Community Health and Eyecare Limited (CHEC - Slough)

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This meant we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

We assessed all quality statements. This is the first assessment for this service. This key question has been rated good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high quality, person-centred care.

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

We have not awarded this service a score for Well-led.

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

The service had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

The provider set a long‑term strategic vision focused on sustaining its services and aligning them with wider local health-economy plans. Leaders embedded the provider’s core values of caring, passion, togetherness, listening, and focus throughout this strategy. Leaders aimed to make healthcare more accessible by bringing services closer to where people lived, offering patients greater choice in how their care was delivered, and reducing waiting times through more efficient pathways.

The provider worked closely with external partners to ensure its plans remained aligned with system priorities. This collaborative approach helped reduce pressure on NHS hospitals and contributed to shorter waiting times for patients.

Leaders fostered a caring and inclusive culture across the service. Local leaders reinforced this positive environment through an open‑door policy and consistently expressed pride in their workforce.

Staff reported feeling supported by their leaders and valued within their teams. Staff described a workplace culture where they felt respected, encouraged, and included. They enjoyed positive working relationships across all grades, demonstrating strong teamwork and effective collaboration. Staff were focused on the needs of patients receiving care and consistently demonstrated a caring and compassionate approach.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

There was a clear management structure in place, with well‑defined lines of responsibility and accountability. Staff reported that leadership within both the service and the wider organisation was strong, with leaders described as well‑respected, highly visible, approachable, and consistently supportive. Managers were passionate about the services they led and worked collaboratively with their teams, fostering a positive, engaged, and cohesive working environment.

Leadership of the service was provided by an on‑site hospital manager, who also acted as the CQC registered manager, and by an on‑site consultant ophthalmologist. They were supported by 2 regional clinical leads and received additional oversight from the wider provider leadership structure, including the regional team and the provider’s chief nursing officer (CNO).

The provider ensured accessible leadership for staff despite senior leaders being based off site at head office or within regional teams.

Locally, the hospital manager maintained effective communication through weekly ‘Friday Reflection’ meetings where operational updates were shared and staff were encouraged to raise concerns, as well as through daily huddles and open informal discussions supported by the small team size.

Senior leaders provided strategic oversight remotely and maintained regular contact with the hospital through scheduled performance and clinical governance meetings. The hospital manager met monthly with the organisation’s CNO to review clinical performance and with the regional manager to monitor progress against organisational objectives.

Staff told us they found leadership easy to access and communication open, consistent, and supportive.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff and leaders acted with openness, honesty, and transparency. Managers encouraged staff to raise concerns and offer ideas; the culture allowed staff to be confident their voices were heard.

The provider promoted a culture in which staff felt able to raise concerns. They carried out engagement activities during 2024/25 across all services to improve awareness and understanding of freedom to speak up. Leaders also introduced freedom to speak up champions at each site to provide additional local support to the freedom to speak up guardians and to make speaking up more accessible for staff. Staff told us they were aware of these arrangements and understood how to raise concerns if needed.

The service provided patients, families and carers with clear information on how to raise concerns and how these would be investigated. Staff were encouraged to respond to immediate concerns or complaints with a view to resolution. The provider had its complaints policy available on the public website for patients and on the intranet for staff, ensuring clear access to the information needed to support the complaints process.

Leaders acted on feedback from patients, carers, and staff and used it to make improvements. Staff completed freedom to speak up training, with 92% compliance in November 2025, supporting a culture where staff feel able to raise concerns and speak up safely.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The service valued diversity and employed staff from a range of cultural and religious backgrounds who spoke several languages. This supported the service in meeting the needs of a diverse community and helped to create an inclusive environment where people felt respected and understood.

At a provider level, leaders carried out an annual Workforce Disability Equality Standard (WDES) assessment and used the 9 WRES indicators to monitor and evaluate performance. The most recent results showed positive progress and reflected the provider’s commitment to promoting equity, inclusion, and fair treatment for staff with disabilities. Findings from the staff survey supported this, with most respondents reporting that people were treated fairly across key aspects of identity and role. In total, 93% of staff stated that people were treated fairly regardless of race, and 91% reported fair treatment regardless of gender.

