Community Health and Eyecare Limited (CHEC - Slough)

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

This means we looked for evidence that people were protected from abuse and avoidable harm.

This is the first assessment for this service. This key question has been rated good. This meant people were safe and protected from avoidable harm.

We looked for evidence that people were protected from abuse and harm. We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that people were safe and protected from bullying, harassment, avoidable harm, neglect abuse and discrimination.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events internally. Lessons were learnt to continually identify and embed good practice.

The service managed patient safety incidents well. Staff recognised and reported incidents and near misses, and leaders investigated them thoroughly. They shared lessons learned with the team and the wider service.

Staff apologised and gave patients honest information and appropriate support when things went wrong. They understood duty of candour, remained open and transparent, and provided patients and families with full explanations when errors occurred. Staff completed duty of candour training, and compliance in November 2025 was 100%.

Staff received feedback from incident investigations, including those internal to the hospital and from across the wider organisation. The hospital manager delivered feedback through meetings, one‑to‑one sessions and team huddles, and we saw evidence of this reflected in meeting minutes.

The organisation had a current Patient Safety Incident Response policy which supported the requirements of the Patient Safety Incident Response Framework . This policy set out the provider’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents and issues, with the aim of learning and improving patient safety. It aligned with national guidance and supported the service’s approach to managing safety, learning, and improvement.

The organisation graded incidents in line with recognised patient safety frameworks, including NHS England’s Learn from Patient Safety Events system and harm‑grading guidance from the Royal College of Ophthalmologists. The service determined harm severity based on the patient’s clinical outcome.

The service reported 110 incidents between November 2024 and November 2025, with 80% (88 incidents) graded as ‘avoided or prevented Harm’, 16.4% (18 incidents) as low harm and 3.6% (4 incidents) as moderate harm.

Local leaders investigated all incidents, with final approval from the Regional Quality Governance and Patient Safety Lead. Leaders told us that none met the threshold for PSII (a Patient Safety Incident Investigation, meaning a more in‑depth, formal investigation triggered only for the most serious or complex safety events).

The service reported no never events between November 2024 and November 2025. Never events are serious, largely preventable safety incidents that should not occur if the available preventative measures are implemented. They included incidents such as wrong‑site surgery or foreign objects left in a person’s body after an operation.

Staff identified and reported risks, confident that the service would address them. They felt confident to intervene and prevent harm from occurring when there was an immediate risk to patients or others.

Staff raised concerns and reported incidents and near misses electronically in line with organisational policy. We reviewed a recent incident involving a patient attending from another site for cataract surgery, where staff noticed the scanned care pathway included out‑of‑date (August 2024) patient consent and biometry (the eye measurements used to calculate the correct lens strength for cataract surgery). They alerted the surgeon, who repeated the biometry and completed new consent in pre‑theatre, allowing the procedure to proceed safely.

Leaders investigated incidents and shared lessons learned with teams and the wider service. Staff told us that themes, trends and learning from incidents were discussed during meetings. Our review of meeting minutes from November 2024 to November 2025 confirmed this.

We saw evidence that incidents were investigated and that appropriate action was taken to reduce the risk of recurrence. For example, staff were reminded to document intra‑operative complications (problems that occur during a procedure) and to complete duty of candour before moving on to the next patient. This followed an incident at another site where documentation had been missed, and duty of candour had been completed only at the end of the theatre list. Learning was shared across all sites to strengthen practice and maintain consistent safety standards.

Our review of 12 patient notes identified two intra‑operative complications after cataract surgery. We cross‑referenced these with the incidents reported and found that both had been appropriately recorded, with duty of candour applied. We also saw evidence that these were shared with staff during meetings.

Senior leaders ensured that actions arising from patient safety alerts were addressed and monitored. They shared ‘Flash Alerts’ when an incident occurred in any part of the organisation, which could promote learning in other locations.

The service worked with patients and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when responsibility for patient care moved between different areas of a service and between providers.

The service prioritised safety and continuity of care throughout the patient pathway and worked with partners to ensure patients were offered the most appropriate service for their needs. Leaders set clear patient selection criteria so patients were only accepted when the service could safely meet their needs, and ensured alternative pathways were available when required.

