Matrix Surgical Limited Also known as Belgrave House

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

This is the first assessment for this service. This key question has been rated Good. This meant people’s outcomes were consistently good, and people’s feedback confirmed this.

We looked for evidence that people and communities had the best possible outcomes because their needs were assessed. We checked that people’s care, support and treatment reflected these needs and any protected equality characteristics, ensuring people were at the centre of their care. We also looked for evidence that leaders instilled a culture of improvement, where understanding current outcomes and exploring best practice was part of their everyday work.

We have not awarded this service a score for Effective.

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

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

The service ensured people’s needs were comprehensively assessed prior to surgery to support effective and safe care. We reviewed 10 sets of care records, which demonstrated that pre-operative assessments were completed in a timely way, either at or shortly after admission, and prior to treatment.

Assessments included detailed consideration of people’s medical history, current medicines, allergies and individual risk factors. Records showed that these assessments were not static; information was reviewed again on the day of surgery to confirm that people’s circumstances remained unchanged and that treatment continued to be tailored to their individual needs. This included confirmation of consent, pregnancy status where relevant, and updated clinical observations such as National early warning score (NEWS) scores.

Staff used information from assessments to develop care plans that addressed identified needs. Care plans reflected clinical decisions such as suitability for local anaesthetic, venous thromboembolism (VTE) risk and prophylaxis, and post-operative care requirements. Post-operative instructions were personalised, demonstrating a holistic approach that considered the individual’s wider needs, recovery and follow-up arrangements.

Care plans were personalised and reflected each person’s health status, risks and preferences. Documentation showed that staff updated care plans and clinical records at key stages, including pre-assessment, admission, and immediately prior to surgery. This ongoing review ensured care remained responsive to any changes in need and reduced the risk of avoidable harm.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards.

Care and treatment were delivered in line with recognised clinical standards for ophthalmic surgery. Patient records demonstrated clear documentation of diagnosis, treatment planning and the clinical rationale for procedures offered. Leaders described how clinical practice was kept up to date through reflection, audit of outcomes and engagement with relevant professional guidance, including National Institute for Health and Care Excellence (NICE) guidance. Clinical governance meeting minutes confirmed that evidence-based practice, new treatments and guidance were routinely reviewed as part of oversight arrangements.

Managers supported staff through regular team meetings, governance discussions and opportunities for reflection. Nursing team meetings and clinical governance forums were used to review incidents, share learning and discuss improvements to care delivery. Leaders promoted an open culture where staff felt supported to contribute to service development and continuous improvement.

Managers identified learning needs through audit findings, staff feedback and service priorities. Training compliance and competencies were regularly reviewed, and staff were supported to access additional training where required, including role-specific and safety training.

Standard operating procedures were active across clinical and operational areas, including pre-operative assessment, surgical procedures, infection control and equipment management. These supported consistency, safety and alignment with evidence-based practice.

People received consistent, evidence-based care that supported good outcomes, safe treatment and effective recovery. Where feedback identified opportunities to improve patient information or consent materials, leaders ensured changes were subject to careful clinical and multidisciplinary review to maintain accuracy while improving clarity and accessibility. This ensured that care remained responsive, personalised and grounded in best practice.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

The service operated as a small, cohesive team, with clearly defined roles and effective communication between clinical, nursing and administrative staff. Staff described coordinated working practices that supported safe delivery of care. The service also worked effectively with professionals outside the organisation, including community optometrists and GPs.

Clear and timely communication supported transitions before and after surgery. Clinicians shared post-operative letters and clinical summaries with referrers and patients using secure methods, ensuring onward care providers had the information they needed to support recovery and identify potential complications early. Patients completed a data sharing consent form to indicate if they consented to sharing.

Effective teamwork reduced the risk of miscommunication and supported people to experience smooth, coordinated care across different stages of their treatment. Managers supported staff through regular team meetings, governance discussions and opportunities for reflection. Nursing team meetings and clinical governance forums were used to review incidents, share learning and discuss improvements to care delivery. Leaders promoted an open culture where staff felt supported to contribute to service development and continuous improvement.

Staff held regular and effective multidisciplinary meetings to support oversight, learning and service development. These included formal clinical governance meetings where safety, incidents, clinical outcomes, staffing, and service improvement were routinely reviewed. There were also regular nursing meetings where operational issues, medicines management, incident reporting and policy updates were discussed. These forums enabled staff to raise concerns, share learning and agree actions, which were tracked through to completion, supporting a culture of continuous improvement and collective responsibility for quality and safety.

Staff shared information about patients effectively within the team, including through structured processes and day-to-day communication. Surgical team briefs, use of standardised documentation, and clear role allocation supported the sharing of key information to maintain patient safety. Staff also described open and accessible communication channels, including direct contact with senior staff and shared email systems, which supported timely information sharing and escalation of concerns where needed. These approaches ensured continuity of care and reduced the risk of omissions during transitions between stages of treatment.