The provider had policies and processes in place to ensure fair and inclusive practice. All policies were subject to an equality impact assessment to identify and address any potential effects of proposed changes on equality and diversity, ensuring that no group was disadvantaged.

Leaders promoted equality and diversity in daily work. Staff attended mandatory training in equality and diversity, and training compliance was 100%.

The provider had a calendar of health and wellbeing initiatives designed to raise awareness, promote inclusivity and celebrate diversity. This included recognising Disability Pride Month among a range of themed events throughout the year.

The provider did not always submit statutory notifications to Care Quality Commission for incidents which met the criteria for reporting serious injury. However, they did have governance processes, clear roles, responsibilities and systems of accountability, and acted on information about risk, performance and outcomes.

The provider supplied incident data from November 2024 to November 2025 as part of the assessment process. This showed that the service had internally reported 4 moderate-harm incidents but had not notified the Care Quality Commission (CQC) at the time they occurred, despite these incidents meeting the criteria for reporting the serious injury to CQC, as they involved structural intraocular (inside the eye) injury and unplanned surgical deviation.

CHEC confirmed they had a clear process for escalating levels of harm which met the threshold for a CQC notification. This suggested that statutory reporting requirements were not always clearly understood or consistently applied across the organisation. In addition, the service did not always calculate risk scores in line with the hospital’s risk matrix, and information on mitigations within the hospital risk register was limited, which reduced clarity around risk prioritisation.

However, the provider had investigated the 4 moderate harm incidents and assessed the level of harm appropriately. The service had managed each event effectively, and all 4 patients had a good final outcome. Leaders ensured the incidents were reviewed through the provider governance processes, and staff took appropriate clinical action at the time.

The service had a risk register, which leaders reviewed monthly. Local leaders escalated operational and patient safety risks to the appropriate regional leads. The service had recently added recent risks such as lift breakdown and heating failure, and controls were in place.

The hospital had an effective internal incident reporting system, and leaders shared learning across teams. The most frequent incident types were patient dissatisfaction and administrative booking errors, followed by surgical complications. Senior leaders reviewed all surgical complications to ensure safe management.

Staff could access the data they needed in easily accessible formats to understand performance and support decision‑making and improvement. Leaders shared key performance information on a notice board in staff areas. The information systems were integrated and secure. Staff completed data security awareness training, with 100% compliance in November 2025.

The service had reported a small number of data breaches but took action to reduce the likelihood of recurrence. Leaders reviewed each breach, provided staff with targeted feedback and reinforced information governance procedures. Staff received reminders about secure handling of patient records, and the service strengthened local processes and monitoring to prevent similar errors.

The service used audit processes and their outcomes to maximise the quality of care. Where improvements were required, leaders ensured action plans were developed and monitored, leading to positive changes. Staff completed local monthly audits, including WHO checklist compliance, resuscitation trolley checks, clinical record‑keeping and consent. We saw this evidenced through staff meeting minutes. Senior leaders audited on‑call doctor performance and cataract complications at a provider level.

The hospital had a comprehensive planned maintenance programme covering key infrastructure, including heating, ventilation and gas scavenging systems. We saw evidence of scheduled servicing and maintenance logs, all of which were up to date.

Staff had access to up-to-date readily available policies. Leaders had oversight of the accuracy and validity of each policy.

The service had a Business Continuity Plan which set out how essential services would be maintained during disruptions such as equipment failure, staff shortages or loss of premises. This supported organisational resilience and ensured leaders had planned for service continuity in the event of an incident.

The provider had a clear clinical escalation pathway, with concerns raised initially to on‑site clinicians, and escalated to regional and senior clinical leaders when required. This supported timely escalation and appropriate oversight of clinical risks.

The governance structure operated at a provider level, with the Clinical Governance Steering Group acting as the central hub. Sub‑committees included freedom to speak up, complaints and incidents, and safeguarding, with additional committees for education and training, information governance, Clinical Advisory Group, and Medical Advisory Committee ).

The provider cascaded information from committees through regular meetings between the hospital manager and provider’s chief nursing officer (CNO), monthly bulletins, outputs from meetings, and, for urgent matters, through ‘after incident reviews’ and ‘Flash Alerts’.