The service was supported by the provider’s Referral and Bookings Management Centre, who triaged all referrals in line with the referral management policy. Staff used this policy to assess information, confirm suitability and direct patients to sites with the appropriate capability. Staff checked patient details to support accurate, safe decision‑making.

The service did not carry out complex procedures and did not use general anaesthetic (medicine that puts you fully to sleep), or sedation (medicine that relaxes you and makes you drowsy), and all procedures were performed under local anaesthetic (medicine that numbs a small area while you stay awake). Staff followed admission criteria to ensure patients were suitable and could be treated safely.

Staff carried out pre‑admission assessments for all patients having cataract procedures to confirm the service could meet their clinical needs safely. They used the provider’s pre‑assessment policy to review key medical conditions, infection risks, and other factors such as mobility, hearing, and implanted devices (for example Pacemakers). Leaders set clear thresholds for suitability, which identified when patients were unsafe to treat on site. Staff referred unsuitable patients to other providers and ensured timely follow‑up. They also shared relevant information with receiving services to support continuity of care.

The service complied with NHS Integrated Care Board’s criteria by listing only symptomatic patients (those experiencing visual symptoms affecting daily activities) for surgery and scheduling review for those without symptoms (patients whose cataracts were not yet causing functional impact).

The service used a standardised Integrated Care Pathway (ICP) to record each stage of care, and staff consistently completed pre‑operative checks, World Health Organisation (WHO) surgical safety checks, to improve patient safety and reduce the risk of errors and patient consent in the 12 patient notes that we reviewed.

Staff followed diabetic protocols, worked with GPs when optimisation was needed and documented discussions about lens options. They also arranged appropriate follow‑up imaging (scans or pictures of the back of the eye) when macular changes (alterations in the central part of the retina responsible for sharp vision) were identified to monitor retinal health and ensure timely referral if needed.

The service referred patients with intraocular pressure above 28 mmHg (the fluid pressure inside the eye, where higher levels increase the risk of glaucoma) to glaucoma services, and directed those needing phacoemulsification (ultrasound to break up and remove the cloudy lens) or minimally invasive glaucoma surgery (small, low‑risk procedures to lower eye pressure) to the one of the provider’s other site.

We observed a YAG laser procedure for posterior capsule opacification (a common post‑cataract surgery condition where the capsule holding the artificial lens becomes cloudy and affects vision). Staff completed the required WHO surgical safety checks to improve patient safety and reduce the risk of errors. These checks included confirming the patient’s identity, consent, past ocular (previous eye conditions, diseases, injuries, or treatments), and medical history, and verifying the correct laterality (which eye) before proceeding.

The service had systems and processes to ensure the correct patients were treated at each stage of the cataract pathway. Staff told us they used the World Health Organisation (WHO) 3‑point pause and safety checklist in theatre to confirm the correct patient, the correct eye and the correct intraocular lens (inside the eye lens) to reduce risk and prevent harm during cataract procedures. However, we were unable to observe this in practice, as there was no cataract theatre list on the day of our assessment. The service reported no never events from November 2024 to November 2025, indicating that these checks and safety processes were effective.

Staff understood surgical safety standards, including the Stop the Line Policy (which allowed staff to pause a procedure if they had any concerns to ensure patient safety), and told us they would use it if needed. We saw evidence of this in a reported incident where a patient arrived in theatre without a wristband. Staff stopped the process and took appropriate action before proceeding.

The service ensured patient records were accessible at all times. Staff maintained paper records and scanned them onto the electronic patient record (EPR) system. Staff across all sites, including the doctor on call, could access the EPR system remotely, which supported continuity of care, enabled timely clinical decisions and ensured teams had the information needed to respond promptly to patient queries or emerging concerns.

The service transferred patients to other hospitals when their eye condition was serious or required urgent specialist care that could not be provided on site. This included emergencies such as sudden rises in eye pressure, signs of a retina (light‑sensitive layer at the back of the eye) beginning to detach, significant eye injuries, or rapidly worsening vision problems. Leaders told us that in these situations, patients were sent to hospital promptly for the urgent treatment they needed.

