 www.moorfields.nhs.uk
Acute services
Outpatients
Facts and data about this service
Moorfields Eye Hospital NHS Foundation Trust provides outpatients services at Moorfields Eye Centre at St George’s Hospital. The outpatient department (OPD) provides adnexal, cataract, external disease, general ophthalmology, glaucoma, medical retina, neuro-ophthalmology and strabismus (squints), paediatrics and vitreo-retinal, optometry and orthoptic. The OPD was open from 8.00am to 6.00pm on a Monday, Wednesday. Thursday, Friday and Saturday, and from 8.00am to 8.00pm on a Tuesday. The department also ran regular glaucoma and medical retina clinics on a Saturday. The urgent care centre (UCC) operated a 24 hour service, 7 days a week, and is run in OPD 9.00 am to 9.00pm. After 9.00pm, the service is ran from the St George's Urgent Care Centre. Patients could access the urgent care clinic via a referral from their optician, GP or any A&E department. Only existing Moorfields patients could self-refer. Patients were triaged on arrival with the most urgent patients being seen first. These patients were offered an assessment and treatment on the same day as the clinic. We visited a range of clinics the OPD and the urgent care centre (UCC). We met with people who use services, who shared their views and experiences of the OPD service. We spoke with 10 patients and a relative who used the services and looked at 17 patient records. We observed how people were being cared for and talked with carers and/or family members and reviewed care or treatment records of people who use services. We spoke with 19 members of staff including doctors, nurses, technicians and administrative staff. We also spoke with the leadership team for Moorfields South division which includes Moorfields at St George’s and Moorfields at Croydon.
In addition, we reviewed national data and performance information about the trust and read a range of policies, procedures and other documents relating to the operation of the OPD and related services.
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The trust had 572,615 first and follow up outpatient appointments from June 2017 to May 2018. The graph below represents how this compares to other trusts.
Total number of first and follow up appointments compared to England
(Source: Hospital Episode Statistics - HES Outpatients)
The following table shows the number of outpatient appointments by site, a total for the trust and the total for England, from June 2017 to May 2018.
Number of appointments by site
Site Name Number of spells Moorfields Eye Hospital 361,314 Moorfields at St George's 72,206 Moorfields at Croydon University 52,607 Hospital Moorfields at Northwick Park 45,104 Moorfields at Ealing 38,773 This Trust 644,392 England 106,785,632
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(Source: Hospital Episode Statistics)
The chart below shows the percentage breakdown of the type of outpatient appointments from June 2017 to May 2018. The percentage of these appointments by type can be found in the chart below:
Number of appointments at Moorfields Eye Hospital NHS Foundation Trust from June 2017 to May 2018 by site and type of appointment.
(Source: Hospital Episode Statistics)
Is the service safe?
By safe, we mean people are protected from abuse* and avoidable harm. *Abuse can be physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse.
Mandatory training The service provided mandatory training in key skills to all staff. Nursing staff training compliance was monitored through an electronic system and discussed as part the outpatient departments (OPD) monthly clinical staff meeting.
Staff told us mandatory training was mostly completed by online as e-learning modules with some training provided face to face. A breakdown of compliance for mandatory training courses from August 2017 to July 2018 for qualified nursing staff in the outpatient department at Moorfields at St. George’s is shown below:
Staff Eligible Completion Trust Met Name of course trained staff rate Target (Yes/No)
Infection Prevention (Level 2) 10 10 100% 80% Yes Conflict Resolution 10 10 100% 80% Yes Page 30
Medicine management training 10 10 100% 80% Yes Counter Fraud 3 3 100% 80% Yes Fire Warden 2 2 100% 80% Yes Prescribing Practice and Formulary for Non-Medical Prescribers 1 1 100% 80% Yes Resuscitation Level 3 (Adult Immediate Life Support) 2 2 100% 80% Yes Infection Prevention (Level 1) 10 11 91% 80% Yes Information Governance 10 11 91% 80% Yes Helping Visually Impaired People 10 11 91% 80% Yes Preventing Radicalisation - Basic Prevent Awareness (eLearning L1&2) 10 11 91% 80% Yes Adult Basic Life Support 9 10 90% 80% Yes Medical Gas Safety 9 10 90% 80% Yes Preventing Radicalisation - Awareness of Prevent (WRAP) 9 10 90% 80% Yes Recruitment and Selection 2 3 67% 80% No Resuscitation Level 3 (Paediatric Immediate Life Support) 1 2 50% 80% No
At Moorfields South at St. George’s, the 80% target was met for 14 of the 16 mandatory training modules for which qualified nursing staff were eligible.
A breakdown of compliance for mandatory training courses from August 2017 to July 2018 for medical staff in the outpatient department at Moorfields South at St. George’s is shown below:
Staff Eligible Completion Trust Met Name of course trained staff rate Target (Yes/No)
Infection Prevention (Level 2) 25 25 100% 80% Yes Infection Prevention (Level 1) 25 25 100% 80% Yes Counter Fraud 8 8 100% 80% Yes Helping Visually Impaired People 25 25 100% 80% Yes Prescribing Practice and Formulary for Medical Prescribers 25 25 100% 80% Yes Recruitment and Selection 8 8 100% 80% Yes Risk and Safety Management 2 2 100% 80% Yes Conflict Resolution 24 25 96% 80% Yes Information Governance 24 25 96% 80% Yes Adult Basic Life Support 22 25 88% 80% Yes Preventing Radicalisation - Awareness of Prevent (WRAP) 20 25 80% 80% Yes Preventing Radicalisation - Basic Prevent Awareness (eLearning L1&2) 20 25 80% 80% Yes Resuscitation Level 2 (Paediatric Basic Life Support) 3 4 75% 80% No
At Moorfields South at St. George’s the 80% target was met for 12 of the 13 mandatory training Page 31 modules for which medical staff were eligible.
(Source: Routine Provider Information Request (RPIR) – Training tab)
During the inspection we saw that for all nursing staff mandatory training was up to date. Safeguarding Staff understood how to protect patients from abuse, they had received training on how to recognise and report abuse. Staff working with children and young people had been trained to safeguarding level three. This had improved since the last inspection. Safeguarding policies and procedures were in place across the trust. These were available electronically for staff to refer to. Staff we spoke with demonstrated an understanding of the safeguarding process. Staff could assess the safeguarding team at the trust headquarters at City Road if they needed advice or support. The service had two safeguarding champions who were responsible for attending safeguarding workshops and cascading any new information to the staff. Safeguarding training included supporting patients with a learning disability and dementia awareness. Passports were in place for patients who had a learning disability. The passport was designed to give hospital staff helpful information to make patients feel more comfortable about the hospital visit. The trust’s safeguarding and child protection policy set out Moorfields’ approach in recording and reporting suspected female genital mutilation (FGM). Staff we spoke with were aware of how to report or raise concerns. The trust set a target of 80% for completion of safeguarding training.
A breakdown of compliance for safeguarding training courses from August 2017 to July 2018 for qualified nursing staff in the outpatient department at Moorfields at St. George’s is shown below:
Staff Eligible Completion Trust Met Name of course trained staff rate Target (Yes/No)
Safeguarding Children (Level 2) 10 10 100% 80% Yes Safeguarding Children (Level 3) 4 4 100% 80% Yes Safeguarding Children (Level 1) 10 11 91% 80% Yes Safeguarding 9 11 82% 80% Yes
Moorfields at St. George’s, the 80% target was met for all four of the safeguarding training modules for which qualified nursing staff were eligible.
A breakdown of compliance for safeguarding training courses from August 2017 to July 2018 medical staff in the outpatient department at Moorfields at St. George’s is shown below:
Staff Eligible Completion Trust Met Name of course trained staff rate Target (Yes/No)
Safeguarding 23 25 92% 80% Yes
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Safeguarding Children (Level 2) 23 25 92% 80% Yes Safeguarding Children (Level 1) 23 25 92% 80% Yes Safeguarding Children (Level 3) 4 6 67% 80% No
At Moorfields at St. George’s, the 80% target was met for three of the four safeguarding training modules for which medical staff were eligible.
(Source: Routine Provider Information Request (RPIR) – Training tab) Cleanliness, infection control and hygiene The service controlled infection risks. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection.
The OPD and the UCC was visibly clean. We saw the daily cleaning schedules were completed when the department was open. Monthly cleaning audits were undertaken across all the clinics showed the OPD consistently scored 100% compliance for the period January 2018 to October 2018. The audit results for July and September were not displayed. In the children’s waiting area in the Dragon centre there were records detailing the daily clean of children’s toys. All the toys were also cleaned with disinfectant once a week. We observed staff complying with infection prevention and control practices (IPC). There were adequate supplies of personal protective equipment (PPE) throughout the department. Hand gel was available for use at the entrance to the OPD and there was signage reminding people of the importance of hand washing. We noted all staff adhered to the hand hygiene, “bare below the elbows” and hospitals uniform protocol in clinical areas. This reduced the risk of infections to staff and patients and was in line with good practice. Hand hygiene audits were undertaken monthly. For the period January 2018 to October 2018 the department scored 100%. This demonstrated that the department was meeting the trust targets for 95% compliance. This had improved since the last inspection. Disposal curtains were in use to screen patients in cubicles and we saw these were dated (8/11/2018) when they were last changed. We observed clinical and domestic waste was appropriately segregated. Purple bins were used for the disposal of cytotoxic waste (injection specific to glaucoma clinics) and blue bins for the disposal on Minims. We observed staff complied with these arrangements. We observed sharps management complied with Health and Safety (Sharp Instruments in Healthcare) Regulations 2013. We saw sharps containers were used appropriately and they were dated and signed when brought into use. Environment and equipment Staff working in treatment areas in a corridor outside the main outpatient area were separate from the main outpatient area. . There was no CCTV. This was similar to what we found at the last inspection. Resuscitation equipment had been relocated in the department to make it more easily accessible and visible. The resuscitation trolleys had paediatric and adult resuscitation equipment. We found evidence that there were daily checks by staff and there were records of a monthly check when the trolley was opened when medicines and stock were checked and re-tagged. There was also a Page 33 quarterly ‘buddy’ check carried out with a member of staff from St George’s Hospital. St George’s Hospital pharmacy were responsible for re-stocking the trolley after use, or when drugs have expired. Children attending the OPD or the UCC waited in the children’s waiting area in the ‘Dragon centre’. Single use items of equipment were readily available. These were easily assessable for staff within the patient treatment bays and stored appropriately. Equipment such as slit lamps, argon lasers and an ophthalmometer were part of the maintenance contract which was managed by the City Road site. Electrical Medical Equipment (EME) had a registration label affixed. Portable Appliance Testing (PAT) labels were attached to electrical systems showing they had been inspected and were safe to use. Safety signage and visual warning lights were displayed externally on rooms where laser procedures took place. The safety checks of equipment were complete and up to date. Assessing and responding to patient risk Staff completed risk assessments for each patient and kept records.
All patients were asked to confirm their name and date of birth, or other identifiable information, prior to undergoing tests or procedures. This meant staff could be certain they were treating the correct patient. Staff we spoke with demonstrated knowledge of risks to patients particularly for people who were frail, elderly, living with dementia or had a learning disability. Staff told us they could access the psychiatric liaison service via the site managers at St George’s Hospital if required. Staff were visible in the waiting area so that they could assist patients who appeared unwell or needed assistance. Staff told us that if a patient became unwell they would be taken to the St George’s Hospital urgent and emergency care department. The UCC provided a walking service for patients who had suffered eye problems. Patients were triaged on arrival with the most urgent patients being seen first. These patients were offered an assessment and treatment on the same day as the clinic. The paediatric pathway for Moorfields at St George’s detailed the referral process, including referrals the UCC, and arrangements for initial outpatient and follow up appointments. We observed staff check patient’s ID and address details to ensure that they had the correct patient before starting the patient’s assessment and administering eye drops. Resuscitation equipment was available within the OPD and staff told us they could bleep the resuscitation team from St George’s Hospital if a patient needed resuscitation. Nurse staffing The service had enough nursing staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. Safer staffing levels were managed and monitored by a specially created software system which analysed clinic activity and staffing requirements to meet the clinic and patients’ needs. Staff we spoke with felt there enough staff for the clinics and services provided. During our inspection we observed that staffing levels were sufficient and there was an appropriate skill mix including optometrists, orthoptists, registered nurses, technicians and health care assistants.
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Senior nursing staff told us that they were seeking to extend nursing roles to further develop their skills. For example, one of the nurse practitioners was qualified as a non-medical prescriber and there was a nurse led angiography clinic held twice a week. Nursing staff levels at the time of the inspections were as follows: 1x Band 8a, 4 x Band 7’s, 4 x band 6’s, 1 x Band 5, 1 x Band 4, 12 x Band 3’s and 1 x co-ordinator. A Moorfields play specialist was in post to support children attending the OPD and UCC. This was an improvement since the last inspection. The trust was out to advert for seeking to recruit a paediatric nurse to work in the department. The post had been vacant since the summer. The UCC was staffed by three nurse practitioners who been in post since the summer. Staff told us bank staff were not often used as it was difficult to get bank staff with ophthalmic experience. However, nurses with general training were used for fluorescein angiography as there is no ophthalmic requirement for this procedure. The photographer required for this had to come from City Road. The OPD were currently seeking to recruit a Band 6 photographer. The trust has reported their staffing numbers below for March 2018 and July 2018. There was an under-establishment of qualified nursing staff in outpatients across the trust. Across the trust, at July 2018 there was an under-establishment of 35.8 WTE staff (fill rate of 81.7%).
As at March 2018 As at July 2018 Planned Actual staff Planned Actual staff Site staff – Fill rate Fill rate - WTE staff – WTE – WTE WTE Moorfields at St. 10.3 7.4 71.8% 10.4 9.4 90.4% George’s
(Source: Routine Provider Information Request (RPIR) –Total staffing tab)
From August 2017 to July 2018, the trust reported a vacancy rate of 14.1% for qualified nursing staff in outpatients:
• Moorfields at St. George’s: 15.3%
At trust level, the reported vacancy rate for qualified nursing staff in outpatients was higher than the trust target of 10%.
(Source: Routine Provider Information Request (RPIR) – Vacancy tab)
Following the inspection, the trust advised this represented one vacancy which was not replaced as the trust was introducing a new model of care within the urgent care centre.
From August 2017 to July 2018, the trust reported a turnover rate of 13.2% for qualified nursing staff in outpatients:
• Moorfields at St. George’s: 26.8%
At trust level, the reported turnover rate for qualified nursing staff in outpatients was within the Page 35
trust target of 15%.
(Source: Routine Provider Information Request (RPIR) – Turnover tab)
Following the inspection, the trust advised this represented the staffing changes due to the introduction of the new model of care within the urgent care centre.
From August 2017 to July 2018, the trust reported a sickness rate of 5.8% for qualified nursing staff in outpatients:
• Moorfields at St. George’s: 1.7%
At trust level, the reported sickness rate for qualified nursing staff in outpatients was above the trust target of 4%.
(Source: Routine Provider Information Request (RPIR) – Sickness tab)
The below table shows the bank and agency usage for qualified and non-qualified nursing staff in outpatients from August 2017 to July 2018. For qualified nursing staff, the trust reported that 12.7% of available hours were filled by bank staff and 0.4% of available hours were filled by agency staff. For non-qualified nursing staff, the trust reported that 17.4% of available hours were filled by bank staff and there was no reported use of agency staff.
Bank usage is greater at Moorfields at St. George’s for both qualified and non-qualified nursing staff when compared to the average across the whole trust. Agency usage was low across the whole trust.
Total hours Bank Agency Unfilled Qualified 2,275 288 (12.7%) 8 (0.4%) 0 (0%) Non-qualified 1,181 206 (17.4%) 0 (0%) 0 (0%)
Moorfields at St George’s
Total hours Bank Agency Unfilled Qualified 124 29 (23.4%) 0 (0%) 0 (0%) Non-qualified 176 63 (35.8%) 0 (0%) 0 (0%)
(Source: Routine Provider Information Request (RPIR) - Nursing bank agency tab) Medical staffing The service had enough medical staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. The OPD medical staffing was provided by the specific eye specialities these were the Vitreo- retinal, cataract, corneal, external diseases, adnexal, glaucoma, medical retina, uveitis, paediatric, neuro ophthalmology, adult strabismus, general ophthalmology and urgent care.. The doctors and
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consultants held clinics across the different sites that Moorfield Eye Hospital NHS Foundation Trust operated from. Each clinic was run by a lead consultant supported by doctors at varying levels of experience; from specialty trainees to clinical fellows. Some consultants closely monitored the work of their junior staff by reviewing decisions made about every patient during the clinic, whereas others delegated work to the junior staff and were available to assist with complex patients or if the junior doctors were unsure. Staff told us that the medical staffing levels were satisfactory and they had time to complete mandatory training and take study leave. Medical staff participated on an out of hours rota as either part of rota that covered the main hospital site at City Roads or were part of the South West Thames on call. The trust has reported their staffing numbers below for March 2018 and July 2018. There was an under-establishment of qualified medical staff in outpatients across the trust. Across the trust, at July 2018 there was an over-establishment of 7.3 WTE staff, although this may be down to issues with data quality.
As at March 2018 As at July 2018 Planned Actual staff Planned Actual staff Site staff – Fill rate Fill rate - WTE staff – WTE – WTE WTE Moorfields at St. 24.8 28.0 112.8% 29.1 22.2 76.5% George’s
(Source: Routine Provider Information Request (RPIR) –Total staffing tab)
From August 2017 to July 2018, the trust reported a vacancy rate of 10.6% for medical staff in outpatients:
• Moorfields at St. George’s: 7.9%
At trust level, the reported vacancy rate for medical staff in outpatients was greater than the trust target of 10%. The vacancy rate was particularly high for medical and dental staff at the Bedford site.
(Source: Routine Provider Information Request (RPIR) – Vacancy tab)
From August 2017 to July 2018, the trust reported a turnover rate of 9.5% for medical staff in outpatients: • Moorfields at St. George’s: 6.2%
At trust level, the reported turnover rate for medical staff in outpatients was within the trust target of 15%.
(Source: Routine Provider Information Request (RPIR) - Turnover tab) Page 37
From August 2017 to July 2018, the trust reported a sickness rate of 1.0% for medical staff in outpatients:
• Moorfields at St. George’s: 0.6%
At trust level, the reported sickness rate for medical staff in outpatients was below the trust target of 4%. Sickness rates for medical staff were low across the three featured locations.
(Source: Routine Provider Information Request (RPIR) – Sickness tab)
The below table shows the bank and locum hours for medical staff in surgery from August 2017 to July 2018. Across the trust, 34,979 hours were filled by bank staff and 10,949 hours were filled by locum staff.
Locum use was particularly high for some of the district hubs offering outpatient services at the trust. Locum use was particularly high at Croydon (6,730 locum hours), Ealing (1,311 locum hours), Northwick Park (919 locum hours), and Potter’s Bar (754 locum hours).
Total Location Bank Locum Unfilled hours Moorfields Eye Hospital (City 286,873 13,980 (4.9%) 0 (0%) 0 (0%) Road) Moorfields at St. George’s 51,646 9,396 (18.2%) 23 (0.04%) 0 (0%) Moorfields at Bedford 29,432 3,723 (12.6%) 749 (2.5%) 0 (0%) All other sites 101,296 7,879 (7.8%) 10,177 (10.0%) 0 (0%) Trust total 469,248 34,979 (7.4%) 10,949 (2.3%) 0 (0%)
Note- Totals may not add up due to rounding.
(Source: Routine Provider Information Request (RPIR) – Medical agency locum) Records Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and available to staff providing care. This had improved since the last inspection. For the three month period August 2018 to October 2018, there were a total of 14,959 appointments attended. Less than 1% (121) of patients were seen without their full medical records. The medical records team located and tracked patient notes. The medical records team were onsite and notes were stored off site and ordered in and prepped in advance of patient appointments. The area staff worked in was limited due to the number of records stored for appointment and waiting to go back to storage. The trust was moving to a new system in early 2019 which would limit the time records were on site and help to free up space. Where patient notes could not be located, a temporary file was put together so the patient’s clinic visit could be appropriately documented. Staff told us if patient records were missing, an incident report was completed. Staff told us the number of missing records on clinic days had declined.
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All previous letters and investigation findings were available to clinicians electronically. Temporary notes were filed in the patient’s permanent folder as soon as possible following their clinic appointment. Records were held in the OPD reception area and, once patients had checked in, the records were placed in wire baskets for the respective clinics with a cardboard coversheet over the outermost set of notes which produced a degree of confidentiality. The OPD and UCC used a combination of paper and electronic patient records (EPR). We looked at 17 sets of records and found that all the records were stamped, signed and dated by the clinical staff. The records we reviewed were easy to navigate and laid out with all relevant photographs. However, we found that 25% of the records did not have a front sheet which detailed information such as next of kin and patient needs. Through the EPS, clinicians had access to clinic letters/prescriptions and images. Records were entered electronically and a letter was generated for the patient’s GP to be sent securely and directly to them. The trust undertook a clinical records audit which included both paper and electronic records across the trust. This identified the trust had improved or maintained 100% compliance in most of the areas reviewed (25); however, it also showed a decline in others (9). For example, paperwork being securely held and bound at St George’s scored 87% compliance which was better than 70% in 2017; and for entries on records being signed in 2018 scored 63% compliance which had declined from 100% in 2017. An action plan was in place with a re-audit scheduled by February 2019. Medicines The service followed best practice when prescribing and storing medicines. Medicines were held in locked treatment rooms and in controlled room temperature cabinets (CRTC’s) located in the OPD and the UCC. Pharmacy staff checked stocks and expiry dates daily. No controlled drugs were held in the department. Fridge temperatures were monitored to ensure they were within range. Fridges were checked via a sensor which was linked to an automated system. This sent alerts to the on-site pharmacy, the off-site out of hours pharmacist and lead nurses via their phones. Patient Group Directions (PGDs) were in place to guide prescription and use of medicines, for example for administration of drops in eye clinic. PGDs are a written instruction for the supply and administration of a specified medicine before a doctor arrived. FP10 prescriptions for the OPD and UCC were held securely in a locked cupboard, and the key kept in a key press with a combination code. There was a record log for when a new pad arrived, and we found this was accurate and up to date. This log was checked daily by two nurses. The pharmacy audited FP10’s every 3 months and where concerns had been highlighted training had been given. FP10 audit data for quarter 2 (August to September 2018) results showed that the OPD at Moorfields at St George’s scored 100%. Medicine prescriptions were printed directly from the hospital computer system and signed by staff before being given to patients. Prescriptions were taken to the hospital pharmacy for dispensing. Three copies were generated to provide one for the patient, one for pharmacy and one to be held in the patients file. Endophthalmitis treatment boxes were held in the OPD and UCC. Pharmacy topped these up if the drugs were used. All the instructions for use were held with the boxes. Page 39
Doctors completed ‘Prescribing Practice and Formulary for Medical Prescribers’ training. Hospital data showed this had been completed by 100% of medical staff which was better than the trust target of 80%. Non-medical prescribers completed ‘Prescribing Practice and Formulary for Non-Medical Prescribers’ training. Hospital data showed this had been completed by 100% of eligible staff, which was better than the trust target of 80%. Medicines awareness training was compulsory for nursing staff working within the outpatients directorate. This training had been completed by 100% of nursing staff, which was better than the trust target of 80%. Pharmacists led the patient education programme “Know your drops programme. The programme ensures patients understand the need for them to take their eye drops and are taught how to administer their eye drops. Incidents Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team. Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event. From September 2017 to August 2018, the trust reported no incidents classified as never events for outpatients.
(Source: Strategic Executive Information System (STEIS))
In accordance with the Serious Incident Framework 2015, the trust reported no serious incidents (SIs) in outpatients which met the reporting criteria set by NHS England from September 2017 to August 2018.
(Source: Strategic Executive Information System (STEIS))
The OPD used an incident reporting system widely used in the NHS to report incidents. In the three month period August to September 2018 a total of 162 incidents were reported, with recorded 90% (147) as no harm, 5% (8) as minor harm, 0.5%(1) as moderate, 3% (5) as a near- and 0.5% (1) as major harm. The largest number of incidents (117) reported related to availability of records. Staff knew how to report incidents. Staff advised most of the incidents reported were for missing notes. Minutes of the monthly clinical team meetings recorded the number of incidents each month and the themes. These included over booking of clinics and missing notes. Incidents were also discussed as part of the clinical governance quarterly meetings. We saw evidence of this within meeting minutes which demonstrated that incidents were regularly discussed and shared learning identified. From November 2014, NHS providers were required to comply with the duty of candour Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The duty of candour is a regulatory duty relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that person. Page 40
Staff received training in duty of candour which was part of their mandatory requirements. Staff were aware of their responsibilities under the duty of candour, which ensured patients and/or their relatives were informed of incidents which affected their care and treatment and they were given an apology and offered support. Safety thermometer The NHS Patient Safety Thermometer is a national tool used to record the prevalence of patient harms and to provide immediate information and analysis for frontline teams to monitor their performance in delivering ‘harm free’ care. This information is intended to help staff focus their attention on reducing inpatient harm and improve the safety of the care they provide. The trust did not provide safety thermometer information for the OPD as the safety information is used in inpatient areas to assess harm. All patients due to be admitted had a venous thromboembolism (VTE) assessment prior to admission. Performance information for Moorfields South demonstrated that the trust had screened 98% of patients for this in the period April 2018 to October 2018.
Is the service effective? Evidence-based care and treatment Policies, procedures and guidelines had been developed in line with national policy. These included the National Institute for Health and Care Excellence (NICE) guidelines. Medical staff within the outpatients department (OPD) participated in local and national audits. Medial staff told us the procedures they used were evidence based and that compliance with NICE guidance was audited regularly. Policies, procedures and guidelines were available to all staff via the trust intranet system and staff demonstrated they knew how to access them. Audits assessing compliance of the Royal College of Ophthalmologists (RCO) and Royal College of Paediatric and Child Health (RCPCH) had been undertaken. The trust provided details of two audits, retinopathy of prematurity screening and driving change in amblyopia (lazy eye) management. Pain relief Staff assessed patients to see if they were in pain. In the urgent care centre (UCC) patients pain was assessed routinely and they were provided with local anaesthetic eye drops or oral analgesia pain relief if required. Patient outcomes Managers monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them. Outcome for PCR in glaucoma patients were better than the national standard: Standard <1.95% Moorfields at St George’s achieves 0.77%. Outcomes for patients receiving treatment for medical retinal conditions were better than national standard in three of the four standards except screening for time from screening to assessment of proliferative diabetic retinopathy. • Endophthalmitis after intravitreal anti-VEGF injections: Standard <0.058% Moorfields at St George’s 0.03%
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• Visual improvement after injections for macular degeneration: Standard >20% Moorfields at St George’s 22.3% • Visual stability after injections for macular degeneration: Standard >80% Moorfields at St George’s 92.2% • Time from screening to assessment of proliferative diabetic retinopathy: Standard 80% Moorfields at St George’s 77% The follow-up to new rate for Moorfields at St George's was lower than the England average from June 2017 to May 2018.
Follow-up to new rate, Moorfields Eye Hospital NHS Foundation Trust.
(Source: Hospital Episode Statistics) Competent staff The service made sure staff were competent for their roles. Managers appraised staff’s work performance to provide support and monitor the effectiveness of the service.
New nursing staff were given a trust and local induction. During the inspection we saw that staff appraisals were up to date. Staff we spoke with told us they had received an appraisal within the last 12 months. Staff told us they had good access to training, this included training in mental health, learning disabilities and dementia awareness. Study days were usually held on a Saturday when required to avoid disruption of week day clinics. There were competency packages for Nurse Practitioner training and staff told us the majority of the training was held at City Road. The trust reported all clinical staff were offered clinical supervision within the trust although, this was not monitored or defined in relation to frequency. However, staff were required to complete and be signed off for clinical competencies. The trust also offered staff the opportunity to seek clinical supervision or coaching externally. Medical staff who were part of the Moorfields training programme told us they were happy with all aspects of their training at Moorfields. There were also plans to further develop and formalize
Page 42 arrangements for medical student placements within the department. There were good arrangements for ophthalmic fellows with an excellent programme of education. They felt supported by the consultants and thought the training and opportunities for research at Moorfields were first class. They felt trainees were listened to and were valued members of the team. From August 2017 to July 2018, 89.4% of staff within outpatients at Moorfields at St George’s received an appraisal compared to a trust target of 80%.
Target Individuals Appraisals Completion Trust Staff group met required complete rate target (Yes/No) Qualified Allied Health 11 11 100.0% 80% Yes Professionals (Qualified AHPs) Support to ST&T staff 4 4 100.0% 80% Yes NHS infrastructure support 1 1 100.0% 80% Yes Medical & Dental staff - Hospital 20 18 90.0% 80% Yes
Qualified nursing & health 11 8 72.7% 80% No visiting staff (Qualified nurses) Grand Total 47 42 89.4% 80% Yes
(Source: Routine Provider Information Request (RPIR) – Appraisal tab)
Information provided by the trust following the inspection showed that 97% of nursing and technician staff had received an appraisal by the end of November 2018. Multidisciplinary working Staff worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care. Weekly multidisciplinary meetings (MDM) were held for different specialities. Meetings were held to discuss specific patient cases and were attended by consultants, radiologists, junior doctors, radiographers and ophthalmologists. Multidisciplinary team (MDT) working was evident throughout the OPD. Most meetings, such as quarterly clinical governance meetings included medical and nursing staff, technical, administrative and clerical staff. Patients were seen by an ophthalmic technician who would do the initial checks such as visual acuity, pressure checks and patient dilation before being seen by a consultant or doctor. There was pharmacist support for all the clinics situated at the on-site pharmacy. They provided information to patients on their medications and medication usage. Patient information was shared with GP’s when patients were discharged or following appointments to ensure continuity of care. We saw that patients from overseas were given letters for their GP. Seven-day services The OPD did not provide a seven day a week service. The department ran ad hoc glaucoma clinics on a Saturday to manage demand and meet individual needs. These clinics were usually dependant on staff working additional hours. Page 43
The UCC operated seven days a week from 8.00am to 9.00pm. Due to the closure of the Moorfields South Duke Elder Eye Unit at St George’s Hospital for refurbishment, outside these hours patients were seen at St George’s Hospital Urgent Care Centre which closed at 2.00am and was covered by nurses on the unit and an on-call consultant. Pharmacy services were available Monday to Friday from 9.30am to 6.00pm and on Saturdays from 9.00am to 5.00pm. On-call pharmacists were contactable via the trusts switchboard outside of regular pharmacy opening hours (from Mon-Fri after 6pm until 9am the following morning), and on Saturdays and Sundays the on-call pharmacist was contactable via switchboard all day. The on-call pharmacist provided trust-wide cover. Health promotion In the OPD patient information was available for most eye conditions/treatments such as laser retinopexy, retinal vein occlusion and infection prevention and control. All the leaflets were in an easy read format with a yellow background and black text. Staff were also aware how patient’s lifestyles could impact on their sight. They told us they would give patients information on smoking, alcohol and diabetes and recommend exercise and changes to their diet. Information and advice was available from the pharmacy to support patients in administering eye drops. A range of compliance aids were available which patients could access via their doctors. On a quarterly basis, the trust would have a ‘know your drops’ campaign to promote better understanding and administration of eye drops. Consent, Mental Capacity Act and Deprivation of Liberty Safeguards Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. We observed staff obtaining verbal consent from patients prior to assessments. Staff in the OPD and UCC understood the importance of gaining patients consent prior to any interventions or assessments. We saw that consent forms were used appropriately in outpatients prior to minor surgical procedures. Staff were aware of their roles and responsibilities under the Mental Capacity Act 2005 (MCA) regarding mental capacity assessments and Deprivation of Liberty Safeguards (DoLS). Staff knew how to contact the mental health liaison service if required. The trust reported that from August 2017 to July 2018 Mental Capacity Act (MCA) training was completed by 74.7% of staff in outpatients compared to the trust target of 80%.
Met Staff Eligible Completion Trust Name of course (Yes/ trained staff rate Target No) Mental Capacity Act Awareness (e- learning) Level 1 559 742 75% 80% No Mental Capacity Act Level 2 and 3 700 944 74% 80% No
Moorfields at St. George’s
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Met Staff Eligible Completion Trust Name of course (Yes/ trained staff rate Target No) Mental Capacity Act Awareness (e- learning) Level 1 44 52 85% 80% Yes Mental Capacity Act Level 2 and 3 39 50 78% 80% No
(Source: Routine Provider Information Request (RPIR) – Training tab) Is the service caring? Compassionate care Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Staff provided treatment and care in a kind and compassionate way and treated people with respect. Staff were seen to be very considerate and empathetic to patients. For example, we saw one patient being supported by a medical doctor to the treatment room, the patient was visually impaired so the doctor had the patient put their hand on their shoulder so the patient could follow them. However, we also observed that patients who were in wheelchairs were not always being pushed and sometimes staff would pull the chairs. This meant that patients could not see where they were being taken and staff were not communicating with the patients. Following the inspection, the trust advised patients were often in porter’s chairs which, by design, are rear steer and are pulled backwards. Patients we spoke with were positive about the staff who provided their care and treatment. They felt the assessment and consultation process was thorough and staff communication and attitude was always good. The waiting area in the OPD had been reconfigured to improve patients’ privacy and confidentiality. The reception area for the UCC was located within closer range of the UCC and had a dedicated triage room. The treatment cubicles had been modified to improved patient’s privacy and confidentiality. However, we did observe that staff did not always pull the privacy curtains across when assessing and treating patients which meant their dignity could be compromised. Following the inspection, the trust advised patients were given a choice on whether the curtains are open or closed. The OPD had a main reception desk which was staffed by reception staff. During the inspection we observed patients queuing to check in and reception staff checking people’s personal data on the electronic record system. However, we observed people could be over heard and there was no signage asking people to wait at a discrete distance from the reception desk. We observed reception staff being friendly and helpful to patients. Following the inspection, the trust advised this has now been address as there is now a line on the floor to promote patient confidentiality. Friends and family test (FFT) results were displayed. For the period October the OPD scored an average of 96% for recommending someone to come to OPD. There were 5,317 patients eligible to respond and 8.6% (456) patients responded. This was lower than the trust target of 15%. During the inspection we observed that FFT cards were available for patient to complete and staff were proactively encouraged patients to complete the cards following treatment. Emotional support Staff provided emotional support to patients to minimise their distress.
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Staff we spoke with were aware of the impact that a treatment or diagnosis could have on a patient emotionally. Patients attending the OPD or the UCC could access the eye clinic liaison officer (ELCO) who provided support and care for patients and assisted patients with registering for the visual impairment certificate. The certificate enabled patients to get further support via social services and access benefits such a half-price TV Licence, help with NHS costs, help with Council Tax bills and tax allowances, leisure discounts and free public transport. The patient experience co-ordinator was available to support patients. They accompanied patients requiring a chaperone, transported patients between services if needed and ensure they their transport was arranged so patients could return home. Understanding and involvement of patients and those close to them Staff involved patients and those close to them in decisions about their care and treatment. Patients we spoke within the outpatients department told us they were involved in their care and understood their treatment and care plans. One patient told us they had a range of tests undertaken on the same day so they did not have to come to several appointments. They told us they had been able to ask questions and the consultant had taken time to explain their treatment to them. They felt listened to and were impressed by the care and treatment that they had received. We observed six patient consultations including three minor eye surgery/biopsies. On each occasion staff introduced themselves to patients and patients were given the opportunity to ask any questions. The OPD had a patient experience coordinator. They would ensure that patients who arrived via transport were appropriately supported. For example, they supported patients who might have required wheelchair assistance. They would also ensure that the patients were checked in, had a chair if they needed and were not kept waiting for their appointment. During the inspection we saw different examples of staff involving patients in their treatment. For example, we observed a member of staff assisting a patient complete forms in a way so they could understand as English was not their first language. We also observed a staff member taking their time and explaining what they were going to be doing to reassure a patient who was very anxious. Is the service responsive? Service delivery to meet the needs of local people The trust planned and provided services in a way that met the needs of local people. The location of the Moorfields OPD within the Laneborough wing was still difficult to find from the main reception at St George’s Hospitals. This was the same at the last inspection. Patients were sent information within their initial appointment letter detailing how to get to the hospital; but it did not include information on where to find the OPD within the hospital. The map of the local area was small which made it difficult for a person who was visually impaired to see. Signage within the OPD was still not clear and would be difficult for a person who was visually impaired to see. However, senior staff advised new signage for the department had recently been approved and ordered. Following the inspection, the trust advised that the new outpatient signage is now in place.
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Information about waiting times were displayed so patients knew how long they would have to wait for their appointments. This had changed since our last inspection. However, the process was reliant on staff updating the times by hand. On the second day of the inspection (10.00am) we observed that the date had not been changed and clinic times displayed were from the previous afternoon. Television information screens were available in clinic waiting areas. The screens showed various types of information about the OPD, including staffing data, and about the trust. Some text on the information screens was small and difficult to read from the waiting area. A full range of outpatient eye clinics were available to meet the needs of the local population which included adnexal, cataract, external disease, general ophthalmology, glaucoma, medical retinal, optometry orthoptics, paediatrics, strabismus, vitreoretinal and support services. The OPD ran 6 days a week from 8.00am to 6.00pm on Monday, Wednesday, Thursday Friday and Saturday and from 8.00am to 8.00pm on Tuesday. This helped to address waiting lists and provide patients choice when booking appointments. The UCC was open Monday to Saturday from 8.00am to 9.00pm. Out of hours patients were seen at St George’s Hospital Urgent Care Centre which closed at 2.00am. Opticians provided a drop-in centre for spectacle repairs and a one stop service for children after seeing the orthoptist for glasses Children attending the OPD or the UCC could wait in the play area of the Dragon centre whilst they waited to attend clinics. A Moorfields play therapist was available Monday to Friday to support children whilst they were waiting. The Dragon centre was part of the paediatric service at St George’s University Hospitals NHS Foundation Trust. Interpreters offering both face to face and telephone interpreting could be pre-booked for patients where English was not their first language. Staff working in the UCC were also able to access a telephone interpreting service. Meeting people’s individual needs The service took account of patients’ individual needs. We observed that on a few occasions staff called out multiple patients’ names at the same time. This could be confusing for patients, particularly older people or people with a hearing impairment. The environment within the OPD was not ideal and this was mainly due to the limitations of physical environment. During the inspection we found the OPD was still crowded and the waiting area cramped. This was identified at the last inspection and was also identified on the Moorfields south divisional risk register. The UCC reception area had been moved to closer to the UCC treatment rooms and provided more privacy and confidentiality. Staff informed us new chairs and signage were on order so that areas in the OPD could be more clearly defined. For example, signage on the floor to specify where patients in wheel chairs should sit and different colour chairs to indicate the split between patients attending the OPD and the UCC. There was still no designated private area for distressed patients and if staff needed more privacy to talk to patients they had to utilise treatment rooms when they were not in use. Following the inspection, the trust advised the ECLO room was also available. Signage to the OPD was small and would be difficult for a person who was visually impaired to see.
