Matrix Surgical Limited Also known as Belgrave House

On this page

• 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 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 avoidable harm.

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. Lessons were learnt to continually identify and embed good practice.

Leaders reviewed responsibilities and priorities to ensure learning, governance and oversight were maintained. This included sustaining clear systems for incident reporting, investigation and shared learning. Staff consistently described clear processes for identifying, escalating and reporting incidents. They demonstrated confidence in what constituted an incident and how to report concerns using the service’s incident reporting system. Incident records from the previous 12 months showed incidents were reported promptly and consistently by staff. Immediate actions were taken, investigations completed and learning outcomes documented. There were no serious incidents recorded during this period, and none met the threshold for external reporting.

The service treated incidents, adverse events and near misses as opportunities for learning rather than blame, with no evidence of a closed, defensive or punitive culture. Records showed that adverse events specific to the service, including medicine dispensing and labelling errors and a surgical complication requiring onward referral, were identified, reported and reviewed appropriately. There were no never events or serious incident reported by the service in the last 12 months.

Staff demonstrated a clear understanding of the duty of candour and described how they were open and transparent with people and their families when things went wrong. Incident investigation reports reviewed showed that patients were given clear explanations of what had happened, why decisions were taken and what the next steps would be.

Learning from incidents was routinely shared and embedded across the staff team. Staff received feedback from investigations of incidents, both internal and external to the service, and described opportunities to discuss this learning collectively. Incident records showed that learning outcomes and actions were clearly documented, allocated to named individuals and monitored to completion. Staff meetings and informal discussions were used to reflect on incidents and near misses, and to agree changes to practice. There was clear evidence that learning led to tangible improvements, such as strengthened checking processes for medicines supplied by third‑party providers, the development and implementation of a formal SOP for managing surgical complications, and improvements to written patient information to better support informed consent and shared decision‑making.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

The service had effective systems to support safe care throughout the surgical pathway. Referral documentation consistently included diagnosis, treatment plans, relevant medical history and risk factors, enabling clinicians to make timely and informed decisions about suitability for surgery.

Pre‑operative assessments were completed in advance of surgery and included comprehensive nursing, anaesthetic and clinical reviews. These assessments were reviewed again on the day of surgery. This provided additional assurance that people remained clinically suitable for treatment and that any emerging risks were identified and appropriately managed. Patient records demonstrated consistent documentation of consent, mental capacity considerations, risk assessments and personalised post‑operative care plans.

Operational systems were closely aligned with clinical safety. Processes ensured that the correct intraocular lenses and required equipment were available in advance, with spare lenses prepared where required. Surgical safety checklist audits demonstrated consistent completion of sign‑in, time‑out and sign‑out checks, including verification of patient identity, procedure, allergies, lens selection and availability. These systems reduced the risk of last‑minute cancellations or delays.

The service worked closely with community optometrists, GPs and other relevant health and social care professionals to support continuity of care. There were effective pathways for onward referral and escalation where additional support or follow‑up was required. Clinicians shared clear, timely post‑procedure correspondence with both referrers and patients using secure systems. Discharge summaries and GP letters included clear post‑operative instructions, medication information and follow‑up arrangements.

Patient records demonstrated consistency and continuity across referral, assessment, surgery and follow‑up, supporting safe transitions between teams and settings. Where people required additional support, staff worked with relevant services to ensure ongoing care needs were understood and addressed after discharge.

The evidence showed a good standard. 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.

Safeguarding arrangements were established and embedded within everyday practice. Safeguarding policies had been recently reviewed, digitised and made accessible via an online platform, ensuring all staff could consistently access up‑to‑date guidance. Staff confirmed they knew how, when and why to raise a safeguarding concern, including how to make a safeguarding referral and follow local authority referral processes. Leaders clearly articulated safeguarding responsibilities and escalation routes, including onward referral to local authority safeguarding teams when required.