The provider had standard operating procedures (SOPs) for on‑call and postoperative triage. Staff used flowcharts for in‑hours and out‑of‑hours pathways to decide whether patients needed advice, review, urgent assessment or escalation. The service used condition‑specific SOPs, such as those for suspected endophthalmitis (a serious eye infection inside the eye) and high postoperative intraocular pressure (pressure in the eye that is too high after surgery), to guide rapid responses.

The organisation operated a 24/7 out‑of‑hours emergency call system through a dedicated on‑call number, with calls going directly to the on‑call doctor, who assessed the level of urgency. Staff followed a SOP outlining the on‑call rota, escalation criteria and the consultant’s triage role, and the service had a separate SOP for emergency transfers. Together, these processes ensured a structured response to postoperative concerns.

Staff kept 2 emergency slots in each clinic to support ‘walk‑ins’ and post‑operative concerns, ensuring patients with urgent issues could be seen promptly without delaying scheduled care. We saw from our review of 12 patient notes that staff had used these slots appropriately.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Staff were able to describe their safeguarding responsibilities and were trained in line with national guidance. All clinical staff had completed level 2 adult and childrens safeguarding training. The registered manager and doctors were trained to level 3. The service had 100% compliance with all required safeguarding training levels in November 2025. The provider’s chief nursing officer (CNO) was the safeguarding lead, held level 4 training, and was supported by an independent safeguarding network.

Staff had access to the provider’s safeguarding policy through the intranet, ensuring up‑to‑date guidance was readily available. The service further supported staff awareness and prompt action by displaying safeguarding flowcharts and QR codes in multiple locations throughout the site. Staff demonstrated an understanding of the escalation process and were able to describe how they would raise a concern.

Staff could give examples of how to protect patients at risk of, or experiencing, significant harm. They understood the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS), and all staff had completed training in both. The MCA protects people aged 16 and over who may lack the capacity to make decisions about their care and treatment. DoLS provides a legal framework for restricting a person’s freedom of movement when necessary to keep them safe or ensure they receive appropriate treatment.

Managers told us they planned to display photographs of clinical staff to support safeguarding, to help patients recognise who was providing their care and to reduce the risk of any confusion about staff identity.

Leaders described an incident where staff had identified signs of possible coercive control involving a patient’s relative and sought advice from the provider’s safeguarding lead. Clinicians continued the consultation but were not assured the patient could give informed consent, so they did not proceed with the procedure. This demonstrated appropriate recognition and escalation of safeguarding concerns.

The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

The hospital did not admit children or young people under 18 years. The service only carried out procedures for adult patients under local anaesthetic, with clear criteria to determine which patients were suitable to be treated at this location.

The organisation managed patient selection through its ‘Referral and Booking Management Centre’. Staff reviewed and triaged referrals within required timeframes, identified urgent and routine cases. They checked referral information and NHS Spine (the national system that securely connects NHS services and patient information across England) records to confirm accurate, up‑to‑date patient details before accepting someone for treatment. Staff escalated any risks or delays and supported patients to be involved in decisions about their care. This structured approach promoted safe and consistent decision‑making about who the service could safely treat.

Staff involved patients in completing safety checks when collecting them from the waiting area and again on arrival in pre-theatre and theatre. They introduced themselves, explained their roles, and checked the patient’s name, date of birth, allergies, expected surgery, surgical site and consent.

The service allowed relatives to act as chaperones in the pre‑theatre room to support patients, reduce anxiety and help ensure they felt comfortable and informed before the procedure. This approach helped involve the patient and their relative in understanding the procedure and managing any associated risks. The service also displayed information advising patients that a chaperone could be present during consultations if required, supporting informed decision making and involvement in their care.

We followed a patient’s pathway through pre‑theatre, theatre and post‑theatre areas. Staff clearly explained the procedure to the patient and their relative (in pre-theatre) and provided reassurance throughout. They encouraged both to ask questions, and the relative told us that staff responded to all queries and addressed any concerns.