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There were no larger chairs for bariatric patients available within the OPD. Following the inspection, the trust advised that a bariatric chair is available in outpatients. Patients who needed physical assistance or guidance had a ‘helping hand’ sticker on the cover of medical notes to highlight patients with specific needs. Staff we spoke with told us patients who were living with dementia, had a learning disability, or suffered from mental ill health would be identified on their patient records and given priority in clinic to be seen quickly. ‘This is me’ documentation was in place for patients identified as having a learning disability. Staff had received dementia awareness and learning disabilities training. A patient we spoke with told us they had been texted the day before and informed their appointment was moved. The patient had contacted the department as they had already travelled from Devon for their appointment and the administrative staff were able to reinstate their appointment to avoid them having to make a further journey. Patients could to be accompanied by a friend or relative. Staff told us they had not been asked to book a chaperone, but would speak with the sister to arrange one if required. Signs offering a chaperone were seen in consulting rooms, and waiting areas. Patients had access to food and drinks to meet their needs. Staff told us the friends of St George’s volunteers came around with a trolley offering drinks in the morning and afternoon, but if there was a shortage of volunteers, this did not happen. Otherwise staff would go around the waiting area at in the late afternoon offering drinks. A water cooler and cups were available in the OPD waiting area. Hot drinks and snacks were available from the coffee shop located in the ground floor of St George’s Hospital or from nearby vending machines. Patients with mobility difficulties could use hospital transport to attend their OPD appointments. Following the inspection, the trust told us they a play specialist who also identified children in need of additional support. Access and flow People could access the service when they needed it. Waiting times from referral to treatment and arrangements to admit, treat and discharge patients were in line with good practice. The trust had an access policy which outlined the referral process for manging referrals to the OPD. Patients accessed the outpatients service via a referral from their optician or GP. Patients were booked for their initial appointment in the relevant clinic by the central bookings office. The OPD was open from 8.00am to 6.00pm on a Monday, Wednesday. Thursday, Friday and Saturday, and from 8.00am to 8.00pm on a Tuesday. The department also ran regular glaucoma and medical retina clinics on a Saturday. For the period November 2017 to October 2018, the OPD had a total of 48,233 attended appointments. 80.7% (38,909) of appointments were follow up, 14.6% (7,021) of patients were discharged and there were no outcomes for 4.8% (2,303) of patients. The trust advised a proportion of the no outcomes would be on the outpatient waiting list awaiting an appointment. Patients accessed the UCC via a referral from their optician, GP or they could self-refer. The urgent care centre (UCC) operated a 24 hour service, 7 days a week, and is run in OPD 9.00 am to 9.00pm. After 9.00pm, the service is ran from the St George's Urgent Care Centre Two consultants on Mondays and Fridays, for the rest of the week one consultant was were available during clinic hours. The UCC had three nurse practitioners who could see and treat patients to help increase the flow through the UCC. One of the nurse practitioners was a non-medical prescriber.
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For the period November 2017 to October 2018, the UCC had 10,353 attendances. 10,295 (99.4%) were new attendances, 0.2%(18) were follow up appointments and 0.4% (40) were patients who could not wait to be seen and classed as DNA (did not attend). For the period May 2018 to October 2018 there were a total of 1,353 referrals from St George’s A&E to the UCC at Moorfields. Staff told us the medical retina clinics were always overbooked, leading to long waits and delays for patients and this was reported as an incident. They said Saturday clinics were needed for this service. The lack of clinic capacity and staffing to meet the demand had been identified on the divisional risk register in August 2018. To mitigate this the trust was looking to run additional clinics, and recruit permanent administrative staff to the medical retina service. Following the inspection, the trust advised additional Saturday clinics are run regularly for the medical retina service. We requested information on the number of over booked clinics, however the trust advised ‘The data for this request is unavailable due to overbooked clinic capacity being artificially high due to the way in which the PAS (patient administration system) records this information’. The pharmacy at Moorfields at St George’s audited its turn-around times for outpatient prescriptions. The audit was conducted over a six day period from Monday to Saturday when the pharmacy was open. The Moorfields pharmacy at St George’s received a total of 209 prescriptions with 90% (188) of prescriptions being turned around within in 20 minutes of which met the audit standard. 10% (21) of prescriptions did not meet the waiting times set for this audit. A re-audit was planned for April 2019. From August 2017 to July 2018 the trust’s referral to treatment time (RTT) for non-admitted pathways has been consistently better than the England overall performance. The latest figures for July 2018, showed 94.5% of this group of patients were treated within 18 weeks versus the England average of 88.3%. The trust’s referral to treatment time (RTT) for non-admitted pathways was better than the England overall performance for all 12 months between August 2017 and July 2018.
Referral to treatment rates (percentage within 18 weeks) for non-admitted pathways, Moorfields Eye Hospital NHS Foundation Trust.
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(Source: NHS England)
One specialty was above the England average for non-admitted pathways RTT (percentage within 18 weeks).
Specialty grouping Result England average Ophthalmology 94.2% 89.2%
(Source: NHS England)
From August 2017 to July 2018 the trust’s referral to treatment time (RTT) for incomplete pathways has been consistently better than the England overall performance. The latest figures for July 2018, showed 94.9% of this group of patients were treated within 18 weeks versus the England average of 87.3%. The trust’s referral to treatment time (RTT) for incomplete pathways has been better than the England overall performance for all 12 months between August 2017 and July 2018.
Referral to treatment rates (percentage within 18 weeks) for incomplete pathways, Moorfields Eye Hospital NHS Foundation Trust.
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(Source: NHS England)
One specialty was above the England average for incomplete pathways RTT (percentage within 18 weeks). Specialty grouping Result England average Ophthalmology 94.8% 88.4%
The trust is performing better than the 93% operational standard for people being seen within two weeks of an urgent GP referral. The performance over time is shown in the graph below. Percentage of people seen by a specialist within 2 weeks of an urgent GP referral (All cancers), Moorfields Eye Hospital NHS Foundation Trust
(Source: NHS England – Cancer Waits)
The trust was performing better than the 96% operational standard for patients waiting less than 31 days before receiving their first treatment following a diagnosis (decision to treat). The performance over time is shown in the graph below. Percentage of people waiting less than 31 days from diagnosis to first definitive treatment (All cancers), Moorfields Eye Hospital NHS Foundation Trust Page 51
(Source: NHS England – Cancer Waits)
From June 2017 to May 2018,
• The ‘did not attend’ rate for Moorfields at Croydon University Hospital was higher than the England average. • The ‘did not attend’ rate for Moorfields at Ealing was higher than the England average. • The ‘did not attend’ rate for Moorfields at Northwick Park was higher than the England average. • The ‘did not attend’ rate for Moorfields at St George's was higher than the England average. • The ‘did not attend’ rate for Moorfields Eye Hospital was higher than the England average.
The chart below shows the ‘did not attend’ rate over time.
Proportion of patients who did not attend appointment, Moorfields Eye Hospital NHS Foundation Trust.
(Source: Hospital Episode Statistics)
Learning from complaints and concerns The service investigated complaints and concerns and shared these with all staff. We reviewed the OPD’s monthly clinical staff meeting minutes for the period August to October 2018 and these demonstrated most complaints during that period related to missing notes, telephones not being
Page 52 answered, and long waiting times. Staff told us that the main complaints they received from patients were waiting times and patient transport. Response time for responding to complaints was monitored by the trust. For the period April 2018 to October 2018, 83% of complaints were responded to within the 25 day timeline. This was lower than the trust target of 90%. From 7 August 2017 to 6 August 2018, there were 108 complaints about outpatients. The trust took an average of 21.1 days to investigate and close complaints, this is in line with their complaints policy, which states complaints should be completed within 25 working days. Across the trust, a high proportion of complaints related to clinical treatment (45.4%) and values and behaviour (24.1%). A breakdown of complaints by site can be found below. Moorfields at St. George’s: There were 14 complaints (13.0%), six of these related to appointments and three related to clinical treatment. (Source: Routine Provider Information Request (RPIR) – Complaints tab)
From 6 August 2017 to 6 August 2018 there were 142 compliments within outpatients across the trust, toe of which related to Moorfields at St George’s. Due to the nature of the data provided we are unable to comment on any themes relating to the compliments received. The trust has reported that: “The compliments we receive focus on the standard of clinical care provided, with patient’s treatment meeting expectations and clinical outcomes being positive. Patients also compliment the care provided by individual members of staff, highlighting their kindness, professionalism and caring attitude which helps patients feel they are being treated personally. Many people comment that caring staff and the calm environment reduces their anxiety.”
(Source: Routine Provider Information Request (RPIR) – Compliments tab)
Is the service well-led? Leadership Managers at all levels had the right skills and abilities to run the service. Moorfields Eye Hospitals NHS Foundation Trust structured services into divisions Moorfields at St George’s was part of the Moorfields south division. The division was headed by a divisional director, a divisional manager and divisional head of nursing. The divisional leads felt the executive leadership supported them and the divisional structure provided for clearer lines of accountability and focus within the division. Following the inspection, the trust advised us, that divisions had delegated financial responsibilities. The local leadership team comprised of a clinical director, service manager and matron. The day to day management of the outpatient department (OPD) nursing and technician staff was overseen by a Band 8a nurse. Senior managers told us their post had been reviewed to strengthen the management of the OPD and had less clinical time. The trust advised they had a Nurse 100 club which is an informal cross divisional support and networking opportunity for learning and sharing success and challenges across the division which meets monthly, It is attended by sisters, matrons, head of nursing and specialist nurses. Team briefs were held in the morning and after lunch. These briefings ensured staff were aware of
Page 53 what clinics were running and identified any potential problems. For example, transport to get patients to the hospital and home and the use of interpreters. Staff were positive about their immediate managers and felt supported. Managers had an open door policy and supported staff in their roles clinically as and when required. Staff we spoke with knew who the divisions leadership team were. Most staff told us they felt valued and that their work was appreciated. Vision and strategy The trust had a vision for what it wanted to achieve and workable plans. The trust had a quality strategy for the period 2017 to 2022. The trust aim was to provide safe care, outstanding outcomes, and positive experience and involvement for all their patients. The Moorfields south division strategic plan 2018/2019 outlined the objectives for the year ahead. The local objectives included to meet the referral to treatment targets at St George’s by September 2018, implement tele-ophthalmology across the south for medical retina, review and redesign urgent care. The vision for St George's is to reduce the numbers of patients who need face to face appointments by using virtual diagnostic clinics, and for less complex patients to have appointments away from the main acute St George's hub for example at the Nelson Health Centre and Queen Mary's Roehampton. Some staff, other than two senior nurses, told us they were aware of some aspects of the strategic plan, but they had little involvement in the recent changes in the environment within the OPD. Some staff felt the department did not have enough space, and some clinics were over booked. Culture Managers promoted a positive culture that supported and valued staff. Staff were enthusiastic about the care and treatment they provided for the people who used their services. They described the OPD department as a good place to work. Staff said there was an open and transparent culture where people were encouraged and felt comfortable about reporting incidents and learning from mistakes. Staff we spoke with told us they felt supported in their roles, had opportunities to develop their skills and had access to further training opportunities. One member of staff told us they could use and extend their existing ophthalmic skills. Emergency nurse practitioners could access further training to become independent prescribers. Staff described good team and peer support; they felt they worked well as a team. We observed good interactions between nursing, administrative, medical staff, patients and relatives working together to achieve good outcomes for patients. Most patients acknowledged a positive and caring ethos and were happy with the care they received. Sickness rates for medical staff (0.6%) and nursing staff (1.7%) for the period August 2017 to July 2018 was lower that the trust target of 4%.
Governance The service had an effective governance system with processes to monitor performance on a regular basis.
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There were a range of meetings within the OPD which staff from across the service attended depending on their role. There were weekly management meetings and monthly clinical staff meetings for nursing and technician staff who worked at Moorfields at St George’s. There were also Moorfields South divisional quarterly clinical governance half days for all staff which was led by the divisional leadership team. In addition, there were quarterly Moorfields South general ophthalmology and urgent care service meetings. These meetings were minuted. Staff told us there was a twice yearly trust governance meeting for all staff. The trust advised they also had monthly multidisciplinary quality forum, and a quality partner whose focus is to maintain the standards of quality and safety across the division. Nursing, medical, and technician staff were clear on their professional role and responsibilities. Management of risk, issues and performance Since the last inspection a service level agreement between Moorfields Eye Hospital and St George’s Hospital had been agreed and signed. This confirmed a commitment by both parties for a new building / floor for Moorfields on the St George’s Site. The SLA was monitored quarterly by both parties. Risks related to Moorfields at St George’s was included as part of the Moorfields south divisional risk register. There were 11 risks identified on the divisional risk register, six of which related directly to St George’s and three were risks across the division. This included patients lost to follow up, overcrowded clinics in the OPD, lack of administration office space. Each risk had a red, amber or green (RAG) rating, had details of when last reviewed and when they were next due to be reviewed. However, it was not clear when the risk had been placed on the risk register and none of the risks had a named manager responsible for the risk. The issues and risks which managers identified were in line with what we found on inspection and these aligned with the risk register. Quarterly clinical governance half day sessions were held for all clinical and administrative staff. Minutes showed quality and safety, audit, activity and finance were discussed as part of the meeting. The minutes provided did not include details of the staff who attended. Following the inspection, the trust advised these sessions were attended by approximately 150 staff. Monthly clinical staff meeting minutes showed incident, family and friends feedback was discussed. The minutes also incorporated quality and performance reports which provided a breakdown on the number and types of incidents that were being reported and a detailed feedback from patients from the FFT test responses. Managing information There were computer stations throughout the areas we visited with access to the trust intranet and staff told us there were enough computers for them to access information when they needed it. Staff had access to policies and standard operating procedures through the intranet. Staff we spoke with confirmed that this information was easily accessible and up to date. Clinicians could access other IT systems, allowing them to view test results and diagnostic imaging, whilst the patient was present. All staff had to complete information governance training as part of their mandatory training modules. Nursing and assistant staff we spoke could tell us with confidence regarding data safety and precautions that should be taken with patient information. The department used mainly paper patient records. We saw that notes throughout the department were held in the OPD reception area and were placed in wire baskets for the respective clinics Page 55 with a cardboard coversheet over the outermost set of notes which produced a degree of confidentiality once patients had checked in. Paper records were utilised throughout the trust and were stored by a third party. Engagement The trust engaged with patients to plan services. The trust provided details of one patient engagement event held in May 2018 which was attended by two patients. The discussions focused on the signage, chair layout, colour and design. A further 22 patients who were attending the OPD or the urgent care centre were also asked for feedback on the signage in August 2018. Because of the patient consultation and engagement, it was agreed the OPD would be known as the ‘Moorfields Outpatient’s and the new signage would reflect this. A further patient engagement meeting was planned for November 2018. The OPD used the friends and family test to engage with patients and gather feedback. Minutes from the monthly clinical staff meetings showed that the results and feedback from the FFT was shared. We saw the OPD had a low responses rate of 8.6% in October 2018 was lower than the trust target of 15%. However, this had improved since the last inspection. During our visit we saw staff offering the Friends and Family test to patients. Learning, continuous improvement and innovation Staff from Moorfields visited local schools to educate them about some of the serious eye problems that can develop. It was hoped that the visits would encourage children to become school champions and through this initiative the children would educate elderly relatives or friends who may not have a good understanding of English or were not aware how to access eye examination or treatment. The trust told us they held a number of GP engagement events
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Moorfields at Bedford
Evidence appendix Kempston Road Date of inspection visit: Bedford 14 to 6 December 2018 MK42 9DJ Date of publication: Tel: <01234 792290> 12 March 2019
This evidence appendix provides the supporting evidence that enabled us to come to our judgements of the quality of service provided by this trust. It is based on a combination of information provided to us by the trust, nationally available data, what we found when we inspected, and information given to us from patients, the public and other organisations. For a summary of our inspection findings, see the inspection report for this trust.
Acute services
Surgery
Facts and data about this service Moorfields Eye Hospital NHS Foundation Trust provides sub-specialty adult surgical care in cataract, glaucoma, vitreoretinal, ocular plastics, ocular oncology, medical retina, corneal disease, strabismus and neuro-ophthalmology. The trust is also the biggest provider for corneal transplants in Europe.
Surgery at the trust is mainly day case, however there are facilities to keep patients overnight should they require it. Patients with more complex medical needs are seen at the St. Georges site where medical support can be provided. Complex oncology patient who may need HDU facilities are seen at St Bartholomew’s Hospital.
These surgical services at the trust are provided across eleven surgical sites.
• Moorfields Eye Hospital (City Road) • Moorfields at Bedford • Moorfields at Croydon • Moorfields at Darent Valley • Moorfields at Ealing Hospital • Moorfields at Mile End
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• Moorfields at Northwick Park • Moorfields at Potters Bar • Moorfields at Queen Mary's • Moorfields at St Ann's • Moorfields at St Anthony's*
* Surgery at this site will transfer back to Duke Elder Ward, St George's, once refurbishment has been completed in Autumn 2018 (Source: Routine Provider Information Request (RPIR) – Sites tab)
The trust had 36,450 surgical admissions from June 2017 to May 2018. Emergency admissions accounted for 2,619 (7.2%), 33,134 (90.9%) were day case, and the remaining 697 (1.9%) were elective.
(Source: Hospital Episode Statistics) Moorfields Eye Hospital (MEH) at Bedford Hospital is a satellite outreach service provided by MEH. The trust carry out day surgery for patients requiring surgical procedures such as cataract surgery. Patients are admitted to the MEH surgical unit on the day of surgery and their procedure is carried out under local anaesthetic. For patients requiring general anaesthetic, they are admitted to the host trust and are not within the scope of this report. Patients are pre- operatively assessed and discharged from the MEH day surgery unit on the day of surgery, which is attached to the operating theatre. During 2017/2018, Moorfields Eye Hospital (MEH) at Bedford surgery site undertook 2,691 operations. As part of our inspection, we visited theatre 7 and the waiting and discharge areas. We spoke with two consultants, one operating department practitioner four nurses, four health care assistants (HCAs) and five patients. We did not inspect the pre- operative assessment area. Pre- operative assessment took place in an outpatient setting within another part of the host trust. We did not inspect the ward or recovery areas within the host trust; this is because they are the responsibility of the other NHS provider.
Is the service safe? Mandatory training The service provided mandatory training in key skills to all staff and made sure most staff completed it. The trust had a corporate induction policy and mandatory training policy that was in date and reviewed regularly; this was last reviewed during March 2016. Staff could access induction training through electronic learning. The trust reported that 100% of staff at MEH at Bedford had completed trust induction and a local induction check list. The trust set a target of 80% for completion of mandatory training.
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Trust level
A breakdown of compliance for mandatory training courses from August 2017 to July 2018 at trust level for qualified nursing staff in surgery is shown below:
Staff Eligible Completion Trust Met Name of course trained staff rate Target (Yes/No) Counter Fraud 18 18 100% 80% Yes Fire Site Cover / Manager 22 22 100% 80% Yes Risk and Safety Management 2 2 100% 80% Yes Infection Prevention (Level 1) 170 171 99% 80% Yes Information Governance 167 171 98% 80% Yes Helping Visually Impaired People 165 171 96% 80% Yes Infection Prevention (Level 2) 162 171 95% 80% Yes Fire Warden 40 42 95% 80% Yes Conflict Resolution 160 171 94% 80% Yes Resuscitation Level 3 (Adult Immediate 80% Life Support) 33 36 92% Yes Resuscitation Level 3 (Paediatric 80% Immediate Life Support) 33 36 92% Yes Preventing Radicalisation - Basic Prevent 80% Awareness (eLearning L1&2) 156 171 91% Yes Adult Basic Life Support 149 171 87% 80% Yes Medicine management training 147 171 86% 80% Yes Preventing Radicalisation - Awareness of 80% Prevent (WRAP) 145 171 85% Yes Medical Gas Safety 138 171 81% 80% Yes Nurse Supply of Medicines 50 66 76% 80% No Recruitment and Selection 12 18 67% 80% No
In surgery, the 80% target was met for 16 of the 18 mandatory training modules for which qualified nursing staff were eligible.
A breakdown of compliance for mandatory training courses from August 2017 to July 2018 at trust level for medical staff in surgery is shown below:
Staff Eligible Completion Trust Met Name of course trained staff rate Target (Yes/No) Infection Prevention (Level 1) 52 52 100% 80% Yes Resuscitation 1 1 100% 80% Yes Counter Fraud 10 10 100% 80% Yes Fire Warden 1 1 100% 80% Yes Resuscitation Level 2 (Paediatric Basic 1 1 100% 80% Yes Life Support) Resuscitation Level 3 (Adult Immediate 4 4 100% 80% Yes Life Support) Page 59
Resuscitation Level 3 (Paediatric 4 4 100% 80% Yes Immediate Life Support) Information Governance 50 52 96% 80% Yes Infection Prevention (Level 2) 49 52 94% 80% Yes Conflict Resolution 48 52 92% 80% Yes Prescribing Practice and Formulary for 48 52 92% 80% Yes Medical Prescribers Resuscitation - Paediatric Advanced/European Life Support 16 18 89% 80% Yes (APLS/EPLS) Preventing Radicalisation - Basic Prevent 46 52 88% 80% Yes Awareness (eLearning L1&2) Helping Visually Impaired People 45 52 87% 80% Yes Resuscitation - Advanced Life Support 15 18 83% 80% Yes (ALS) Adult Basic Life Support 42 52 81% 80% Yes Recruitment and Selection 8 10 80% 80% Yes Preventing Radicalisation - Awareness of 41 52 79% 80% No Prevent (WRAP)
In surgery the 80% target was met for 17 of the 18 mandatory training modules for which medical staff were eligible.
All other sites A breakdown of compliance for mandatory training courses from August 2017 to July 2018 for qualified nursing staff in surgery at all other sites across the trust is shown below:
Staff Eligible Completion Trust Met Name of course trained staff rate Target (Yes/No) Conflict Resolution 6 6 100% 80% Yes Medicine management training 6 6 100% 80% Yes Infection Prevention (Level 2) 6 6 100% 80% Yes Counter Fraud 1 1 100% 80% Yes Helping Visually Impaired People 6 6 100% 80% Yes Medical Gas Safety 6 6 100% 80% Yes Preventing Radicalisation - Awareness of Prevent (WRAP) 6 6 100% 80% Yes Preventing Radicalisation - Basic Prevent Awareness (eLearning L1&2) 6 6 100% 80% Yes Recruitment and Selection 1 1 100% 80% Yes Infection Prevention (Level 1) 6 6 100% 80% Yes Information Governance 6 6 100% 80% Yes Adult Basic Life Support 5 6 83% 80% Yes
Across all other sites at the trust, the 80% target was met for 12 of the 12 mandatory training modules for which qualified nursing staff were eligible.
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(Source: Routine Provider Information Request (RPIR) – Training tab) Staff participated in training delivered both face to face and via electronic learning. Most nursing staff we spoke with were up to date with their mandatory training; nursing managers had good oversight of staff who still required training. We saw there were gaps in training in learning disability, recruitment and selection and risk and safety management mandatory training; this was due to staff absence or newly introduced training. We requested data on compliance of mandatory training specific to the surgery department at Bedford, however, the trust was not able to provide data specific to surgery staff. The data provided is for all staff at Moorfields Bedford. We saw evidence that most mandatory training was meeting the trust target in all core skills, for example infection control, safeguarding and basic life support (BLS). We saw evidence that most Moorfields mandatory training was meeting the trust target of 80%, for example duty of candour (86%), dementia (81%) and mental capacity act awareness (96%). However, there was training that was not meeting the trusts target, for example learning disability (77%), risk and safety management (33%) and recruitment and selection (69%). This represented a small portion of training that was not meeting the trust target. Learning disability training was recently introduced; the uptake for this training had not yet reached the target at the time of our inspection. Safeguarding Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. The trust set a target of 80% for completion of safeguarding training. Trust level
A breakdown of compliance for safeguarding training courses from August 2017 and July 2018 at trust level for qualified nursing staff in surgery is shown below:
Staff Eligible Completion Trust Met Name of course trained staff rate Target (Yes/No) Safeguarding Children (Level 3) 1 1 100% 80% Yes Safeguarding Children (Level 1) 168 171 98% 80% Yes Safeguarding Children (Level 2) 165 171 96% 80% Yes Safeguarding 157 171 92% 80% Yes
In surgery the 80% target was met for all four of the safeguarding training modules for which qualified nursing staff were eligible.
A breakdown of compliance for safeguarding training courses from August 2017 to July 2018 at trust level for medical staff in surgery is shown below:
Staff Eligible Completion Trust Met Name of course trained staff rate Target (Yes/No) Safeguarding Children (Level 1) 50 52 96% 80% Yes
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Safeguarding 49 52 94% 80% Yes Safeguarding Children (Level 2) 48 52 92% 80% Yes Safeguarding Children (Level 3) 20 22 91% 80% Yes
In surgery the 80% target was met for all four of the safeguarding training modules for which medical staff were eligible.
All other sites
A breakdown of compliance for safeguarding training courses from August 2017 to July 2018 for qualified nursing staff in surgery at all other sites across the trust is shown below:
Staff Eligible Completion Trust Met Name of course trained staff rate Target (Yes/No) Safeguarding 6 6 100% 80% Yes Safeguarding Children (Level 2) 6 6 100% 80% Yes Safeguarding Children (Level 1) 6 6 100% 80% Yes
Across all other sites at the trust, the 80% target was met for all three of the safeguarding training modules for which qualified nursing staff were eligible.
(Source: Routine Provider Information Request (RPIR) – Training tab)
Posters were visible in all surgical consultation areas to remind staff who the safeguarding leads were and how to contact them. As this satellite service was based within the host trust, the protocol for reporting was for staff to initially alert the host trust safeguarding team and then MEH safeguarding team for record keeping purposes. The host trust took the responsibility for MEH patients attending this site. The safeguarding policy was kept in a folder on the consulting desk within the theatres consultation area. We found it was complete and up to date. Staff were aware of the safeguarding policy, who to contact and when to alert the team. Staff were comfortable raising safeguarding concerns. They gave us an example of a safeguarding concern escalated to their manager, and safeguarding team. We were provided with examples of concerns staff would report as a safeguarding and the process they would follow. We requested safeguarding training completion rates for surgery staff only at Moorfields Bedford, however the trust was only able to provide site completion rates. At MEH at Bedford, 98% of clinical staff had completed level one safeguarding for adults, 94% had completed level two safeguarding for adults and 100% of staff requiring level three training had completed their training. Cleanliness, infection control and hygiene The service controlled infection risk well. Staff kept themselves, equipment and the premises clean. They used control measures to prevent the spread of infection. MEH had an infection prevention and control (IPC) link nurse within surgery. They attended IPC meetings and cascaded findings to the nursing divisional lead and the matron. They also produced a bulletin called ‘Bug Brief’ where any IPC issues and updates were written and sent out to all Page 62 surgery staff. We saw evidence that the ‘Bug Brief’ covered topics and updates on the trust’s flu campaign and a hand hygiene campaign. We saw evidence that the ‘Bug Brief’ alerted staff to updates in policies, such as the hand hygiene policy, measles vaccination policy, and linen handling and laundry policy. It also directed staff to upcoming training and conferences. All staff we met with and observed were bare below the elbows. We saw staff washing their hands after each patient, and once they had cleaned or sterilised equipment. Hand gel also used as appropriate. Consultants were observed washing their hands before and after each patient. The trust hand hygiene audit results showed 100% compliance between January and April 2018, and July 2018 and October 2018. The lowest hand hygiene audit showed 90% compliance in May 2018, which was lower than the trust target of 95%. The trust reported 100% compliance for the monthly cleaning schedule audit between January and October 2018. Moorfields worked with staff when compliance fell below the target. Clinical waste bins were available and used appropriately. Sharps bins were present in all consulting areas as well as inside the operating theatre. These were all labelled correctly, dated and signed. We noticed the lid on one of the sharps bins did not have its temporary lid completely closed. An audit from March 2018 showed that the surgery service was performing 100% compliance in meeting best practice guidelines in sharps management. This meant that we were assured that staff knew how to manage sharps bins and sharps materials in a safe way and knew how to mitigate risks associated with sharps. We observed the discharge lounge chairs and tables being cleaned with disinfecting wet wipes after each patient use. Disposable curtains were regularly changed and in date. The sink was visibly clean; it conformed to HBN 009 standards, and contained elbow taps. There was soap, hand gel and hand cream available. Paper towels were present for staff to use after washing their hands at the sink. All items were full and ready for use. The operating theatre was bright and visibly clean. The sinks conformed to standard. An operating chair was used instead of a trolley bed. Staff used a fluid absorption pad on the head rest of the chair to prevent infection between patients, and to trap any water used during the procedure to stop it wetting the patient’s clothing. The operating chair was wiped with disinfecting wipes between patients. We observed all theatre equipment being cleaned between each patient. There were generally two scrub nurses working within theatres on the same list. The nurses took it in turns to scrub in, therefore the other nurse could prepare and scrub in ready for the next procedure. Examination gloves and aprons were readily available for staff to use as required. We noted green ‘I am clean’ sticker pads on the wall in the discharge area, but did not see any in use on equipment. There was a sluice room to the side of the theatre. All waste from the theatre was taken to this location for disposal. The porters for the host trust were responsible for collecting the waste from theatres. At the end of each day, the theatre was cleaned by the host trust. Every six months the theatre was deep cleaned. Cleaning schedules were available and completed; MEH had a copy of these, however they fell under the responsibility of the host trust. This was the same for maintenance of the building standards. Page 63
The trust provided an audit for slit lamp decontamination for July 2018 for the surgery department at Bedford; they scored 100% compliance. The trust did not provide any other audit results for slit lamp decontamination. Infection control of the operating theatre was audited. Information provided by the trust for 31 August 2018, showed an overall score of 93% compliance. This was similar to the audit in 2017 which scored 94% compliance. The target for compliance is 85% or above. MEH Bedford undertook annual infection control audits for surgical site infection, isolation precautions, intravenous catheters, slit lamp, and hand hygiene facilities. These scored 100% in their audit between April 2018 to October 2018. Environment and equipment The service had suitable premises and equipment and looked after them well. The trust had use of one theatre at the host trust and this was shared with the host trust. Other types of surgery were carried out in the theatre, including dental and colorectal surgery. This was the same situation that we found during our last inspection during 2016. We were satisfied, after seeing appropriate documentation in 2016 that the situation had been risk assessed, environmentally tested and considered safe by MEH and the host trust. We were informed by MEH surgical staff that from December 2018 onwards, the operating theatre would be solely for MEH use, and the host trust would be moving their lists to another theatre. Equipment was either disposable and single use, or multi use. Multi use equipment that had been used was placed in large metal lockable storage cabinet outside the main theatre door. The trust had a service level agreement (SLA) with a third party to decontaminate used equipment and return this to the department. The trust had previously encountered problems with the surgical equipment decontamination company; they had found some of the items damaged. This had been rectified, and the third party had agreed to replace any items of equipment damaged during their decontamination process. MEH at Bedford hospital was a satellite service. This hospital was a considerable distance from the main MEH at City Road, London. The equipment used by the service was very specialised; the trust was aware of this issue, and mitigated equipment risks by ensuring there was adequate stock at least one week in advance of all surgeries, as well as having a large number of spare prepared surgical packs to cover all eventualities. If for any reason, an item of equipment was required but not available at the location, the trust was still able to get this couriered from MEH at City Road, London. At times, specialist intra ocular lenses (IOLs) were required that were outside of the normal stocked range. The senior sister would receive an email from the surgeon requesting the special lens. This was then ordered by the sister at least one week in advance of the surgery to ensure it arrived on time. Storage of equipment and consumables for theatres was based in the corridor next to the operating theatre. There were designated cupboards for MEH use. There were some shared storage cupboards between MEH and Bedford, and this had caused some tension between the staff of the two trusts. This had led to the colour coding of consumables in certain storage cupboards, to ensure each trust used and paid for their own items. There was one resuscitation trolley available within the department. This remained the responsibility of the host trust. It was kept in the host trust’s recovery room. It was easily accessible to the MEH theatre and available for use. In the corridor between all the theatres, there
Page 64 were two trolleys; one was a difficult airway trolley (adults) and a separate paediatric airway trolley. These were checked by either MEH or the host trust for compliance. There was a checking sheet attached to the trolleys, however there was no system in place for checking these; it was on a first come first served basis. The paediatric trolley was sealed; however, the adult trolley was open shelving and had no way to seal these. This meant the adult trolley could be used after checking and have items removed without anyone being aware of this. All equipment seen in consulting areas was visibly clean, had been serviced and portable appliance tested (PAT). No issues or problems had been reported by staff about equipment. Within theatres, the area comprised one small waiting area, separated by small divider and reception desk. The area nearest to the entrance door was where patients were greeted and checked in for their surgery. This contained wipe clean seats with arms and a television. There were also leaflets available. The reception desk was half way through the room on the left-hand side. Patients that had completed their surgery were taken to the back of the waiting area for post- operative care/recovery and discharge. This discharge area contained a work station for observations to be carried out both before and after surgery. This work station contained patient records, medications and the trusts policies and procedures. The waiting areas were small and cramped. Patients were encouraged to bring someone with them to their appointment, however there was not always enough space for this. There were three fridges within the waiting area. One was a drugs fridge, one was a sandwich and refreshments fridge (for patients post operatively or diabetic patients), and an ambient fridge for other medications. The service kept the drug fridge locked at all times. We saw evidence that fridge temperatures were monitored daily and recorded. Staff were aware of how to measure the fridge temperatures and what procedures to follow in the event the temperatures were not correct. We were given an example of when the temperatures for the drug fridge were incorrect, the process that the staff followed and how this was rectified; this included the disposal of medications that may have been affected by the incorrect temperature of the fridge. Theatre daily checklists were seen completed and signed; these included theatre temperature and fridge temperatures. Just at the entrance to the operating theatre, there was a bank of lockers available for patient use to store any valuables during their procedure. In July 2018, an assessment undertaken on behalf of the host trust for theatre ventilation showed a lower than the health technical memoranda (HTM) standard of air changes in the anaesthetic room. An action plan was put in place and the Moorfields infection control team were notified. Following interventions by the engineer from the host trust, it was reported that pressures were improved and the action was completed successfully. Assessing and responding to patient risk Staff completed and updated risk assessments for patients. They kept clear records and asked for support when necessary. All patients were assessed on the day prior to surgery. Observations were recorded pre- operatively to ensure there were no reasons for the procedure not to take place. Patients with diabetes were seen on the list, as appropriate. Consideration was taken into account for medication and eating times, to ensure the patient health was not compromised. Patients who had been in hospital over the past year, lived in a care home or had an open wound were screened for methicillin-resistant Staphylococcus aureus (MRSA). If a patient tested positive
Page 65 for this, they were placed last on the list for the day. Therefore, enough time was considered appropriate for the air changes and cleaning to take place to remove any contamination from the theatre before the next list. Patients were monitored, if required using the National Early Warning Score (NEWS) system. There were clear policy and guidelines placed within the post-operative area as to when and how this should be used. Monitoring equipment was available within the department for this purpose. Each patient was monitored again post operatively to ensure all baseline observations were within normal limits before the patient was discharged. The reception and waiting area were very small, therefore the receptionist, Band 5 nurse and nurse in charge were all available and able to monitor all patients with ease within the department, for any signs of deterioration. An audit of seven patients’ notes completed by the trust in June 2018, showed that NEWS documentation compliance had worsened from the previous year. However, the trust had an action plan in place to educate staff; the action plan was recorded as completed by the time of inspection. The service had emergency medical equipment and processes in place for deteriorating patients. There was an agreement with the host trust that staff could call the resuscitation team for emergencies. As part of the service level agreement, staff would take deteriorating patients to the host trust’s accident and emergency department for assessment and treatment. MEH at Bedford staff did not fill out (VTE) assessments for day case procedures in ophthalmology. This was only used for patients undergoing general anaesthetic (GA) under the host trusts clinical care. This is acceptable and compliant with guidelines. A system was in place to support patients after discharge. There was an emergency number they could call for out of hours advice, 24 hours a day, seven days a week. Patients could go to the Moorfields City Road site or another local NHS hospital as they shared the ophthalmic on-call rota with them. Discharge information given to the patient had contact details for both hospitals. There was a trust wide and local policy for major incident planning. Local risks identified included breakdown of theatre machinery, failure of biometry equipment and staffing shortages on the day of work. There was an action plan in place to mitigate risks of disruption to the service. The trust wide plan set out staff roles in case of a major incident. Prior to surgical procedures, staff used the World Health Organisation (WHO) “Surgical Safety Checklist and five steps to safer surgery”. We observed this being carried out during surgical procedures. The trust provided an audit for the WHO checklist; compliance was 100% in all areas except in answering the question: “Was the 'Sign In' prompt completed and in the correct order?” which was 90%. No action plan was received from the trust. Nurse staffing The service had enough nursing staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. The surgical department used an acuity tool to determine the number of staff required to provide patients with safe care and treatment. Managers maintained a list of nursing staff and skills they were competent to perform. This allowed managers to safely move staff to different clinical and non-clinical areas depending on the needs of the service. The MEH at Bedford surgery site did not use agency staff due to the specialist service it provided. They rarely used bank staff from other Moorfields locations because of their remote distance from
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other sites. They relied on their own staff to work additional shifts in the case of absences or gaps in the rota. The theatre aimed to have two scrub nurses on any given day. This allowed one scrub nurse to be in theatres, whilst the other nurse prepared for the next surgery. The trust has reported their staffing numbers below for March 2018 and July 2018. There was an under-establishment of qualified nursing staff in surgery across the trust. The lowest staff fill rate at July 2018 was seen at Moorfields at St. Georges, with the site having 12.9 WTE fewer nursing staff in post than they had planned for.