Staff had completed safeguarding training required for their roles, including safeguarding adults and children to the required levels. Training records demonstrated good oversight of compliance and renewal dates. Staff were able to explain how they would identify adults and children at risk of, or experiencing, abuse, neglect or significant harm. This included understanding the importance of sharing information and working in partnership with external agencies, such as local authority safeguarding teams and other health or social care professionals.

Staff demonstrated awareness of vulnerability beyond immediate clinical risk and spoke knowledgeably about equality, protected characteristics and the risk of discrimination. They were able to give clear examples of how they would protect patients from harassment, discrimination and sexual safety risks, including those related to age, disability, gender, race or other protected characteristics under the Equality Act. Equality and diversity training was embedded within mandatory training requirements and reinforced through leadership expectations and service values.

There were safe procedures for children visiting the service. Staff showed awareness of safeguarding considerations when children were present, including supervision, maintaining appropriate boundaries, and responding to any concerns promptly in line with policy.

No safeguarding concerns were identified during the assessment, and there was no evidence of gaps in safeguarding oversight, training or practice.

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 service worked with people to understand and manage risks associated with surgical treatment including completing individualised risk assessments, undertaking pre‑list safety briefings, and ensuring appropriate arrangements were in place to respond to emergencies. Staff used recognised clinical tools and structured documentation to support the early detection and response to patient deterioration, which formed an integral part of maintaining patient safety and improving outcomes. Patient records demonstrated the use of national early warning scores (NEWS), including documentation of scores, appropriate escalation, and timely medical review where required. This supported consistent clinical decision-making and ensured deteriorating patients were identified and responded to promptly.

Staff communicated with patients in a way they could understand. Information was provided in different formats, including written materials such as patient information leaflets and personalised “journey” booklets, and staff adapted their approach depending on individual needs. Reasonable adjustments and additional time were offered where people had communication difficulties, and patients were supported to involve family members or others in discussions to aid understanding and decision-making.

A formal standing operating procedure (SOP) set out roles, responsibilities and expectations when complications occurred, including patient communication, referral arrangements, documentation and internal reporting. Where learning identified gaps, such as the need for clearer written information about referral pathways or risks associated with specific co‑morbidities, actions were agreed and completed, including revisions to patient information leaflets and consent documentation.

Governance systems supported continuous improvement. Actions arising from feedback and clinical governance discussions included reviewing and updating consent documentation and patient information resources, ensuring they reflected individual risks and supported shared decision-making.

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

Clinical and theatre environments were clean, well-organised and maintained. We observed that clinical areas were visibly tidy, with infection prevention and control measures ongoing. This included access to hand hygiene facilities and staff used personal protective equipment when required. Sharps containers were correctly assembled, labelled and not overfilled, and different waste streams, including hazardous and clinical waste, were clearly segregated and disposed of safely.

Medicines and hazardous substances were stored securely, with mitigation to manage risks, such as locked cupboards and compliance with Control of Substances Hazardous to Health (COSHH) requirements. Sluice and storage areas were organised, with consumables stored off the floor, in date and with intact packaging.

Theatre safety systems were embedded in practice. Daily checklists were completed to ensure safe set-up of theatre areas, and key safety information such as staffing levels, learning bulletins and audit results were displayed to support team awareness. Where staffing levels varied from plan, staff were able to explain mitigating actions.

Fire safety arrangements were effective, with clear and unobstructed evacuation routes, functioning fire doors and appropriate safety signage. Gas and safety systems were checked, with no concerns identified in panel indicators.

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 a small but stable staffing model with clear roles and responsibilities. Core staff were experienced and familiar with the service, and sessional staff were known to local systems and procedures. The multidisciplinary team included a resident surgeon, a theatre manager (registered nurse), an office manager, and a sessional nursing team supporting pre- and post-operative care.

Managers described how staffing arrangements were reviewed and adjusted during periods of absence to ensure safety and continuity were not compromised. Managers ensured that new staff received an induction and role-specific training. Ongoing professional development was supported through structured CPD activity, including clinical education sessions delivered by experienced clinicians to ensure practice reflected current evidence and guidance.