The service received 32 Friends and Family Test responses in October 2025, around 3.5% of the 903 patients seen that month. The ‘Friends and Family Test’ is a quick, anonymous NHS survey that asks patients about their overall experience of care). Although the small sample size meant the feedback was less reliable, the comments we reviewed indicated that patients felt involved in their care. Patients reported being listened to, given clear instructions, and having procedures explained in ways that reduced anxiety and helped them feel reassured. This was also supported by a 99.22% positive satisfaction score from an additional patient feedback platform used by the service.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The service operated from a purpose‑built, 3‑storey commercial building constructed in 2001 and occupied only the first floor. The environment followed national guidance and included an operating theatre, a dedicated laser room, a treatment room for minor procedures, a pre-theatre and post-theatre room, consulting rooms and a waiting area, each equipped to support safe and effective care.

The service ensured medical devices had scheduled service checks and equipment had annual calibration testing. We checked 2 electrical items in theatre (phaco machine and microscope) and found both to have undergone electrical safety testing in the last 12 months.

Leaders maintained oversight of equipment to ensure it was safe and ready to use. Equipment audits were completed and outcomes shared with staff. Staff told us they had enough equipment to carry out their work safely and to support the treatment and care needs of patients. There were effective processes to ensure repair or replacement of broken or missing equipment.

Specialist equipment used in the operating theatres was used in accordance with national guidance and regulatory requirements, and we saw evidence of the service records.

The service had effective processes for the management of accountable items, including swabs, instruments, and sharps. We observed safe handling and disposal practices. Surgical instrument trays were traceable, with tracking systems to ensure full accountability from decontamination to point of use.

The service displayed hazardous‑waste warning signage when required. Staff stored Control of Substances Hazardous to Health (COSHH) products securely in locked cupboards within a designated storage area.

Staff followed appropriate laser safety procedures. They used illuminated warning lights outside the laser room and secured access with a keypad‑locked door to prevent accidental entry. Staff stored the laser key safely in a key cupboard when not in use. The laser, manufactured in March 2025, had not yet reached the date for its first scheduled service.

The service had a Laser Protection Supervisor (LPS) who oversaw safe laser use, and a service level agreement for access to a Laser Protection Adviser (LPA). Leaders told us the most recent adviser visit had taken place on 25 September 2025 and confirmed that no actions were required. The service followed relevant guidance, including the MHRA’s ‘Lasers, intense light source systems and LEDs: guidance for safe use in medical, surgical, dental and aesthetic practices’ (2015), which they used to inform local policies and support safe systems of work.

Staff used an illuminated visual acuity chart, ensuring consistent lighting conditions and supporting accurate and reliable vision testing. Staff ensured good stock levels and stock rotation of consumables and lenses. We checked a random sample of items in the theatre clean store room and found all in date.

Staff had access to emergency equipment. The resuscitation trolley was well stocked and included the 2021 Resuscitation Council UK guidelines, and staff completed daily and weekly checks to ensure it remained safe and ready for use. Eye‑wash solutions were also in date.

Staff had access to emergency equipment and medicines for endophthalmitis (a serious internal eye infection) and high intraocular pressure (high pressure inside the eye), stored in an accessible, clearly labelled box within the clinical area. Staff followed a standard operating procedure (SOP) describing when to use the box, the actions to take and how to escalate concerns, and they told us they knew how to access it in an emergency.

The hospital carried out regular maintenance, servicing and testing of its water systems in line with national guidance to minimise the risk of Legionella (a water‑borne bacteria that can make people very sick if it gets into the lungs). Leaders commissioned a specialist water hygiene company to complete a risk assessment when the service registered in 2021 and reviewed this regularly. The most recent inspection in August 2025 identified no defects, providing assurance that the water systems were managed safely.

The service completed annual inspection and verification of its critical ventilation systems, including the air handling unit for the theatre, in line with national guidance. The May 2025 assessment reported no defects. These routine inspections helped ensure safe, compliant airflow and appropriate environmental conditions in clinical areas.

The service used an electronic system to record and track equipment and facilities faults. In 2025, staff logged 21 issues, including theatre equipment faults and facility repair requests. Managers assigned priority ratings, and most jobs had been completed. Staff told us they had no concerns about how maintenance issues were managed.