As at March 2018 As at July 2018 Planned Actual staff Planned Actual staff Site staff – Fill rate Fill rate - WTE staff – WTE – WTE WTE Moorfields Eye 148.6 134.3 90.4% 154.2 139.6 90.5% Hospital (City Road) Moorfields at St. 27.0 21.7 80.4% 35.6 22.7 63.8% George’s All other 5.0 6.0 120.0% 6.0 5.8 96.7% sites Total 180.6 162.1 89.8% 195.8 168.1 85.8%
(Source: Routine Provider Information Request (RPIR) –Total staff tab)
From August 2017 to July 2018, the trust reported a vacancy rate of 14.1% in surgery:
• Moorfields Eye Hospital (City Road): 12.1% • Moorfields at St. George’s: 25.3% • All other sites providing surgical services: 7.4%.
Vacancy rates for qualified nursing staff in surgery at the trust were higher than the trust target of 10%.
(Source: Routine Provider Information Request (RPIR) – Vacancy tab) We requested data for vacancies for surgery at Moorfields Bedford, however the trust was not able to provide us with surgery specific data. Vacancy rates for all qualified nursing staff at Moorfields Bedford was 7.1% which was lower than the trust target of 10%.
From August 2017 to July 2018, the trust reported a turnover rate of 3.4% in surgery.
• Moorfields Eye Hospital (City Road): 3.3% • Moorfields at St. George’s: 0.0% • All other sites providing surgical services: 23.3%.
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Turnover rates for qualified nursing staff in surgery at the trust were lower than the trust target of 15%. The high turnover rate reported for ‘All other sites’ seems high due to low numbers of staff.
(Source: Routine Provider Information Request (RPIR) – Turnover tab)
From August 2017 to July 2018, the trust reported a sickness rate of 6.7% in surgery:
• Moorfields Eye Hospital (City Road): 6.3% • Moorfields at St. George’s: 9.0% • All other sites providing surgical services: 4.7%.
Sickness rates for qualified nursing staff in surgery at the trust were higher than the trust target of 4%.
(Source: Routine Provider Information Request (RPIR) – Sickness tab) From September 2017 to September 2018, the Moorfields Bedford site reported a sickness rate of 6.6% which was similar to the trust average at 6.7%. Sickness rates for qualified nursing staff at Bedford was 9.57% which was higher than the trust target of 4%. The trust was not able to provide us with sickness rates specific to surgery staff at Moorfields Bedford.
The below table shows the bank and agency usage (hours) for qualified and non-qualified nursing staff in surgery from August 2017 to July 2018. For qualified nursing staff, the trust reported that 21.2% of available hours were filled by bank staff and 2.7% of available hours were filled by agency staff. For non-qualified nursing staff, the trust reported that 19.2% of available hours were filled by bank staff and 0.2% of available hours were filled by agency staff.
Bank usage is greater at Moorfields at St. George’s for both qualified and non-qualified nursing staff when compared to the average across the whole trust.
Total hours Bank Agency Unfilled Qualified 2,165 466 (21.2%) 59 (2.7%) 0 (0%) Non-qualified 604 116 (19.2%) 1 (0.2%) 0 (0%)
Moorfields Eye Hospital (City Road)
Total hours Bank Agency Unfilled Qualified 1,816 367 (20.2%) 45 (2.5%) 0 (0%) Non-qualified 457 75 (16.4%) 1 (0.2%) 0 (0%)
Moorfields at St George’s
Total hours Bank Agency Unfilled Qualified 324 92 (28.4%) 14 (4.3%) 0 (0%) Non-qualified 122 39 (32.0%) 0 (0%) 0 (0%)
*All other sites
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Total hours Bank Agency Unfilled Qualified 60 7 (11.7%) 14 (4.3%) 0 (0%) Non-qualified 24 2 (8.3%) 0 (0%) 0 (0%)
*Figures in the table relate to staffing in theatres at Moorfields at Croydon.
(Source: Routine Provider Information Request (RPIR) - Nursing bank agency tab) We were told that due to the specialty service provided by MEH, agency staff were not used. Instead, substantive staff would work bank shifts to cover any shortfalls. This meant qualified staff with knowledge in MEH procedures were always staffing the surgical unit. At MEH at Bedford, from April 2018 to October 2018, 7.9% of administrative and clerical shifts were covered by bank staff, less than 1% of shifts for theatre technicians were covered by bank staff and 4% of nursing shifts were covered by bank staff. No medical shifts were covered by bank staff. Medical staffing The service had enough medical staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. The trust has reported their staffing numbers below for March 2018 and July 2018. There was an under-establishment of medical and dental staff in surgery across the trust. At July 2018, there were 6.5 WTE fewer staff in post than the trust had planned for. Staffing data provided was only relevant to Moorfields Eye Hospital (City Road).
As at March 2018 As at July 2018 Planned Fill rate Planned Actual staff Fill rate Actual staff Site staff – staff – WTE – WTE - WTE WTE Moorfields Eye 49.5 46.1 93.1% 51.4 44.9 87.2% Hospital (City Road) Total 49.5 46.1 93.1% 51.4 44.9 87.2%
(Source: Routine Provider Information Request (RPIR) –Total staffing tab)
From August 2017 to July 2018, the trust reported a vacancy rate of 5.6% in surgery.
• Moorfields Eye Hospital (City Road): 8.2%
Vacancy rates for medical and dental staff in surgery at the trust were lower than the trust target of 10%. The trust has also reported that there was a total vacancy WTE of -10 for medical staff at St. George’s and this is the reason for the discrepancy between the vacancy rate reported for the trust overall and the vacancy rate reported for City Road.
(Source: Routine Provider Information Request (RPIR) – Vacancy tab)
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We requested data for vacancies for surgery at Moorfields Bedford, however the trust was not able to provide us with surgery specific data. Vacancy rates for qualified medical staff for MEH at Bedford was 18.5%, which is higher than the trust target of 10%. The trust had an action plan in place to mitigate this risk; there was a business case approved to have another glaucoma consultant in post. From August 2017 to July 2018, the trust reported a turnover rate of 7.4% in surgery. This turnover rate relates to the surgical services provided at Moorfields Eye Hospital (City Road) as no turnover data was provided for other sites at the trust. This is lower than the trust target of 15%.
(Source: Routine Provider Information Request (RPIR) – Turnover tab)
From August 2017 to July 2018, the trust reported a sickness rate of 0.5% in surgery. This sickness rate relates to the surgical services provided at Moorfields Eye Hospital (City Road) as no sickness data was provided for other sites at the trust. This is lower than the trust target of 4%.
(Source: Routine Provider Information Request (RPIR) – Sickness tab) From September 2017 to September 2018, MEH reported sickness rates for qualified medical staff at Bedford was 0.95%, which was lower than the trust target rate of 4%. The trust was not able to provide us with sickness rates specific to surgery for MEH at Bedford.
The below table shows the bank and locum hours for medical staff in surgery from August 2017 to July 2018. Across the trust, 9,949 hours were filled by bank staff and 859 hours were filled by agency staff. This usage was mainly at Moorfields Eye Hospital (City Road).
Location Total Bank Locum Unfilled hours Moorfields Eye Hospital (City Road) 102,918 9,949 (9.7%) 859 (0.8%) 0 (0%) Moorfields at St. George’s 0 50 0 0 Trust total 102,918 9,999 (9.7%) 859 (0.8%) 0 (0%)
(Source: Routine Provider Information Request (RPIR) - Medical agency locum tab) The trust told us 3,723 hours were filled by bank medical staff for MEH at Bedford this included outpatients department.
At June 2018, the proportion of consultant staff reported to be working at the trust was lower than the England average and the proportion of junior (foundation year one-two) staff was lower.
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Staffing skill mix for the whole time equivalent staff working at Moorfields Eye Hospital NHS Foundation Trust This England Trust average Consultant 43% 49% Middle career^ 34% 11% Registrar Group~ 19% 28% Junior* 4% 11%
^ Middle Career = At least 3 years at SHO or a higher grade within their chosen specialty ~ Registrar Group = Specialist Registrar (StR) 1-6 * Junior = Foundation Year 1-2, Other and Local HCHS Doctor Grades
(Source: NHS Digital Workforce Statistics) Records Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date and easily available to all staff providing care. We found patients’ medical records were stored in a cabinet inside the consulting room. The cabinet was closed but unlocked. This room was only used by theatre staff as an admin room and doubled as a consulting room for any pre- and post-operative checks made by the nurse or consultant. Patients were not left in the room unattended. Lists were run between two and three times a day. A number of patients were asked to attend at the same time, and then they were seen in a particular order. The records for patients being seen in the current clinic were kept within the post-operative recovery area on the top of the counter and desk in two separate piles. The patients waiting for discharge had their records and take-home medications waiting, with a yellow laminated sign reading ‘Private and Confidential’ placed on top of it. Files for patients waiting to have their procedure were laid out on the counter; each file had a yellow private and confidential A4 sheet placed at the front of it. They were not locked or placed away securely. Patients waiting could have access to the records, although at most times, a member of staff was present close by. We brought this to the attention of the matron and divisional lead nurse, and they were working on finding a safer solution to the storage of records at the time of our inspection. All the records we saw on our inspection showed consent had been obtained. Writing was clear and able to be understood. Documentation was signed and dated. Both paper records from MEH and the host trust had to be completed and placed in the patient record that remained with the host trust. Moorfields also kept computer records of surgical procedures The trust maintained good relationships with local optometrists. At the time of patient discharge, patients would receive a copy of their discharge letter. The trust also sent a letter to the patient’s
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GP and optometrist, to keep all medical professionals involved with the patients care up to date with their care plan. Patient records contained details of patients’ mental health, learning disability, autism and dementia status. This was indicated on the patient’s record by a butterfly sticker for patients living with dementia, and a helping hands sticker for patients requiring additional assistance. MEH staff managed the eye clinic services on behalf of the host trust and used the host trust’s computer systems. Staff could access records at Moorfields City Road if necessary. At the time of our inspection the MEH at Bedford site was not using the same electronic health record system as most of the trust. The trust had plans to update their electronic health record system so that the Bedford site could also access this. Access would allow pathology results to be available across the whole trust, and for full electronic prescribing. Medicines The service followed best practice when prescribing, giving, recording and storing medicines. Patients received the right medication at the right dose at the right time. The trust had a medicine management policy for patient group directives, which was reviewed in November 2018 and we saw that staff followed it. All the medicines seen on the inspection were in date and stored correctly. Drug fridges were available both in the theatre waiting area and within the theatre itself. The fridges displayed the temperature on the outside display and these were recorded daily. These fridges were locked at all times. Controlled drugs (CDs) were kept locked in appropriate cabinets within the department. We saw they were recorded appropriately and details logged in the CD book. There were patient group directives (PGDs) in place for the use and dispensing of medications. Staff were aware of the PGD, how it applied and where to find this. The PGD was seen and signed appropriately. Take home medications were prepared on the morning of the patients’ procedure, and ready for dispensing and collection at discharge. The medications were ordered in advance by the MEH department, and these were supplied by the host trust. There were no issues with obtaining the appropriate medicines from the host trust. They were always available and no issues had been reported by MEH staff. We observed patients being given their take home medications. The dosage and procedure was explained to both the patient and their relative by the nurse in charge. They made sure the patient understood the instructions and checked if the patient could administer their eye drops. For patients that were unable to administer their own eye drops, either their relative was given instructions or aids were provided to the patient. Incidents The service managed patient safety incidents well. Staff recognised incidents and reported them appropriately. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support. Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a
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From September 2017 to August 2018, the trust reported two incidents classified as never events for surgery. Both never events concerned a “surgical/invasive procedure meeting SI criteria”. Details of the two never events can be found below:
• 26/01/2018 Moorfields Eye Hospital (City Road) - Incorrect intraocular lens fitted during surgery. Following this, an exchange of lens took place with no further issues. • 21/06/2018 Moorfields at St. George’s – Patient attended Moorfields Urgent Care a few days after surgery complaining of an uncomfortable eye. It was identified that the patient would require a corrective procedure. Following corrective surgery, it was identified that an incorrect procure had been performed during the first surgery.
(Source: Strategic Executive Information System (STEIS))
All staff we spoke with during the inspection could tell us about the never events that had occurred at other locations. There were no never events in surgery at Bedford. They could explain learning that came from the incident and we were able to see how this had changed their practice as part of the trust team. This was evidence that staff had learned from the event and passed that learning throughout the trust team. We were shown paperwork used as evidence of the changes made since the never event.
In accordance with the Serious Incident Framework 2015, the trust reported three serious incidents (SIs) in surgery which met the reporting criteria set by NHS England from September 2017 to August 2018. Of these, the most common types of incident reported were:
• Surgical/invasive procedure incident meeting SI criteria with two (67% of total incidents). • Treatment delay meeting SI criteria with one (33% of total incidents).
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Site specific information can be found below:
• Moorfields Eye Hospital (City Road): two incidents • Moorfields at St. George’s: one incident
(Source: Strategic Executive Information System (STEIS)) Incidents were reported on the trust-wide electronic reporting system; this facilitated staff reporting incidents and allowed effective monitoring. Staff we spoke with could identify incidents that would be reported and how to report them. Incidents would be reported to both the host trust via their incident reporting system and to MEH own incident reporting system; this allowed for continuity and sharing of learning across the site. Staff confirmed they received feedback from incidents reported during staff meetings, clinical governance meetings, and by email. Recently, the trust’s quality team released a bulletin for shared learning across all the trust’s sites. The bulletin contained information and, themes learned from incidents, and peer reviews across the trust’s sites. Safety thermometer The service used safety monitoring results. The Safety Thermometer is used to record the prevalence of patient harms and to provide immediate information and analysis for frontline teams to monitor their performance in delivering harm free care. Measurement at the frontline is intended to focus attention on patient harms and their elimination.
Data collection takes place one day each month – a suggested date for data collection is given but wards can change this. Data must be submitted within 10 days of suggested data collection date.
Data from the Patient Safety Thermometer showed that the trust reported no new pressure ulcers, no falls with harm and no new catheter urinary tract infections from August 2017 to August 2018 for surgery.
(Source: NHS Digital) MEH does carry out venous thromboembolism (VTE) assessments for surgical patients. Pressure ulcers were only relevant for patients attending with current ulcers, as the time in surgery was approximately 30 minutes, therefore not long enough for a patient ordinarily, to develop a pressure ulcer.
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Is the service effective? Evidence-based care and treatment The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance. During the pre-operative assessment, patients had the eye for the procedure marked to show the surgical site. This was standard procedure. Moorfields at Bedford participated with the host trust to collect data for the Commissioning for Quality and Innovation (CQUIN) scheme, which is intended to deliver clinical quality improvements and drive transformational change. Data provided on the CQUIN scheme for NHS electronic- referrals from November 2016 to June 2017 showed that they did not meet their target of 4% by September 2017. Following the inspection the trust told us the information relates to the whole of Bedford Hospital and Moorfields did not have any appointment slot issues (AIS). Staff were notified of new guidance and changes through staff meetings and clinical governance meetings. The link nurse would inform staff of updates to evidence-based care by local team meetings or posters. They also developed a document called a ‘Bug Brief’ which was used to inform staff of infection prevention and control (IPC) changes on a quarterly basis. The MEH at Bedford site, along with the host trust, underwent a ‘Getting It Right the First Time’ (GIRFT) observation, to identify areas of unwarranted variation in clinical practice and/or divergence from best practice. The findings showed there was an excellent relationship between the host trust and MEH at Bedford, and an excellent relationship between clinical and managerial staff. There was good use of theatre time and good use of community optometry and innovative practice. The GIRFT observation also recommended some actions to improve patient flow, the service quality, and patient outcomes. The standard for posterior capsular rupture (PCR) in cataract surgery was set at less than 1.95% and the rate for MEH at Bedford was 0.68% in 2016/2017. The target for infectious endophthalmitis after cataract surgery was set at less than 0.08%. The rate for MEH at Bedford was 0.0% in 2016/2017. There was no national patient reported outcome measures (PROMs) for cataract surgery. However, the trust undertook an assessment of the performance of general ophthalmology at MEH at Bedford from October 2017 to December 2017. In a survey of 37 patients, 86.5% said their symptoms were better or much better/cured. There was an action plan devised from the results to re-audit in a year, and to disseminate the results to the team at Bedford. The standard for good vision after cataract surgery is greater than 90%; MEH at Bedford reported an outcome of 90% for 2016/2017 which was an improvement from 87.9% in 2015/2016. The trust provided audit information for cataract surgery outcomes for 2017 for MEH at Bedford surgery. There were 2025 cataract operations during 2017, with no operative complications in 96.5% of cases. This is better than the national average of 95%. There were no post-operative complications in 86% of cases which is better than the national average of 85%. The trust provided audit information for entropion and ectropion for MEH at Bedford for 2017/2018. It showed entropion success rates were 100%, which is better than the standard of 95%. The success rates for ectropion surgery were 100%, which was better than the standard of 80%. The trust provided audit information for Dacryocystorhinostomy (DCR) surgery for MEH at Bedford for 2017/2018. Results showed that 36 of 37 operations were successful (97.3%), and only one
Page 75 was non-successful (2.7%). Of the 37 operations, 10 were carried out by endonasal and 27 carried out externally; there was one complication with internal scarring. This was an improvement from 2014. The trust provided audit information from ptosis surgery from November 2015 to November 2016 which showed success rates of 96%; this was higher than the national standard of 57%. Following this audit, MEH at Bedford put in place an action plan to re-audit ptosis surgery in a year. We saw evidence of this. The trust provided audit data from April 2017 to April 2018 which showed a 97.5% success rate; this was better than the 2016/2017 standard of 85%. The trust had an action plan to re-audit in one year to demonstrate they were able maintained their standards. Safety and efficacy of an intracameral mydriatic injection was audited. Results showed that there were 13 injections performed by a single surgeon between March 2017 to May 2017. There was an overall success rate of 70% in all patients, with 100% success rate in three out of 13 patients who had a pre-operative large pupil. An action plan was in place to continue with the standard mydriatic eye drops until further data was collected on the intracameral mydriatic. This action plan also requested data comparisons on outcomes with pre-operative insertion of a mydriatic pellet into the lower eye lid versus the specific intracameral drug trialled prior to any changes being made. Nutrition and hydration Staff gave patients enough food and drink to meet their needs. The service adjusted for patients’ religious, cultural and other preferences. All patients could eat and drink as normal prior to their surgery, unless they were being sedated or having a general anaesthetic (GA). Those patients were admitted to the host trust surgical ward and are not within the remit of this report. Patients undergoing local anaesthetic were offered refreshments within the department and able to visit the host trust restaurant as required. This was based almost opposite the MEH theatre reception entrance. After all procedures, patients were offered light refreshments; if it was lunchtime onwards, or the patient had any medical conditions such as diabetes, they were offered a sandwich. In the event the patient had dietary requirements that could not be catered for within the department, staff were able to obtain suitable refreshments. Pain relief Staff assessed and monitored patients regularly to see if they were in pain. They did have a have suitable assessment tools for those unable to communicate, however staff were unaware of this tool and how to use it. Patients were given topical local anaesthetic prior to their procedure. Pain was scored on a scale of one to ten; patients living with dementia or with learning difficulties had a hospital passport provided by the host trust. This passport identified how patients may be able to express their pain levels, however none of the MEH at Bedford staff were aware of this document or how to use it. After surgery, patients were still feeling the effects of the local anaesthetic, therefore they were not generally in pain. Patients were advised to take paracetamol if they were in pain post procedure and once at home. Patient outcomes Managers monitored the effectiveness of care and treatment and used the findings to improve them.
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There were no emergent ophthalmic readmissions for MEH Bedford surgery patients within 30 days of their procedure for the period between November 2017 and October 2018. Emergency readmission rates for MEH at Bedford surgery patients within 30 days for non-ophthalmic complication ranged from 0.4% to 1.6% from November 2017 to October 2018. Trust level Elective Admissions – Trust Level
Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 is represents the opposite. Top three specialties for specific trust based on count of activity
From May 2017 to April 2018, patients at the trust had a higher expected risk of readmission for elective ophthalmology admissions when compared to the England average. We note that due to the specialist nature of the care and treatment provided by the trust those figures are not fully comparable and are not used to form any judgments.
Non-Elective Admissions – Trust Level
Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 is represents the opposite. Top three specialties for specific trust based on count of activity
From May 2017 to April 2018, patients at the trust had a higher expected risk of readmission for non-elective ophthalmology admissions when compared to the England average. We note that due to the specialist nature of the care and treatment provided by the trust those figures are not fully comparable and are not used to form any judgments.
(Source: Hospital Episode Statistics - HES - Readmissions (01/05/2017 - 30/04/2018)) Competent staff The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service. From August 2017 to July 2018, 70.8% of staff within surgery at the trust received an appraisal compared to a trust target of 80%.
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Target Individuals Appraisals Completion Trust Staff group met required complete rate target (Yes/No) Qualified Allied Health 18 16 89.9% 80% Professionals (Qualified AHPs) Yes Medical & Dental staff - Hospital 44 36 81.8% 80% Yes Qualified nursing & health 171 117 68.4% 80% visiting staff (Qualified nurses) No Support to ST&T staff 60 40 66.7% 80% No NHS infrastructure support 5 2 40.0% 80% No Grand Total 298 211 70.8% 80% No
All other sites
From August 2017 to July 2018, 84.4% of staff within surgery at all other sites at the trust received an appraisal compared to a trust target of 80%.
Target Individuals Appraisals Completion Trust Staff group met required complete rate target (Yes/No) Qualified nursing & health 6 6 100.0% 80% Yes visiting staff (Qualified nurses) Qualified Allied Health 1 0 0.0% 80% No Professionals (Qualified AHPs) Grand Total 7 6 85.7% 80% Yes
(Source: Routine Provider Information Request (RPIR) – Appraisal tab) The corporate induction policy recognised that all new staff, including bank staff, required general and specific induction to the trust and their work area. Managers were required to evidence that all staff had received a local induction. We asked MEH to provide appraisal rates for MEH at Bedford staff, however the trust was not able to break this down for surgery staff only. Completion rates for all MEH Bedford staff of annual appraisals was 86% which met the trust target of 80%. The trust had an up-to-date policy on medical revalidation and appraisals, to confirm registered doctors were practicing in accordance with the General Medical Council (GMC) regulations. The trust required all doctors to undergo an annual appraisal by an appraiser that was familiar with their area of expertise. The trust was proactive in training and furthering staff education. They were aware that they were based far from the main City Road site in London, and that staff were not easily able to cover shortfalls in cover at short notice. To help mitigate this risk and circumstance, the management team at MEH at Bedford Hospital had started to train their staff across the various disciplines required to continue smooth running of the department. This meant staff were multi-skilled and could work both in theatres as well as outpatients. There were other examples where administrative staff could work across the department. The trust devised an equality and diversity training plan. Training was conducted by e-learning for equality and diversity level 1; training had Page 78 been completed by 98% of MEH at Bedford staff. Managers were working to ensure all new staff were aware of issues facing their patient population group and could guide them in all settings. Multidisciplinary working Staff of different kinds worked together as a team to benefit patients. Doctors, nurses and other healthcare professionals supported each other to provide good care. Senior managers were involved in joint training with the host trust to improve planned care. The trust maintained good relationships with the local community. Senior managers were part of the non-prescriber board, liaised with Healthwatch, worked with the clinical commissioning group (CCG) for the eyecare steering group and communicated with infection control with Bedford County Council. The trust employed an Eye Care Liaison Officer (ECLO) five days a week for MEH at Bedford. The ECLO worked with patients to signpost them to community resources such as the sight concerns group. The ECLO aided patients in obtaining resources they needed, such as low vision aids. Additionally, the ECLO referred patients to patient support groups such as the macular degeneration support group. There were plans in place to work with the glaucoma patient support group in early 2019. The ECLO maintained relationships with other ECLOs across the trust, and attended the ECLO forum. This meant that the ECLO would be able to collaborate with other satellite sites to improve practice at the Bedford site. Seven-day services MEH theatre opening hours were Monday to Friday 7.30am until 6pm. There were some Saturday clinics to cope with demand if required. There was no seven-day service at this satellite site. There was an out of hours telephone line open to all patients that had undergone surgery. This was staffed by another local trust alongside MEH. Patients could attend a sister trust if they needed to be seen out of hours, by the on-call ophthalmologist or their team. The trust had a nurse led helpline that was available 9.00am to 9.00pm Monday to Friday and 8.30am to 5.00pm on Saturday which was staff by ophthalmic nurses. Health promotion The trust conducted health promotional events. An example given was for eye drops. A team from the main site attended the host trust at regular intervals, especially when a glaucoma clinic was taking place, to give advice to patients on administering eye drops. They were also able to give out aids to patients that were finding self-administration difficult. Consent, Mental Capacity Act and Deprivation of Liberty Safeguards Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. They followed the trust policy and procedures when a patient could not give consent. The trust reported that from August 2017 to July 2018 Mental Capacity Act (MCA) training was completed by 74.6% of staff in surgery compared to the trust target of 80%.
Met Staff Eligible Completion Trust Name of course (Yes/ trained staff rate Target No) Mental Capacity Act Awareness (e- learning)* 240 306 78% 80% No
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Mental Capacity Act Level 1** 194 276 70% 80% No
The breakdown by site was as follows:
All other sites
Met Staff Eligible Completion Trust Name of course (Yes/ trained staff rate Target No) Mental Capacity Act Level 1** 7 7 100% 80% Yes Mental Capacity Act Awareness (e- learning)* 7 7 100% 80% Yes * Following fac-ac it is noted that this course relates to MCA Level 1 training ** Following fac-ac it is noted that this course relates to MCA Levels 2&3 training.
There was no specific training module available for deprivation of liberty.
(Source: Routine Provider Information Request (RPIR) – Training tab)
We reviewed patient records and found all consent forms were completed in line with MEH trust policy. They were signed and dated appropriately and retained in the patient’s records. We also observed the process of several patients being given appropriate information and consenting to their procedure. The trust had a system whereby certain nurses had been trained to take the patient through the consent process at their initial pre-operative appointment. All relevant information was given to the patient about their procedure, and information leaflets were presented to the patient for further consideration and to provide time for them to digest the details. This gave the patient time to ask any questions prior to their surgery. The trust had policies on consent, caring for patients with dementia, learning disability, and Mental Capacity Act and Deprivation of Liberty safeguards which were all up-to-date and reviewed regularly. Nurse consenters had a process in place to note if a patient did not have the mental capacity to consent at pre-assessment. In these cases, the nurse would put a marker on the computer record to alert the theatre medical team and consultant. These patients had to be consented by the consultant. Is the service caring? Compassionate care Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. The Friends and Family Test response rate for surgery at Moorfields Eye Hospital NHS Foundation Trust was 26% for July 2018. The friends and family test performance between April 2018 and June 2018 showed that of 281 patients between 96.3% and 100% said they would recommend the service. In July 2018 to September 2018, over 99% of patients said they would recommend the service.
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We observed staff being kind and compassionate to patients on several occasions. Staff talked patients through every step of the post-operative period and explained what was happening. Patients we spoke with told us that staff, overall were excellent and were very kind, knowledgeable, and courteous. Staff members were understanding and non-judgemental of patients with learning disabilities, dementia and mental health issues. Staff discretely identified vulnerable patients and made allowances for extra time whilst they were within the surgery department. Staff maintained patient’s privacy and dignity by using curtains. As the clinic area, waiting area and post-operative area were very close, staff would speak in low voices so other patients or their family and carers could not over hear. Patients told us they felt staff maintained their privacy and dignity and felt respected whilst using the service. During the pre-operative assessment, staff explained to patients that during their procedure, the theatre staff and consultant may talk between themselves; it was also explained this was done to ensure the correct procedure was taking place, for the correct patient, with the correct equipment and at the correct site. Patients told us this made them feel more comfortable and at ease. Emotional support Staff provided emotional support to patients to minimise their distress. Some patients were given bad news during their appointment at the hospital. An eye care liaison officer (ECLO) was available to see these patients and offer them advice, guidance and practical assistance to help them manage their condition. The ECLO had links with local and national charities that could support patients through their condition; based within the department, support was available Monday to Friday during the clinic hours. If a patient was to receive difficult news staff took them into a private room where they had peace and quiet and privacy. They were also given time to ask any questions that may have had. We observed staff supporting patients to relieve their anxiety in theatre by reassuring them and taking time to listen to them. Understanding and involvement of patients and those close to them Staff involved patients and those close to them in decisions about their care and treatment. Patients were encouraged to bring a relative or friend with them to their appointments. We spoke with five patients and their family members or carers; they were very positive about their care and treatment by the surgical team. Patients commented “very thorough” and “treatment was very good”; however, patients did say that waiting times and staffing levels could be improved. A patient’s relative said they “felt well cared for” and “the chairs were comfortable”. All patients we spoke with said they felt involved in their care planning and understood the procedure they were having. They told us they received high quality information in a format they could understand. Staff encouraged patients and their families or carers to use the health passport documentation for patients with learning difficulties or dementia. This helped staff to understand the patient’s preferences without having to ask the patient each time they visited the department. Patients we spoke with said that they were involved and understood their care most of the time. However, patients waiting to go into surgery told us on multiple occasions that they did not
Page 81 understand why some patients received eye drops or pellets for pupil dilation. This misunderstanding made some patients more anxious about the care they received. Staff worked with vulnerable patients to arrange appointments that were most suitable to their needs. We observed staff placed these patients at the start of the list to minimise their time in the surgical unit. Staff also arranged for patients who needed to have their eye pressures measured following surgery to have them checked within the clinic on the same day as surgery, to minimise the stress of a return appointment. Is the service responsive? Service delivery to meet the needs of local people The trust planned and provided services in a way that met the needs of local people. When demand required, Saturday clinics were run by MEH to reduce waiting lists. Patients arrived at two separate times throughout the day during clinic times, Monday to Friday. On Wednesdays, the services had three theatre lists, meaning that patients could have surgery later in the day if it was more convenient. Patients were seen and pre- operatively assessed. The theatre team met for two briefings daily before each list began. At this briefing, the order of the list was decided and each patient informed of this. The waiting area and discharge area were small and cramped. Patients were told to arrive at set times for pre- assessment prior to their surgery. This meant between six and eight patients arrived at the same time with a relative or friend. At times, there was not enough seating within the area for all arrivals to sit. The arrival times were not staggered, therefore all patients for morning or afternoon surgery arrived at the same time. The discharge area was approximately the same size, however this area was less crowded; patients would come out of surgery, one at a time, with a time gap of at least 30 minutes. This meant the discharge of patients was staggered and no issues of overcrowding were present. The trust provided us with theatre utilisation time, which can be an indicator for efficiency of the service. In 2018/2019, theatre session utilisation was 96%, this is increased from 2017/2018 when it was 92%. Meeting people’s individual needs The service took account of patients’ individual needs. Patients were admitted to the MEH theatre department for their surgery. They were encouraged to bring a relative or friend with them for support and to assist them post procedure. The patients’ relative or friend could wait within the waiting area for the patient to return from their surgery and then could accompany them to the discharge area. All patients and their relatives or friends were offered light refreshments whilst waiting for their procedure and post operatively. The surgical team met before each list to discuss the cases they were about to see. Once a patient order had been established, the patients were informed; they were also kept up to date if any delays occurred. Due to the nature of the waiting/discharge area being combined, there was a lack of privacy for patients and their relatives. Discharge discussions took place in the discharge area at the back of the main waiting area; this was open and discussions could be heard across the room, especially if a patient had hearing difficulties and staff had to speak louder. This situation was the same as when we inspected the department in 2016. There was a consultation room opposite the theatre that could be used for more private conversations if required.
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Diabetic patients were placed in an appropriate place on the list, to take into account of their nutritional status. This was to ensure they could safely maintain their sugar levels and take any medication or regular meals they required. Patients with bariatric needs were catered for with appropriate chairs in the waiting room and wheelchairs for transportation via porters. Trolley beds were available for surgical procedures to support the patient appropriately during surgery and through their initial recovery. During initial pre-operative assessment, patients are checked for any positioning difficulties. A reminder was sent to the team a minimum of one week prior to surgery; this allowed time for the trust to ensure any mobility aids such as hoists were available for the patient at the time of their appointment. The administrative staff also had a list of patients to call each week to remind them to stop taking certain medications prior to surgery. Patients with learning difficulties, dementia or mental health issues were placed on the list at an appropriate time to match their needs. An example was given where a patient suffering with dementia was placed on the list after 10am, as those caring for the patient informed staff of the patient’s routine. With dementia it can be important to keep to a routine to assist the patient. The hospital had a flagging system to alert staff if patients had additional needs. For dementia patients, a purple butterfly sticker was placed on the cover of the patients’ records. For vulnerable patients, those with mobility problems, learning difficulties or mental health issues, a sticker showing hands was placed on the cover of the record. The hands denoted ‘helping hands’, so that staff knew these patients may need extra time, increased assistance or other forms of help through their visit to the hospital; it also alerted staff to patients with additional needs who required specific equipment to be available for their appointment. Patients with learning difficulties were encouraged to have a relative or carer with them throughout their visit. This was to help keep them calm and help them to understand the procedure, and to allay any unnecessary worry and stress. If a patient did not have a relative or next of kin and did not have the capacity to make decisions, the department held a best interest meeting regarding the patient prior to the procedure. The consultant would discuss the patient with the team and those involved with the patients care in their home setting, before any decisions were made. Patients with learning difficulties or communication needs could also use a hospital passport. This document travelled with the patient throughout any hospital or clinic visit. There was a section that showed the health care professional how to identify if the patient is in pain. This tool was provided by the trust for staff to identify pain in vulnerable patients. Patients living with dementia were seen on the list at a time that best suited their daily lives. Some patients would not be ready to leave their home before 10am as this was their routine. To enable as little disruption as possible, the team booked the patient in at a time that was most appropriate. Each dementia patient had a ‘passport’ and was seen for their procedure under GA with their carer or relative present. These patients were always admitted to the host trusts surgical ward and remained under the care of the host trust. If the patient did not have a carer or relative, the trust had a mental capacity advocate present to assist in making decisions for the patient’s best interests. The administrative team kept a separate list of patients that had been accepted for surgery and were able to attend the department for their procedure at short notice. These patients were alerted to any short notice cancellations, and asked if they wished to attend in advance of their arranged appointment. This reduced the time patients were on the waiting list. Patients that had communication problems were catered for. Translators were booked in advance of the patient’s appointment or procedure to ensure smooth running of the list and less risk of Page 83 delays. Interpreters were also available for patients with hearing problems. The trust also had access to a telephone translation service for any eventuality where these services were required as an emergency or for any unexpected situation. Patients requiring either of these services were identified at their initial appointment and pre-operative assessment prior to being referred for surgery. Some leaflets were also available in in multiple languages. Staff at MEH Bedford could request documents to be printed in Braille from the main Moorfields site, although the trust informed us they had not been requested for many years. When we last inspected MEH at Bedford Hospital in 2016, we found the lack of signage to the MEH department difficult for patients to navigate. During this inspection, we observed a change in signage; this being predominantly on the main directional boards within the host trust. All the MEH signage was black writing on a yellow background, so that it stood out for those with sight impairment. We did find locating the theatre reception was still difficult, as it was an entrance door behind an alcove, making it easy to walk past. If you walked from the other direction, it became visible as the door contained two yellow signs. In the corridor just in front of the door was a very small hanging yellow sign to indicate the entrance, however this was not very noticeable due to its position and size. Some patients found it difficult to self-administer their own eye drops. In this event, an auto dropper was provided to the patient with an explanation as to how to use the aid. Access and flow People could access the service most times when they needed it. Waiting times from referral to treatment were mostly in line with good practice. The average length of stay of a patient undergoing day case surgery was approximately 4 hours and 45 minutes. Patients were requested to attend the hospital at specific times; these were set for once in the morning and once in the afternoon for respective lists. All patients arrived at the designated time. This could mean between six to eight patients arrived with their relatives at the same time. Patients were seen in a specific order as decided by the surgical team dependent on patient needs and procedure, and infectious status. Once the order of the list was set, patients were made aware of their queuing status and kept informed. Due to the nature of surgery, some cases took longer than expected, therefore the length of time in the department varied for each patient. Post operatively, once patients had their observations taken, been provided with refreshments, information about their procedure, medications and discharge information, they were free to leave the department. On occasions, some consultants staggered the start times of their lists, therefore patients had less waiting time in the department. This was dependent upon the consultant and how they decided to run their list. The trust said they had a whiteboard where waiting times were kept up to date. We did not see this on our inspection and patients were not aware of this updating tool. Trust Level – elective patients
From June 2017 to May 2018, the average length of stay for elective patients at the trust was 1.8 days, which is lower compared to the England average of 3.9 days.
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Note: Top three specialties for specific trust based on count of activity.
The average length of stay for ophthalmology elective patients at the trust was 1.8 days, which is as expected compared to the England average of 1.9 days.
Trust Level – non-elective patients
The average length of stay for All non-elective patients at the trust was 0.2 days, which is lower compared to the England average of 4.9 days.
Note: Top three specialties for specific trust based on count of activity.
The average length of stay for Ophthalmology non-elective patients at the trust was 0.2 days, which is lower compared to the England average of 1.8 days.
