Matrix Surgical Limited Also known as Belgrave House

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

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.

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 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.

Staff consistently described a clear understanding of the provider’s vision and values and how these were applied within their roles and day-to-day practice. The provider’s mission, “to provide an exceptional eyecare experience,” was well embedded across the service and aligned with a clear set of values including being friendly, knowledgeable, supportive, and focused on excellent communication and patient experience.

Staff reported that they felt able to raise concerns about any disrespectful, discriminatory or inappropriate behaviours without fear of negative consequences, supporting a culture of openness and respect.

The provider’s senior leadership team had effectively communicated this vision and set of values to frontline staff. Staff recognised the importance of delivering a calm, trusted, and expert service, and described how this translated into providing personalised care, taking time with patients, and ensuring clear communication about treatment options. This demonstrated that organisational priorities were not only understood but meaningfully applied in practice.

There were clear systems and opportunities for staff to contribute to discussions about the strategy and development of the service. Evidence showed that staff input was actively sought through appraisals, group discussions, and involvement in business literature and service development initiatives. Staff engagement was particularly evident in planned service improvements, such as enhancing patient information materials, increasing training opportunities, and strengthening staff resilience and engagement as part of the provider’s forward planning. This inclusive approach supported a sense of ownership and collective responsibility for the direction of the service.

Staff were able to clearly explain how they contributed to delivering high-quality care. This included maintaining strong clinical governance through standardised operating procedures across clinical, administrative and management functions, ensuring consistency and safety in care delivery. Staff also described a focus on continuous learning, patient feedback, and improving outcomes, which aligned with organisational goals to enhance service quality and patient experience.

Evidence collected during this inspection indicated a positive and open culture, where staff felt supported, valued, and able to contribute to continuous improvement. Feedback mechanisms, including patient feedback and team discussions, were used to inform service development and reinforce a learning culture.

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.

Leaders within the service demonstrated they had the skills, knowledge and experience to perform their roles effectively. The registered manager had extensive clinical experience, including over 20 years working as an optometrist, and brought a strong understanding of both clinical practice and service development. This experience supported informed decision-making and ensured leadership was grounded in a clear understanding of patient care, safety, and service delivery.

Leaders showed a strong understanding of the services they managed and could clearly describe how teams worked together to deliver high-quality care. There was evidence of robust oversight of clinical outcomes, patient feedback, and service performance, with regular reviews used to identify improvements and implement change. For example, leaders described how patient and staff feedback directly informed improvements to patient information, clinical pathways, and service design, demonstrating an embedded culture of continuous learning and development.

Leaders actively maintained oversight of governance, risks, and operational challenges. Where pressures arose, such as staffing changes or increased workload, leaders demonstrated adaptability and collective problem-solving. Responsibilities were redistributed, priorities were clearly set, and additional resource was secured to maintain safe and effective care. This showed resilience within the leadership team and a clear focus on maintaining quality and safety.

Leaders were visible and approachable within the service. The leadership structure was described as open and non-hierarchical, with staff at all levels encouraged to contribute equally. This fostered a supportive environment where staff felt comfortable sharing ideas, raising concerns, and contributing to improvements. Evidence from team engagement activities, service development discussions, and feedback processes supported that leaders were accessible and actively engaged with both staff and the day-to-day running of the service.

Leaders promoted a compassionate and inclusive culture. There was a clear emphasis on staff wellbeing, with leaders describing a strong sense of responsibility for ensuring staff were supported, happy, and able to develop in their roles. The service’s culture prioritised respect, teamwork, and shared goals, with a focus on delivering the best possible outcomes for patients while also supporting staff development and satisfaction.

Leadership development opportunities were available within the service. Staff were supported through training, appraisals, and opportunities to expand their roles and skills, as reflected in service plans to increase training activity and staff development.

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

Managers and staff had access to feedback from patients, carers and staff, and there was clear evidence that this was actively used to drive improvements. Feedback was logged, reviewed and investigated, with identified learning outcomes and actions recorded and tracked to completion.

The service supported open communication between patients, staff and senior leaders. Leaders created opportunities for patients and staff to share feedback directly. Staff were encouraged to raise feedback in meetings and discussions, and this was used alongside patient feedback to inform governance processes and service development.

Formal systems and policies were also available to support feedback and speaking up. The provider had a complaints policy, duty of candour policy and whistleblowing policy, which provided clear guidance on how concerns could be raised and managed. These processes supported transparency, accountability and learning across the organisation.

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.

Leaders demonstrated an awareness of equality, diversity and inclusion through established policies and inclusive ways of working. The provider had a range of policies to support fair and equitable treatment of staff, including equality and diversity, bullying and harassment, and grievance policies. These policies provided a framework for promoting respectful and inclusive working practices across the service.

There was evidence that flexibility and adaptability were embedded within the workforce model to account for individual circumstances and service needs. During periods of operational pressure, such as staff absence, leaders described how roles and responsibilities were flexibly redistributed across the team, with staff working collaboratively to ensure continuity of care.