The service had an up‑to‑date fire risk assessment, fire plan and evacuation procedure. The plan showed escape routes, fire exits and firefighting equipment, and the most recent fire risk assessment (updated July 2025) confirmed suitable escape routes, fire detection, alarm systems and documented procedures were in place.

The service also held a current Emergency Lighting Periodic Inspection and Testing Certificate from October 2025, which reported no defects. Fire safety equipment was available and maintained, and fire exits were unobstructed.

Staff separated clinical waste appropriately, used the correct bins, and stored waste securely in locked containers until collection. They ensured sharps bins were correctly labelled and not overfilled. The service had a contract for waste collection, monitored collection activity, and staff told us no collections had been missed. We saw that the service increased the number of bins and the frequency of collections when needed. However, general waste bins did not have lids or pedal mechanisms and remained open.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

The service had enough clinical, nursing and support staff with the right skills, training and experience to keep patients safe. The team included 2 theatre practitioners and 5 ophthalmic theatre assistants (4 at level 2 and 1 at level 4), supported by clinical and administrative staff. Staff had completed the role‑specific competencies required for their posts, with 100% compliance recorded in November 2025. Competency records showed staff were assessed as able to carry out their duties safely and effectively.

Leaders ensured there were enough staff to safely care for patients. They used recognised guidance to determine required staffing levels and followed the Association for Perioperative Practice (AfPP) guidelines when planning theatre rotas. This included meeting minimum recommended levels of 2 scrub practitioners, 1 circulating staff member, 1 technician for pre‑theatre checks, 1 technician for admissions, and 1 discharge nurse.

All staff completed Adult and Paediatric Basic Life Support (BLS), with 100% compliance in November 2025. Two members of staff were also required to complete Immediate Life Support (ILS); 1 had completed this and the second was due to complete it during their probation. Leaders monitored life‑support training and competencies to ensure staff remained safe and appropriately skilled.

The provider followed a structured process for granting practising privileges to sessional doctors to ensure only suitably qualified and compliant clinicians worked within the organisation. They engaged sessional ophthalmologists under a formal consultancy agreement outlining duties, indemnity requirements and adherence to organisational policies.

Leaders monitored ongoing compliance through the Medical Practitioner Appraisal Framework (MPAF). This included scheduled 2‑yearly checks of DBS (Disclosure and Barring Service) status, mandatory training, professional registration, indemnity, identity and right‑to‑work documentation, appraisal currency and any historic compliance gaps. The provider prioritised these checks based on the time since initial registration, reviewing larger cohorts annually when they approached 2 years since onboarding.

The medical workforce included both sessional clinicians and directly employed staff, and the provider applied the same governance and competency requirements to all clinicians.

The service had staff with the appropriate training and qualifications to operate the YAG laser safely. Ophthalmologists, fully registered optometrists and level 1 registered nurses with an ophthalmology qualification used this equipment. Staff completed YAG laser training, consent training (including assessing capacity under the Mental Capacity Act 2005), and laser safety training before undertaking any practical work. Supervising clinicians assessed competency before staff operated the laser independently.

The service’s lead optometrist, who also acted as the Laser Protection Supervisor (LPS), had completed recognised laser safety and clinical training and held documented competency in YAG capsulotomy. As LPS, they were responsible for day‑to‑day safe laser use, including ensuring compliance with the ‘Local Rules’ (the site‑specific safety instructions that set out how the laser must be used safely), maintaining safety controls such as personal protective equipment , signage and documentation, and supporting staff training and incident reporting.

The provider managed recruitment and induction centrally to ensure a consistent approach, and staff told us they had completed their induction. The service supported staff learning and development and ensured they received any specialist training required for their roles. Managers identified staff training needs and gave them the time and opportunity to develop their skills and knowledge. The hospital manager was notified when onboarding checks were completed. Leaders told us the provider’s clinical educator was developing an induction with competency assessments.

The provider operated a 24/7 on‑call system for urgent concerns. A doctor covered the on‑call rota for a full week and responded to calls from all provider sites. Each region had a stand‑up hospital with a theatre team available to return a patient to theatre urgently if required.