(Source: Hospital Episode Statistics)
From August 2017 to July 2018, the trust’s referral to treatment time (RTT) for admitted pathways for surgery was better than the England average. Over the 12-month period, the trust performance ranged from 77.4% to 84.4%, which compares to the England average range for the same period of 64.6% to 71.5%.
In the most recent month, July 2018, 81.5% of admitted pathways at the trust were completed within 18 weeks for surgical pathways. This compares to the England average of 67.0%.
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(Source: NHS England)
The trust target for RTT was 90% for admitted patients. Between January 2018 and September 2018, the trust met their target four out of nine times with an average of 93.8%. The months they met their target were: January, February, April and May. On the months where they didn’t meet the target, the average was 88.2%. The trust target for completion within 18 weeks was 92%. However, between April 2018 and October 2018, MEH at Bedford did not meet this target; the average completion rate was 87.2% during this time. The trust provides surgical services for ophthalmology only. The trust was above the England average for RTT rates (percentage within 18 weeks) for admitted pathways within ophthalmology surgery.
Specialty grouping Result England average Ophthalmology 82.2% 68.5%
From November 2017 to October 2018, the average cancellation rate for MEH Bedford surgery was 5.8%. In the same time period, the re-booking rate within 28 days was 100%. A last-minute cancellation is a cancellation for non-clinical reasons on the day the patient was due to arrive, after they have arrived in hospital or on the day of their operation. If a patient has not been treated within 28 days of a last-minute cancellation then this is recorded as a breach of the standard and the patient should be offered treatment at the time and hospital of their choice.
With exception to Q1 2017/2018, the number of cancelled operations at the trust as a percentage of elective admissions has been similar to the England average for the period July 2016 to June 2018. In Q1 2017/18 the trust cancelled 177 surgeries, which was a large increase from the previous quarter where the trust only cancelled 38 procedures.
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Cancelled Operations as a percentage of elective admissions - Moorfields Eye Hospital NHS Foundation Trust
Over the two years, the percentage of cancelled operations at the trust that were not treated within 28 days has been below the England average. In the most recent quarter (Q1 2018/2019), 9% of cancelled operations were not treated within 28 days (from 85 cancelled surgeries). This was a sharp increase from the previous quarter, where 0% of cancelled operations were not treated within 28 days.
The trust had a system in place to prevent gaps within the theatre list. At pre-assessment at the start of the week, staff asked patients if they would be willing to be put on a contact list to be called on the day of surgery or at short notice. We talked to one patient whose appointment was cancelled in the morning and rescheduled for the afternoon. Percentage of patients whose operation was cancelled and were not treated within 28 days - Moorfields Eye Hospital NHS Foundation Trust
(Source: NHS England) The trust had an up-to-date policy in place for patients visiting MEH at Bedford requiring emergency care; they were referred to the host trust’s emergency department. Staff told us about a time where a patient had become unwell before surgery and they transferred them to the host trust’s emergency department.
Learning from complaints and concerns The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff. The trust had a complaints policy that was up-to-date; they aimed to process responses within 25 working days. The trust would send a holding letter if a final response was not possible within the 25-day time frame. Page 87
All members of staff within MEH at Bedford hospital could explain the duty of candour, the steps that are taken and how it is used. They were not able to provide an example as to when this had been used at the satellite location. The main complaints received from patients visiting the trust were waiting times in clinic after their arrival for their procedure, and appointment cancellations. We requested average waiting times for patients, however, this was not provided by the trust. From 7 August 2017 to 6 August 2018 there were 29 complaints about surgery trust-wide. The trust took an average of 22.8 days to investigate and close complaints, this is in line with their complaints policy, which states complaints should be completed within 25 working days. Across the trust, a high proportion of complaints received in surgery (75.9%) related to clinical treatment. A breakdown of complaints by site can be found below.
Moorfields Eye Hospital (City Road): There were 13 complaints (44.8%), eight of these related to clinical treatment and three related to admissions and discharge.
Moorfields at St. George’s: There were six complaints (20.7%), five of these related to clinical treatment.
All other sites: There were 10 complaints in total.
(Source: Routine Provider Information Request (RPIR) – Complaints tab)
There were nine complaints between November 2017 to November 2018 for the surgery department for MEH at Bedford. Most complaints were dealt with informally. We reviewed two complaints and saw evidence that complaints were fully investigated and responses were sent within agreed time frames. We also saw evidence of learning and were assured that learning was disseminated to staff. Patients found waiting times were an issue, however they were happy to wait due to the specialist nature of the service. Not all patients we spoke with were aware of the complaints procedure. There were information leaflets in the pre-operative area on how to make a complaint to the service. The trust had a program called ‘You said, we did’, where the trust made changes based on patients’ complaints. For example, patients wanted flexibility to leave the day care unit whilst waiting for their surgery; they wanted to visit the restaurant or go outside. In response, the service started a process of informing patients about the progress of the theatre list and where they were situated on the list.
From 6th August 2017 to 6th August 2018 there were 45 compliments within surgery. A breakdown by site can be found below.
Location Number of compliments Moorfields Eye Hospital (City Road) 9 Moorfields at St. George’s 1 Moorfields at Bedford 10 Trust- wide 20 All other sites 5
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Total 45
Due to the nature of the data provided we are unable to comment on any themes relating to the compliments received. The trust has reported that:
“The compliments we receive focus on the standard of clinical care provided, with patient’s treatment meeting expectations and clinical outcomes being positive. Patients also compliment the care provided by individual members of staff, highlighting their kindness, professionalism and caring attitude which helps patients feel they are being treated personally. Many people comment that caring staff and the calm environment reduces their anxiety.”
(Source: Routine Provider Information Request (RPIR) – Compliments tab) There were 10 thank you cards received from MEH at Bedford patients. Management uploaded thank you cards and letters onto the computer system and emailed them to the employees. Is the service well-led? Leadership Managers at all levels in the service had the right skills and abilities to run a service providing high-quality sustainable care. MEH at Bedford surgery came under the Moorfields North division. The leadership team consisted of two joint divisional directors, the divisional manager and the divisional head of nursing. There was also a clinical director and assistant general manager for the Bedford site. The Moorfields North division was under the direction of the Chief Operating Officer (COO) who was led by the Chief Executive Officer (CEO). Clinical governance meetings and operational meetings for MEH at Bedford came under the quality forum for the Moorfields North divisional board. This meant that the Moorfields North divisional board had oversight for the north division which facilitated learning across sites. The trust leadership had a plan in place for a trust director to visit MEH at Bedford quarterly. However, staff we spoke with said the leadership team were not visible within this site. Staff told us that whilst nursing management was visible in the surgery department, non-clinical management was less visible. Since our previous inspection in 2016 we saw there had been changes to the management team for MEH at Bedford hospital. The sister had been promoted to the position of Matron and the matron had also been promoted. The promotion was from matron to divisional nursing lead for the north division. Both were happy in their new roles and felt supported to do their job well. The divisional nursing lead could convey this change as a positive, as there was knowledge as to the working of the satellite service at a considerable distance from the main MEH site at City Road, London. She was able to understand the needs of the satellite service and relate to staff, as she herself had previously been in this role. The trust had also introduced a new role to the management team. They now had an assistant director of operations that was based on site full time.
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Vision and strategy The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community. The trust provided us with information for Moorfields trust vision and strategy, however there was no specific strategy for the surgery division at Bedford; although there was a trust vision, staff at Bedford were not clear on how that related to their day to day work. The trust had identified the following values it wanted to aspire to be: caring, organised, excellent, and inclusive. Most staff we spoke with knew the trust vision and values. We saw the partition behind the reception desk within the pre-operative area displayed the trust’s values, with staff’s response on how they displayed each one. Culture Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. During our last inspection in 2016, we observed that MEH and the host trust did not work as well as they could have done together. MEH staff felt unwelcome at the trust, and encountered problems with porters and hospital transport services, as well as the theatre they used at the host trust. Since changes to management have taken place, the staff have reported a much better relationship with the host trust, and appear more content and happier in their working environment. There were still a few issues surrounding theatre consumables and storage, however both trusts had an understanding and were working together on them. We were told of examples where the two services worked together for patient safety. There was improved engagement with the host trust and together they had completed a Getting It Right the First Time (GIRFT) project. The consensus from speaking with staff was that MEH at Bedford hospital was a positive place to work, with plenty of opportunity to increase expertise and skill level in a specialist environment. We did however see the department had a small number of staff to manage the day to day clinics. Staff from other MEH clinics for example, the outpatients department, were expected to assist within the theatre department as required. Some members of staff had been given specialist training to enable them to carry out extended roles during times where staffing fell short. Not all staff were happy with this situation, however, they felt they had to work as a team and help each other. All staff spoken with were open and honest. They were confident to raise issues with management where necessary. Managers had an open-door policy and were working on improving communication. There were no reports of bullying and harassment since our last inspection. The trust staff survey from August 2017 to August 2018 showed that 92% to 93% of staff would recommend MEH as a place to receive treatment and 71% to 85% would recommend MEH as a place to work.
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Governance The trust used a systematic approach to continually improve the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish. Governance meetings took place every quarter. Three of the meetings were held at a local level, and the fourth was a trust wide meeting. All staff were given the ability to attend and were invited. Staff could listen and contribute to the meetings; all staff were sent an email of the outcomes of the meeting, with any updates and actions that had been decided. Incidents and events were discussed at this meeting and the learning was shared. Within the theatre department, there was a folder that contained a number of MEH policies. There was also a note on the index page to remind colleagues to look on the intranet for other policies not held within the folder. All policies seen were in date, although we did find the PGD for surgery medications to be out of date on the intranet. Senior nurses and managers attended quarterly MEH at Bedford clinical governance meetings; they were also invited to attend clinical governance meetings at Moorfields City Road. Staff of all grades were invited to attend the clinical governance meetings. We saw evidence that staff from all grades attended these meetings. We reviewed three sets of minutes from clinical governance meetings and saw that learning from incidents, complaints, friends and family test and serious incidents were discussed and disseminated throughout the whole team. Managers conducted an interactive learning activity during meetings where staff were tested on their knowledge. Staff found this to be a helpful group learning session. We reviewed meeting minutes and saw that a formal agenda was kept for consistency. Other topics discussed at clinical governance meetings included electronic rostering, site specific patient outcomes, information governance, audit results, learning cases, and included presentations from members of staff. Staff discussed shared learning from incidents and actions were put in place where required for audit results and new best-practice guidance. Management of risk, issues and performance The trust had systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. There was a risk register for the satellite site for MEH at Bedford hospital. The divisional lead nurse and the matron could tell us the most urgent items on the register. These were, the risk of flooding within the theatre when it rains, and risk of infection in theatres because of a shared theatre with gastroenterology procedures classed as dirty procedures. Mitigation was put in place for times when the theatre had water issues. MEH could move to another operating theatre if it was available or they had to cancel the list. This occurred approximately one year ago, however it did not affect the theatre as the water damage occurred to the corridor rather than the theatre. The trust had regular minuted quality and safety meetings; the MEH at Bedford quality partner discussed incidents and themes, addressed serious incidents and learning. The risk register showed four departmental and four divisional risks. There were actions in place, however, we did not see evidence on the risk register that it was updated regularly. We saw
Page 91 evidence that the risk register for MEH at Bedford was discussed at each Moorfields North division performance review and clinical governance meetings. Medical staff based MEH at Bedford sat on various clinical and non-clinical trust boards to promote performance and mitigate risks. For example, clinicians at the site had a presence on a safe working group, digital innovation group, the trust management board and the National Institute for Health Research for ophthalmology in East England. Senior nursing staff at MEH Bedford attended several boards trust-wide. We saw evidence that some nurses were link nurses and would attend trust-wide meetings; they provided feedback information to the MEH at Bedford team. We also saw several senior nurses were involved in the divisional quality meeting. Information management The trust collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards. All patients attending MEH at Bedford hospital were classed as the host trust’s patients under the service level agreement (SLA) between the two trusts. MEH had their own paper and computer patient records, however, they were required to complete a proforma for each patient for the host trust’s records. This proforma was kept inside the patient paper records, stored by the host trust. We were not made aware of any problems or issues that MEH had due to missing or late records. Engagement The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively. Behind the reception desk at the entrance to the MEH theatre check in desk, there was a division board between the waiting and discharge area. This division board was used by staff to write messages to patients and other members of staff regarding their commitment to care and wellbeing of those working and attending the department. The trust engaged with staff and patients alike. For patients, there was an age related macular degeneration (AMD) support group facilitated by MEH staff, primarily the ECLO, however it was maintained and conducted by the patients themselves. It was also attended by the clinical director and two staff nurses. The trust was very proactive in helping patients manage their own conditions whilst offering guidance and support. The trust was involved with several sight loss charities and the local authority. They attended meetings to keep contact and to use this as a medium for information sharing to help the local community. Each month the ECLO produced a report that was sent to the hospital board and to the local authority. This included statistics on patients registered as sight impaired, severely sight impaired and those issued with low visual aids; this figure could also include glaucoma patients and those registered with age related macular degeneration, as well as other ocular conditions. The local authority and charities could keep the trust up to date on help and assistance that was available; the trust was able to provide patient number and conditions to assist with the provision of care and support within the community. A staff divisional bulletin had just been produced at the time of our inspection. It was thought it would be released monthly but this had not yet been decided. It gave a very brief summary of specific issues and notifications that the trust felt staff should be informed about. This
Page 92 encompassed incident reporting, shared learning, never events, complaints, friends and family test, compliment of the month, risks for the division, dates for the diary, Schwartz rounds, duty of candour and housekeeping tips from the divisional lead nurse. Staff were able to offer ideas and allowed to develop themselves as well as their ideas. This was encouraged and we could see progression since the previous inspection. In the 2017 staff survey, the trust identified the top areas of focus in MEH North division were communication between managers and staff, support, flexible working, pressure to come into work when unwell and working extra hours and discrimination, bullying and harassment from patients and staff. There was an action plan devised from the results and the trust monitored the progress. The trust was in the process of implementing a project of Experienced Based Co-Design (EBCD) where staff and patients collaborate on changes within the organisation. The trust was in the process of recruiting patients at the time of our inspection, however, some patients recruited were already making an impact. An interview of a patient with a learning difficulty was shown to staff as a learning exercise as part of the Schwartz rounds. Staff told us that the impact of the patient sharing their perspective was very powerful. The trust did not conduct a picker survey for surgery during 2017/2018 or 2018/2019 as they did not have enough overnight inpatients to qualify. Picker surveys gathered experiences of people who received inpatient services. Learning, continuous improvement and innovation The trust was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation. We saw evidence the trust had started an administrative apprenticeship in October 2018. There were several administrative staff supported to obtain National Vocational Qualifications (NVQ). This meant the leadership at the MEH at Bedford site was supportive in administrative staff developing new skills. The trust had action and impact plans for new innovations at the site. For example, we saw evidence of several occasions where staff had been trained in advanced skills; this resulted in reduced waiting times and cost savings. Some advanced skills included: nurses carrying out consenting procedures, healthcare assistants trained to do fluorescein angiography, staff obtaining specialist glaucoma certifications and nursing staff obtaining a diploma in independent prescribing. An innovation taking place at MEH at Bedford Hospital was rather than glaucoma patients having to be seen at the glaucoma clinic to have their intra ocular pressures checked post operatively, the theatre department was now able to check the patient one-hour post operatively within the clinic. This meant less waiting time and inconvenience for patients. MEH at Bedford hospital had decided staff needed to understand the measurements of the eye (axial length) and how powers of intra ocular lenses were decided. They sent staff to learn to undertake the task of biometry (a measurement of the eye used for cataract surgery), so they were multiskilled and understood the reason behind pre- operative assessment and preparation. Equally, biometry staff were sent to theatres to understand the procedure once they had taken the reading for surgery. The department held Schwartz rounds. This is a chance for staff of all grades and skill level to attend a meeting together; interesting or difficult cases are discussed and experiences shared. This can be particularly helpful if there is an unusual occurrence, so staff are aware of steps taken and learning in the event of a similar situation occurring at a later date.
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Leaders in quality improvement for the Moorfields North division had recently released the first of their staff bulletins. The bulletin was a document that provided succinct information on incident reporting, complaint themes and possible solutions, shared learning, results from the friends and family test, never events, and top risks on the risk register. The bulletin also shared compliments from patients with staff, congratulated staff members for achievements, shared infection control tips, important dates and information on duty of candour. Acute services
Outpatients
Facts and data about this service
Moorfield at Bedford covered a large geographical area and treated patients not just from the local Bedford area but from other regions such as South Essex, Milton Keynes, and Cambridge. The service provided wide range of clinical services and cared for patient with routine eye care needs to rare and complex conditions. Bedford Hospital services are part of the Moorfields North directorate. The Bedford South eye centre was co-located with general hospital services; it provided comprehensive outpatient and diagnostic care as well as more complex eye surgery. This centre offered secondary, tertiary, and quaternary sub-specialty ophthalmology for cataract, external disease, glaucoma, medical retina, and oculoplastic clinics. The Bedford North centre was in the Bedford Enhanced Services Centre (or Bedford Hospital North Wing as it is known locally). It focused on outpatient and diagnostic services for eye conditions including cataract, paediatrics and strabismus. Patients are receiving most of their diagnostics and clinical opinion on the same visit. The department also ran ‘stable monitoring clinics’ within glaucoma and medical retina services. This is when a patient attends for a series of diagnostics and these are reviewed virtually by a clinician avoiding unwarranted visits and ensuring the most efficient use of patient time. Patients who present through the A&E and urgent care facilities of the host hospital could also be accommodated to fast track emergency pathways. The service at Bedford South included an emergency service were patients could visit directly after being referred by their local GP or optometrist.
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The trust had 572,615 first and follow up outpatient appointments from June 2017 to May 2018. The graph below represents how this compares to other trusts.
(Source: Hospital Episode Statistics - HES Outpatients)
The following table shows the number of outpatient appointments by site, a total for the trust and the total for England, from June 2017 to May 2018.
Site Name Number of spells Moorfields Eye Hospital 361,314 Moorfields at St George's 72,206 Moorfields at Croydon University 52,607 Hospital Moorfields at Northwick Park 45,104 Moorfields at Ealing 38,773 This Trust 644,392 England 106,785,632
(Source: Hospital Episode Statistics)
The chart below shows the percentage breakdown of the type of outpatient appointments from June 2017 to May 2018. The percentage of these appointments by type can be found in the chart below:
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(Source: Hospital Episode Statistics)
Is the service safe?
By safe, we mean people are protected from abuse* and avoidable harm. *Abuse can be physical, sexual, mental, or psychological, financial, neglect, institutional or discriminatory abuse. Mandatory training The service provided mandatory training in key skills to all staff and made sure everyone completed it. The trust set a target of 80% for completion of mandatory training. At Moorfields at Bedford, the target was met for 15 of the 16 mandatory training modules for which qualified nursing staff were eligible.
A breakdown of compliance for mandatory training courses from August 2017 to July 2018 for medical and nursing staff in the outpatient department at Moorfields at Bedford is shown below:
Staff Eligible Completion Trust Met Name of course trained staff rate Target (Yes/No)
Infection Prevention (Level 2) 11 11 100% 80% Yes Information Governance 11 11 100% 80% Yes Conflict Resolution 11 11 100% 80% Yes Infection Prevention (Level 1) 11 11 100% 80% Yes Prescribing Practice and Formulary for Medical Prescribers 11 11 100% 80% Yes Preventing Radicalisation - Basic Prevent Awareness (eLearning L1&2) 11 11 100% 80% Yes Risk and Safety Management 1 1 100% 80% Yes Adult Basic Life Support 10 11 91% 80% Yes Helping Visually Impaired People 10 11 91% 80% Yes Preventing Radicalisation - Awareness of Prevent (WRAP) 10 11 91% 80% Yes Counter Fraud 3 4 75% 80% No Page 96
Recruitment and Selection 2 4 50% 80% No
At Moorfields at Bedford, the 80% target was met for 10 of the 12 mandatory training modules for which medical staff were eligible.
(Source: Routine Provider Information Request (RPIR) – Training tab)
During inspection we reviewed the staff training records and noted staff had achieved 100% compliance on counter fraud, medical gas safety and medicine awareness trainings. Safeguarding Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff had training on how to recognise and report abuse and they knew how to apply it. The trust set a target of 80% for completion of safeguarding training.
A breakdown of compliance for safeguarding training courses from August 2017 to July 2018 for qualified nursing staff in the outpatient department at Moorfields at Bedford is shown below:
Staff Eligible Completion Trust Met Name of course trained staff rate Target (Yes/No)
Safeguarding Children (Level 3) 5 5 100% 80% Yes Safeguarding 20 21 95% 80% Yes Safeguarding Children (Level 1) 20 21 95% 80% Yes Safeguarding Children (Level 2) 19 21 90% 80% Yes
At Moorfields at Bedford, the 80% target was met for all four of the safeguarding training modules for which qualified nursing staff were eligible.
A breakdown of compliance for safeguarding training courses from August 2017 to July 2018 medical staff in the outpatient department at Moorfields at Bedford is shown below:
Staff Eligible Completion Trust Met Name of course trained staff rate Target (Yes/No)
Safeguarding Children (Level 2) 11 11 100% 80% Yes Safeguarding Children (Level 3) 2 2 100% 80% Yes Safeguarding Children (Level 1) 11 11 100% 80% Yes Safeguarding 10 11 91% 80% Yes
At Moorfields at Bedford, the 80% target was met for all four of the safeguarding training modules for which medical staff were eligible.
(Source: Routine Provider Information Request (RPIR) – Training tab)
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The electronic record system used by staff alerted them of any safeguarding issues once an alert was created for patients who were known to the department. The department developed close links with the local authorities safeguarding team. Staff we spoke to had a good knowledge of safeguarding protocols and awareness of issues they should be concerned about when treating children and young adults. They spoke of appropriate examples were safeguarding protocols were initiated by members of staff. They were also aware of who to contact such as the safeguarding teams and safeguarding champions should they need advice in relation to safeguarding. Cleanliness, infection control and hygiene The service controlled infection risk well. Staff kept themselves, equipment, and the premises clean. They used control measures to prevent the spread of infection. There were housekeeping staff responsible for cleaning all areas of the department and we found all areas were maintained to a good standard of cleanliness. Patients and relatives told us they were satisfied with the level of cleanliness in the department. Areas we visited were tidy, clean, and uncluttered. The department undertook monthly cleaning audits results of which indicated appropriate level of cleanness in all months of 2018. There was sufficient access to hand gel dispensers, handwashing, and drying facilities. Hand washing basins had a sufficient supply of soap and paper towels. Services displayed signage prompting people to wash their hands and gave guidance on good hand washing practice. We saw staff adhering to good hand hygiene practice. The department undertook monthly hand hygiene audits results of which indicated satisfactory level of compliance with the trust policy in all months of 2018. The trust set a 96% compliance target and the staff achieved it in 9 out of 11 months of 2018. Waste audit undertaken by the site services manager in October 2018 identified correct practice was followed by staff across the department. The trust did not provide data which would allow long term findings and trends analysis. There was a colour-coded system for disposal of waste, and clear segregation of clean and dirty equipment and staff followed it correctly. Sharps bins were available in treatment areas where sharps may be used. This was in line with health and safety regulation 2013 (The sharps regulations). We saw labels on sharps bins with signatures of staff, showed the date it was assembled, and by whom. Sharps bins were not overflown and the service had arrangements for their appropriate disposal. Environment and equipment The service had suitable premises and equipment and looked after them well. The main waiting area in both locations had sufficient seating available and it was visibly clean. The trust did not participate in Patient-Led Assessments of the Care Environment (PLACE). They undertook their own environmental audits in February 2017 in response to our previous report which commented on lack of suitability of the environment for visually impaired patients. The assessment was generic, not site or room specific, and it was not clear if affected groups of patients were involved in it. It identified potential trip hazards and that highly polished floors could present a problem to some patients. The trust had addressed those two issues and in addition replaced some of the signage around the department in line with standards recommended by The Royal National Institute of Blind People. However, they were still to implement some of the other
Page 98 adaptions listed on the assessment that would help visually impaired patients being more independent within the clinic environment. This included solid colour channel leading patients to reception desk. We observed there were no other adaptations to support visually impaired patients for example use of continuous handrails or contrasting colour schemes throughout the environment. There were toilets that were accessible to people with mobility difficulties and nappy changing facilities for parents with children. Medical equipment inspected was serviced and tested for electrical safety with labels showing when the next test was due or last test carried out. This included clinical equipment, fire extinguishers and medical gas cylinders. Staff reported that they had no issues with maintaining equipment and the team responsible for repairs responded promptly. The resuscitation trollies checked were securely sealed so it was clear if someone had accessed the resuscitation equipment. The service had systems to ensure emergency equipment was checked daily by staff. Although we saw that all equipment was present, including equipment for smaller or paediatric patients’ daily checks were not always carried out. The checklist which was to be signed by staff was incomplete at both locations. The environment children were cared for was not child- and family-friendly. As described in the Departments of Health Standard for Hospital Services (‘Getting the right start: National Service Framework for Children’) in outpatient clinics where children are seen side-by-side with adults there needs to be some geographical separation. For example, through partitioning waiting areas. It is to ensure that children are not exposed to potentially frightening experiences; and equally, so that adults feeling ill are not disturbed by noisy children. The trust did not follow best practice as children clinics and waiting room were not separated from adults’ areas. There was a children play area for children to play with play therapist seen engaging children. The play area had limited space which meant if the clinic was busy not all children were able to sit and play in their designated area. In addition, the children waiting and play area were in the opposite part of the designated waiting area for adult to seat. Staff told us children and adults went through a separate door, each located at the opposite end, when called by staff for consultation or pre- assessment. The consultation rooms were accessed from the same corridor and half of the corridor was designated to children the other half to adults. Staff told us they ensured children and adults were not called into the consultation at the same time and this was their way of managing the risk. However, we observed adults and children being guided through the same part of corridor using the same entrance. Assessing and responding to patient risk The service carried an initial triage of all referrals to establish if there were any emergencies. Doctors told us that they reserved some clinics for emergency patient such as those referred to them by local GPs. They said that they could see urgent referrals on the same day. The department followed a triage protocol developed in May 2018 which helped them to identify what classified an acute condition and needed an immediate response. It included eye injuries such as retinal tear, severe trauma, or chemical burn as well as medical conditions such as acute glaucoma or sudden visual loss. Guidelines they followed also specified high and low risk conditions. The triage was undertaken by an optometrist in consultation with a consultant when required. The service had processes for managing misdirected referrals in order to avoid any potential delays. All referrals were to be processed within two days of receipt. An appointment should be Page 99 made within 10 working days of receipt. Although staff told us they met this time limit we were unable to verify it as the service did not monitor this metric. To meet the required NHS standards, suspected cancer referrals (two-week rule) must be seen by a specialist within 14 days of receipt of the GP referral. Although the service did not often deal with patients who had suspected cancer they had a process to allow for the deadline to be met and for the pathway to be suitably tracked. Staff said they were always able to accommodate an urgent appointment to prevent any potential deterioration. We reviewed three clinic lists. Lists showed that 30 patients, seen at the Bedford North clinics, did not experience breach for the two-week rule. The rule was set for patients that were at risk of condition deterioration. The nurse-led Bedford South clinic list also showed that 17 patients there were seen within the two-week rule. However, the ophthalmology consultant clinic in Bedford South, which had 50 patients booked, showed eight patients were in breach of the two-week rule. The service undertook a paediatric assessment which checked if birth delivery history was recorded (full-term or pre-term), any developmental issues, current medication, any potential allergies, and past medical history. This allowed staff to assess risk prior consultation taking place and take into consideration when offering any treatment. The service did not monitor repeat cancellation rates. The service reported that their commissioners had no monitoring requirement for repeat cancellation and the department had no access to suitable cancellation data. However, when a cancellation occurred the team supposed to leave the comment within patient’s electronic record so that when the patient makes further contact staff were aware of their history. In the table below, we show staff compliance with the resuscitation training rates which indicate compliance with the trust target of 80%. Non- Requirement Compliant Staff Total Compliant % Target % Compliant Resuscitation Level 1 2 0 2 100 80 Resuscitation Level 2 (Adult Basic Life 60 5 65 92 80 Support) Resuscitation Level 2 (Paediatric Basic Life 7 0 7 100 80 Support) Nurse staffing At the time of the inspection there were enough staff on duty to meet the needs of the patients. Staff had the right qualifications, skills, training, and experience to keep people safe from avoidable harm and to provide the right care and treatment. Bank staff were used to maintain numbers and an appropriated skill mix of staff in the department. The trust has reported their staffing numbers below for March 2018 and July 2018. There was an under-establishment of qualified nursing staff in outpatients across the trust. Across the trust, at July 2018 there was an under-establishment of 35.8 WTE staff (fill rate of 81.7%).
As at March 2018 As at July 2018 Planned Actual staff Planned Actual staff Site Fill rate Fill rate staff – - WTE staff – WTE – WTE Page 100
WTE Moorfields 22.0 19.9 90.4% 20.5 18.9 92.1% at Bedford
(Source: Routine Provider Information Request (RPIR) –Total staffing tab)
From August 2017 to July 2018, the trust reported a vacancy rate of 14.1% for qualified nursing staff in outpatients:
• Moorfields at Bedford: 9.0%
At trust level, the reported vacancy rate for qualified nursing staff in outpatients was higher than the trust target of 10%.
(Source: Routine Provider Information Request (RPIR) – Vacancy tab)
From August 2017 to July 2018, the trust reported a turnover rate of 13.2% for qualified nursing staff in outpatients:
• Moorfields at Bedford: 9.7%
At trust level, the reported turnover rate for qualified nursing staff in outpatients was within the trust target of 15%.
(Source: Routine Provider Information Request (RPIR) – Turnover tab)
From August 2017 to July 2018, the trust reported a sickness rate of 5.8% for qualified nursing staff in outpatients:
• Moorfields at Bedford: 6.2%
At trust level, the reported sickness rate for qualified nursing staff in outpatients was above the trust target of 4%.
(Source: Routine Provider Information Request (RPIR) – Sickness tab)
The below table shows the bank and agency usage for qualified and non-qualified nursing staff in outpatients from August 2017 to July 2018. For qualified nursing staff, the trust reported that 12.7% of available hours were filled by bank staff and 0.4% of available hours were filled by agency staff. For non-qualified nursing staff, the trust reported that 17.4% of available hours were filled by bank staff and there was no reported use of agency staff.
Moorfields at Bedford
Total hours Bank Agency Unfilled Qualified 261 11 (4.2%) 0 (0%) 0 (0%) Non-qualified 191 16 (8.4%) 0 (0%) 0 (0%)
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(Source: Routine Provider Information Request (RPIR) - Nursing bank agency tab) Medical staffing The service had vacancies for medical staff. This meant there was not always sufficient number of doctors with the right qualifications, skills, training, and experience to keep people safe from avoidable harm and to provide the right care and treatment. The trust has reported their staffing numbers below for March 2018 and July 2018.
As at March 2018 As at July 2018 Planned Actual staff Planned Actual staff Site staff – Fill rate Fill rate - WTE staff – WTE – WTE WTE Moorfields 14.2 8.8 61.8% 12.1 10.6 87.3% at Bedford
(Source: Routine Provider Information Request (RPIR) –Total staffing tab)
From August 2017 to July 2018, the trust reported a vacancy rate of 10.6% for medical staff in outpatients:
• Moorfields at Bedford: 29.7%
At trust level, the reported vacancy rate for medical staff in outpatients was greater than the trust target of 10%. The vacancy rate was particularly high for medical and staff at the Bedford site.
(Source: Routine Provider Information Request (RPIR) – Vacancy tab)
From August 2017 to July 2018, the trust reported a turnover rate of 9.5% for medical staff in outpatients:
• Moorfields at Bedford: 10.9%
At trust level, the reported turnover rate for medical staff in outpatients was within the trust target of 15%.
(Source: Routine Provider Information Request (RPIR) - Turnover tab)
From August 2017 to July 2018, the trust reported a sickness rate of 1.0% for medical staff in outpatients:
• Moorfields at Bedford: 0.3%
At trust level, the reported sickness rate for medical staff in outpatients was below the trust target of 4%. Sickness rates for medical staff were low across the three featured locations.
(Source: Routine Provider Information Request (RPIR) – Sickness tab)
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The below table shows the bank and locum hours for medical staff in outpatients from August 2017 to July 2018. Across the trust, 34,979 hours were filled by bank staff and 10,949 hours were filled by locum staff.
Total Location Bank Locum Unfilled hours Moorfields at Bedford 29,432 3,723 (12.6%) 749 (2.5%) 0 (0%)
(Source: Routine Provider Information Request (RPIR) – Medical agency locum)
Records Staff kept detailed records of patients’ care and treatment. Records were clear, up-to-date, and easily available to all staff providing care. The service did not carry out routine records quality audits to monitor completeness and if best standards were met at all times. The service used an electronic patient record system and all paper records were scanned and kept as an electronic copy. Staff used systems provided by local host trust as well as the Moorfields systems and could easily connect to both. They told us that both systems run well and quickly. This meant that staff need to duplicate a number of records as both trusts required access to them and their systems were not interconnected. For example, those related to complaints or incidents needed to be reported on both trust’s systems. The department initiated ‘the note lite project’ in 2017, they told us it was a challenging process as they worked with two local NHS trusts and needed to ensure all professionals involved in patients care had access to appropriate electronic records systems across all three trusts (including Moorfields Eye Hospital NHS Foundation Trust). They scanned all patients’ paper records onto electronic patients record system to ensure clinics could operate paperless. The department provided access to the host trust’s portal and their own electronic patients records system to allied health professionals working for the local NHS community trust which they worked in partnership with. Staff reported that in the past they experienced missing notes as the host trust did not use the tracking system effectively. By having everything scanned they ensured all time access ophthalmology patient’s records as well as ‘clinical home page’ managed by the host trust. This in return allowed them to see if professionals from other specialities were involved with the patient and access records if needed. This access to records was reciprocated. The department also achieved financial savings derived from the fact that the records pulling service had ceased. The process improved as there was no need to track and reconcile the notes and staff had instant access to the medical information improved quality of care. Medicines The service followed best practice when prescribing, administering, recording, and storing medicines. Patients received the right medicines at the right dose at the right time. Medicines were in date and well organised. The date was recorded when individual packs were opened. The medicine fridges were kept locked and fridges used for medicines storage in all areas were monitored daily for temperature. The temperature log showed they remained within safe temperature range. There was an alarm system for the medication fridge and environmental
Page 103 temperature changes to notify responsible senior members of staff, and the estate department, if temperatures were outside of the recommended range. Medicines information was available to clinical staff via the intranet and was easily accessible. No controlled drugs were kept at the department. Emergency medicines were available to staff, it included medication to support people undergoing anaphylactic shock and those with hypoglycaemia. The resuscitation trolley was sealed, and oxygen was available and in date. The trust undertook audit of safe storage and secure handling of medicines in March 2018. Where actions had been identified local managers and leads were allocated to address the shortcomings. These related mostly to room temperature control as not all the rooms where the medicines were stored had temperature controlled within them. The audit was to be repeated in 12 months’ time (March 2019) as part of the trust’s on-going medicines management programme. Incidents Although staff recognised incidents and reported them appropriately the service did not always manage patient safety incidents well. Managers investigated incidents and shared lessons learned with the whole team and the wider service, however, actions were not always taken promptly in response to incidents. When things went wrong, staff apologised and gave patients honest information and suitable support.
Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event.
From September 2017 to August 2018, the trust reported no incidents classified as never events for outpatients.
(Source: Strategic Executive Information System (STEIS))
In accordance with the Serious Incident Framework 2015, the trust reported no serious incidents (SIs) in outpatients which met the reporting criteria set by NHS England from September 2017 to August 2018.
(Source: Strategic Executive Information System (STEIS))
The trust did not hold mortality and morbidity meetings. They reported quarterly on learning from deaths through the clinical governance committee. The trust had identified one patient’s death in first two quarters of 2018/2019 and told us that it did not fall within the scope of the learning from deaths policy. No learning and improvement opportunities have been identified. From May 2018 to November 2018 Moorfields at Bedford’s outpatients department reported 58 incidents. Eleven at Bedford North Wing and further 47 at Bedford South. Actual impact Total No Harm 48 Minor 4
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Moderate 6
Breakdown of incidents reported at Bedford North Wing: Cause Group/Cause Total Abuse Towards Staff 1 Appointments and Referrals 2 Information Governance & Security 1 IT 1 Medical Devices 1 Patient Safety 1 Prepping of Health Records 2 Safeguarding 2 Grand Total 11
Breakdown of incidents reported at Bedford South Wing: Cause Group/Cause Total Abuse Towards Staff 1 Appointments and Referrals 33 Diagnosis & Treatment 2 Infection Control 4 Outpatient Organisation of Care 2 Patient Falls 2 Prepping of Health Records 1 Quality of Clinical Documentation 1 Transport 1 Grand Total 47
The service carried out analysis of Bedford South ‘appointment – no appointment booked’ (30 incidents within the appointments and referrals category). Twenty-eight of the 30 incidents were reported in relation to un-booked appointments identified after outpatient glaucoma review undertaken in 2017 (appointments which were to take place in years 2014 – 2017). The requirement to undertake the review, which remained on-going, was identified in the action plan in response to a serious incident investigated by the trust in October/November 2017. In July 2017 the service identified an incident where a patient attended glaucoma clinic 31 months after their appointment was due. It was recognised that the patient did not receive a follow-up appointment back in 2014. In response to this incident complete retrospective analysis of glaucoma patients since 2014 was to be undertaken to identify any other patients who did not
Page 105 receive an outcome from their appointment. In November 2017 the trust identified that administration processes at Moorfields Bedford back in 2014 were inadequate and noted in the incident investigation report that processes since then had been implemented to reduce the risk of future recurrence. However, we were not assured the process the trust had was effective and would prevent similar occurrences. We reviewed a glaucoma waiting list and noted that many patients still appeared on the appointments booking system as awaiting follow up appointment. A member of staff responsible for overseeing appointment bookings and monitoring waiting lists told us that they were unable to confirm if they had or had not been seen for their follow up. This was because the person dealing with the waiting list was on a long-term leave, there was no system to verify information without verifying individual patient’s records. Following the inspection, the trust told us they implemented an assurance process to identify errors and ensure all patients with no follow up appointments, when one required, are identified promptly. The trust had started an audit to check if the process was effective. It was to be completed over a prolonged period to ensure it was fully accurate. The duty of candour (DoC) is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain ‘notifiable safety incidents’ and provide reasonable support to that person. Staff we spoke to were aware of their responsibilities under duty of candour, which ensured patients and/or their relatives were informed of incidents that had affected their care and treatment and they were given an apology. Staff had received training on duty of candour and during inspection compliance rate was 83% compared to the trust target of 80%. Safety thermometer The Safety thermometer was not used within ophthalmology. The mobility of patients who attended outpatients clinics was to be assessed by the nurse who was looking after them. The patient administration system had a facility to show a red flag against the patient’s name to warn staff to look for extra requirements or needs for the patient. The trust told us the department monitored and identified trends through analyses of incidents and safeguarding reports. Managers used this to improve the service.