The hospital manager met monthly with the regional manager on a one‑to‑one basis to review progress against objectives, with a formal quarterly review in place. They also maintained established links with head office colleagues and, after each meeting with the CNO, shared the slide pack and key information with the local team.

At a local level, the hospital manager held ‘Friday reflection’ meetings and monthly team meetings, where staff discussed incidents, audit results, policy updates, performance, and service issues. Staff at all levels were clear about their roles and accountabilities. They had job descriptions, and these set out expectations and responsibilities.

Leaders reported that the organisation had updated its Patient Safety Incident Response Framework (PSIRF) plan to meet national requirements and set priority workstreams, including post‑operative complications and medicines errors. They told us PSIRF had strengthened governance and learning, with ‘After Incident Reviews’ and ‘Flash Alerts’ improving oversight of patient safety risks.

Communication processes were embedded in daily routines, including safety briefings and staff meetings.

Staff completed modern slavery training, supporting the organisation’s legal responsibilities and reinforcing a culture of ethical practice and safeguarding against exploitation. Compliance in November 2025 was 100%.

The provider held an up‑to‑date Employers’ Liability Insurance Certificate, demonstrating compliance with statutory requirements and appropriate organisational oversight.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Senior leaders actively collaborated with external stakeholders to improve services and share learning. The provider had established a formal partnership with the Royal National Institute of Blind People to provide dedicated Eye Care Liaison Officer services across the group. Senior leaders also worked with charities to enhance inclusion and develop animated information videos for people with learning disabilities.

The provider partnered with a university to support clinical placements for medical and optometry students, helping develop the future workforce. It also worked closely with healthcare professionals by providing education and collaborative learning opportunities through its continuing professional development programme.

The service engaged with the local community by inviting a local Member of Parliament to visit the site and learn about the services provided. In addition, the provider implemented new activity‑planning requirements as directed by the NHS Integrated Care Board who commissioned NHS care, ensuring local pathways remained aligned with system priorities.

The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research.

Staff were committed to continually learning and improving services. Staff participated in clinical audit, benchmarking and quality improvement activities, including contributing data to the National Ophthalmology Database (NOD) to monitor patient outcomes. The service’s ophthalmologist contributed to ongoing research in the fields of cataract and corneal surgery.

Staff reported feeling encouraged and supported to pursue professional development and external learning opportunities. For example, a non‑clinical staff member who was interested in progressing into an optical assistant role said they felt confident their manager would support them to complete the organisation’s training programme.

The provider proactively developed its workforce to support safe medicines use, encouraging clinicians to complete independent prescribing training to improve decision‑making and patient pathways. It established a training programme to provide advanced surgical training for specialist registrars, placing trainees across specialist hospitals to gain experience in high‑volume cataract surgery.

The service had adopted an artificial intelligence (AI)‑powered telephone assistant, introduced through an initiative promoted by the Integrated Care Board, to contact patients having cataract procedures at key points in their pathway, monitor recovery, and gather feedback. The system identified any concerns that required clinical review and alerted staff, helping to release clinical time and provide accessible follow‑up without patients needing to return to the clinic.

The provider introduced a cloud‑based data platform during 2024/25, automating manual processes and improving data accuracy, which contributed to strong clinical coding audit results and supported ongoing quality improvement. It also reviewed and updated its data security and information governance processes to maintain compliance with national standards and respond to emerging risks.

The provider promoted continuous improvement through its clinical governance arrangements, and the hospital had a Quality Improvement Plan in place to support this work at a local level.

Leaders reported that, in 2024 the organisation introduced a hands‑free stock management system using ‘Radio Frequency Identification’ technology. This reduced the time staff spent managing stock and allowed them to spend more time on direct patient care.

The provider’s quality improvement objectives for 2024/5 included implementing and maintaining the Patient Safety Incident Response Framework (PSIRF), developing an electronic medicines management system, and completing biennial Medical Practitioners Assurance Framework (MPAF) checks.

It also set strategic quality aims for 2025 to 2028 focused on improving patient safety, enhancing patient and staff experience, and advancing digital transformation. The strategy included developing workforce skills and education, with goals such as increasing incident reporting, reducing negative patient feedback, and supporting trainee surgeons to undertake a greater proportion of cataract procedures.