The hospital received support from a facilities engineer assigned to its region, who mainly dealt with structural issues, and staff reported no concerns about the engineer’s response when support was required.

Managers made sure staff attended team meetings or had access to the information shared if they could not attend. We saw evidence of meeting notes, and staff reported good attendance at meetings.

Staff completed all mandatory training relevant to their roles, including conflict resolution, health and safety, patient safety level 1, sustainability, moving and handling and data security. Training compliance in November 2025 was 100%, except for freedom to speak up training at 92%. Leaders monitored compliance and received reminders when updates were due, which helped ensure staff maintained the skills and knowledge needed to deliver safe care.

Staff with additional responsibilities also completed the required role‑specific training. The infection, prevention and control (IPC) lead nurse had completed level 1 IPC training, and the moving and handling lead had completed level 1 moving and handling training. This ensured staff with designated roles had the competencies needed to oversee these areas safely.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service managed infection risks well. The service used systems to identify and prevent surgical site infections. Staff used equipment and control measures to protect patients, themselves, and others from infection. They kept equipment and the premises visibly clean.

All areas were visibly clean, free from clutter and had suitable furnishings which were clean and well-maintained. Staff cleaned theatres and laser rooms when in use, and our review of completed cleaning checklists and the physical environment supported this.

The theatre environment followed national guidance, with separate areas to support safe flow from clean storage and preparation through to dirty equipment and waste management. The management of clean and used surgical equipment and the flow through theatre reduced the risk of cross contamination.

The service had appropriate storage for sterile packs, uniforms and linen. Staff checked the condition of sterile packs before they were opened and prior to use. Staff had access to a spillage kit containing the essential materials needed to safely clean and dispose of bodily fluid spills.

The service carried out appropriate testing of water outlets and theatre air‑exchange systems to support safe infection, prevention and control. Staff completed regular testing of water quality, which helped minimise the risk of waterborne pathogens (microorganisms such as bacteria, viruses, fungi and parasites that can cause disease when they enter the body). They routinely checked theatre ventilation systems to ensure adequate air changes and clean airflow during procedures. These measures supported a safe environment for both patients and staff.

Staff evidenced instrument tracking through monthly records for instruments and handpiece flushing. They completed all required checks for all surgical trays, and consistently logged serial numbers and confirmed the correct instruments were available. Our review of monthly audit sheets for the past 12 months showed consistent compliance with the tracking process.

The hospital had a service level agreement with an external company to clean, sterilise and process surgical instruments. Instruments were managed off site, with the company collecting used items, re‑processing them and returning them to the service. Leaders provided evidence of the contract, which confirmed the work met recognised safety standards.

Staff had access to the provider’s current ‘Infection Prevention and Control (IPC) Policy’ and supporting guidance, which reflected national standards. The IPC lead nurse had completed level 1 IPC training, including the provider’s Practical Foundation Assessment (PFA), and provided staff with IPC guidance and audit tools. Staff could seek infection‑control advice from the IPC lead nurse when needed.

The IPC lead nurse also carried out monthly environmental audits. The most recent audit in October 2025 showed 90% compliance, above the organisation’s 85% target. Leaders identified 3 areas that were only partially compliant: the clinical environment (85%), sharps handling and disposal (77%) and hand hygiene (82%). They developed an action plan to address the risks, which included the lack of hand‑wash basins in a consultation room and diagnostic room, and a small theatre without a separate preparation room. The audit confirmed that leaders had risk‑assessed and mitigated these issues.

Staff completed self‑reported hand‑hygiene audits, with average compliance of 92% between May and October 2025. Leaders monitored adherence to the IPC policy through regular audits, which showed overall IPC compliance between 93% and 100%, and 100% compliance in sharps audits for the same period.

The service monitored surgical site infection rates and reported no cases of endophthalmitis (a serious eye infection that can lead to loss of vision if untreated) from November 2024 to October 2025. This result demonstrated effective infection‑control measures and safe surgical practice across the year.