Is the service effective? Evidence-based care and treatment The service provided care and treatment based on national guidance and evidence of its effectiveness. Managers checked to make sure staff followed guidance. Staff always had access to up-to-date, accurate and comprehensive information on patients’ care and treatment. All staff had access to an electronic records system that they could all update. The service used a combination of National Institute for Health and Care Excellence (NICE) and the Royal College of Ophthalmologists (RCOphth) guidelines to determine the treatment that was provided. It included guidelines on management of diabetic retinopathy for the best management of various aspects of diabetic eye disease or guidelines on macular degeneration. The policies, care and treatment pathways, and clinical protocols we reviewed were based upon recognised guidance, including that of NICE and RCOphth. They were stored on the trust intranet. The service undertook numerous clinical audits to ascertain if patient’s clinical needs were met appropriately. For example, they reviewed acute eye services at Moorfields Bedford in a view of
Page 106 implementation of community optometrist minor eye conditions scheme in 2017. Previous audits undertaken by the department demonstrated that substantial proportion of all referrals into the acute eye service could be managed by a community optometrist. The audit in 2017 examined the type of referrals into the acute clinic to allow for future comparison once the scheme was in full operation county wide. Other audits were designed to compare clinical practice outcomes and evaluate effectiveness of treatment. This included use of Ranibizumab for treating diabetic macular oedema, or effectiveness of protocol for cycloplegia for retinoscopy. Clinical audit results were discussed amongst clinicians and any action plans were approved by the trust’s clinical audit assessment committee. The department had system and operated a framework to effectively respond and comply with guidance received from the National Institute for Health and Care Excellence (NICE). It helped to ensure that the correct process was followed upon publication of new NICE guidance and provide assurance of appropriate implementation, dissemination, and monitoring of NICE guidance. The clinical governance and clinical audit department oversaw the process and the outpatients department’s compliance with the trust policy and NICE guidelines. Nutrition and hydration Patients we spoke with were satisfied with the drinks they were offered. Staff were proactive and we observed them supporting patients with accessing beverages even when they were busy. Patients and their relatives could access snacks, food, or hot drinks at one of the catering outlets provided by the host trust. Patients were referred to a dietician if there were concerns with their weight or food intake. Patients were assessed during pre-operation appointments, this included height and weight assessment and if low BMI was identified staff contacted patient’s GP who then referred to dietitian. If patient was diabetic staff involved a diabetic nurse in patients care. Pain relief Staff assessed and monitored patients regularly during procedures such as eye injection to see if they were in pain. They gave additional pain relief when necessary to ease pain. Paracetamol and ibuprofen were given to patients for pain such as headache after being prescribed by a doctor. Patient outcomes Managers monitored the effectiveness of care and treatment and used the findings to improve them. They compared local results with those of other services to learn from them. From June 2017 to May 2018, the follow-up to new rate for Moorfields at Bedford, at 3.2, was higher than the England average (approximately 2.2). Although it was lower than in many other trust’s location, it was higher than expected by the commissioners of the service (2.8).
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(Source: Hospital Episode Statistics)
Patients visiting the outpatients department were mostly receiving the majority of their diagnostics and clinical opinion on the same visit. The department run ‘stable monitoring clinics’ within glaucoma and medical retina services. This was when a patient attended for a series of diagnostics and these were reviewed virtually by a clinician (without patient being present) avoiding unwarranted visits and ensuring the most efficient use of patient time. It was designed for patient with glaucoma that had been reviewed by consultant who advised that patient’s condition was stable.
The department also provided retinal therapy for patients with wet age-related macular degeneration (AMD). The service was consultant-led and was supported by senior nurses who could deliver advanced procedures and autonomous care. Competent staff The service made sure staff were competent for their roles. Managers appraised staff’s work performance and held supervision meetings with them to provide support and monitor the effectiveness of the service. From August 2017 to July 2018, 79.3% of staff within outpatients at the trust received an appraisal compared to a trust target of 80%.
From August 2017 to July 2018, 80.6% of staff within outpatients at Moorfields at Bedford received an appraisal compared to a trust target of 80%.
Target Individuals Appraisals Completion Trust Staff group met required complete rate target (Yes/No) Medical staff - Hospital 11 11 100.0% 80% Yes Qualified Healthcare Scientists 1 1 100.0% 80% Yes
Qualified nursing and health 21 20 95.2% 80% Yes visiting staff (Qualified nurses)
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Qualified Allied Health 15 12 80.0% 80% Yes Professionals (Qualified AHPs) Support to ST&T staff 37 26 70.3% 80% No NHS infrastructure support 8 5 62.5% 80% No Grand Total 93 75 80.6% 80% Yes
(Source: Routine Provider Information Request (RPIR) – Appraisal tab)
During inspection we noted improvement in the appraisal rate and staff had achieved 86% compliance against the trust target of 80%.
All consultants have been trained to undertake the role of educational supervisors. All clinical staff were offered clinical supervision within the trust however, this was not monitored or defined in relation to frequency. The trust also offered staff the opportunity to seek clinical supervision or coaching externally. Clinical supervision of trainee doctors was recorded and reviewed during the local faculty group (LFG) meetings. An LFG report, also referring to clinical supervision rates, was reviewed by the specialist services education committee which met bimonthly. Student nurses and allied health professionals in training such as optometrists and orthoptists had an established supervision programme which was in line with the requirements of their professional bodies standards for education and training. This was monitored in terms of meeting the standards of their future registration. Student nurses also received regular teaching sessions on clinical subjects and professional issues. Newly qualified nurses and allied health professionals were provided with a mentor and received support through the trust preceptorship programme. The trust told us that all staff attended the trust induction, they were also provided with an in-house site-specific induction to the service at Bedford. The trust organised a six-month long nurse development programme which equipped them with eye specific knowledge, it was provided to junior nurses working within the department. Multidisciplinary working Staff of different kinds worked together as a team to benefit patients. Doctors, nurses, and other healthcare professionals supported each other to provide good care. We observed a positive culture where discussions were held and all staff could openly contribute. Doctors, allied health professionals and nurses told us that multidisciplinary team (MDT) working within the department was part of their way of working. They all spoke of teamwork and joint working and the way in which it enhanced good working relations as well as the patient experience. The service worked with their commissioners and stakeholders such as Bedford Hospital, Royal National Institute of Blind (RNIB), Moorfield Eye Charity, Friends of Moorfields, Royal College of Ophthalmologists, Vision UK, College of Optometrists, and Embassies in the development of the service. Regular engagement activities were held which provided an opportunity to discuss the provider’s services and strategies.
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The service provided patients with an opportunity to experience pharmacist led consultations within the clinic promoting and encourage good eye drop compliance and provide support to patients and their carers. Seven-day services The nature of clinical care provided at Moorfields at Bedford meant that some of the national drivers to deliver seven-day services did not naturally aligned with the trust’s model of care. The department did not provide care to patients with life threatening conditions and had protocols for appropriate management of systemically unwell patients. Those was based on cooperation with community services including local GPs and optometrist as well as local emergency service providers. The trust operated a dedicated ophthalmic emergency department at City Road site, which provides a 24 hour per day, 7-day a week ophthalmic emergency service. Patients were provided with contact details for emergency out of hours services provided by one of the local NHS trusts. The department supported local hospitals’ services by contributing staff to their on-call rota. Health promotion The service had undertaken number of initiatives to educate patients and public on how to maintain eye health and how poor life style choices might affect health. For example, they produced a leaflet for public on ‘life style tips’ that would minimise risk factors for macular degeneration. Staff informed patients on impact of smoking on eye health and its link to developing age-related macular degeneration, glaucoma, and cataracts. Smoking cessation was discussed during appointments and staff made referrals to cessation service clinic in on patient’s behalf. The service supported Bedford Eye Care Working Group which was formed to help raise public and professional awareness of eye health, eye care and sight loss in Bedfordshire and to make these a key item in prevention plans, educational agendas, and appropriate campaigns. In September 2018 the service participated in ‘know your drops’ campaign organised by the trust’s pharmacy team. The campaign aimed to promote and encourage good eye drop compliance and provide support to patients, carers, and staff regarding best techniques for administering eye drops. It supported trust’s objective to deliver the highest standards of patient experience, outcomes, and safety across all trust’s sites. It also provided patients with an opportunity to experience pharmacist led consultations within the clinic. Consent, Mental Capacity Act, and Deprivation of Liberty Safeguards Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. They followed the trust policy and procedures when a patient could not give consent.
The trust reported that from August 2017 to July 2018 Mental Capacity Act (MCA) training was completed by 74.7% of staff in outpatients compared to the trust target of 80%. The table below presents the breakdown for staff working at Moorfields at Bedford.
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Met Staff Eligible Completion Trust Name of course (Yes/ trained staff rate Target No) Mental Capacity Act Level 1* 56 68 82% 80% Yes Mental Capacity Act Awareness (e- learning)** 72 93 77% 80% No * Following comments from the trust it is noted that this course relates to MCA levels 2 and 3 ** Following comments from the trust it is noted that this course relates to MCA level 1. (Source: Routine Provider Information Request (RPIR) – Training tab)
The trust told us that the compliance rate had improved for both Mental Capacity Act and Mental Capacity Act Awareness training with staff achieving 89% and 96% compliance rate in November 2018.
A Mental Capacity Act audit was completed in 2017, focusing on the implementation of the MCA policy and auditing whether capacity assessments were documented. It also reviewed if support was given to patients with complex needs, if best interest decision making involved consultation, whether the patient’s wishes and views were established, and audited suitability of balancing risks with rights. Action plans were undertaken following gaps and all actions had been completed. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. They knew how to support patients experiencing mental ill health and those who lacked the capacity to make decisions about their care.
Is the service caring? Compassionate care Patients were treated and cared for with compassion, respect, and dignity. Feedback from patients and their relatives were positive. We observed staff speaking to patients and their families in an appropriate and caring way. Patients’ feedback received by the trust in 2018 highlighted that patients felt that staff kindness, professionalism and caring attitude had helped them during their care and they were treated as an individual. The department was committed to maintaining patient dignity through their campaigns and during inspection we observed posters on display in clinics on the ‘delivering dignity at Moorfield’. We observed that patient’s dignity was maintained by staff throughout their care and treatment. Patients told us that staff respected and maintained their privacy, dignity and confidentiality and their consultation took place in private rooms. Although patients could speak to the receptionist during inspection without being overheard by others, the reception desk was in the general waiting area. This meant when it was busy privacy could be compromised. Nurses and health care assistant could chaperone during consultation or examination when necessary. Staff spoke to patients in a respectful manner and advised them appropriately. We saw staff introduced themselves to patients and their relatives by their first name and job title. Patients we spoke to were familiar with staff in the clinics and knew their name. This was in line with the NICE QS15 Statement 3 guidelines. We spoke to five patients and their relatives during inspection. Patients and relatives reported good care and experience in the service. Patients we spoke to told us they found the care
Page 111 received to be compassionate and would recommend the service to their friends and family. Specific comments received included “very compassionate and great support”, “amazing staff”, “kind and professional staff”, “nurse and receptionist were friendly”, “staff have respected and maintained by privacy and dignity”, “I was treated with compassion and dignity”, “all staff were caring and supportive from downstairs to upstairs”. “Staff are excellent, friendly, helpful and make you feel comfortable”. Staff showed an encouraging, sensitive, and supportive attitude to patients and relatives that accessed the service. We saw several examples of compassionate care during patient’s consultation. For example, we observed staff helping elderly patients to stand up and guiding visually impaired patients around the clinic. We observed nursing and reception staff offering and helping patients to prepare hot drinks whilst waiting for their appointment. We observed five patient consultations and noted that staff took time to interact with patient and were caring, compassionate, aware of the patients’ needs and offered support and reassurance when necessary. For example, we observed staff offering support in a caring manner to a patient that was in pain during consultation. We also observed a staff member walking and directing a patient to the consultation room in a polite and caring manner and asking them politely if they would like to take their coat off. The staff also asked patients how they were doing since the last visit, what additional support they needed and if they came alone. The Friends and Family Test performance at Moorfields Eye Hospital NHS Foundation Trust was consistently higher than the England average from December 2017 to July 2018.
This Trust England Average
99% 98% 97% 96% 95% 94% 93% 92% 91% 90% Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18
The Bedford’s department Friends and Family Test results were displayed in the clinic waiting areas. The October 2018 result showed that 95% of patients would recommend the service and 1.6% would not recommend the service. The October 2018 response rate was 30.3% which was an improvement from the last inspection (15%) and previous month’s response rates (18% in September 2018).
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Emotional support Staff understood the impact of patients care, treatment or condition to their wellbeing and those close to them. Patient we spoke to told us they felt staff were concerned not just about their clinical condition but also about their emotional, and social needs. Staff provided patients and their families with compassionate care and emotional support to minimise their distress and anxiety. Staff treated and involved patients and their families as partners in assessing and meeting their emotional and social needs, which was understood as being crucial in the patient care. We observed that staff discussed and explored patients’ emotional well-being during consultation. We noted that where patients were receiving specialist support and medicines helping them to manage mental health conditions staff took their time to explore the effectiveness of their medicines, specialist support and signposted patients and their families to other available support. Comments from the hospital surveys in 2018 showed that many patients commented that the ‘caring staff and the calm environment had helped to reduce their anxiety’. Patient and their families in vulnerable and emotional circumstances had access to counsellors who were available on request. The counselling service was available from the time of diagnosis, throughout treatment and during follow-up. Patients and relatives were also signposted to other external counselling service such as the Samaritans and British Association of Counselling and Psychotherapy (BACP). The service had nurse counsellors that ran a support group for patients that experienced sight loss. The doctors were responsible for registering people as partially sighted and completed required paperwork. The nurses and doctors assessed patients for risk of depression or mental health needs and liaised with the GP, patient local hospital or made a referral to the mental health service for continuation of care as appropriate. Being diagnosed with an eye condition can be difficult to come to terms with for patients and their loved ones. Research has shown that eye clinic liaison officers (ECLO) is one of the most effective ways of supporting patients in the eye clinic as they are key in helping patients understand the impact of their diagnosis, maintain their independence and providing them with emotional and practical support for their next steps. The service had an ECLO who supported patients with sight loss and signposted them to the social service, community, and voluntary support available in the community. The trust told us and we observed that since the last inspection the service had strengthened the presence of the ECLO in the clinics. Patients and their families who received life-changing diagnosis were supported and given information on how to access further support services. The service had Royal National Institute of Blind (RNIB) leaflets available on emotional support service available for blind or partially sighted people who may be feeling depressed or experiencing feelings of sadness, anger or anxiety with their new diagnosis or condition. We observed staff informing patients and their relatives about this service and going through the leaflets with them which contained the helpline and how to register with the organisation. The service also organised focused groups and activities to inform patients of available services and resources from the RNIB which provided practical information and advice for people living with sight loss.
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Understanding and involvement of patients and those close to them Patient and those close to them were treated as active partners in the planning and delivering of their care and treatment. Patients were giving appropriate information and encouraged to make decisions about their care and treatment. Patients told us staff were patient, very thorough and answered all their questions. Their comments included; “nurse told me what I needed to do and explained in a way that I could understand the rationale why other investigation were to be carried out”, “I feel involved in my care and doctor explained my care to me and my wife and used picture during his explanation, “my consultation with doctors and nurses were not rushed”. Patients told us they had received copies of letters sent between the hospital and GP about their referrals and summary of the care and treatment received. This was also evident in the patients’ records reviewed during inspection. Staff consulted patients on their preference in sharing information with their relatives and we saw that this was respected and reviewed throughout patient care, which was in line with the NICE guidance. Patients and their relatives also commented that staff involved their loved ones in their care and treatment. We observed a clinic consultation and assessment of a paediatric patient with the parent present. We noted that the doctor developed quick rapport with the child and the parent, which made the child feel comfortable. The doctor also used sign language to ensure the child and parent understood what they were saying. We observed four other patients’ appointments and noted that staff discussed at length with patients about their clinical condition, care plan, and suggested treatment with emphasis on patient choice. Patients were not rushed during their appointments and staff answered all questions the patient and families had. We saw that staff gave written information to support information given verbally. Staff also spoke to patients slowly in simple and plain language in a way patient could understand without the use of medical jargons. Staff also empowered and supported patients and their relatives to use and link with support networks and advocacy such as Muscular Society, RNIB, and Samaritans to help impact positively on their health, care, and wellbeing. We observed that patients were given information on their next appointment and told when they would receive their test result. Is the service responsive? Service delivery to meet the needs of local people The service planned and delivered care in a way that reflected the needs of the population of patients who accessed the service to ensure continuity of care. Patients’ needs and preferences were considered and acted on to ensure services were delivered to meet those needs. In the waiting areas we saw a board and welcome leaflets that introduced patients to staff who were involved in their care and their roles and responsibilities. We observed that all staff had visible yellow badges which highlighted their role for patients and visitors to identify who they were. The nurses in charge also had a visible yellow arm band for staff and patients to know who oversaw the shift.
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Moorfields at Bedford covered a large geographical area and treated patients not just from the local Bedford area but from other regions such as South Essex, Milton Keynes, and Cambridge. The service provided a wide range of clinical services and cared for patient with routine eye care needs to rare and complex conditions. The facilities and premises were appropriate and patient centred. During inspection there were sufficient seating in the waiting areas and no patient was observed standing. There was a separate play area for children in the North clinic, although this play area had limited space and was not separated from adults waiting areas and the hospital cafeteria. As described in the Departments of Health Standard for Hospital Services (‘Getting the right start: National Service Framework for Children’) in outpatient clinics where children are seen side-by-side with adults. There needs to be some physical separation, for example, through partitioning waiting areas. This is to ensure that children are not exposed to potentially frightening experiences; and equally, so that adults feeling ill are not disturbed by children. The trust did not follow best practice when they took the decision to organise additional children’s clinics at the Bedford North site. They did not exhibit a full understanding of what it meant to be cared for in an appropriate child- and family- friendly environment. There was sufficient parking at the North clinic hospital but limited space at the Bedford South clinic as the parking was used by patients, staff and visitors visiting the Bedford hospital. Staff were aware of the challenge with parking at the South clinic and told us they advised patients where possible they should come by public transport or be dropped off by loved ones. Moorfields at Bedford clinics was accessible using the public transport. The hospital website had information on how to get to the clinic using the public bus and train service with links to their website. The hospital website had important information about the service which included; hospital address, treatment offered, car parking and parking cost, social media handles, patients, and staff stories, how to make a complain, infection control and research. The website had an archive of the hospital web chats that covered question and answer on diverse topics such as cataract, diabetes, and other eye conditions. The website also had teaching and health promotion advice on eye health such as; eye condition, know your eye drops, looking after the eye and anatomy of the eye. The hospital website could be automatically translated to other languages apart from English such as French, Filipino, Irish, Hindi and Arabic and many others. The hospital website was modified to reflect the needs of the patient that accessed the service. For example, the font size of the texts could be adjusted to patient preference and had the option of using a normal or high contrast where the text could be changed to bright yellow, blue, black, and other colours. This ensured patients with a visual impairment or whose language was not English could still access the website for information about the hospital, their condition and treatment. Letters sent to patients and posters displayed in the clinic waiting areas were in font size 14 or larger to represent the service’s patient population. Patients were provided with written relevant information such as contact details and hospital map about the service in an accessible format before their appointment. The service provided clinics in the evening for private patients and late afternoon for other patients with work or school commitments. The service had support systems in place to aid the delivery of care and treatment to patients in need of additional support. We noted that the service used a sticker system on patients’ record to
Page 115 identify patients with learning disability, living with dementia, reduced mobility, or those who required hospital transport. The signage in the clinic had improved since the previous inspection and was more readable to patients with sight impairment. The service used high contrast colours proven to be more readable and to help to enhance independence, safety, and accessibility for people with visual impairment. Patients we spoke to liked the signage. Staff were proud of the improvements and use of increased contrast signage in clinics. There was a café in the reception area and canteen in the hospital that were accessible to patients, relatives, and staff. Patients and relatives had access to free water and hot drinks in the clinics waiting areas. From June 2017 to May 2018, the ‘did not attend’ rate for the trust was higher than the England average. The hospital did not provide the DNA rate for the hospital. The service had a text reminder service that reminded patients before their appointment.
The chart below shows the ‘did not attend’ rate over time across the trust.
(Source: Hospital Episode Statistics)
For Moorfields at Bedford, from November 2017 to October 2018, the DNA rates varied between 8.7% and 12.5% for new patients, and 6.7% and 10.8% for follow-up appointments. Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul-18 Aug- Sep Oct- 17 18 18 18 18 18 18 18 18 18 18 New 10% 9.6% 9.2% 9.8% 10.5% 9.5% 9.5% 8.7% 9.3% 10.3% 11% 12.5% Follow- 8.7% 8.6% 8.7 8.7% 10.8% 9.2% 8.1% 8.5% 7% 8.40% 6.7% 7.2% up
Meeting people’s individual needs The needs and preferences of patients were considered when delivering and coordinating services, including those who were in vulnerable circumstances or had complex needs. Care and treatment was coordinated with other services and stakeholders, to ensure the needs of patients and their families were met.
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There was wheelchair access to the clinics with accessible toilets which were suitable for people with reduced mobility. The service patient transport (ambulance) service had wheel chair access for patients with mobility issues and was generally on time for picking up and dropping off patients. Staff told us when there was delay in patient transport service they would request a taxi for patients to ensure they did not wait for too long to be picked up from home or clinic. The service identified the care needed for specific patient’s groups such as learning disability or dementia through flags on their electronic system and using ‘This is Me’ documentation for dementia patients and the ‘Patient Passport’ for people with a learning disability, cognitive impairment, or additional communication needs. During inspection, staff told us that although the Moorfield electronic system could flag up patients with learning disability however the Bedford hospital system did not flag up patients with learning disability and the service was working with the hospital to resolve this issue. There were robust policies, ‘easy read’ material, and specific pathways for patients with learning disability and dementia accessing the service. The service also had posters on delivering care for patients with learning disabilities in the clinics as part of their campaign to ensure patient and their families received appropriate support from staff. The Accessible Information Standard (AIM) aims to make sure that people who have a disability, impairment or sensory loss get information that they can access and understand. We noted that the trust consulted with 3,000 current patients who were certified as having a certificate of visual impairment to identify under the AIS requirement, to establish the format in which they would like the trust to communicate with them and to meet that need. The trust provided various British Sign Language and written or audio communication aids as part of the AIS to meet the needs of patients with additional needs which included; hands on signing, visual frame signing, lip speaker, lip reader, lip reading, Makaton, speech-to-text, Braille, easy read, large print; signing DVD, text relay transcription and voice output communication aid. Deaf or hard of hearing patients could be supported with hearing loops which we observed in the clinics. During inspection in the paediatric clinic we observed a consultation where staff was using sign language to communicate with a child with hearing needs. Interpreter services were available for patients for whom English was not their first language if required. During inspection staff told us the service no longer offered face to face translation to interpret other languages and only used face to face for sign language. However, the serviced used telephone translation service for patients whose first language was not English. The service had an eye clinic liaison officer (ECLO) that offered support and low vision assessment for patients struggling to read or visual impairment. We saw posters and leaflets about the ECLO support available in the clinics. Since the last inspection the trust had improved patients experience in the clinics following patients’ feedback. This included patient monitoring, provision of hot drinks, water dispensers and message bussing. There were hot drink machines and water dispensers in the clinics with adequate cups that was available complimentary at any time to patients and their families. The wards had relevant information leaflets available which included leaflets on emergencies such flashes and floaters in the eye. Leaflets also contained information on PALS and the right to treatment within 18 weeks of referral from GP and if this was not met that patients should contact
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PALS. Other leaflets seen in the clinics contained information on the National Dementia helpline and Alzheimer’s helpline and website. Staff told us that translation of documents and leaflets to all languages could be provided to patients and their relatives when required. Follow up appointments were given to patients in timely manner during clinic consultation and we saw that staff accommodated patient preferences and commitments. We observed patients who requested an early or late appointment at their next appointment were granted their requests. The service scheduled 20-minute appointment for new patients to ensure they were given enough time to ask staff questions about their care. These also ensured new patients were also able to have follow-up tests when necessary. The service had a breastfeeding facility for breastfeeding mothers that were patients, relatives, or visitors. The service had a children play area for children to play and during inspection we observed the play therapist engaging children with different play activities. However, the play area had limited space which meant if the clinic was busy not all children will be able to sit and play in the designated play area. In addition, the children waiting and play area was opposite part of the designated adult waiting area, which meant adult and children could see and seat next to each other. Staff told us and we observed that children and adult went through a separate door when called by staff for consultation or pre-assessment. The consultation and meeting rooms were in one corridor and half of the corridor belonged to both children and adult each. During inspection staff told us and we observed that staff ensured children and adult were not called into the consultation at the same time to reduce the risk. However, staff did not always use opposite entrances into the clinic areas and children were guided through the same areas as adults. This was the risk mitigation practice they were supposed to adhere to. Patients we spoke to told us they experience delays in been seen in the clinic and would love to see an improvement in the service on waiting times. During the inspection we observed the clinics were busy and patients waited for up to an hour before being seen. It could take up to three or four hours before they were being discharged. This is because of the lengthy patient’s pathway which included a nurse assessment, diagnostics, and consultation with a doctor. We observed displayed poster in the clinic that advised patient that if they were waiting for 30 minutes before been seen by the nurse they should alert the receptionist. The trust did not audit how many patients experienced delays of longer than 30 minutes. The 2017/18 glaucoma clinic trust survey showed that around 75% of patients felt informed about waiting times, supported whilst waiting for their appointment, were given an accurate waiting time and knew where to get refreshments. We saw and staff told us that when patient waited for long, staff prepared cup of tea or coffee from the vending machine for patients particularly for those that were elderly or had difficult with their sight or mobility. We observed and patients told us they often experienced challenges in finding parking space in the South clinic car park. We saw a long queue of cars and noted that drivers found it difficult to find available car park on both days we inspected the service. This queue was from the hospital entrance and extended to the road in front of the hospital. Patient we spoke to told us they would love to see an improvement in car parking as this was an issue. A patient with physical disability told us car parking was a challenge for them despite having a blue badge for disabled parking. However, a patient told us that once they were late to the clinic due to the hospital parking and staff understood the reason for the delay and waited for patient even though the patient was the last patient scheduled for the afternoon.
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A patient we spoke to commented that they often had difficulty contacting the service on the phone. Specific comment was; “you can ring for two days and not get through and an occasion I had to travel six miles to the clinic just to change my appointment and speak to staff. Access and flow The service received referrals from hospital and GP for patients who accessed the service. Patients could not self-refer to the service. Patients used the ‘choose and book system’ for their first appointment and the service accepted GP referral letters for emergency booking. Moorfields at Bedford had their own booking system which differed from the Moorfield booking system. Staff had to complete other referrals forms for Moorfield at Bedford patients that were transferred to or from other Moorfield clinics. The service had clinics twice a week in the evening for private patients. During inspection we observed private patient arriving for their appointment which was held on Wednesday and Thursday from 5pm to 8pm. Staff told us that clinic appointments were rarely cancelled, however, patients experienced delays due to the busy clinics. Staff told us they would still run clinics when people were off sick, including asking patients to visit another location when necessary or distributing patients to other clinic doctors. Date provided by the trust indicated that cancellation rate was usually above 10%, the trust did not comment on what the reasons were for these cancellations.
Moorfields at Bedford August 2018 September 2018 October 2018 All appointments 528 455 551 Cancelled 62 66 98 Percentage cancelled 10.5% 12.7% 15.1%
Patients follow up appointments were offered as requested by staff and were mostly booked on the day of the initial appointment. Patients told us it was easy to book their follow-up appointment and to change their appointments. The service had issues around clinic capacity and space. We noted that the service had not undertaken an assessment on the utilisation of clinics and how to maximise capacity on use of clinic rooms. There was 100% utilisation of the clinic space in the outpatient clinics compared to the 40% utilisation in diabetic clinics. Staff told us this had been raised with the executives and they felt they will have more clinic space in outpatient in the New Year with the aim to take more patient appointment and move some clinic from the North clinic to the South clinic. We observed no improvement since the last inspection in the clinic capacity in the glaucoma clinic. Although the service still had limited capacity in the glaucoma clinic, the trust told us they had significantly improved the glaucoma pathway for patients since the last inspection. The trust had an ‘experience based co-design’ (EBCD) work stream was working at improving clinic flow with the aim to reduce late running clinics and improve patient and staff experience. We noted that patients and staff such as the receptionists were part of this work stream. The managers attended weekly access meeting with their commissioners to discuss and raise any issues on capacity, space, referral to treatment time (RTT) and did not attend (DNA) appointment.
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The service had introduced the ‘virtual clinics’ and stable monitoring clinics in December 2017 for glaucoma patients and patients with age-related macular degeneration (AMD) with an aim to save patients’ numerous trips to hospital and free up glaucoma specialists’ time. These are nurse-led clinics for patients with stable eye conditions to enable patients to be seen, tested, and discharged within an hour to deal with demands which was in line with the NICE guidance on 2-week referral to treatment. Under this system patient results were reviewed by a consultant within three days and a message was sent to patient to confirm the outcome and to schedule any further appointment. The service commenced a joint Wednesday clinic three months ago at the North clinic to address the access and flow issue, this had helped clear the clinic waiting time and RTT backlog. Staff told us there had been an improvement to their RTT and had achieved their 18 weeks target. The paediatric clinic had scheduled eight clinics in the morning with 15 minutes slot and 13 clinics scheduled for the afternoon. Staff told us previously there was a backlog paediatric which had now been cleared and the paediatric RTT achieved 90%. The service had introduced a life telephone service with secure voice mail which was used to triage and managed urgency of patient referral to improve access and flow. This was led by an optometrist who could provide local GPs and community optometrists with an advice on condition management and on how to access the service should there be a need. Staff we spoke with told us they had issues around the waiting list. During inspection the highest wait for patients awaiting an appointment was 34 weeks with 44 people on the waiting list. As a result, the service managers had created extra clinics and overbooked some clinics to scheduled appointment for patients waiting long for booking. Senior staff told us they knew their patient profile and DNA rates which was why they overbooked some of the clinics to ensure other patients were accommodated. We reviewed the waiting list for non-emergency appointment for patients waiting to be booked for their appointment during inspection. The non-emergency clinic booking waiting time ranged from four weeks to 34 weeks for various clinic appointments. The cataract clinic had 34 weeks wait with first appointments currently booked for June 2019. The glaucoma clinic for stable patient was 21 weeks wait and 20 weeks for paediatric patients. We noted that 646 (76%) patients were booked for glaucoma appointment and 206 (24%) patients were awaiting booking. Of the 76% patients booked, 67% patients booked were over 18 weeks. Staff we spoke with told us the key issues were waiting time and capacity and occasionally four patients were booked to see the same doctor at the same time which caused the delay. Staff also commented they were not sure if there were admission criteria for the number of patient to be seen in a clinic. Patients we spoke with told us they experienced delays before been seen in the clinic. Patient specific comment on clinic waiting time included; “there are large volumes of people that attend the clinic and the delay I experience in the clinic is the waiting for injection for four to five hours from start to finish and not the pre-assessment”. We observed nurses advising patients during their consultation that there was a 90 minutes delay to see doctor following the nurse assessment. The service introduced a new initiative following patient feedback on waiting times which included the use of a white board in the reception area on waiting times and receptionist communicating with staff to obtain real waiting time information before updating board. The service also introduced a staff floor walker that toured the clinic and explained the waiting times to patients, and in particular for patients that could not see the board information. We noted that information Page 120 displayed on waiting times in clinics for patients in the waiting area was not up to date. Patients told us that this was not reflective of their delays. On one occasion the board showed no delays but patients told us they had one-hour delay since the time the appointment was booked for. Staff told us the reason for clinic delays varied such as emergency appointments, use of translations and consultation for patients with additional needs. The service reserved some clinics for emergency patients such as when a GP wants a patient to be seen quickly. During inspection we noted that the service received and saw urgent referral the same day. Staff and patients told us doctors did not rush patients and took the time to answer their questions and queries which can then result in delay in other patients being seen. For example, staff spend 20-30 minutes for elderly patients or those with complex needs during consultation. Leaflets were seen in the clinic which advised patients that examination or consultation varied depending on nature and complexities and the whole visit may take up to four hours. The leaflet also advised that the clinic always tried to see patients in time order however young children or those requiring emergency treatment were given priority. The leaflet also gave a summary of the patient appointment pathway which began with the nurse consultation, diagnostic imaging or other ocular examination if required before been seen by a doctor. The DNA rate for the period of September 2018 was 9% overall which was a slight improvement from August 2018 (9.4%). We saw that each clinic was overbooked weekly to reschedule DNA appointments. Staff told us the text service which was recently introduced had improved the DNA rates and previously DNA rates had reached 11% in some months. Patients now received a 48 hours reminder for appointment to prevent DNA. The trust had a reporting system in place to monitor patients without an outcome or action after an attendance in outpatient. These potential ‘lost to follow up patients’ were reviewed on a weekly basis at the trust access board meetings. Any patients that are potential lost to follow up were validated weekly, with any patients that have been lost contacted with a clinically appropriate appointment booked. Patients who have potentially come to harm because of lost to follow up were reported via the trust incident system and discussed at the weekly incident panel. The trust management of follow up patients within the required time frame was in line with recent ophthalmology commissioning guidelines, Royal College of Ophthalmologists guidelines and feedback from the Getting It Right First Time deep dive visit in June 2018. Staff told us there had been improvement in scanning of patients’ referrals and they had achieved 100% in a recent audit on check referrals and this was a result of two administrative staff allocated to support with the scanning. There had also been improvement to the referral acknowledgement letter from the service being sent out and the service achieved 86% in a recent audit compared to the previous result of 14%. From August 2017 to July 2018 the trust’s referral to treatment time (RTT) for non-admitted pathways has been consistently better than the England overall performance. The latest figures for July 2018, showed 94.5% of this group of patients were treated within 18 weeks versus the England average of 88.3%. The trust’s referral to treatment time (RTT) for non-admitted pathways has been better than the England overall performance for all 12 months between August 2017 and July 2018.
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(Source: NHS England)
One specialty was above the England average for non-admitted pathways RTT (percentage within 18 weeks).
Specialty grouping Result England average Ophthalmology 94.2% 89.2%
(Source: NHS England)
From August 2017 to July 2018 the trust’s referral to treatment time (RTT) for incomplete pathways has been consistently better than the England overall performance. The latest figures for July 2018, showed 94.9% of this group of patients were treated within 18 weeks versus the England average of 87.3%.
The trust’s referral to treatment time (RTT) for incomplete pathways has been better than the England overall performance for all 12 months between August 2017 and July 2018.
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(Source: NHS England)
One specialty was above the England average for incomplete pathways RTT (percentage within 18 weeks).
Specialty grouping Result England average Ophthalmology 94.8% 88.4%
(Source: NHS England)
Moorfields at Bedford did not meet the referral to treatment times standard for incomplete pathways from January 2018 to August 2018 (92% of pathways completed within 18 weeks). They also did not meet the standard for non-admitted pathways (95%) within the same period. The latest data provided by the trust for the Moorfields at Bedford is presented in the table below (% of pathways completed within 18 weeks).
Jan. Feb. March April May June July Aug. 2018 2018 2018 2018 2018 2018 2018 2018 Non- 83% 86% 85% 81% 91% 86% 82% 86% admitted pathways Incomplete 89% 86% 85% 87% 89% 88% 86% 85% pathways
Data provided by the trust during inspection showed that the trust cancer two weeks from urgent GP referral to first appointment for the period of 2017/2018 achieved 97% and 100% of patients were waiting less than 6 weeks for their diagnostic test.
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The trust was performing better than the 93% operational standard for people being seen within two weeks of an urgent GP referral. The performance over time is shown in the graph below.
(Source: NHS England – Cancer Waits)
The trust is performing better than the 96% operational standard for patients waiting less than 31 days before receiving their first treatment following a diagnosis (decision to treat). The performance over time is shown in the graph below.
(Source: NHS England – Cancer Waits)
Staff told us the service had achieved 100% in the Age-related macular degeneration RTT for injection from time of referral. Learning from complaints and concerns There were processes in place to ensure complaints were dealt with effectively. Information was displayed and provided to patients on how to report concerns and make a complaint. Patients and relatives could make a complaint verbally or written, by face to face contact, telephone calls, PALS or through the hospital website. The trust also monitored complaints through feedback received from the NHS Choices and social media, patient participation groups including the patient and carer forum, the AIS patient implementation group and the patient participation and experience committee. We saw there were leaflets and posters in the clinics with information on how to make complaints. We noted that patients were also encouraged to give their feedback using the feedback form in the reception areas. The reception area had TV screen that included information on how to make a complaint and encouraged patients to share their ideas on what they would like to see change in the service.