The service demonstrated effective working relationships across the wider organisation and with external partners. There were established links with community optometrists and clear pathways for referral, follow-up and escalation, alongside defined arrangements for out-of-hours care to ensure patients could access the right support when needed. Internally, staff worked collaboratively across clinical and administrative roles to coordinate scheduling, patient flow and follow-up tracking, ensuring that care was well organised and responsive to patient needs.

Systems and relationships within the service supported strong multidisciplinary working, effective communication and coordinated care delivery, helping to ensure patients experienced safe, seamless care across the service.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduced their future needs for care and support.

Although the service’s core function was surgical, staff demonstrated a clear commitment to supporting people’s longer-term health, recovery and ongoing eye care. People were provided with detailed information before and after surgery, including a “cataract journey” booklet and tailored advice to help them understand their procedure, recovery expectations and how to manage their eye health at home. This information was regularly reviewed and updated in response to patient feedback to ensure it remained relevant and meaningful.

Staff described how they adapted information to meet different needs, recognising that some people wanted more detailed or technical explanations about their treatment options. This included expanding written information about intraocular lenses and providing additional guidance to support informed decision-making and self-management.

The service also contributed to wider population health by delivering continuing professional development (CPD) sessions for community optometrists and offering ongoing advice, helping to build confidence and capability in managing eye conditions beyond the clinic setting. This demonstrated a broader commitment to prevention, early intervention and improving outcomes across the system.

People were better supported to understand their recovery, recognise any concerns early and manage their eye health following treatment. Strong links with community professionals ensured continuity of care and timely access to further support. This holistic approach helped maximise the benefits of surgery, improved patient experience and contributed to better long-term outcomes.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

Leaders described how clinical outcomes, patient feedback and operational performance were reviewed routinely through established governance systems, including clinical governance meetings and regular audit activity. The service was not required to submit to national audits, as this is only required for NHS contract providers. Up to 2 January 2026, the Registered Manager reported no serious complications across 584 cataract procedures, including zero cases of endophthalmitis and no posterior capsule rupture, a key indicator of poorer outcomes.
The service placed strong emphasis on understanding outcomes from the patient’s perspective, not only through clinical measures but through people’s experiences of care. Leaders explained that patient feedback was actively sought, reviewed weekly at management level and used alongside clinical audit data to inform service improvements. Feedback had directly led to changes in written information, such as revisions to the patient journey booklet and surgical information to improve clarity, accessibility and responsiveness to individual information needs.

Staff also used technology effectively to support patient care and improve access to timely information. Leaders described the use of systems to monitor clinical outcomes, turnaround times and patient pathways, as well as digital platforms to capture feedback and support communication with patients and referrers. These systems enabled prompt access to key clinical information, such as diagnostic results and treatment planning data, supporting timely decision-making and continuity of care.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Consent processes were clear, well-established and consistently applied. People were provided with clear, detailed information about the risks, benefits and alternatives to treatment in advance of surgery, including written information and pre-operative discussions. Records demonstrated that consent was obtained in advance and reconfirmed on the day of surgery, ensuring decisions remained current and valid.

Staff took all practical steps to enable people to make their own decisions. Patients were supported through accessible information, pre-operative consultations and opportunities to reflect prior to signing consent. Documentation showed that discussions included expected outcomes, risks and post-operative care, supporting informed choice and shared decision-making. There was no evidence of people being rushed or pressured.

For patients who may have impaired mental capacity, staff demonstrated a clear understanding of Mental Capacity Act (MCA) requirements. Training records confirmed staff had completed MCA and Deprivation of Liberty protection safeguarding (DoLS) training, including consent-specific learning, ensuring they had the knowledge to assess capacity appropriately.

Capacity assessments were undertaken and recorded where indicated, and documentation reflected that this was considered on a decision-specific basis, particularly for significant decisions such as surgery and anaesthesia. Records reviewed included prompts for MCA/DoLS considerations and appropriate escalation where required.

Staff were knowledgeable about supporting people who may not have capacity to make specific decisions. They knew about best interest decisions and how to record these. Records and processes showed consideration of the person’s wishes, feelings, and wider context, including involvement of others where appropriate (for example, legal representatives or those with power of attorney). This demonstrated a person-centred and legally compliant approach to decision-making.

Consent discussions included clear explanations of risks, benefits and alternatives and were documented appropriately. Consent was obtained in advance and reconfirmed on the day of surgery, ensuring decisions remained current and informed. Where appropriate, people were supported to make advance decisions about their treatment, including the option to refuse care or delay procedures, and these preferences were respected and recorded.

People felt informed, involved and supported to make decisions about their care. This reduced the risk of distress, misunderstanding or inappropriate treatment, and promoted autonomy and confidence in the care provided.