Care was delivered through a coordinated team with the the required skill mix for the service. The team included a consultant ophthalmologist, optometrist, theatre nurses, scrub nurses, and pre- and post-operative nursing staff, supported by administrative staff. Leaders described strong partnership working with community optometrists and GPs, including provision of advice and guidance, and Continuing Professional Development (CPD) events to support shared care arrangements. While the service did not routinely require input from a broader range of allied health professionals due to its focused surgical model, referral pathways ensured patients could access additional specialist input where required.

Staff were experienced, qualified and had the necessary skills to meet patient needs. Training records demonstrated a high level of compliance with mandatory training, including safeguarding, infection prevention and control, life support, and medicines management. Additional specialist competencies were maintained, including laser safety training and ophthalmology-specific clinical skills. Inspection notes indicated that staff demonstrated good clinical knowledge and competency in practice, including consistent checks of patient identity, consent and clinical documentation.

Practising privileges arrangements provided assurance that clinicians worked within their scope of practice. Practising privileges ensure clinicians perform only those procedures they are trained, assessed, and authorised to deliver. Leaders described robust recruitment, annual review of practising privileges and ongoing oversight through appraisal and NHS performance review processes.

Safe recruitment and practising privileges processes meant that staff worked within their scope of practice. Practising privileges were subject to formal checks, including annual review of scope of practice declarations and appraisal documentation, to ensure clinicians remained competent and worked within agreed limits.

The theatre rota demonstrated planned staffing for surgical lists, with identified staff allocated to each session. This showed a consistent approach to workforce planning and use of a regular team familiar with the service.

When developing and maintaining the sessional workforce, leaders focused on recruiting staff who were already known to the service or had worked together previously in other settings. This supported team cohesion, familiarity with processes, and safe delivery of care.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading by following policies. Infection and prevention and control data was collected and reviewed. Where required, actions were taken to improve shortcomings.

Infection prevention and control (IPC) practices were embedded in routine care. Staff followed hand hygiene principles and used personal protective equipment (PPE) as required. We saw good availability of handwashing facilities and appropriate use of PPE within clinical areas during the inspection visit.

Clinical areas were clean, well maintained and fit for purpose. We saw clean, tidy and organised spaces, with furnishings suitable for the environment and we did not identify any concerns regarding cleanliness. In the operating theatre, infection prevention controls were embedded in routine safety processes.

Cleaning processes and safety checks were effective. Records demonstrated routine environmental cleaning, alongside daily theatre safety checks and checklists being completed to support consistent standards of hygiene. Specialist areas demonstrated appropriate IPC and safety controls. Audits of one of the lasers used in the service confirmed that PPE was available and used, appropriate safety signage was in place, and local rules and safety documentation were maintained, with ongoing quality assurance reviews scheduled.

Wider environmental and safety risks related to IPC were considered and managed. Inspector notes referenced monitoring processes such as water safety (e.g. legionella considerations), indicating oversight of environmental infection risks.

There was no evidence of IPC incidents, outbreaks or unmanaged risks There were no hospital acquired infections reported in the last 12 months. Incident logs we reviewed did not identify any infection prevention or control concerns. Effective IPC arrangements reduced the risk of avoidable infection and cross-contamination and supported the delivery of safe surgical care and positive patient outcomes.

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

Medicines were stored securely, with temperature monitoring and regular checks to ensure medicines remained safe for use.

Records showed medicines were prescribed, administered and documented correctly, with staff checking patient identity and consent prior to administration.

Medicines were labelled, stored in date, and stock levels were monitored. Evidence also showed that medicines management processes, including dispensing, administration and recording, were carried out in line with national guidance.

People received clear guidance about post-operative medicines such as self-administered eye drops, and leaders described how feedback informed improvements to information provided to patients. People were supported to use medicines safely after treatment, reducing the risk of harm or complications.

Checks of medicines management systems demonstrated that items were in date, correctly labelled and subject to routine monitoring, including fridge temperature logs.