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Summary reports of complaints and compliments were sent to divisional management teams weekly and complaint themes were produced on a quarterly basis. Staff we spoke with were knowledgeable on the complaints trends received in the service and how to handle complaints. Staff told us they were informed about complaints about the service through staff meetings and bulletins. Patients we spoke with knew that they could make a complaint if they wanted and said they were comfortable bringing up issues to staff. The hospital published a monthly ‘You Said, We Did’ bulletin which outlined steps they had taken to address concerns from patients and staff. We saw several examples of changes made to the service which included a floor walker in place following complaints on waiting time and patient not getting accurate estimate on waiting time. Other changes made to the service because of patient’s complaint and feedback included development and implementation of a virtual clinic model with the aim of reducing patient waiting time, implementation of a text reminder messaging service, new signage in the clinics and introduction of dedicated play specialists where children are seen. The service had also updated the standard letter sent to patients based on feedback received. The November 2018 staff bulletin showed that the division received 21 formal complaints and 162 PALS queries in the 2017/2018 financial year and the main theme was waiting time for clinic and the bulletin highlighted that staff should ensure they update the white board and inform patients how long the wait. From 7th August 2017 to 6th August 2018, there were 108 complaints about outpatients. The trust took an average of 21.1 days to investigate and close complaints, this is in line with their complaints policy, which states complaints should be completed within 25 working days. Across the trust, a high proportion of complaints related to clinical treatment (45.4%) and values and behaviour (24.1%). A breakdown of complaints by site can be found below. Moorfields at Bedford: There were five complaints (4.6%), two of these related to clinical treatment and two related to waiting times. (Source: Routine Provider Information Request (RPIR) – Complaints tab)
From 6th August 2017 to 6th August 2018 there were 142 compliments within outpatients across the trust. It included 28 received by outpatients at Moorfields at Bedford.
Location Number of compliments Moorfields at Bedford 28
Due to the nature of the data provided we are unable to comment on any themes relating to the compliments received. The trust has reported that:
“The compliments we receive focus on the standard of clinical care provided, with patient’s treatment meeting expectations and clinical outcomes being positive. Patients also compliment the care provided by individual members of staff, highlighting their kindness, professionalism and caring attitude which helps patients feel they are being treated personally. Many people comment that caring staff and the calm environment reduces their anxiety”.
(Source: Routine Provider Information Request (RPIR) – Compliments tab)
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Is the service well-led? Leadership Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care. Bedford site had their own clinical director, matron and a deputy general manager that managed the service and represented it within the North London division. There were clear lines of management responsibility and accountability within the outpatients department. Senior managers were aware of issues faced by the local teams. The senior management team had regular meetings with the host trust’s management team and local commissioners to discuss issues related to service delivery. They told us that communication had improved and was effective and they could influence decisions affecting service delivery in cooperation with the host trust. Vision and strategy The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community. The trust had wanted to aspire to be: caring, organised, excellent, and inclusive. Most staff we spoke with knew the trust vision and values. We saw the trust values were displayed in waiting areas for patients to take note of. There was no specific written long-term strategy for the department and the departments objectives and plans were driven by the local clinical commissioning group and its goals were aligned with the host trust’s. The trust had completed reviewing the clerical and administrative staffing structure across the geographical patch. This meant that some new administrative job roles were created and staff need to reapply for them. Staff talked about those changes in positive way saying that it created new professional development opportunities. Culture Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. The division prepared an action plan in response to findings from 2017 NHS Staff Survey with a view to improve communication between managers and staff and increased pressures on staff working extra hours. The action plan also aimed to address more negative than expected findings in relation to discrimination, bullying and harassment from patients and staff. Leaders aimed to improve staff experience by promoting participation and completion of the trust’s management development programme for managers at all levels. They produced divisional communications bulletin which was to be shared with staff. They were also working on developing a training session on bullying and harassment, stress management and emotional resilience. As there were no trainee doctor’s grades on rotation at Moorfield at Bedford the service did not take part in the General Medical Council trainee doctor survey. Staff worked well together as a team and supported one another. Agency staff told us they felt supported, involved and part of the team. Staff felt able to raise concerns and discuss issues with the managers of the department.
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Governance The trust used a systematic approach to continually improve the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish. The department held clinical governance meetings quarterly. We noted that clinical governance meetings were well attended by staff in various roles. Those meetings were used to discuss clinical audits, changes to staffing, incidents and complaints, patients experience and feedback gathered through patients’ surveys amongst other topics. We reviewed minutes from clinical governance meetings and saw that learning from incidents, complaints, friends and family test and serious incidents were discussed and disseminated. Representatives of the service attended Moorfield’s governance meetings which took place quarterly and governance meetings at the host trust. They also participated with the ‘access board meeting’ with the local trust’s outpatients department. This is where they discussed key performance indicators such as referral to treatment standards or did not attend rates Management of risk, issues, and performance The department had effective systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. The department identified eight risks on their local risk register. Each of the risks identified had mitigation actions listed against them and action on further controls to be put in place identified. Actions had a date for review in near future listed as well as person responsible for monitoring those actions. The highest scored four risks listed on department’s risk register: • On-going issues with equipment used for intra-ocular lens (IOL) power calculation (cause unknown). • Increased demand on the service with no additional clinic space. • Lack of performance monitoring tools relating to the host trust’s patient information management system. • Lack of consultants to meet clinical demand in the glaucoma service. The department had no Commissioning for Quality and Innovation (CQUIN) targets set which would be directly related to provision of the service. Staff knew the clinical governance arrangements. When incidents occurred, they worked together to identify any areas that needed improvement. Complaints and incidents were regularly reviewed during staff meetings and during quarterly clinical governance meetings. Staff we spoke to were aware of patterns and trends in incidents and complaints. Investigation reports suggested authors sought assurances that the Duty of Candour was fulfilled and that the hospital provided person involved with right information in an open and transparent way. Local managers and divisional leaders had access to data that allowed them to review departments performance. It included data on cancellations, number of appointments when patients did not attend or data related to referral timeliness. This allowed them to identify and deficient performance and address shortfalls.
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Information management The department collected, analysed, managed, and used information well to support all its activities, using secure electronic systems with security safeguards. We were not made aware of any data security breaches that occurred at the hospital within the past 12 months prior the inspection. Access to individual patient’s records was restricted to authorised staff who had varied access rights and editing privileges granted in accordance with their job role. Electronic records were stored in line with data security standards and entries made in patient’s records could be easily ascertained to person creating them. Information was shared effectively across variety of care settings including community ophthalmology services, patient’s GP or optometrist. When required the department submitted reports through available systems such as the National Reporting and Learning System (NRLS) and the Strategic Executive Information System (StEIS) promptly to support shared learning and to share information with external bodies. The department used information available through performance reports and local audits to inform and improve service planning. This was easily available and easy to understand for staff involved in care and treatment delivery, the information was also timely and relevant. Engagement The department engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively. Staff told us they felt engaged in the day to day operation of the department and could influence changes. They had regular staff meetings which they used to share information related to complaint or incidents, for learning and sharing examples of good practice and to provide support to one another. Staff said they felt listened to when they had suggestions related to service delivery. The trust had a patient participation strategy and governance framework that set out the organisational approach to patient involvement and engagement. The patient carer forum (PCF) was established to seek assurance that representative groups of patients and carers and to ensure they were considered when making decisions. This forum gained assurance from the trust- wide, local, and children and young persons’ reference groups. The trust sent a quarterly ‘Friend of Moorfield’ newsletter, which contained recent activities carried out by the friend of Moorfield group (consisting of past patients, staff and public) and other latest information about the trust. Patients were invited to attend board and membership council meetings to discuss their experience of services and how pathways might be improved. Learning disability/dementia group meetings were held quarterly. The meeting offered the opportunity for learning disability groups, and patient and carer representatives to feedback on issues and challenges that they faced when visiting the hospital. It also was used for sharing positive experiences. Action plans were developed to ensure that patients with complex needs were included in the planning of improvements to the service delivery and patients’ experience. An example of this was the development of simplified easy read versions of patient letters, particularly those that were sent to confirm appointments.
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The department engaged patients by encouraging them to take part in surveys such as Friends and Family. They also undertook five local patient surveys within the previous 12 months. It included paediatric transition survey which was to promote understanding amongst staff of what it meant for young people to be transferring to the adult service. The results indicated 97% participants confirmed they knew what to expect and were well prepared by Moorfields staff. Learning, continuous improvement and innovation The department was committed to improving services by learning from when things went well and when they went wrong, promoting training, research, and innovation. The department used ‘This is me’ leaflet for patient living with dementia and their carer. It was developed in partnership between Royal College of Nursing and the Alzheimer Society. The trust told us this initiative had received significant praise from other charity organisation supporting people with mental health condition and from the NHS England’s representatives. The department involved patients in taking decision in meaningful way. For example, they undertook a survey to check if patients were happy to use an electronic self-check-in process. The results indicated that 96% felt that using the kiosks was a confidential process and 84% of patients would be happy to use a mobile app to check-in. The trust won an award from the national health professional journal in ‘Protecting patients and changing global practice’ category for the quality of their investigation of preventable eye infection.
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Moorfields Eye Hospital
Evidence appendix 162 City Road, Date of inspection visit: London, 14 to 6 December 2018 EC1V 2PD Tel: 020 7253 3411 Date of publication: www.moorfields.nhs.uk 12 March 2019
This evidence appendix provides the supporting evidence that enabled us to come to our judgements of the quality of service provided by this trust. It is based on a combination of information provided to us by the trust, nationally available data, what we found when we inspected, and information given to us from patients, the public and other organisations. For a summary of our inspection findings, see the inspection report for this trust. Acute services
Surgery
Facts and data about this service Moorfields Eye Hospital NHS Foundation Trust provides sub-specialty adult surgical care in cataract, glaucoma, vitreoretinal, ocular plastics, ocular oncology, medical retina, corneal disease, strabismus and neuro-ophthalmology. The trust is also the biggest provider for corneal transplants in Europe.
Surgery at the trust is mainly day case, however there are facilities to keep patients overnight should they require it. Patients with more complex medical needs are seen at the St. Georges site where medical support can be provided. Complex oncology patients who may need HDU facilities are seen at St Bartholomew’s Hospital.
These surgical services at the trust are provided across eleven surgical sites.
• Moorfields Eye Hospital (City Road) • Moorfields at Bedford • Moorfields at Croydon • Moorfields at Darent Valley • Moorfields at Ealing Hospital • Moorfields at Mile End • Moorfields at Northwick Park
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• Moorfields at Potters Bar • Moorfields at Queen Mary's • Moorfields at St Ann's • Moorfields at St Anthony's*
* Surgery at this site will transfer back to Duke Elder Ward, St George's, once refurbishment has been completed in Autumn 2018 (Source: Routine Provider Information Request (RPIR) – Sites tab)
The trust had 36,450 surgical admissions from June 2017 to May 2018. Emergency admissions accounted for 2,619 (7.2%), 33,134 (90.9%) were day case, and the remaining 697 (1.9%) were elective.
(Source: Hospital Episode Statistics)
Is the service safe? By safe, we mean people are protected from abuse* and avoidable harm. *Abuse can be physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse. Mandatory training The service provided mandatory training in key skills to all staff and made sure everyone completed it. Mandatory training completion rates
The trust set a target of 80% for completion of mandatory training.
Moorfields Eye Hospital (City Road)
Nursing Staff
A breakdown of compliance for mandatory training courses from August 2017 to July 2018 for qualified nursing staff in the surgery department at Moorfields Eye Hospital (City Road) is shown below:
Staff Eligible Completion Trust Met Name of course trained staff rate Target (Yes/No) Counter Fraud 14 14 100% 80% Yes Fire Site Cover / Manager 21 21 100% 80% Yes Risk and Safety Management 1 1 100% 80% Yes Infection Prevention (Level 1) 138 139 99% 80% Yes Information Governance 135 139 97% 80% Yes Helping Visually Impaired People 133 139 96% 80% Yes Conflict Resolution 131 139 94% 80% Yes Infection Prevention (Level 2) 131 139 94% 80% Yes Fire Warden 31 33 94% 80% Yes
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Preventing Radicalisation - Basic Prevent 80% Awareness (eLearning L1&2) 129 139 93% Yes Resuscitation Level 3 (Adult Immediate 80% Life Support) 33 36 92% Yes Resuscitation Level 3 (Paediatric 80% Immediate Life Support) 33 36 92% Yes Adult Basic Life Support 122 139 88% 80% Yes Preventing Radicalisation - Awareness of 80% Prevent (WRAP) 121 139 87% Yes Medicine management training 119 139 86% 80% Yes Medical Gas Safety 111 139 80% 80% Yes Recruitment and Selection 11 14 79% 80% No Nurse Supply of Medicines 41 54 76% 80% No
Following our inspection, we received evidence from the trust that the trust targets for training in Recruitment and Selection and Nurse Supply of Medicines had been surpassed, meaning that all of the targets for mandatory training had been met.
Medical Staff
A breakdown of compliance for mandatory training courses from August 2017 to July 2018 for medical staff in the surgery department at Moorfields Eye Hospital (City Road) is shown below:
Staff Eligible Completion Trust Met Name of course trained staff rate Target (Yes/No)
Infection Prevention (Level 1) 52 52 100% 80% Yes Resuscitation 1 1 100% 80% Yes Counter Fraud 10 10 100% 80% Yes Fire Warden 1 1 100% 80% Yes Resuscitation Level 2 (Paediatric Basic Life Support) 1 1 100% 80% Yes Resuscitation Level 3 (Adult Immediate Life Support) 4 4 100% 80% Yes Resuscitation Level 3 (Paediatric Immediate Life Support) 4 4 100% 80% Yes Information Governance 50 52 96% 80% Yes Infection Prevention (Level 2) 49 52 94% 80% Yes Conflict Resolution 48 52 92% 80% Yes Prescribing Practice and Formulary for Medical Prescribers 48 52 92% 80% Yes Resuscitation - Paediatric Advanced/European Life Support (APLS/EPLS) 16 18 89% 80% Yes Preventing Radicalisation - Basic Prevent Awareness (eLearning L1&2) 46 52 88% 80% Yes Helping Visually Impaired People 45 52 87% 80% Yes
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Resuscitation - Advanced Life Support (ALS) 15 18 83% 80% Yes Adult Basic Life Support 42 52 81% 80% Yes Recruitment and Selection 8 10 80% 80% Yes Preventing Radicalisation - Awareness of Prevent (WRAP) 41 52 79% 80% No
At Moorfields Eye Hospital (City Road) surgery department, the 80% target was met for 17 of the 18 mandatory training modules for which medical staff were eligible.
Following our inspection we received evidence from the trust that the target for completion of Preventing Radicalisation- Awareness of Prevent (WRAP) had been surpassed, meaning that the mandatory training targets for medical staff had been met. Staff told us that their line managers were responsible for ensuring that their teams were up-to-date with mandatory training. They told us that mandatory training was delivered both face-to-face and as e-learning. Nursing and medical staff told us that the training was interesting and meaningful. Some nursing staff told us that they were occasionally required to complete mandatory training in their own time, although they were reimbursed for this. Safeguarding Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Safeguarding training completion rates
The trust set a target of 80% for completion of safeguarding training.
Moorfields Eye Hospital (City Road)
Nursing Staff
A breakdown of compliance for safeguarding training courses from August 2017 to July 2018 for qualified nursing staff in the surgery department at Moorfields Eye Hospital (City Road) is shown below:
Staff Eligible Completion Trust Met Name of course trained staff rate Target (Yes/No) Safeguarding Children (Level 3) 1 1 100% 80% Yes Safeguarding Children (Level 1) 136 139 98% 80% Yes Safeguarding Children (Level 2) 135 139 97% 80% Yes Safeguarding* 128 139 92% 80% Yes *Safeguarding provides ‘Safeguarding Adults: Levels 1 and 2 Training’
Medical Staff
At Moorfields Eye Hospital (City Road) surgery department the 80% target was met for all four of the safeguarding training modules for which qualified nursing staff were eligible.
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A breakdown of compliance for safeguarding training courses from August 2017 to July 2018 for medical staff in the surgery department at Moorfields Eye Hospital (City Road) is shown below:
Staff Eligible Completion Trust Met Name of course trained staff rate Target (Yes/No) Safeguarding Children (Level 1) 50 52 96% 80% Yes Safeguarding* 49 52 94% 80% Yes Safeguarding Children (Level 2) 48 52 92% 80% Yes Safeguarding Children (Level 3) 20 22 91% 80% Yes *Safeguarding provides ‘Safeguarding Adults: Levels 1 and 2 Training’
At Moorfields Eye Hospital (City Road) surgery department the 80% target was met for all four of the safeguarding training modules for which medical staff were eligible.
The trust exceeded the minimum compliance rate for all safeguarding training for all staff groups. Staff were had a clear understanding of their responsibility to safeguard patients. They were aware of the procedure for escalating safeguarding concerns and were able to name the nominated safeguarding leads. Staff we spoke with were aware of child sexual exploitation and what procedures to follow should they have a concern regarding these issues. Staff had also completed PREVENT training as part of their safeguarding training. PREVENT is a government scheme to safeguard people and communities from the threat of terrorism. There was a hospital-wide safeguarding team who provided support and training to staff in respect of safeguarding issues. Nursing staff spoke highly of the support provided by the safeguarding team. They said that the team was easily accessible when staff wanted to raise safeguarding concerns. Cleanliness, infection control and hygiene
The service controlled infection risk well.
The environment in both theatres and the wards was visibly clean and clutter free. We observed cleaning staff carrying out regular ward rounds. Cleaning staff had access to appropriate cleaning equipment and had been made aware of the required standards for cleanliness. There was a trust policy which outlined the patient cohorts who were to undergo pre-surgery MRSA screening. There was an infection control team within the hospital and staff spoke highly of them. The IPC nursing team undertook regular walkabouts in clinical areas, inspecting equipment, the environment, sharps containers, waste bins and hand hygiene. Where they identified issues, the team gave immediate feedback to staff before providing a written report with recommendations for improvement. The team produced a monthly newsletter and we saw copies of this in staff areas. There were facilities on the wards for patients to be kept in isolation to prevent the spread of infection. Staff told us that they made use of appropriate advanced personal protective equipment (PPE) when entering the rooms of these patients, and their doors were kept shut at all times. We did not observe any patients in isolation during our inspection.
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Yellow sharps boxes were in use throughout the service, and were appropriately signed and dated and not over-filled. Some theatre nursing staff raised concerns regarding infection prevention and control in theatres. In particular, they were concerned that patients were allowed to wear their own shoes and clothes into theatres and that this presented an infection risk. However, senior staff advised that this was the standard level of infection prevention and control in ophthalmology theatres and therefore did not constitute poor practice nor present an increased risk of infection. We had sight of policies which indicated this was the case. The staff who raised the concerns said that they head raised their concerns to the trust and had felt that their concerns had been ignored. Environment and equipment The service had suitable premises and equipment and looked after them well. The hospital was visibly clean and clutter free on the wards, theatres and in public areas. Staff told us that sterile surgical kits were readily available and usually fully complete. Kits that were not complete would be marked as such. The hospital had an on-site decontamination unit and team. Theatre staff told us that they had a positive working relationship with the decontamination team. Turnaround for sterilisation was 12 hours, but kits could be fast tracked if necessary. Surgical equipment was appropriately stored in the surgical equipment stores. Resuscitation trolleys were available on all of the wards, in theatres and in the resuscitation areas, as well as in the foyer outside the private reception. The trolleys were uniform in design, meaning that they would be easily identifiable and located by staff in the event of an emergency. All of the trolleys were appropriately stocked with necessary equipment and medicine. The trolleys had numbered breakable seals to prevent equipment being removed or tampered with. Nurses carried out daily checks of the trolleys and signed a log to indicate they had done so. We checked each of the log books which indicated that this was done every day. Fire doors were clearly signed and fire exit routes were kept clear. In the public toilets within the private suit, however, there was a door to the lift shaft which was signed to indicate it should be kept locked. This was not the case during day one of our inspection. We escalated this as a concern to the sister responsible for the private wards. Later that day, the head of nursing informed us that she had been made aware of the issue. The door was immediately locked and a note sent round to all facilities and maintenance staff and contractors reminding them of the importance of locking such doors. When we checked the door the following day, it was locked. Assessing and responding to patient risk Staff completed and updated risk assessments for each patient. At our inspection of May 2016, there were concerns regarding the use of the World Health Organisation’s (WHO) Five Steps to Safer Surgery checklist. The WHO Surgical Safety Checklist is a checklist that was developed to decrease errors and adverse events, and increase teamwork and communication in surgery. During this inspection, the WHO checklist was carried out appropriately, with opportunity for all of the staff present in the theatre to speak where appropriate. Staff told us that the WHO checklist was very effective, withal team members being given an opportunity to voice any concerns about the planned progress of the operation or their understanding of the surgery that was due to take place. We observed this at the time of the inspection.
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The use of the WHO checklist in theatres was audited trust-wide on a monthly basis. We had sight of the audit results for October 2018. The City Road site scored 100% in all aspects of the audit. Staff told us that theatres consistently scored 100% in the audit. Surgical ward staff used an electronic monitoring system to observe patients’ vital signs and these were entered into an electronic touchpad system. Patients’ vital signs such as blood pressure, pulse, and breathing rates were measured and escalated using the Early Warning Scores (EWS). This system provided an escalation trigger protocol. Patients who scored above a seven were referred to the critical care outreach team. If staff had concerns at any point during a patient’s care, they could escalate these for urgent review by the consultant. We saw EWS were used in all patient records we reviewed. The trust audited the completion of the EWS, and the latest audit showed all surgical wards had scored 100% for correctly escalating patients to the outreach team. Risk assessments were undertaken on each patient on admission to the wards and documented in patient notes. Nursing staff carried out intentional rounding’s (a structured process where nurses carry out regular checks with individual patients). We saw this took place and it was documented in patient records. Patients confirmed nurses regularly visited and carried out checks on them. The resuscitation team provided level 1 cardiopulmonary resuscitation (CPR) training to non- clinical staff who requested it. Anaesthetic staff told us that they were expected to care for patients awaiting transfer from the hospital in theatre recovery in the event of a collapse or cardiac incident within the hospital. Where patients stayed in the hostel, their suitability for staying in the hostel accommodation was assessed by the nurse at pre-assessment, in accordance with exclusion criteria. There was no nursing or medical cover for patients staying in the hostel, who were deemed medically fit to do so. There was, however, a Band 2 warden available throughout the night, who could escalate patients to the accident and emergency staff in the event of an emergency. Nurse staffing The service generally had enough nursing staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment. The trust has reported their staffing numbers below for March 2018 and July 2018. There was an under-establishment of qualified nursing staff in surgery across the trust.
As at March 2018 As at July 2018 Planned Actual staff Planned Actual staff Site staff – Fill rate Fill rate – WTE staff – WTE – WTE WTE Moorfields Eye 153.9 139.3 90.6% 158.5 143.6 90.6% Hospital (City Road)
(Source: Routine Provider Information Request (RPIR) –Total staff tab)
Vacancy rates
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From August 2017 to July 2018, the hospital reported a vacancy rate of 12.1% in surgery:
Vacancy rates for qualified nursing staff in surgery at the trust were higher than the trust target of 10%.
(Source: Routine Provider Information Request (RPIR) – Vacancy tab)
In spite of the vacancy rate being higher than the trust target, the vacancy rate at the City Road site was one of the lowest in surgery across the trust.
Turnover rates
From August 2017 to July 2018, the hospital reported a turnover rate of 3.3% in surgery.
Turnover rates for qualified nursing staff in surgery at the trust were significantly lower than the trust target of 15%.
(Source: Routine Provider Information Request (RPIR) – Turnover tab)
Sickness rates
From August 2017 to July 2018, the hospital reported a sickness rate of 6.3% in surgery:
• Moorfields Eye Hospital (City Road): 6.3%
Sickness rates for qualified nursing staff in surgery at the trust were higher than the trust target of 4%.
(Source: Routine Provider Information Request (RPIR) – Sickness tab)
Bank and agency staff usage
The below table shows the bank and agency usage (hours) for qualified and non-qualified nursing staff in surgery from August 2017 to July 2018.
Moorfields Eye Hospital (City Road)
Total hours Bank Agency Unfilled Qualified 1,816 367 (20.2%) 45 (2.5%) 0 (0%) Non-qualified 457 75 (16.4%) 1 (0.2%) 0 (0%)
(Source: Routine Provider Information Request (RPIR) - Nursing bank agency tab)
Staffing levels were generally good, with limited reliance on bank and agency staffing. Senior staff told us that, where possible, the division sought to use its own staff in a bank capacity as they were familiar with the work of the hospital. Where the use of agency staff was unavoidable, the division tried to make use of regular agency staff, who were familiar with the wards or theatres in which they would be working. All agency staff and bank staff working in a new area of
Page 137 the hospital were required to undertake an induction into that area. We saw evidence of these having taken place.
Each ward displayed the planned and actual staffing levels on at the entrance. During our inspection, all of the surgical wards were fully staffed in accordance with planned levels. Some staff on the NHS wards told us that they were often one staff member down. They said, however, that whilst this could increase their workload, they did not feel that it had a negative impact on the care provided to patients.
Medical staffing
The service had enough medical staff with the right qualifications, skills, training and experience to keep people safe from avoidable harm and to provide the right care and treatment.
The trust has reported their staffing numbers below for March 2018 and July 2018. There was an under-establishment of medical and dental staff in surgery across the trust. At July 2018, there were 6.5 WTE less staff in post than the trust had planned for. Staffing data was only provided for Moorfields Eye Hospital (City Road).
As at March 2018 As at July 2018 Planned Fill rate Planned Actual staff Fill rate Actual staff Site staff – staff – WTE – WTE – WTE WTE Moorfields Eye 49.5 46.1 93.1% 51.4 44.9 87.2% Hospital (City Road) Total 49.5 46.1 93.1% 51.4 44.9 87.2%
(Source: Routine Provider Information Request (RPIR) –Total staffing tab)
Vacancy rates
From August 2017 to July 2018, the trust reported a vacancy rate of 8.2% in surgery at the City Road site.
Vacancy rates for medical and dental staff in surgery at the trust were lower than the trust target of 10%. The trust has also reported that there was a total vacancy WTE of -10 for medical staff at St. George’s and this is the reason for the discrepancy between the vacancy rate reported for the trust overall and the vacancy rate reported for City Road.
(Source: Routine Provider Information Request (RPIR) – Vacancy tab)
Turnover rates
From August 2017 to July 2018, the hospital reported a turnover rate of 7.4% in surgery. This is lower than the trust target of 15%.
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(Source: Routine Provider Information Request (RPIR) – Turnover tab)
Sickness rates
From August 2017 to July 2018, the trust reported a sickness rate of 0.5% in surgery. This sickness rate relates to the surgical services provided at Moorfields Eye Hospital (City Road) as no sickness data was provided for other sites at the trust. This is lower than the trust target of 4%.
(Source: Routine Provider Information Request (RPIR) – Sickness tab)
Bank and locum staff usage
The below table shows the bank and locum hours for medical staff in surgery from August 2017 to July 2018. Across the trust, 9,949 hours were filled by bank staff and 859 hours were filled by agency staff. This usage was mainly at Moorfields Eye Hospital (City Road).
Location Total Bank Locum Unfilled hours Moorfields Eye Hospital (City Road) 102,918 9,949 (9.7%) 859 (0.8%) 0 (0%) Moorfields at St. George’s 0 50 0 0 Trust total 102,918 9,999 (9.7%) 859 (0.8%) 0 (0%)
(Source: Routine Provider Information Request (RPIR) - Medical agency locum tab)
Staffing skill mix
At June 2018, the proportion of consultant staff reported to be working at the trust was lower than the England average and the proportion of junior (foundation year one-two) staff was lower.
Staffing skill mix for the whole time equivalent staff working at Moorfields Eye Hospital NHS Foundation Trust This England Trust average Consultant 43% 49% Middle career^ 34% 11% Registrar Group~ 19% 28% Junior* 4% 11%
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^ Middle Career = At least 3 years at SHO or a higher grade within their chosen specialty ~ Registrar Group = Specialist Registrar (StR) 1-6 * Junior = Foundation Year 1-2, Other and Local HCHS Doctor Grades
(Source: NHS Digital Workforce Statistics)
Despite the fact that the proportion of consultant staff and junior doctors was lower than the English average, the service advised that this was due to changes that the service had brought about in the management of ophthalmology arising from research. There was an on-call rota for out-of-hour consultant cover. Medical cover for emergencies within the directorate was provided by the medical staff based in the accident and emergency department and the anaesthetic service. In addition, anaesthetic staff based in theatres told us that they were expected to care for patients awaiting transfer from the hospital in theatre recovery in the event of a collapse or cardiac incident within the hospital. They said that this was very rare. However, they recognised that this could have the potential to impact on the care being provided to those patients already in recovery. Records Staff kept detailed records of patients’ care and treatment. We examined 11 patients’ records, including ward records and surgical notes. The trust made use of both electronic and paper records, with nursing notes and observations being recorded on paper. Records were appropriately and securely stored in locked cabinets and trolleys. Staff made sure they locked computer screens before leaving them. Records were accurate, detailed and fit for purpose. The patient record templates ensured that a patient’s notes detailed the entirety of their journey through the services all within the same folder. Patient notes included medical histories, including allergies, pre-assessment notes, observations, risk assessments, the WHO theatre checklist and discharge information. At the inspection of May 2016, staff had expressed concern regarding accessing records and the use of temporary records. Staff we spoke with told us that this had improved since the last inspection. They said that records were usually readily available and the use temporary records was rare. Medicines The service followed best practice when prescribing, giving, recording and storing medicines. The trust carried out a range of medicines-related audits to assess how they were performing, and to identify areas for improvement. These included audits of controlled drugs, FP10 prescriptions and safe and secure handling of medicines. Staff told us that the pharmacy team were a valuable resource in identifying issues with medicines and encouraging improvement. In all of the areas we inspected, there was good clinical input by the pharmacy team, providing advice to staff and patients, and making clinical interventions with medicines to improve patient safety. Arrangements for the supply of medicines were good. There were effective arrangements in place for medicines supplies and advice out of hours. The main pharmacy department operated extended hours 9am to 9pm every weekday and 9am to 7pm on Saturday and there was a satellite pharmacy for the day case surgical wards.
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Medicines stocked in the wards were managed safely. They were checked regularly and out-date- stock was destroyed and replaced by the pharmacy team. Arrangements were in place to ensure that medicines incidents were reported, recorded and investigated and staff we spoke with knew how to report incidents involving medicines. Controlled drugs (CD) were managed appropriately, with stock balances in all locations checked daily. CDs were kept in a locked cupboard and the keys were held by the nurse in charge on a shift. Two members of nursing staff signed the CD book for each CD that was administered or refused and destroyed. All of the CD cupboards were kept locked throughout our inspection. Incidents The service managed patient safety incidents well. Never Events
Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event.
From September 2017 to August 2018, the hospital reported one incident classified as never events for surgery at City Road. The never event concerned a “surgical/invasive procedure meeting SI criteria”. Details of the never event can be found below:
• 26/01/2018 Moorfields Eye Hospital (City Road) - Incorrect intraocular lens fitted during surgery. Following this, an exchange of lens took place with no further issues.
(Source: Strategic Executive Information System (STEIS))
We saw evidence that the never event had been appropriately investigated, with a root cause analysis (RCA) carried out, which set out actions to ensure the error was not repeated. Staff we spoke with were aware of the incident and the learning from it. In addition staff were able to discuss the cause and learning outcomes from a never event which had occurred at another Moorfields site.
Breakdown of serious incidents reported to STEIS
In accordance with the Serious Incident Framework 2015, the trust reported three serious incidents (SIs) in surgery which met the reporting criteria set by NHS England from September 2017 to August 2018. Of these, the most common types of incident reported were:
• Surgical/invasive procedure incident meeting SI criteria with two (67% of total incidents). • Treatment delay meeting SI criteria with one (33% of total incidents).
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Site specific information can be found below: • Moorfields Eye Hospital (City Road): two incidents • Moorfields at St. George’s: one incident
(Source: Strategic Executive Information System (STEIS))
Staff used an electronic system to report incidents. Staff told us that they felt confident and supported to report incidents. They said that incidents were treated as learning opportunities. Once an incident was reported it was reviewed by senior staff and, where appropriate, allocated for investigation. Learning from incidents was shared with staff in email newsletters and at handovers. The majority of staff told us that they received feedback in respect of any incidents they reported. In addition, staff we spoke with were aware of learning from incidents they had not been involved in or reported from across the trust. This demonstrated that learning from incidents was widely shared. A small number of staff in theatres told us that they had reported concerns through the electronic system to which they had not received a direct response. They accepted that senior staff disagreed that their concerns (which related to IPC and are discussed elsewhere in this report) were founded, but felt that their concerns had been immediately dismissed and not properly considered. They were also dissatisfied that they had not received a direct response to the concerns they had raised. The trust investigated serious incidents by conducting root cause analysis investigations. Serious incidents were discussed at governance meetings, and the learning cascaded to staff by their line managers. The duty of candour is a regulatory requirement for healthcare professionals to be open and honest with patients when something that goes wrong with their treatment or care causes, or has the potential to cause, harm or distress. This means that healthcare professionals must tell the patient (or, where appropriate, the patient’s advocate, carer or family) when something has gone wrong, apologise to the patient, offer an appropriate remedy or support to put matters right (if possible) and explain fully to the patient the short and long term effects of what has happened. Staff we spoke with were aware of their obligations under the DoC. We saw examples of DoC letters in respect of the serious incidents we reviewed. Safety thermometer The service used safety monitoring results well.
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The Safety Thermometer is used to record the prevalence of patient harms and to provide immediate information and analysis for frontline teams to monitor their performance in delivering harm free care. Measurement at the frontline is intended to focus attention on patient harms and their elimination.
Data collection takes place one day each month – a suggested date for data collection is given but wards can change this. Data must be submitted within 10 days of suggested data collection date.
Data from the Patient Safety Thermometer showed that the trust reported no new pressure ulcers, no falls with harm and no new catheter urinary tract infections from August 2017 to August 2018 for surgery.
(Source: NHS Digital)
Information from the safety thermometer was displayed prominently on each of the wards, detailing the ward’s performance in the previous quarter.
Is the service effective?
Evidence-based care and treatment The service provided care and treatment based on national guidance and evidence of its effectiveness. Policies, procedures and guidelines were easily accessible to staff through the intranet. Policies were up to date and had been reviewed in line with their stated review dates. There were also up- to-date physical copies of policies available in the nurses’ station in each ward. We reviewed a number of policies and procedures. These had been developed in line with relevant national guidance and best practice information from bodies including the National Institute for Health And Care Excellence (NICE) the Royal College of Nursing (RCN) and the Royal College of Ophthalmologists (RCOphth). A number of staff we spoke with were undertaking enhanced professional training through programmes provided jointly by University College London. The surgical services had established clinics to review all patients who had undergone graft surgery one and two years after their surgery. Data collected at the clinic was submitted to NHS Blood and transplant (NHSBT) for benchmarking, as well as being stored within the service in order to learn from best-practice.
Nutrition and hydration Patients who were nil-by-mouth prior to surgery were prioritised on the theatre list, in order to ensure that they were not kept without food for too long. Where patients were nil-by-mouth this was clearly indicated on the board above their bed. Pain relief Staff assessed and monitored patients regularly to see if they were in pain.
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Recovery nursing staff were responsible for pain management immediately following surgery. They told us that they would ensure patients’ pain was managed prior to their transfer to the ward. Nursing staff on the ward administered pain relief to patients as appropriate. Patients’ pain levels were assessed using a pain score card which scored pain from 0-10. We saw completed pain assessments in patients’ records. Options for post-operative pain management were discussed with patients as part of their pre- assessment. Patients we spoke with on the wards told us that their pain was being managed effectively. Patient outcomes Managers monitored the effectiveness of care and treatment and used the findings to improve them. Relative risk of readmission
Elective Admissions - Moorfields Eye Hospital (City Road)
Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 is represents the opposite. Top three specialties for specific site based on count of activity
From May 2017 to April 2018, patients at Moorfields Eye Hospital (City Road) had a higher expected risk of readmission for elective ophthalmology admissions when compared to the England average.
Non-Elective Admissions - Moorfields Eye Hospital (City Road)
Note: Ratio of observed to expected emergency readmissions multiplied by 100. A value below 100 is interpreted as a positive finding, as this means there were fewer observed readmissions than expected. A value above 100 is represents the opposite. Top three specialties for specific site based on count of activity
All patients at Moorfields Eye Hospital (City Road) had a higher expected risk of readmission for non-elective ophthalmology admissions when compared to the England average. However, the hospital had a significant number of long term patients, with ongoing care needs.
Further, 12 months after surgery 98% of patients had a successful outcome against a national
Page 144 standard of 90%. Also 91% of patients have the same or better vision following cataract surgery against a national standard of 90%.
The trust participated in the National Ophthalmology Database Audit. In the 2018, which covered the three year period to 2018, the trust carried out 183,812 eligible cataract operations. Of these, 83.1% operations were performed before 30th June 2017 and had the potential for two months follow up. Of these 89,248 (58.5%) operations had no postoperative complication data recorded, 55,341 (36.3%) had ‘none’ recorded as the postoperative complication and 8,074 (5.3%) had at least one postoperative complication recorded. The percentage of operations with a postoperative complication record (none or a complication) or no postoperative complication record varied significantly between the participating centres, with nine centres having no records of any specific postoperative complications. The city road site was in the lower quartile for post-operative complications. Competent staff The service made sure staff were competent for their roles. Appraisal rates
Moorfields Eye Hospital (City Road)
From August 2017 to July 2018, 70.8% of staff within surgery at Moorfields Eye Hospital (City Road) received an appraisal compared to a trust target of 80%.