Leaders also demonstrated a supportive approach to staff wellbeing and individual needs. There was a clear emphasis on ensuring staff were “happy in their role” and able to progress, with leaders taking active steps to monitor workload, prioritise tasks, and provide additional support where required. This included bringing in additional resource, such as external bookkeeping support, to reduce pressure on staff and maintain a sustainable working environment.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The service had a clear governance framework that supported safe, high‑quality and sustainable care. Clinical governance meetings reviewed incidents, complaints, audits, risks and service development. Staff recorded actions, set deadlines and assigned leads, and the action tracker showed actions progressed to completion and key information was shared across the team. Staff learned from incidents and complaints. For example, one complaint led to improved consent processes and clearer patient information on risks, treatment options and escalation routes. Governance systems tracked these changes and showed a strong culture of learning and improvement. Staff carried out audits on surgical safety, theatre use and outcomes. Results showed no concerns and improved patient outcomes after protocol changes. Leaders reviewed findings, used them to improve the service and ensured clear ownership, timescales and follow‑up.

Leaders maintained a continuous cycle of review, learning and improvement. Teams discussed audit results, outcomes and new ideas regularly and progressed actions through structured tracking. The service managed risks effectively. Leaders kept and reviewed a risk register that recorded risks such as staff capacity and workload. They set clear actions to reduce risks, including task prioritisation and shared responsibilities. Staff concerns matched recorded risks, and leaders responded to maintain safe care. The service also responded well to emergencies and disruption. Policies guided staff, and leaders adapted to challenges such as staff shortages by adjusting rotas and deploying additional support.

Leaders balanced financial and operational decisions with quality and safety. They considered patient need and long‑term sustainability and prioritised high‑quality care. Staff stored care records and confidential data securely, and audits showed records and safety checks were completed. Leaders monitored compliance and strengthened oversight. The service used clear and efficient systems to manage information, with governance, audit and feedback processes embedded in daily work. Digital systems improved access to policies and supported consistent practice. Staff had suitable equipment, IT and procedures to perform their roles, and leaders monitored equipment and acted when required. Information governance systems protected confidentiality, and staff used secure methods, including encrypted email, to share information. Managers used data on performance, outcomes, staffing and feedback, reviewed it regularly and used it to identify risks, improvements and support decision‑making.

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

Leaders actively engaged with external stakeholders to support the delivery of high-quality, joined-up care. The service had developed strong links with community optometrists, GPs and other healthcare providers, working collaboratively to ensure patients received appropriate and timely care across the pathway. For example, the service provided an advice and guidance function for community clinicians, enabling them to seek specialist input and make informed decisions about referrals and ongoing care.

Leaders also engaged with the wider healthcare community through educational initiatives, including continuing professional development (CPD) events for external clinicians. These sessions supported knowledge sharing, built professional relationships and helped ensure consistency in standards of care across services. This demonstrated a proactive approach to partnership working and improving patient outcomes beyond the immediate service.

There was evidence that feedback from external stakeholders was valued and used to inform service development. Engagement with community professionals influenced improvements in communication, referral processes and service design, ensuring that the service remained responsive to the needs of the wider healthcare system.

The service showed effective partnership working and community engagement, underpinned by strong relationships with external stakeholders and a commitment to collaborative, patient-centred care.

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

The service had a highly embedded culture of continuous learning and improvement, where innovation was actively encouraged, supported and led to demonstrable changes in care delivery. Staff at all levels were empowered to contribute ideas, with leaders fostering an open and inclusive environment where improvements were co-developed and implemented. Feedback from both staff and patients was systematically reviewed and used to drive meaningful change, including enhancements to patient information, communication approaches and care pathways. This showed that learning was not only encouraged but consistently translated into improvements in patient experience and outcomes.

Staff were given time and structured opportunities to engage in improvement work through well-established governance processes. Clinical governance meetings and action tracking systems provided a clear mechanism for identifying opportunities, developing solutions and monitoring progress. Staff were involved in these processes and were able to see how their contributions directly influenced service development, reinforcing a strong sense of ownership and engagement in quality improvement.

Innovation within the service was proactive, responsive and aligned to identified patient and system needs. For example, the development of an advice and guidance service for community optometrists addressed gaps in local provision and improved access to specialist clinical input, supporting better outcomes and more integrated care. The service also demonstrated forward planning and innovation in its strategic development, including expanding clinical services, enhancing patient education resources and increasing training and engagement opportunities for both staff and external partners. These initiatives reflected a commitment to evolving the service in response to demand and feedback.

Staff demonstrated a clear understanding of quality improvement methodologies and how to apply them in practice. Leaders described a structured and iterative approach to improvement, involving identifying issues, gathering and reviewing feedback, developing proposals, testing changes and refining them based on evaluation. This systematic approach ensured that improvements were evidence-based, inclusive and sustainable.

The service actively monitored clinical quality through ongoing audit activity and performance review. Staff participated in local audits of clinical processes and outcomes, with findings discussed at governance meetings and used to inform further improvements. This demonstrated a continuous cycle of measurement, learning and improvement embedded within everyday practice. The service was involved with a research project for a specific eye condition, they were the only service at the time of this inspection undertaking clinical trials for this.