Staff followed infection‑control principles, including proper handwashing and appropriate use of personal protective equipment. Theatre staff followed good practice to minimise the risk of cross‑infection during treatment and care. Staff also supported infection‑prevention measures by adhering to the uniform policy; no nail varnish or jewellery was worn, and clinical staff were bare‑below‑the‑elbows to allow full hand decontamination.

The service used automated flushing equipment to clean eye‑surgery instruments safely. Staff used this system to flush the narrow internal channels with pressurised water and air, providing a more reliable clean than manual methods. Leaders ensured staff followed national guidance, which required immediate rinsing and adherence to the manufacturer’s instructions to reduce infection risk. Staff received training through completion of the Circulating in Theatre competency, which applied to ophthalmic assistants (level 2) and registered nurses and required reassessment every 3 years.

However, the service did not have a risk assessment or standard operating procedure (SOP) in place for the use of this equipment. We raised this with leaders, who responded promptly by undertaking a risk assessment and developing a SOP, which was in draft form and awaiting sign‑off through the provider’s governance processes. The theatre also had no separate space for laying up theatre trolleys due to its small size; this had been identified in the service’s environmental audit, and leaders confirmed it had been risk‑assessed and mitigated.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involve people in planning, including when changes happen.

The service used systems and processes to safely prescribe, administer, record and store medicines. Staff stored medicines safely in locked cupboards and fridges within the storeroom. They monitored the temperature of the medicine rooms and the medicine fridges and knew what actions to take if these were outside the recommended limits. Staff followed a standard operating procedure displayed above the fridge, which guided them on correct storage requirements.

Staff followed systems and processes to prescribe and administer medicines safely. In theatres, drugs were prepared once prescribed by the surgeon. Staff completed medicines records accurately and kept them up to date. Staff followed a clearly documented process for the dispensing of medicine for patients to take home.

The provider had a medicines management policy that covered safe prescribing, storage and use of medicines, including safe antibiotic use. Leaders required antibiotics to be prescribed in line with local guidance to reduce the risks of resistance and infection. Staff followed this policy by checking local guidance before prescribing.

We reviewed patient records and found that staff had administered intraoperative antibiotics during cataract surgery to reduce the risk of infection in line with national guidance. Staff documented this clearly, checked for allergies and used appropriate alternatives when required.

The service also used the provider’s medicines management policy to guide staff on responding to medicines incidents. Staff prioritised patient care, reported any medicines incident or near miss and recorded it in the patient’s notes. Leaders investigated incidents promptly and ensured the prescriber was contacted so appropriate actions were taken to keep patients safe.

We also found that staff reported an incident in which a patient’s eye drops were labelled incorrectly. Although the drops themselves were identical, staff still reported the issue to support learning and reinforce safe practice.

Staff were encouraged to report any suspected adverse reactions through the ‘Medicines and Healthcare products Regulatory Agency Yellow Card Scheme’. Leaders reviewed all medicines errors, and the provider’s medical director identified themes and shared learning at the Clinical Governance Steering Group.

Staff had access to emergency medicines for endophthalmitis and high intraocular pressure, stored in an accessible, clearly labelled box within the clinical area. Staff followed a standard operating procedure describing when to use the box, the actions to take and how to escalate concerns, and they told us they knew how to access it in an emergency.

The service maintained effective governance of medicines and completed prescription audits as part of its local audit programme. Staff completed a monthly medicines and consumables stock take and kept clear records of the ordering, receipt and disposal of medicines. Staff disposed of out‑of‑date medicines in the medicines‑disposal blue bin. Leaders oversaw these processes to ensure safe and compliant practice.

The provider shared medicines safety alerts with hospital managers, who ensured the alerts were acted on locally. Staff checked stock, removed affected items and followed supplier instructions for replacement or disposal.

Leaders promoted continuous learning and encouraged clinicians to complete independent prescribing training to enhance clinical decision-making and streamline patient pathways.

The provider currently sent eye drops to patients from their head office. Leaders told us they planned to change this, so patients would attend 30 minutes before their appointment to have drops administered on site, which would improve the safety and oversight of medicines use.

The service did not employ a pharmacist or pharmacy adviser, but it received an annual external audit of its medicines management processes carried out by an independent pharmacy service. The service did not use opiates (controlled drugs).