Target Individuals Appraisals Completion Trust Staff group met required complete rate target (Yes/No) Qualified Allied Health 14 13 92.9% 80% Yes Professionals (Qualified AHPs) Medical & Dental staff - Hospital 44 36 81.8% 80% Yes Support to ST&T staff 57 38 66.7% 80% No Qualified nursing & health 139 89 64.0% 80% No visiting staff (Qualified nurses) NHS infrastructure support 5 2 40.0% 80% No Grand Total 259 178 68.7% 80% No
(Source: Routine Provider Information Request (RPIR) – Appraisal tab)
All of the staff we spoke with during the inspection told us that their appraisals were up-to-date. They told us that appraisals were meaningful and said that their line managers challenged and supported them to further their practice and undertake professional development. A number of staff we spoke with were being funded by the hospital to undertake further study. For example, one of the healthcare assistants we spoke with was being supported to undertake an access course to allow them to undertake training as a nurse associate.
All clinical staff had access to additional ophthalmic education and training. One of the nurses we spoke with told us that that this was invaluable in helping her to support patients and understand their treatment. Page 145
Multidisciplinary working Staff of different kinds worked together as a team to benefit patients. Staff described a positive multi-disciplinary team (MDT) working culture. We saw numerous examples of positive, productive interactions from all disciplines and all degrees of seniority. The hospital had a service level agreement with another nearby trust, for the transfer of patients who deteriorated following surgery. Senior staff told us they had a positive working relationship with this trust. There were regular MDT meetings on each of the wards at which the care of each of the patients was discussed. In addition, there was a theatre users’ group, which included representatives from across the professions. Seven-day services The surgery services provided elective care and treatment Monday to Saturday and a seven-day emergency service. Day case surgery took place Monday to Friday. There was, however, the option to flex the service up to accommodate patient lists on Saturdays when necessary due to patient numbers.
There was overnight care for patients requiring ophthalmic nursing care only. There was no medical care provision for patients overnight and therefore patients who required this would be transferred to other hospitals. There was, however, access to emergency medical care provided by the medical team based in the accident and emergency department.
Health promotion There were signs throughout the hospital directing patients and their relatives to appropriate support for smoking cessation and reducing alcohol. There were signs throughout the hospital encouraging staff and patients to use the stairs in order remain active. There was information available to patients regarding diabetes, a common contributory factor to eye conditions and signposting diabetic patients to support groups and services.
Consent, Mental Capacity Act and Deprivation of Liberty Safeguards The majority of staff understood how and when to assess whether a patient had the capacity to make decisions about their care. Staff understood their roles and responsibilities under the Mental Health Act 1983 and the Mental Capacity Act 2005. Mental Capacity Act and Deprivation of Liberty training completion
Moorfields Eye Hospital (City Road)
Met Staff Eligible Completion Trust Name of course (Yes/ trained staff rate Target No) Mental Capacity Act Awareness (e- learning)* 205 267 77% 80% No Mental Capacity Act Level 1** 164 237 69% 80% No *The E-Learning course provides MCA Level One Training
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**The MCA Level 1 course provides both MCA Level 2 and 3 Training.
(Source: Routine Provider Information Request (RPIR) – Training tab)
All of the staff we spoke with had undertaken the Mental Capacity Act 2005 training for which they were eligible. Staff had a clear understanding of consent. They were able to explain their responsibility under the Mental Capacity Act 2005 (MCA) and had a clear understanding of the Deprivation of Liberty Safeguards (DoLS). However, one of the nursing staff we spoke with informed us that they would obtain consent to treatment from a patient who did not speak English from their relative, as opposed to from an interpreter. This would not be valid consent to treatment. We escalated this to the head of nursing, who informed us that additional training would be provided on the ward in question. We found no evidence of a relative having consented to treatment on behalf of a patient in any of the records we examined. Is the service caring? Compassionate care Staff cared for patients with compassion. We spoke with six patients and their relatives. All of the patients we spoke with praised the kindness and compassion of staff. They said that staff went out of their way to ensure that they received the best possible care. We observed a number of positive, caring interactions between staff and patients. For example, we observed a nurse in recovery singing to a very young patient to calm them whilst another nurse went to notify the patient’s guardian that the surgery had been completed. In addition, when we discussed patients with staff, observed staff discussions about patients they spoke with genuine care and compassion. At our inspection of May 2016, concerns were identified around patients’ privacy and dignity not being prioritised. During this inspection, we saw examples of patients’ privacy and dignity being maintained by staff, for example by the use of a side room for a sensitive discussion and staff asking patients if they wanted the curtains beside their bed drawn. Friends and Family test performance
The Friends and Family Test response rate for surgery at Moorfields Eye Hospital NHS Foundation Trust was 26% for July 2018. A breakdown of FFT performance by site and ward can be found below.
Moorfields Eye Hospital (City Road)
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Note - The formatting above is conditional formatting which colours cells on a grading from highest to lowest, to aid in seeing quickly where scores are high or low. Colours do not imply the passing or failing of any national standard. Wards with a response rate of less than 100 have been removed.
Key 100% 50% 0%
The FFT results for the City Road wards were highly positive, with the majority of patients indicating that they would recommend Moorfields to friends and family. Emotional support Staff provided emotional support to patients to minimise their distress. There was a nurse counselling service available within the hospital. The service was made up of specialist nurses who had received counselling training funded by the trust, as well as one full time counsellor. The counselling services provided emotional and practical support to patients coming to terms with sight loss and was available to all patients. Patients could self-refer to the counselling services or could be referred by pre-assessment or ward staff. Staff we spoke with throughout the hospital were aware of the counselling service. There were leaflets throughout the hospital for patients detailing emotional support available from charities and support groups. There was a multi-faith prayer room in the hospital which could be accessed by patients and staff. Understanding and involvement of patients and those close to them Staff involved patients and those close to them in decisions about their care and treatment. Patients and their relatives that we spoke with told us that they were kept informed about their care and the impacts and potential impacts of the care decisions they were making. Staff we spoke with recognised the importance of patients being able to make informed decisions about their care. One nurse told us that if she did not know the answer to a patient’s concern, she encouraged them to write it down in order that they remembered to ask the consultant during their ward round. One patient we spoke with told us how they had been kept informed about all aspects of their care and treatment, including their discharge and what to expect at their follow-up appointments. Is the service responsive? Service delivery to meet the needs of local people The service worked collaboratively with commissioners and other trusts across London, to ensure services were appropriately planned and delivered. In particular, the service had a number of service level agreements with local trusts whereby they would accept patients requiring certain types of eye surgery, whilst the service was able to transfer patients to other trusts in the event of a patient deteriorating or requiring treatment covered by another surgical speciality. Patients attending the hospital were referred from across London and the wider UK, as well as patients attending under a service level agreement with the government of Malta and private patients attending from overseas. In response to the long distances travelled by a significant number of patients, and given the potential impact on the ability to travel immediately following eye surgery, the hospital provided hostel accommodation on site on Mackellar Ward (which was otherwise used for day cases) from
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9pm to 6am. Patients’ suitability for staying in the hostel accommodation was assessed by the nurse at pre-assessment, in accordance with exclusion criteria. There was no nursing or medical cover for patients staying in the hostel, who were deemed medically fit to do so. There was, however, a Band 2 warden available throughout the night, who could escalate patients to the accident and emergency staff in the event of an emergency. Meeting people’s individual needs The service took account of patients’ individual needs. The service made use of a telephone translation system. We saw evidence in patient notes of this service having been used. Staff we spoke with were aware of the translation services and of the trust’s policy regarding the use of interpreters to gain consent. One nurse we spoke with, however, said she rarely made use of the system and relied on relatives to translate. This was not in line with the trust’s policy in respect of patients who did not speak English. We raised this with the head of nursing during the inspection, who subsequently met with all of the nurses on the relevant ward and reinforced the consent policy. There were link nurses within the hospital for patients with dementia and learning difficulties. Staff said the link nurses were highly supportive in providing training and information on the care of these patients. There was a hospital-wide were eye clinic liaison officer team based within the hospital who could support patients by offering practical and rehabilitation advice and information on living with sight loss as well as assisting them to access relevant additional benefits and support in the community, as well as signposting them to other services and charities. In addition, there was Certificate of Visual Impairment (CVI) nursing team, who supported patients to register for CVI status. The recovery area for patients who had undergone laser surgery was kept darkened in order to help with patients’ recovery. Bariatric patients were brought forward in surgical lists, in order to ensure that there was sufficient time to arrange appropriate transport on their discharge. The pharmacy had a braille printer, which they used to print directions for taking medicines in braille. Longer documents in braille could also be ordered as and when required. Water, tea, coffee and snacks were made available to day surgery patients whilst in waiting areas. Patients we spoke with told us they had been offered tea and coffee and were being “well looked after”. Inpatients could order meals from a menu which catered for a wide range of dietary requirements. Access and flow People could access the service when they needed it. Patient’s surgical pathways were planned at pre-assessment, including arranging dates for surgery and all follow-up appointments. This ensured patient’s preferences were taken into account and therefore meant that patients were less likely to cancel surgery and follow-up appointments. Patients had the option for booked or walk-in pre-assessment appointments. Staff told us that approximately 60% of walk-in patients were from other clinics within the hospitals. The pre-assessment clinic was nurse-led. In response to complaints regarding waiting times in pre-assessment, the service had introduced a telephone pre-assessment service for patients with no co-morbidities. Staff told us they had received positive feedback on the telephone system. Most pre-assessments were valid for four months and if there had been no change in the patient’s
Page 149 general health, for example in the event of a cancelled operation, the patient would not need to attend a further pre-assessment appointment. In the case of cataract surgery, the pre-assessment remained valid for 6 months for the second eye. This allowed for patients to undergo the second operation without undergoing further pre-assessment. Staff told us that these innovations had a significant impact on patient satisfaction and had reduced waiting times. The admissions team was responsible for auditing the number of patients that needed a second pre-assessment appointment as a result of not undergoing surgery within four months of their initial pre-assessment appointment. Staff in pre-assessment told us that the majority of patients had their surgery within six to eight weeks of their surgery. This was reflected in the hospital’s score in respect of the percentage of patients seen within 18 weeks of referral, which was significantly better than the England average. Anaesthetists were available at five of the pre-assessment clinics per week. Where a patient needed to see an anaesthetist when there was not one present in the clinic, staff told us that they could contact one from elsewhere in the hospital to undertake the assessment. Where this was not possible, the patient would be booked to attend a further appointment with an anaesthetist, with the other pre-assessment checks being completed at this stage. Patients with dementia or learning difficulties were identified at pre-assessment and a sticker was added to their notes in order to notify staff throughout the pathway that the patient required extra support. Staff told us that there was work ongoing to introduce electronic records which included templates for each stage of the clinical process by March 2019. They said that they believed this would improve flow through the service. There had been a project to stratify cataract surgery lists, meaning that patients requiring more complex surgery would be seen on a separate list. This meant that there would be less congestion in the system for patients requiring less complex cataract surgery. Average length of stay
Moorfields Eye Hospital (City Road) - elective patients
From June 2017 to May 2018, the average length of stay for elective patients at Moorfields Eye Hospital (City Road) was 1.7 days, which is lower compared to the England average of 3.9 days.
Note: Top three specialties for specific site based on count of activity.
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The average length of stay for Ophthalmology elective patients at Moorfields Eye Hospital (City Road) was 1.7 days, which is as expected compared to the England average of 1.9 days.
Moorfields Eye Hospital - non-elective patients
The average length of stay for non-elective patients at Moorfields Eye Hospital (City Road) was 0.2 days, which is lower compared to the England average of 4.9 days.
Note: Top three specialties for specific site based on count of activity.
The average length of stay for ophthalmology non-elective patients at Moorfields Eye Hospital (City Road) was 0.2 days, which is lower compared to the England average of 1.8 days.
Referral to treatment (percentage within 18 weeks) - admitted performance
From August 2017 to July 2018, the trust’s referral to treatment time (RTT) for admitted pathways for surgery was better than the England average. Over the 12-month period, the trust performance ranged from 77.4% to 84.4%, which compares to the England average range for the same period of 64.6% to 71.5%.
In the most recent month, July 2018, 81.5% of admitted pathways at the trust were completed within 18 weeks for surgical pathways. This compares to the England average of 67.0%.
(Source: NHS England)
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Referral to treatment (percentage within 18 weeks) – by specialty
The trust provides surgical services for ophthalmology only. The trust was above the England average for RTT rates (percentage within 18 weeks) for admitted pathways within ophthalmology surgery.
Specialty grouping Result England average Ophthalmology 82.2% 68.5%
Cancelled operations
A last-minute cancellation is a cancellation for non-clinical reasons on the day the patient was due to arrive, after they have arrived in hospital or on the day of their operation. If a patient has not been treated within 28 days of a last-minute cancellation then this is recorded as a breach of the standard and the patient should be offered treatment at the time and hospital of their choice.
With exception to Q1 2017/2018, the number of cancelled operations at the trust as a percentage of elective admissions has been similar to the England average for the period July 2016 to June 2018. In Q1 2017/18 the trust cancelled 177 surgeries, which was a large increase from the previous quarter where the trust only cancelled 38 procedures.
Cancelled Operations as a percentage of elective admissions - Moorfields Eye Hospital NHS Foundation Trust
Over the two years, the percentage of cancelled operations at the trust that were not treated within 28 days has been below the England average. In the most recent quarter (Q1 2018/2019), 9% of cancelled operations were not treated within 28 days (from 85 cancelled surgeries). This was a sharp increase from the previous quarter, where 0% of cancelled operations were not treated within 28 days.
Percentage of patients whose operation was cancelled and were not treated within 28 days - Moorfields Eye Hospital NHS Foundation Trust
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(Source: NHS England)
Learning from complaints and concerns The service treated concerns and complaints seriously, investigated them and learned lessons from the results, and shared these with all staff. Summary of complaints
From 7th August 2017 to 6th August 2018 there were 29 complaints about surgery. The trust took an average of 22.8 days to investigate and close complaints, this is in line with their complaints policy, which states complaints should be completed within 25 working days. Across the trust, a high proportion of complaints received in surgery (75.9%) related to clinical treatment.
Moorfields Eye Hospital (City Road): There were 13 complaints, eight of these related to clinical treatment and three related to admissions and discharge.
(Source: Routine Provider Information Request (RPIR) – Complaints tab)
There was information for patients on how to complain throughout the hospital, and feedback forms were made widely available. Patients could complain in writing, directly to a member of staff or online. The Patient Advice and Liaison Service (PALS) were responsible for providing confidential advice and support to patients, carers and relatives to resolve concerns about their care and guiding patients through the hospital’s services. Staff were able to describe changes in practice arising out of learning from complaints and concerns. For example, the service had introduced a telephone pre-assessment system in response to concerns complaints about the waiting times for appointments.
Number of compliments made to the trust
From 6th August 2017 to 6th August 2018 there were 9 compliments within surgery at City Road.
Due to the nature of the data provided we are unable to comment on any themes relating to the compliments received. The trust has reported that:
“The compliments we receive focus on the standard of clinical care provided, with patient’s treatment meeting expectations and clinical outcomes being positive. Patients also compliment the care provided by individual members of staff, highlighting their kindness, professionalism and caring attitude which helps patients feel they are being treated personally. Many people comment
Page 153 that caring staff and the calm environment reduces their anxiety.”
(Source: Routine Provider Information Request (RPIR) – Compliments tab) Is the service well-led? Leadership Managers at all levels in the trust had the right skills and abilities to run a service providing high-quality sustainable care. The NHS clinical service on the City Road hospital site as a whole constituted a division within the trust. The divisional leadership team was made up of a divisional director, divisional manager, divisional head of nursing and clinical director for support services. All of the staff we spoke with spoke highly of the trust wide, divisional and local leadership. Staff said that the senior leadership were very visible within the hospital. The trust’s senior leadership team carried out planned visits to clinical areas. The most recent formal visit to the surgical directorate at City Road was a visit by the trust’s chief executive to the theatre suite on 9 August 2018. Throughout the service, ward staff said managers and leaders were approachable and responsive to them. Nurse team leaders told us they felt well supported by more senior leaders. In theatres, the majority of staff spoke highly of the local leadership team, although a small number of staff told us that they did not feel that they were not always listened to in respect of the concerns they raised about infection prevention and control and, in particular, patients being allowed to wear their own clothes and shoes in theatres. The staff accepted, however, that the leadership disagreed with them that this was an issue, but felt that the matter had not been discussed fully with them. Vision and strategy The trust had a vision for what it wanted to achieve and workable plans to turn it into action developed with involvement from staff, patients, and key groups representing the local community. The trust’s values were called the “Moorfields way” and called on staff to be organised, inclusive, excellent and caring. All staff we spoke with at all levels within surgery were aware of these values. The surgical directorate shared the trust-wide vision of excellence, which encompassed a five year commitment from 2017-2022 to deliver patient centred care with exceptional clinical outcomes and excellent patient experience by working together to discover, develop and deliver the best eye care. All of the staff we spoke with were aware of the trust’s vision and told us that they shared it and felt empowered to contribute towards it. In order to achieve its vision, the trust had a five year strategy from 2017-2022 which it described as “a call to action for everyone in Moorfields to work together to embed a culture of quality, make positive changes and drive behaviour to deliver an outstanding patient experience”. All of the staff we spoke with were aware of the strategy and said that they were proud to contribute to it. Culture Managers across the trust promoted a positive culture that supported and valued staff, creating a sense of common purpose based on shared values. There was a highly motivated, positive culture throughout the service. All of the staff we spoke to were proud to work for Moorfields. They described it as a supportive environment, in which they
Page 154 were encouraged to undertake new challenges. A significant number of staff we spoke with were undertaking additional training courses funded by the division. Staff spoke positively of the “no blame” culture in respect of incident reporting and said that it made them feel empowered to drive improvement in the service. Following the May 2016 inspection, the hospital had appointed a number of freedom to speak up guardians, as part of the NHS’s wider Freedom to Speak Up initiative. Staff could escalate confidential concerns to the guardians which could then be investigated by the governance leads. Governance The trust used a systematic approach to continually improving the quality of its services and safeguarding high standards of care by creating an environment in which excellence in clinical care would flourish. There were effective clinical governance structures in place to ensure safe care. Since the May 2016 inspection, the trust had introduced a new divisional structure, with Moorfields City Road operating as a division in its own right with its own divisional manager, director, manager for clinical support and manager for access. Senior staff told us that the new structure allowed for a more coherent governance structure within the hospital and “made more sense” than the previous system. Within surgery, there were separate clinical governance meetings for each of the surgical specialities, which were held with staff working within those specialities from all Moorfields sites. Staff told us that the cross-site nature of the meetings meant that relevant learning could be shared across the trust. The single speciality nature of the meetings meant that the meeting agenda remained focussed. We saw evidence of these meetings and evidence that learning from other specialities was discussed when relevant. These were well attended by staff from each of the professions and included clear evidence of actions taken in response to concerns raised. The clinical governance meetings for each of the surgical specialities fed into the clinical governance meeting for the various divisions as a whole. Management of risk, issues and performance The trust had systems for identifying risks, planning to eliminate or reduce them, and coping with both the expected and unexpected. There was a divisional risk register for the hospital. In addition, there were risk registers for each department within the hospital, for example theatres and surgical wards which fed into the divisional risk register. However, there was not a divisional risk register for the City Road site, or a risk register for the surgical wards. We were provided with the theatre risk register. Risks were scored with a risk rating and a residual risk rating which related to the level of risk following the implementation of the mitigating actions. The risks had been reviewed on a regular basis and, where appropriate, a new residual score given or additional mitigating actions added. The highest residual rating for a risk on the theatres was a score of eight, which related to the risk of staff being injured by falling oxygen cylinders in theatres. All of the risks on the risk register were operational rather than strategic. In addition, all of the risks were speculative, identifying potential risks which could arise, for example a sharps injury, as opposed to risks highlighted by incidents which had occurred or risks within the processes being followed. This suggested that risks were considered only in general terms, rather than also relating specifically to the practice in the service and specifically to historic incidents.
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The local leadership on the wards and in theatres were aware of how to escalate an item for consideration for inclusion on the risk register. However, the nature of the risks on the theatre risk register suggested that this may not have been done, or that risks that had been escalated had not been added. Information management The trust collected, analysed, managed and used information well to support all its activities, using secure electronic systems with security safeguards. There was a monthly performance dashboard, which gave details on operational performance. The trusts performance was rated to highlight where performance was not at target. Engagement The trust engaged well with patients, staff, the public and local organisations to plan and manage appropriate services, and collaborated with partner organisations effectively. There were regular patient engagement meetings at which patients were invited to give feedback on their experience of care. We had sight of the minutes of the patient participation and experience committee, which was well attended by senior staff and indicated that the patient voice was being taken seriously by the hospital. There was a trust-wide magazine circulated within the hospital which kept patients, relatives and staff up-to-date with news within and impacting on the trust. Staff noticeboards and newsletters were used to keep staff informed of developments and engagement opportunities. There was a theatre users group at which staff from all professions could provide feedback and raise concerns about issues impacting their work in theatres. The trust held an annual staff awards ceremony. All staff had the opportunity to nominate colleagues for awards in various categories, which would then be presented at a ceremony. Learning, continuous improvement and innovation The trust was committed to improving services by learning from when things went well and when they went wrong, promoting training, research and innovation. The trust was the largest provider of NHS-funded ophthalmology education and training. The trust worked in partnership with the University College London (UCL) Institute of Ophthalmology. A number of staff we spoke with were undertaking enhanced professional training through programmes provided jointly by UCL. Surgical staff and researchers from UCL had worked collaboratively since 2007 on the London project to cure blindness, the results of which were published in March 2018. The hospital was part of the North Central London Sustainability and Transformation Plan with a number of other trusts in the area to support strategic planning across London. Since the May 2016 inspection, the hospital had appointed new clinical leadership staff in digital technology and telemedicine to develop effective systems to improve clinical outcomes. There were a number of projects within the surgical directorate in respect of telemedicine including the option for pre-assessment to be completed remotely. Acute services
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Outpatients
Facts and data about this service
The outpatients service at Moorfields Eye Hospital offers a range of specialist outpatient eye clinics, including clinics for glaucoma, medical-retinal, external diseases, vitreoretinal, uveitis, adnexal and contact lenses. Overall, the trust received over 740,000 patient visits from 2017 to 2018. From June 2017 to May 2018, the trust had 572,615 first and follow up outpatient appointments. Patients can access expertise from eye specialists including optometrists (who complete eye health and vision assessments and provide prescriptions for glasses if needed), orthoptists (specialists in defects of eye movement) and ophthalmologists (a doctor specialising in medical and surgical eye conditions).
We visited the outpatients services at the Moorfields Eye Hospital City Road site for two unannounced inspection days on 14th and 15th November 2018. During our inspection we inspected all outpatient clinic areas and spoke with 32 members of staff including doctors, nurses, allied health professionals and ancillary staff. We also spoke with the outpatients leadership team, and 16 patients and relatives. We reviewed 16 patient records and checked many items of clinical and non-clinical equipment.
The trust had 572,615 first and follow up outpatient appointments from June 2017 to May 2018. The graph below represents how this compares to other trusts.
Total number of first and follow up appointments compared to England
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(Source: Hospital Episode Statistics - HES Outpatients)
The following table shows the number of outpatient appointments by site, a total for the trust and the total for England, from June 2017 to May 2018.
Number of appointments by site
Site Name Number of spells Moorfields Eye Hospital 361,314 Moorfields at St George's 72,206 Moorfields at Croydon University 52,607 Hospital Moorfields at Northwick Park 45,104 Moorfields at Ealing 38,773 This Trust 644,392 England 106,785,632
(Source: Hospital Episode Statistics)
The chart below shows the percentage breakdown of the type of outpatient appointments from June 2017 to May 2018. The percentage of these appointments by type can be found in the chart below: Page 158
Number of appointments at Moorfields Eye Hospital NHS Foundation Trust from June 2017 to May 2018 by site and type of appointment.
(Source: Hospital Episode Statistics) Is the service safe? By safe, we mean people are protected from abuse* and avoidable harm. *Abuse can be physical, sexual, mental or psychological, financial, neglect, institutional or discriminatory abuse. Mandatory training Mandatory training completion rates
The trust set a target of 80% for completion of mandatory training.
Trust level
A breakdown of compliance for mandatory training courses from August 2017 to July 2018 at trust level for qualified nursing staff in outpatients is shown below:
Staff Eligible Completion Trust Met Name of course trained staff rate Target (Yes/No)
Resuscitation 1 1 100% 80% Yes Prescribing Practice and Formulary for Non-Medical Prescribers 4 4 100% 80% Yes Risk and Safety Management 6 6 100% 80% Yes Infection Prevention (Level 1) 179 180 99% 80% Yes Helping Visually Impaired People 177 180 98% 80% Yes Counter Fraud 34 35 97% 80% Yes Fire Warden 28 29 97% 80% Yes Information Governance 172 180 96% 80% Yes Conflict Resolution 170 179 95% 80% Yes Infection Prevention (Level 2) 170 179 95% 80% Yes Nurse Supply of Medicines 123 131 94% 80% Yes
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Preventing Radicalisation - Basic Prevent Awareness (eLearning L1&2) 170 180 94% 80% Yes Medicine management training 165 179 92% 80% Yes Resuscitation Level 3 (Adult Immediate Life Support) 12 13 92% 80% Yes Adult Basic Life Support 163 179 91% 80% Yes Medical Gas Safety 155 179 87% 80% Yes Preventing Radicalisation - Awareness of Prevent (WRAP) 156 179 87% 80% Yes Recruitment and Selection 28 35 80% 80% Yes Resuscitation Level 3 (Paediatric Immediate Life Support) 10 13 77% 80% No Fire Site Cover / Manager 6 10 60% 80% No Resuscitation Level 2 (Paediatric Basic Life Support) 2 4 50% 80% No
In outpatients the 80% target was met for 18 of the 21 mandatory training modules for which qualified nursing staff were eligible.
A breakdown of compliance for mandatory training courses from August 2017 to July 2018 at trust level for medical staff in outpatients is shown below:
Staff Eligible Completion Trust Met Name of course trained staff rate Target (Yes/No)
Risk and Safety Management 7 7 100% 80% Yes Infection Prevention (Level 1) 219 221 99% 80% Yes Information Governance 213 221 96% 80% Yes Resuscitation Level 3 (Adult Immediate Life Support) 20 21 95% 80% Yes Resuscitation Level 3 (Paediatric Immediate Life Support) 20 21 95% 80% Yes Counter Fraud 56 60 93% 80% Yes Prescribing Practice and Formulary for Medical Prescribers 206 221 93% 80% Yes Conflict Resolution 203 221 92% 80% Yes Helping Visually Impaired People 203 221 92% 80% Yes Infection Prevention (Level 2) 202 221 91% 80% Yes Preventing Radicalisation - Basic Prevent Awareness (eLearning L1&2) 186 221 84% 80% Yes Adult Basic Life Support 180 221 81% 80% Yes Preventing Radicalisation - Awareness of Prevent (WRAP) 170 221 77% 80% No Recruitment and Selection 45 60 75% 80% No Resuscitation Level 2 (Paediatric Basic Life Support) 20 29 69% 80% No
In outpatients the 80% target was met for 12 of the 15 mandatory training modules for which Page 160 medical staff were eligible.
Moorfields Eye Hospital (City Road)
A breakdown of compliance for mandatory training courses from August 2017 to July 2018 for qualified nursing staff in the outpatient department at Moorfields Eye Hospital (City Road) is shown below:
Staff Eligible Completion Trust Met Name of course trained staff rate Target (Yes/No)
Infection Prevention (Level 1) 54 54 100% 80% Yes Counter Fraud 12 12 100% 80% Yes Fire Warden 9 9 100% 80% Yes Prescribing Practice and Formulary for Non Medical Prescribers 1 1 100% 80% Yes Risk and Safety Management 2 2 100% 80% Yes Information Governance 53 54 98% 80% Yes Conflict Resolution 52 54 96% 80% Yes Adult Basic Life Support 52 54 96% 80% Yes Infection Prevention (Level 2) 52 54 96% 80% Yes Helping Visually Impaired People 52 54 96% 80% Yes Preventing Radicalisation - Basic Prevent Awareness (eLearning L1&2) 49 54 91% 80% Yes Resuscitation Level 3 (Adult Immediate Life Support) 10 11 91% 80% Yes Medicine management training 48 54 89% 80% Yes Nurse Supply of Medicines 33 38 87% 80% Yes Recruitment and Selection 10 12 83% 80% Yes Resuscitation Level 3 (Paediatric Immediate Life Support) 9 11 82% 80% Yes Medical Gas Safety 44 54 81% 80% Yes Preventing Radicalisation - Awareness of Prevent (WRAP) 43 54 80% 80% Yes Fire Site Cover / Manager 5 8 63% 80% No
At Moorfields Eye Hospital (City Road), the 80% target was met for 18 of the 19 mandatory training modules for which qualified nursing staff were eligible
A breakdown of compliance for mandatory training courses from August 2017 to July 2018 for medical staff in the outpatient department at Moorfields Eye Hospital (City Road) is shown below:
Staff Eligible Completion Trust Met Name of course trained staff rate Target (Yes/No)
Risk and Safety Management 3 3 100% 80% Yes Infection Prevention (Level 1) 144 146 99% 80% Yes Information Governance 139 146 95% 80% Yes Page 161
Counter Fraud 36 38 95% 80% Yes Resuscitation Level 3 (Adult Immediate Life Support) 20 21 95% 80% Yes Resuscitation Level 3 (Paediatric Immediate Life Support) 20 21 95% 80% Yes Prescribing Practice and Formulary for Medical Prescribers 131 146 90% 80% Yes Helping Visually Impaired People 130 146 89% 80% Yes Conflict Resolution 129 146 88% 80% Yes Infection Prevention (Level 2) 128 146 88% 80% Yes Preventing Radicalisation - Basic Prevent Awareness (eLearning L1&2) 122 146 84% 80% Yes Adult Basic Life Support 118 146 81% 80% Yes Preventing Radicalisation - Awareness of Prevent (WRAP) 110 146 75% 80% No Recruitment and Selection 27 38 71% 80% No Resuscitation Level 2 (Paediatric Basic Life Support) 13 19 68% 80% No
At Moorfields Eye Hospital (City Road), the 80% target was met for 12 of the 15 mandatory training modules for which medical staff were eligible.
Staff we spoke with during the inspection told us they were up to date with their mandatory training and were given time to complete this.
(Source: Routine Provider Information Request (RPIR) – Training tab) Safeguarding Safeguarding training completion rates
The trust set a target of 80% for completion of safeguarding training.
Trust level
A breakdown of compliance for safeguarding training courses from August 2017 to July 2018 at trust level for qualified nursing staff in outpatients is shown below:
Staff Eligible Completion Trust Met Name of course trained staff rate Target (Yes/No)
Safeguarding Children (Level 3) 12 12 100% 80% Yes Safeguarding Children (Level 1) 175 180 97% 80% Yes Safeguarding Children (Level 2) 173 179 97% 80% Yes Safeguarding 172 180 96% 80% Yes
In outpatients the 80% target was met for all four of the safeguarding training modules for which qualified nursing staff were eligible.
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A breakdown of compliance for safeguarding training courses from August 2017 and July 2018 at trust level for medical staff in outpatients is shown below:
Staff Eligible Completion Trust Met Name of course trained staff rate Target (Yes/No)
Safeguarding Children (Level 1) 210 221 95% 80% Yes Safeguarding Children (Level 2) 204 221 92% 80% Yes Safeguarding 203 221 92% 80% Yes Safeguarding Children (Level 3) 16 22 73% 80% No
In outpatients the 80% target was met for three of the four safeguarding training modules for which medical staff were eligible.
Moorfields Eye Hospital (City Road)
A breakdown of compliance for safeguarding training courses from August 2017 to July 2018 for qualified nursing staff in the outpatient department at Moorfields Eye Hospital (City Road) is shown below:
Staff Eligible Completion Trust Met Name of course trained staff rate Target (Yes/No)
Safeguarding Children (Level 3) 2 2 100% 80% Yes Safeguarding Children (Level 2) 54 54 100% 80% Yes Safeguarding 54 54 100% 80% Yes Safeguarding Children (Level 1) 54 54 100% 80% Yes
At Moorfields Eye Hospital (City Road), the 80% target was met for all four of the safeguarding training modules for which qualified nursing staff were eligible.
A breakdown of compliance for safeguarding training courses from August 2017 to June 2018 for medical staff in the outpatient department at Moorfields Eye Hospital (City Road) is shown below:
Staff Eligible Completion Trust Met Name of course trained staff rate Target (Yes/No)
Safeguarding Children (Level 1) 138 146 95% 80% Yes Safeguarding 134 146 92% 80% Yes Safeguarding Children (Level 2) 133 146 91% 80% Yes Safeguarding Children (Level 3) 4 8 50% 80% No At Moorfields Eye Hospital (City Road), the 80% target was met for three of the four safeguarding training modules for which medical staff were eligible. Staff we spoke with had safeguarding training and understood how to recognise abuse and make safeguarding referrals when necessary. (Source: Routine Provider Information Request (RPIR) – Training tab) Cleanliness, infection control and hygiene
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The service controlled infection risk well. Staff kept uniforms, equipment and the premises clean. They used control measures to prevent the spread of infection. We observed slit lamps and visual fields machines cleaned down after each use. Clinics we reviewed were visibly clean, hand hygiene audits were displayed at the entrance of the hospital and showed that clinics one to four had a compliance of 100% from April to September 2018 and in October 2018 the result was 75% which was below the trust target of 95%. The average trust hand hygiene compliance scores were 98.5% from April 2017 to March 2018. We observed staff following correct hand hygiene techniques during the inspection. Cleaning schedules were in place, although some schedules were missing for June and July 2018. Cleaning staff also worked outside of clinic hours so that there was minimum disruption to patients and staff. Environment and equipment Staff looked after equipment well. Daily temperature logs were completed, crash trolleys were checked and tamper proof. There was good patient flow around the equipment and the lighting was appropriate in the clinic areas. Alcohol hand gels were in place and clinical wipes were available and used to wipe equipment. We observed staff wearing personal protective equipment (PPE) such as gloves and aprons and these were readily available. We observed infectious waste and domestic waste containers being used appropriately, sharp containers were labelled clearly and not overloaded and appropriate spillage kits were available.
Staff commented that having to move equipment between clinics was difficult, due to lack of space. The lower ground floor was confined in terms of space with low ceilings and no natural daylight. However, space was available for disabled patients and clinics appeared organised and the reception displayed waiting times.
In the previous inspection, space in the outpatients department was limited and there was insufficient seating in patient waiting areas. Since the last inspection, the space committee had opened a new clinic on Cayton Street, an extra clinic on the lower ground floor, and had tried to make the building more clinical. Work had been done to move some non-clinical administrative staff to another building and use that building for training and education instead. Further work was in progress to make the main building more clinical. Assessing and responding to patient risk Staff were aware of what to do in a medical emergency. They were aware of the contact number for the emergency crash team and staff we spoke with were aware of where the nearest crash trolley was and had received basic life support training. The policy for the management of adult and paediatric medical emergencies were up-to-date and staff knew how to access these policies.
Availability of ‘floorwalkers’ to monitor patients’ wellbeing had improved since the last inspection. Floorwalkers were responsible for overseeing patient welfare in the waiting areas.
Nurse staffing The trust has reported their staffing numbers below for March 2018 and July 2018. There was an under-establishment of qualified nursing staff in outpatients across the trust. Across the trust, at July 2018 there was an under-establishment of 35.8 WTE staff (fill rate of 81.7%).
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As at March 2018 As at July 2018 Planned Actual staff Planned Actual staff Site staff – Fill rate Fill rate - WTE staff – WTE – WTE WTE Moorfields Eye 59.9 55.2 92.2% 57.9 46.4 80.1% Hospital (City Road) Moorfields at St. 10.3 7.4 71.8% 10.4 9.4 90.4% George’s Moorfields 22.0 19.9 90.4% 20.5 18.9 92.1% at Bedford All other 98.0 84.2 85.9% 106.5 84.8 79.7% sites Total 190.2 166.7 87.6 195.3 159.5 81.7%
(Source: Routine Provider Information Request (RPIR) –Total staffing tab)
Vacancy rates
From August 2017 to July 2018, the trust reported a vacancy rate of 14.1% for qualified nursing staff in outpatients:
• Moorfields Eye Hospital (City Road): 16.6%
At trust level and at Moorfields City Road, the reported vacancy rate for qualified nursing staff in outpatients was higher than the trust target of 10%. The trust told us that there was a higher vacancy factor for unregistered workforce which had contributed to the overall high figure.
(Source: Routine Provider Information Request (RPIR) – Vacancy tab)
Turnover rates
From August 2017 to July 2018, the trust reported a turnover rate of 13.2% for qualified nursing staff in outpatients:
• Moorfields Eye Hospital (City Road): 12.6%
At trust level, the reported turnover rate for qualified nursing staff in outpatients was within the trust target of 15%.
(Source: Routine Provider Information Request (RPIR) – Turnover tab)
Sickness rates
From August 2017 to July 2018, the trust reported a sickness rate of 5.8% for qualified nursing staff in outpatients:
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• Moorfields Eye Hospital (City Road): 3.5%
At trust level, the reported sickness rate for qualified nursing staff in outpatients was above the trust target, however, the City Road site was below the trust target of 4%.
(Source: Routine Provider Information Request (RPIR) – Sickness tab)
Bank and agency staff usage
The below table shows the bank and agency usage for qualified and non-qualified nursing staff in outpatients from August 2017 to July 2018. For qualified nursing staff, the trust reported that 12.7% of available hours were filled by bank staff and 0.4% of available hours were filled by agency staff. For non-qualified nursing staff, the trust reported that 17.4% of available hours were filled by bank staff and there was no reported use of agency staff.
Bank usage is greater at Moorfields at St. George’s for both qualified and non-qualified nursing staff when compared to the average across the whole trust. Agency usage was low across the whole trust.
Total hours Bank Agency Unfilled Qualified 2,275 288 (12.7%) 8 (0.4%) 0 (0%) Non-qualified 1,181 206 (17.4%) 0 (0%) 0 (0%)
Moorfields Eye Hospital (City Road)
Total hours Bank Agency Unfilled Qualified 714 73 (10.2%) 0 (0%) 0 (0%) Non-qualified 234 41 (17.5%) 0 (0%) 0 (0%)
(Source: Routine Provider Information Request (RPIR) - Nursing bank agency tab)
During the inspection, the clinics we visited were well staffed and bank staff were used when permanent members of staff were on leave or sick. The head of nursing told us that staffing levels needed to improve for employing health care assistants and technicians and that they were looking at ways to improve retention for these staff. Medical staffing The trust has reported their staffing numbers below for March 2018 and July 2018. There was an under-establishment of qualified medical staff in outpatients across the trust. Across the trust, at July 2018 there was an over-establishment of 7.3 WTE staff, although this may be down to issues with data quality.
As at March 2018 As at July 2018 Planned Actual staff Planned Actual staff Site staff – Fill rate Fill rate - WTE staff – WTE – WTE WTE Moorfields 139.0 123.3 88.7% 136.6 116.7 85.4%
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Eye Hospital (City Road) Moorfields at St. 24.8 28.0 112.8% 29.1 22.2 76.5% George’s Moorfields 14.2 8.8 61.8% 12.1 10.6 87.3% at Bedford All other 49.6 42.3 85.2% 55.7 91.3 *164.0% sites Total 227.6 202.3 88.9% 233.5 240.8 103.1%
*The over-establishment seen for ‘all other sites’ is a result of the staffing figures reported for the satellite site at Purley. At July 2018, the trust reported a planned staff figure of 0.1 WTE and an actual staff figure of 45.1 WTE.
(Source: Routine Provider Information Request (RPIR) –Total staffing tab) Medical staffing: When consultants were off sick or on annual leave clinics were reduced for highly qualified fellows to run alone. These fellows were experienced and had access to relevant protocols. Bank or locum staff were not used. Patients were informed by receptionists if consultants were away. Vacancy rates
From August 2017 to July 2018, the trust reported a vacancy rate of 10.6% for medical staff in outpatients:
• Moorfields Eye Hospital (City Road): 9.1%
At trust level, the reported vacancy rate for medical staff in outpatients was greater than the trust target of 10%. At Moorfields Eye Hospital in City Road, the vacancy rate was lower than the trust target of 10%.
(Source: Routine Provider Information Request (RPIR) – Vacancy tab)
Turnover rates
From August 2017 to July 2018, the trust reported a turnover rate of 9.5% for medical staff in outpatients:
• Moorfields Eye Hospital (City Road): 12.4%
At trust level and at Moorfields Eye Hospital, City Road, the reported turnover rate for medical staff in outpatients was within the trust target of 15%.
(Source: Routine Provider Information Request (RPIR) - Turnover tab)
Sickness rates
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From August 2017 to July 2018, the trust reported a sickness rate of 1.0% for medical staff in outpatients: • Moorfields Eye Hospital (City Road): 1.2%
At trust level, the reported sickness rate for medical staff in outpatients was below the trust target of 4%. Sickness rates for medical staff were low at the City Road site.
(Source: Routine Provider Information Request (RPIR) – Sickness tab)
Bank and locum staff usage
The below table shows the bank and locum hours for medical staff in surgery from August 2017 to July 2018. Across the trust, 34,979 hours were filled by bank staff and 10,949 hours were filled by locum staff.
Locum use was particularly high for some of the district hubs offering outpatient services at the trust. Locum use was particularly high at Croydon (6,730 locum hours), Ealing (1,311 locum hours), Northwick Park (919 locum hours), and Potter’s Bar (754 locum hours).
Total Location Bank Locum Unfilled hours Moorfields Eye Hospital (City 286,873 13,980 (4.9%) 0 (0%) 0 (0%) Road) Moorfields at St. George’s 51,646 9,396 (18.2%) 23 (0.04%) 0 (0%) Moorfields at Bedford 29,432 3,723 (12.6%) 749 (2.5%) 0 (0%) All other sites 101,296 7,879 (7.8%) 10,177 (10.0%) 0 (0%) Trust total 469,248 34,979 (7.4%) 10,949 (2.3%) 0 (0%)
Note- Totals may not add up due to rounding.
(Source: Routine Provider Information Request (RPIR) – Medical agency locum)
We spoke with a bank staff member who felt well supported and received a local induction with the trust and an induction with their agency prior to starting. Records The trust used paper and electronic records. Staff told us they used electronic records to access blood results, letters to the GP and scans. The electronic records could be accessed cross- site. Paper records also available. The leadership team told us that they planned to go ‘paper light’ within two years. The medical records team located and tracked patient notes. Administrative staff from clinics collected the records relevant to their individual speciality before the clinics started. Where patient notes could not be located, a temporary file was put together so the patient’s clinic visit could be appropriately documented. All previous letters and investigation findings were available to clinicians electronically. Temporary notes were filed in the patient’s permanent folder as soon as possible following their clinic appointment.
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Records we reviewed were clear, up-to-date and contained all relevant information. However, we saw some records left under desks in certain clinic areas and some records were left unattended. The trust responded by saying that there was limited space to store notes in clinics, however, this was escalated directly to the chief operating officer who requested a review of notes storage in clinics by the divisional management teams. The trust also stated that a review of the flow of notes was required.
The record keeping audit from February 2018 showed 85% compliance with filing notes in correct sections which was a slight reduction compared with 86% in 2017. The score was 100% for records belonging to the correct patient which had improved since 2017. Although action plans were put in place such as reminding staff of the trust standards of record keeping, there was still a common theme of missing or misfiled notes recorded as incidents by the trust. Medicines Medicines were stored securely and fridge temperatures were monitored and recorded daily. Controlled drugs (CDs) were checked daily and emergency medicines were available & checked daily. Allergies recorded on prescription charts were in line with NICE guidance and principles of antimicrobial stewardship implemented.
The trust had a comprehensive range of patient group directives which were available on trust intranet site. These were monitored and reviewed by the non-medical supply of medicines group. A specialist pharmacist supported the outpatient oncology clinics, for example arranging homecare medicines when required and were part of the weekly multidisciplinary (MDT) meetings.
A pharmacist ran an ocular inflammatory service for patients receiving long term immunosuppressant therapy for approximately 400 patients. This monitored all aspects of therapy, ensuring for example, blood tests were monitored & reviewed. A comprehensive range of patient information leaflets was provided with to take out (TTO) medicines. Information could be provided in large print or in braille if required. Patients were assessed to check if they needed to use a compliance aid to administer their eye drops. These were provided free to patients if required.
The trust had a specialist antibiotic pharmacist and current guidelines were available on the trust intranet and via a smart phone app. The trust also had a medicines safety officer, a senior clinical pharmacist and a CD accountable officer who participated in local CD intelligence network. Incidents The incidents reported contained action plans and staff recognised incidents and reported incidents appropriately. However, there was a general lack of awareness of learning from incidents and staff could only give vague answers of examples of when learning had occurred from an incident and what the most recent incidents were.
The main themes of the incidents reported in the last six months were missing or misfiled notes, delays in receiving notes, abusive behaviour towards staff, prescribing errors, over booked clinics and some information governance and security incidents had occurred. One of the information and governance security incidents stated that the wrong appointment letter had been sent to the wrong patient and the action plan showed that it was discussed with the team, however, it was unclear if the correct patient had been informed from the action plan.
Although the trust had completed a clinical record keeping audit that resulted in action plans such Page 169
as reminding staff of the trust standards of record keeping, there was still a common theme of missing or misfiled notes.
Never Events
Never events are serious patient safety incidents that should not happen if healthcare providers follow national guidance on how to prevent them. Each never event type has the potential to cause serious patient harm or death but neither need have happened for an incident to be a never event.
From September 2017 to August 2018, the trust reported no incidents classified as never events for outpatients.
(Source: Strategic Executive Information System (STEIS))
Breakdown of serious incidents reported to STEIS
In accordance with the Serious Incident Framework 2015, the trust reported no serious incidents (SIs) in outpatients which met the reporting criteria set by NHS England from September 2017 to August 2018.
(Source: Strategic Executive Information System (STEIS)) Safety thermometer We did not observe a safety thermometer displayed at the entrance to the clinics. The director of nursing told us that they did not complete safety thermometer audits. However, the trust was monitoring falls via a falls safety committee and venous thromboembolism (VTE) via a reporting system at the trust.
Is the service effective? Evidence-based care and treatment The service provided care and treatment based on national guidance and evidence of its effectiveness. The virtual glaucoma clinic was a technician led service with patient information reviewed by a consultant or senior glaucoma specialist clinician. The optometrist led glaucoma clinic was also supported by ophthalmic technicians. The optometric technician did the initial tests and then the optometrist saw the patient and referred the patient to the doctor if the pressures in their eyes were high. Patients received results within two to three weeks. The clinic ran effectively and there was an emphasis on training and progression. The cataract and corneal services had set up clinics to review all patients undergoing graft surgery at one and two years post-op. They had developed a database to collect the information and to submit it electronically to NHS Blood and Transport (NHSBT). This database would help them to query their own data and not rely on NHSBT for analysis of our outcomes.
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Six audits were reviewed and this included the orbital decompression audit which showed good results and as there were no available standards for comparison this could now be an established benchmark for future audits. The virtual glaucoma inter observer comparison audit also showed good results except for the optic disc assessment. This was a recognised inter-observer issue and imaging and IT lent itself to minimising such variations. The virtual glaucoma audit showed that the patient satisfaction survey was good but there was some inter-site variability that needed to be addressed. The lid malposition survey showed good results with a 90% success rate. The cataract complication rate was comprehensive of all cases and complications were well below the national standards. The trabeculectomy audit results were near the national standard of 66% achieving one third intra ocular pressure reduction. Nursing staff had opportunities to be involved in research and audits, for example an advanced practitioner recently presented an audit on did not attend rates in injection suites. The director of nursing told us that nurse staff took part in infection prevention and control and slit lamp cleanliness audits. There was a nurse led service for keratoconus management which meant easier access for patients, improved patient outcomes and experience and increased capacity to support the medical workforce. Optometrists in the retinal therapy unit were trained to give injections to patients such as ranibizumab and aflibercept. Ranibizumab and aflibercept are targeted therapies and can be used to treat age related macular degeneration. Protocols for glaucoma and uveitis were available and up-to-date. The department had published a recent paper on the effectiveness of trabeculectomy in normal tension glaucoma, this demonstrated minimum complications and good maintenance of vision and fields if intra ocular pressure was reduced by 30% from base line in normal tension glaucoma. Moorfields Eye Hospital worked with the University College London (UCL) institute of Ophthalmology as a successful hospital university partnership in ophthalmology. Moorfields Eye Hospital was one of the 20 sites nationally that had National Institute for Health Research (NIHR) Biomedical Research Centre (BRC) status and the only BRC dedicated to eye research. Moorfields Eye Hospital and UCL set up the London Project to Cure Blindness which restored the sight of the first patients receiving a new treatment derived from stem cell technology. The project aimed to see if sight loss caused by wet age-related macular degeneration (AMD) could be improved by using stem cell-based treatment. In March 2018, results showed that patients who received stem cell treatment regained their reading vision. The partnership between the two hospitals were also involved in many other research studies and staff at the health information hub were providing leaflets on these studies to patients and offering them opportunities to participate in these studies. Many research studies were available and staff provided information to patients on these studies, such as age related macular degeneration and cataract research. Their collaborative and pioneering research study with DeepMind Health showed that artificial intelligence could help to diagnose eye diseases. This study showed that artificial intelligence could recommend the correct referral decision for over 50 eye conditions with 94% accuracy, matching world-leading eye experts. As well as helping future generations of patients receive more timely care, they hoped that this work would lead to significantly improved patient experience for the management of chronic and urgent eye disease. Nutrition and hydration
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Patients had access to water machines in clinic areas. Coffee shops and hospital shops were available for patients to buy food. Pain relief We did not observe any pain leaflets or posters displayed with details of who to contact if a patient was in pain. However, we observed some staff members asking patients how they were after attending clinics. Patient outcomes Follow-up to new rate
From June 2017 to May 2018,
The follow-up to new rate for Moorfields Eye Hospital was higher than the England average. The trust told us that this reflected the fact that a high proportion of patients at the City Road site had complex conditions and chronic diseases. The trust also told us they had undertaken a review with their commissioners of new to follow-up ratios and they agreed that these should not be included in their contractual arrangements due to the nature of eye disease management at Moorfields.
Follow-up to new rate, Moorfields Eye Hospital NHS Foundation Trust.
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(Source: Hospital Episode Statistics)
The outpatients service manager told us the new to follow up ratios were higher in the glaucoma and medical retina clinics and the cataract clinics had a ratio of 1:1. Competent staff Appraisal rates
From August 2017 to July 2018, 79.3% of staff within outpatients at the trust received an appraisal compared to a trust target of 80%.
Target Individuals Appraisals Completion Trust Staff group met required complete rate target (Yes/No) Qualified Healthcare Scientists 3 3 100.0% 80% Yes
Qualified nursing & health 180 158 87.8% 80% Yes visiting staff (Qualified nurses) Medical & Dental staff - Hospital 175 153 87.4% 80% Yes
Qualified Allied Health 245 206 84.1% 80% Yes Professionals (Qualified AHPs) Support to ST&T staff 230 153 66.5% 80% No NHS infrastructure support 65 39 60.0% 80% No Grand Total 898 712 79.3% 80% No
Moorfields Eye Hospital (City Road)
From August 2017 to July 2018, 80.2% of staff within outpatients at Moorfields Eye Hospital (City Road) received an appraisal compared to a trust target of 80%.
Target Individuals Appraisals Completion Trust Staff group met required complete rate target (Yes/No) Qualified Healthcare Scientists 2 2 100.0% 80% Yes
Qualified Allied Health 185 162 87.6% 80% Yes Professionals (Qualified AHPs) Medical & Dental staff – Hospital 110 94 85.5% 80% Yes
Qualified nursing & health 54 45 83.3% 80% Yes visiting staff (Qualified nurses) NHS infrastructure support 39 26 66.7% 80% No Support to ST&T staff 105 68 64.8% 80% No Grand Total 495 397 80.2% 80% Yes
(Source: Routine Provider Information Request (RPIR) – Appraisal tab)
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Multidisciplinary working We saw evidence of MDT meetings held for oncology services. These meetings were attended by pathologists, clinical nurse specialists, consultants, radiologists, the service manager and a multidisciplinary co-ordinator. We observed patients notes which contained MDT input for example from pharmacists, consultants, radiologists and nurses. Seven-day services Some clinics were available in the evenings from Monday to Friday and on Saturdays. A rapid access clinic for vitreoretinal patients was available seven days per week. During the inspection we noted that some clinics were available in the evenings such as the glaucoma clinic which was open until 8pm on Wednesday 14th November 2018 and the uveitis clinic ran until 7pm. Health promotion We observed health promotion information displayed around clinics such as leaflets on smoking cessation, alcohol support groups, promotion of healthy eating and glaucoma leaflets. There was a health information hub at the entrance of the hospital which contained many different leaflets such as leaflets about Alzheimer’s disease, the Macular society, retina UK and other eye conditions. Consent, Mental Capacity Act and Deprivation of Liberty Safeguards Mental Capacity Act and Deprivation of Liberty training completion
The trust reported that from August 2017 to July 2018 Mental Capacity Act (MCA) training was completed by 74.7% of staff in outpatients compared to the trust target of 80%. For Moorfields Eye Hospital (City Road) 72% had completed e-learning (level one), and 71% had completed level two and three training.
Met Staff Eligible Completion Trust Name of course (Yes/ trained staff rate Target No) Mental Capacity Act Level 1 559 742 75% 80% No Mental Capacity Act Awareness (e- learning) 700 944 74% 80% No
The breakdown by site was as follows:
Moorfields Eye Hospital (City Road)
Met Staff Eligible Completion Trust Name of course (Yes/ trained staff rate Target No) Mental Capacity Act Awareness (e- learning) Level 1 380 531 72% 80% No Mental Capacity Act Level 2&3 292 413 71% 80% No
Staff at Moorfields Eye Hospital (City Road) told us that they had undertaken online and face to face training in the MCA, and had regular updates. They were clear about the process to follow if they had reason to be leave a patient did not have capacity to consent to an investigation or treatment.
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The trust had a clear process in place for assessing patients’ capacity to consent. The lead healthcare professional completed a standard form demonstrating that the patient’s capacity had been assessed. If a patient signed consent to a procedure in advance, this was checked with them again at the time of the procedure.
If a patient was unable to consent, a best interest decision was recorded, by at least two healthcare professionals, carers involved, such as family members or care home management, and a safeguarding, learning disability or dementia champion. Staff were clear of the importance that the patient should be likely to benefit from any procedure carried out.
Staff made efforts to find out in advance if patients had special needs, including completing a hospital passport if they had communication difficulties. These included relevant information such as how the patient might behave when upset or frightened, how best to support them, how they communicate that they are in pain, their routines, and preferences. Staff used a ‘helping hands’ sticker to alert other staff to patients who might have particular needs.
Staff gave examples of adjustments they made for patients with particular needs, such as providing a quite space for some patients with autism who found the waiting areas stressful, prioritising patients with challenging behaviour to be seen first. In one case a patient who found clinical areas stressful, was seen briefly in a quiet corridor.
Staff advised that patients who found it difficult to verbalise or complete eyesight tests using standard equipment could be referred to orthoptics where they had access to more diagnostic tests, including use of pictures instead of letters.
(Source: Routine Provider Information Request (RPIR) – Training tab)
Is the service caring? Compassionate care Friends and Family test performance
The Friends and Family Test performance at Moorfields Eye Hospital NHS Foundation Trust was consistently higher than the England average from December 2017 to July 2018.
Outpatients Friends and Family Test performance – Moorfields Eye Hospital NHS Foundation Trust
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This Trust England Average
99% 98% 97% 96% 95% 94% 93% 92% 91% 90% Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18
Staff cared for patients with compassion. Feedback from patients confirmed that staff treated them well and with kindness. Comments received from patients and relatives included ‘Excellent staff’, ‘Staff are good, very happy with staff here over all’, ‘experience here has been very good’. One patient commented that staff came over and introduced themselves and arranged for a receptionist to keep an eye on their buggy while the child went into the clinic with the patient. We observed posters advertising the friends and family test (FFT) in clinic areas and displayed in main corridor in from entrance. Results displayed were from September 2018 where 10.4% of patients attending completed the feedback. Out of these patients, 95.7% of patients were likely to recommend the service and 1.3% were not likely to recommend the service. In August 2018, 11.6% of patients attending completed feedback. Out of these patients, 97.5% were likely to recommend the service and 1.1% were not likely to recommend the service.
However, on a few occasions we observed staff who did not acknowledge patients and were abrupt in answering questions. One patient had been seen at the trust for three years and commented that ‘Everything had been amazing until now’. The patient said that the processes had gone wrong that week. The patient had an operation on Wednesday and was discharged but did not get a follow up appointment and when they called, there was no record of the appointment. Some patients commented that ‘waiting times were long’, however, they were informed of the waiting times on the display boards of the clinics. Emotional support Staff provided emotional support to patients to minimise their distress. People told us that they felt that staff understood the emotional impact of their conditions. We observed a volunteer walking an elderly patient to a clinic. They were providing assurance to the patient and talking to each other in a friendly way. Volunteers were helpful, friendly, smiling and approachable. They approached people to ask if they needed help.
There was a multi-faith room and chapel. The room contained prayer mats, the Quran, bible and hymn books. There was a notice that said the room was ‘a place for quiet reflection for those of all faiths’. The room was basic with chairs for people to sit. There was a sign that said ‘we want your view. Post questionnaires in box’, but there were no questionnaires and no box available.
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A counselling service was available with plenty of signs around the clinics and entrance. Staff could liaise on behalf of the patients if they came to the desk and help them access the counselling service.
Staff were aware of external organisations, such as charities, who could provide additional support and assistance to visually impaired patients. We observed staff offering patients contact details for these services.
Schwarz rounds were introduced as support sessions for staff dealing with challenging and stressful situations. These were informal sessions held in the board room at lunch time and lunch was provided. However, not all staff were able to attend these sessions. Staff who could attend commented that they really enjoyed the sessions and that they were about personal experience rather than corporate change.
Only certain cubicles had curtains which meant that sharing information with patients was not always private. Understanding and involvement of patients and those close to them Staff involved patients and those close to them in decisions about their care and treatment. Patients received detailed information about their care and treatment. Patients told us they felt that clinicians in the outpatient departments listened to their needs and wishes regarding their treatment.
We observed a good rapport between patients, their relatives and the doctors. Patients we spoke with felt listened to and involved in their consultations. Patients commented that they had always been told what to expect and made informed decisions based on the detailed information provided. Is the service responsive? Service delivery to meet the needs of local people Did not attend rate
From June 2017 to May 2018,
• The ‘did not attend’ rate for ENGLAND was higher than the England average. • The ‘did not attend’ rate for Moorfields Eye Hospital was higher than the England average.
The chart below shows the ‘did not attend’ rate over time.
Proportion of patients who did not attend appointment, Moorfields Eye Hospital NHS Foundation Trust.
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(Source: Hospital Episode Statistics)
The DNA rates for Moorfields Eye Hospital at City Road was 10.3%, 10.8%, 9.5% in August, September and October 2018 respectively. To address the high DNA rates, an automated twice a day text message service, patient forum and an external provider to outsource sending out letters was introduced to help reduce the workload for clerical staff. Meeting people’s individual needs Patients we spoke with commented that waiting times were long, however, they were informed of what the waiting times were, and we observed signs in clinic areas that stated waiting times for clinics. There was also a buzzer system where a patient could leave and come back when the buzzer went off. In February 2018, the trust had introduced self-check-in kiosks which had been specifically designed for visually impaired patients and offered a range of accessibility options and a choice of 11 languages. The trust had conducted a six-month pilot of the kiosks at City Road and during July, an average of 35% of patients used them to check in to their appointments. Since the inspection, the trust told us that during December 2018, additional patient check-in kiosks were introduced at City Road and other sites and overall, the trust had 17 kiosks across these sites. The trust told us that 14 languages were available and that the kiosks were used to assist in capturing accessible information communication data from patients. We saw a copy of a hospital passport for patients with a learning disability, cognitive impairment or additional communication needs coming into hospital. It was designed to be completed by patients or their relatives to identify information about the patient that staff needed to know, such as how they preferred to communicate, what to do if they were anxious or distressed, how they would tell staff if they were in pain, their likes and dislikes and their support needs in aspects of daily living.
There was also a ‘This is me’ leaflet Alzheimer’s disease to help patients receive support in an unfamiliar place. It contained information about how to communicate with the patient, their mobility status, eating and drinking and hearing and eyesight which could be filled in. There were televisions and magazines in the waiting areas to keep patients occupied whilst waiting for appointments. Vending machines were also available at the entrance and in some clinic areas.
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We did not see any posters displayed offering language support to patients. However, interpreters were booked via a translation service. Interpreters were able to stay for two hours, so if patients had not been seen, the interpreter could have left. Patients with an interpreter were not given priority, however, if it was nearing the end of the two hours the receptionists let the doctor know that the interpreter had to leave. If the translator did not turn up, clinic appointments were rebooked and an incident form was completed.
There was information displayed and leaflets on the Patient Advice and Liaison services (PALs) in the entrance, clinic areas and in the health information hub. The leaflets also explained how to access an interpreter in different languages to help patients speak with PALS. The PALs office door was open and patients could come in with any concerns or complaints or write to the PALs team. This was followed up with a call or email.
In the previous report, the signage was not clear and patients were unclear on how to get to different clinics. The signage had improved since the last inspection and there was a large colour coded map that matched the clinics at the entrance of the hospital. There were painted lines on the floor which directed the patients towards clinics, the walls also had coloured lines that showed the way to each clinic, how many meters, and name of clinic. Volunteers were also available at the entrance of the hospital to help patients with directions. However, patients were still unclear of where to go and we observed patients asking staff for directions.
The trust had a ‘friends of Moorfields shop’ where there was a display of aids e.g. talking clocks and glasses accessories. Items from this shop was cheaper for patients as the shop bought them directly from the manufacturers and sold it as cost price. People also donated hand knitted items such as poppies and baby clothes. There was no profit made on these items. There was also the option for patients to order items from a catalogue which could be sent directly to the patient or to the shop for collection. A shop manager and volunteer worked at the shop.
We observed a blind art gallery where the trust had displayed art in the corridors. There was a deaf message service with hearing loops at the desk. We observed volunteers assisting patients with the self-service check in. The self-check in screens displayed big clear words.
We observed clear visual aids on walls for example, by the alcohol hand gel there was a big image of hands and by the stairs there was a big image of a person on stairs. These were all larger and clearer for patients with visual problems. There was a hospital shop with a fridge containing sandwiches so that patients could have the choice of ask for sandwiches vegetarian, halal, dairy free and gluten free sandwiches without having to go to an external coffee shop.
There was a multi-disciplinary clinic specifically for patients with complex learning disability needs which was run jointly by optometrists and orthoptists. This was started a year ago and these clinics ran once a month on Fridays. The clinic was created so that patients with complex learning disability needs did not have to be seen multiple times. There was a safeguarding adults advisor who previously had experience as a learning disability nurse and was able to provide specialist advice on learning disabilities when necessary. The safeguarding adults advisor was part of the learning disability and dementia group. This was a quarterly meeting which patients could attend
Page 179 and feedback their experience at the trust. There was also a hospital passport for patients with cognitive impairment which was available at the health information hub.
Access and flow Referral to treatment (percentage within 18 weeks) – non-admitted pathways
From August 2017 to July 2018 the trust’s referral to treatment time (RTT) for non-admitted pathways has been consistently better than the England overall performance. Data for July 2018, showed 94.5% of this group of patients were treated within 18 weeks versus the England average of 88.3%.
The trust’s referral to treatment time (RTT) for non-admitted pathways has been better than the England overall performance for all 12 months between August 2017 and July 2018.
Referral to treatment rates (percentage within 18 weeks) for non-admitted pathways, Moorfields Eye Hospital NHS Foundation Trust.
(Source: NHS England)
More recent RTT data showed that the trust performed better than the England average with 97% in August 2018 and 96.7% in September 2018.
Referral to treatment (percentage within 18 weeks) non-admitted performance – by specialty
One specialty was above the England average for non-admitted pathways RTT (percentage within 18 weeks).
Specialty grouping Result England average Ophthalmology 94.2% 89.2%
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(Source: NHS England)
Referral to treatment (percentage within 18 weeks) – incomplete pathways
From August 2017 to July 2018 the trust’s referral to treatment time (RTT) for incomplete pathways has been consistently better than the England overall performance. The latest figures for July 2018, showed 94.9% of this group of patients were treated within 18 weeks versus the England average of 87.3%.
The trust’s referral to treatment time (RTT) for incomplete pathways has been better than the England overall performance for all 12 months between August 2017 and July 2018.
Referral to treatment rates (percentage within 18 weeks) for incomplete pathways, Moorfields Eye Hospital NHS Foundation Trust.
(Source: NHS England)
Referral to treatment (percentage within 18 weeks) incomplete pathways – by specialty
One specialty was above the England average for incomplete pathways RTT (percentage within 18 weeks).
Specialty grouping Result England average Ophthalmology 94.8% 88.4%
(Source: NHS England)
Cancer waiting times – Percentage of people seen by a specialist within 2 weeks of an urgent GP referral (All cancers)
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The trust is performing better than the 93% operational standard for people being seen within two weeks of an urgent GP referral. The performance over time is shown in the graph below.
Percentage of people seen by a specialist within 2 weeks of an urgent GP referral (All cancers), Moorfields Eye Hospital NHS Foundation Trust
(Source: NHS England – Cancer Waits)
Cancer waiting times – Percentage of people waiting less than 31 days from diagnosis to first definitive treatment (All cancers)
The trust is performing better than the 96% operational standard for patients waiting less than 31 days before receiving their first treatment following a diagnosis (decision to treat). The performance over time is shown in the graph below.
Percentage of people waiting less than 31 days from diagnosis to first definitive treatment (All cancers), Moorfields Eye Hospital NHS Foundation Trust
(Source: NHS England – Cancer Waits)
Patients we spoke with during the inspection commented that waiting times were long. We requested for the trust to provide data on waiting times to determine how long patients had to wait from arrival to their first appointment. The trust responded by saying that they did not consistently capture the time patients were seen, but they captured the entire journey time from arrival until the time the patient left the building. The outpatient journey times were a key performance indicator which was reported in their integrated performance report.
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Target median clinic journey times were met for new patient appointments and for patient follow up appointments, however, the calculation of a reasonable wait was not straightforward as it depended on the specialty and most outpatient clinics involved patients waiting to see more than one member of staff. Further, targets for data completeness were not met and the trust had an action plan in progress to address this. The trust was working to ensure that they kept patients better informed about the waiting time to see the final clinician. This involved estimating times per clinic or clinician on each given session and this was then updated on the patient information boards in that clinic. However, this was a manual process and was not captured centrally. The trust also included the expected whole visit time in the outpatient appointment letter that patients received so that they knew what to expect on each visit. Is the service well-led?
Learning from complaints and concerns From 7th August 2017 to 6th August 2018, there were 108 complaints about outpatients. The trust took an average of 21.1 days to investigate and close complaints, this is in line with their complaints policy, which states complaints should be completed within 25 working days. Across the trust, a high proportion of complaints related to clinical treatment (45.4%) and values and behaviour (24.1%). A breakdown of complaints by site can be found below.
Moorfields Eye Hospital (City Road): There were 66 complaints (61.1%), 30 of these related to clinical treatment and 20 related to values and behaviour.
(Source: Routine Provider Information Request (RPIR) – Complaints tab)
Number of compliments made to the trust
From 6th August 2017 to 6th August 2018 there were 142 compliments within outpatients. A breakdown by site can be found below.
Location Number of compliments Moorfields Eye Hospital (City Road) 53 Moorfields at St. George’s 2 Moorfields at Bedford 28 Trust- wide 44 All other sites 15 Total 142
Due to the nature of the data provided we are unable to comment on any themes relating to the compliments received. The trust has reported that:
“The compliments we receive focus on the standard of clinical care provided, with patient’s treatment meeting expectations and clinical outcomes being positive. Patients also compliment the care provided by individual members of staff, highlighting their kindness, professionalism and caring attitude which helps patients feel they are being treated personally. Many people comment that caring staff and the calm environment reduces their anxiety.”
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The trust had a learning outcomes section from complaints, however, most of the staff we spoke with were unable to provide clear examples of when learning had occurred from complaints and responses were variable. (Source: Routine Provider Information Request (RPIR) – Compliments tab)
Leadership Since the last inspection, the trust had introduced a new divisional structure with improved quality roles, focus and responsibility. The divisional leadership team was made up of a divisional director, divisional manager, divisional head of nursing and clinical director for support services. The access directorate was led by the deputy chief operating officer and had an outpatients manager. The trust had appointed a joint director of education with the aim to bring their partnership with the UCL institute of Ophthalmology closer and support them to achieve their objectives. The leadership team were also focusing on supporting enhanced roles for nursing staff by enrolling some staff members on leadership programmes and increasing the number of apprentices in new work areas. Experienced clinicians and management staff led the outpatients services. The leadership team were supported in their roles by the trust management. Staff told us they felt valued by the directorate leadership team and that their work was appreciated. Staff we spoke with felt supported by their line managers and felt that the executive team were visible within the hospital. Vision and strategy The trust launched their five-year strategy in July 2017 with a new purpose which was working together to discover, develop and deliver the best eye care. Their five year strategy brought together all aspects of their work across clinical care, research and education, and this applied to all their services in the UK and United Arab Emirates. We requested the trust’s strategy for outpatients specifically but did not receive this from the trust. The trust also launched their first quality strategy in November 2017. The aim of the strategy was for everyone at Moorfields to work together to embed a culture of quality, make positive changes and drive behaviour to deliver an outstanding patient experience. Most of the staff we spoke with were not aware of the values or strategy of the trust, however, they were all positive about working at the trust and some were able to tell us where they would find this information. Culture Staff felt supported and motivated and there was a positive culture within the workplace. Staff told us they felt valued in their roles and some told us that their expertise in in certain areas was acknowledged and used. They told us that management teams tried to ensure they had opportunities for career progression and were supported to develop their skills. For example, some nurses we spoke with had enrolled in leadership management programs and others had become advanced nurse practitioners. Optometrists and nurses had extended roles and some were trained to give injections in the retinal therapy unit. During our inspection, staff did not raise any concerns about bullying, harassment, physical violence or discrimination within the outpatients department. However, we noted results from the 2017 NHS staff survey which showed that the bottom five ranking scores were staff experiencing discrimination, staff experiencing harassment, bullying or abuse from patients or relatives or staff, staff believing that the trust provided equal opportunities for career progression and staff
Page 184 experiencing physical violence from staff. The top five ranking scores from the NHS were staff motivation, quality of appraisals, staff satisfaction with the quality of work and care they were able to deliver, confidence in reporting unsafe clinical practice, quality of non-mandatory training, learning or development. This corroborated with what was observed during the inspection.
Governance The trust had established a refreshed annual clinical governance programme which started in November 2017. This was a trust-wide annual half day conference focusing on organisational culture and patient safety. During this day, the trust presented audits and discussed recommendations such as how to improve patient concordance in amblyopia management and latest trials for staff to be aware of. Pharmacists also gave a presentation about their ocular therapeutics service at this conference. The division held monthly quality meetings which contained an attendance list and had representation from senior manager, matrons, pharmacy team and other heads of services. Patient safety and experience, clinical effectiveness and innovation, audits and action plans were discussed at these meetings. Governance meetings for different specialities within outpatients were held quarterly. The glaucoma minutes from June 2018 showed that learning from incidents, complaints and claims were discussed. Audit outcomes and vision impairment and disability awareness were also discussed. The adnexal minutes from June 2018 also discussed audits outcomes, learning from incidents, complaints and claims and future projects. The cataract, corneal, medical retina, and external disease service meeting minutes contained similar information. These minutes stated that incidents were ‘mostly missing notes’ however there was no mention of an action plan to address the missing notes incidents. The trust told us that action plans were developed to address this trust wide rather than at a location level. The London Inflammatory Ocular Network (LION) governance meeting minutes had an attendee list, but no job titles next to the names and discussed quality improvement projects, presentations on eye conditions, audits and future projects. However, there was no section on learning from complaints and incidents in these meeting minutes. The optometry meeting minutes discussed learning on incidents and complaints, infection control, mandatory training, appraisals, service improvement, audits and data protection. The vitreo-retinal meeting minutes contained an attendee list with no job titles next to the names. These minutes also contained information on learning from complaints, incidents and claims and audit outcomes. Management of risk, issues and performance Senior staff were aware of the risk register and what their top three risks were and any plans they were aware of to address these risks. Senior staff told us that one of the risks was that none of the staff in the trust had advanced life support training, only immediate life support training, however this was not reflected in their local risk register. The trust told us that this risk was outside of the hours 08.30 to 18.00, Monday to Friday and that this was reflected on their divisional risk register. Some of the risks reflected on the risk register were speculative, identifying potential risks which could arise, for example a sharps injury, this suggested that some of the risks on the risk register were considered in general terms. Most of the risks documented on the risk register were up to date and some reflected our inspection findings. The risk register showed that risk scoring was completed and actions to mitigate risks were delegated to specific members of staff with review dates. Page 185
Information management Information governance mandatory training had been completed and the trust target for this training was met by nursing and medical staff.
Although the trust had completed a clinical record keeping audit that resulted in action plans such as reminding staff of the trust standards of record keeping, there was still a common theme of missing or misfiled notes. Engagement The NHS staff survey from 2017 showed that staff engagement was above average (4.01). Staff we spoke with felt mangers listened and tried to find solutions to problems experienced. The trust had continued the development of staff networks following on from the establishment of MoorAbility, their first network for staff with a disability. There was now a network for Black Asian Minority Ethnic (BAME) staff (BeMoor) and Lesbian Gay Bisexual Transgender (LGBT) staff (MoorPride). GMC survey results from 2017 were satisfactory overall and local clinicians and managers made changes to improve areas that required improvement. Staff from the Friends of Moorfields health information hub tried to engage patients and helped run events and awareness days such as macular week and diabetes day etc. They also arranged for doctors to come and talk about the work they were undertaking with stem cells. A learning disability and dementia group was available for patients quarterly and this was an opportunity for staff to engage with patients and obtain feedback on how they could improve their services for this cohort of patients. Many signs were displayed for patients to complete FFT forms. The last outpatient survey for Moorfields Eye Hospital was conducted in February 2012. Learning, continuous improvement and innovation Moorfields eye Hospital worked with the University College London (UCL) institute of Ophthalmology as one of the world’s successful hospital university partnership in ophthalmology. Moorfields Eye Hospital was one of the 20 sites nationally that had National Institute for Health Research (NIHR) Biomedical Research Centre (BRC) status and the only BRC dedicated to eye research. Moorfields Eye Hospital and UCL set up the London Project to Cure Blindness which restored the sight of the first patients receiving a new treatment derived from stem cell technology. Their collaborative and pioneering research study with DeepMind Health showed that artificial intelligence helped to diagnose eye diseases. The NHIR granted a clinical trial for finger prick autologous blood (FAB) to treat severe dry eyes. The cataract and corneal services had recruited 15 patients to date. These services had also just finished the European stem cell trial: Holocore, and were starting another trial for 10 years called Holosight. Moorfields led a multi- centre trial of standard cataract surgery versus femtosecond laser assisted surgery and had completed follow up which was due to be reported within the next month. There was a nurse led service for keratoconus management which meant easier access for patients, improved patient outcomes and experience and increased capacity to support the medical workforce. The trust continued to support enhanced roles for a good mix of staff
Page 186 disciplines from advanced nurse practitioners through to optometrists undertaking retinal injections. The trust won the UK National Patient Safety Award (clinical governance and risk safety) in 2017.
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