Optegra Maidstone

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

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.

The service promoted a strong culture of safety, openness and continuous learning, supported by effective governance and risk management processes. Staff understood their safeguarding responsibilities and delivered care through safe patient pathways with appropriate oversight. The environment was clean, well maintained and supported safe care, with effective infection prevention and control and medicines management arrangements. Patients were actively involved in their care, and staffing levels, skills and competencies were sufficient to meet patient needs safely.

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

We scored the service as 4. Evidence shows an outstanding standard of care. The service had a strong, proactive and positive culture of safety, based on openness and complete honesty. They actively listened to concerns about safety and thoroughly investigated and reported safety events. Lessons were always learnt to continually identify and embed good practice.

The service demonstrated a strong learning culture, with effective systems to identify, record and act on learning from incidents, complaints, audits, patient feedback and external guidance. Learning was captured within a structured learning log, with actions allocated, tracked and reviewed through clinical governance meetings and senior oversight.

In 2024, the service had implemented the Patient Safety Investigation Response Framework (PSIRF). PSIRF is a mandatory NHS framework for handling patient safety incidents. It shifts focus from blaming individuals to learning, promoting a "just culture" where incidents are investigated proportionately to identify system improvements and support those affected.

The service’s leaders and senior nurses ensured there was a proactive and positive culture of safety, based on openness and honesty. Staff were empowered to escalate concerns, and it was clear concerns were known by leaders and not overlooked. Staff were forthcoming with examples of incidents that had occurred within the service and across Optegra. They told us lessons were learnt to continually identify and embed good practice. We reviewed a Patient Safety Incident Investigation (PSII) report concerning the insertion of an incorrect lens. The purpose of the investigation was to understand why the incident occurred and to identify and implement actions to prevent a recurrence. Optegra also ensured national learning across all sites was shared surrounding the need to highlight the lens power on packaging to reduce the risk of recurrence in future. Assurances surrounding the effectiveness of this learning would be sought through audit.

There had been no reported never events in the preceding year. Never Events are serious, preventable safety incidents which should not occur if the available preventative measures are followed. They include things like wrong site surgery or foreign objects left in a person’s body after an operation.

Duty of Candour was well embedded within Optegra, and staff were familiar with their responsibilities to apply it in line with both professional and regulatory requirements. Locally, staff or teams involved in any event requiring the application of Duty of Candour were proactive to ensure this was addressed and actioned in a timely manner. The weekly Quality Improvement and Learning Team (QILT) meeting included follow-up checks to confirmed that the patient had received both a verbal and written apology, and that appropriate communication and disclosure had taken place. Our review of the QILT meeting minutes from April 2026 and a Duty of Candour letter to a patient dated February 2026 confirmed this.

This process supported consistent monitoring, accountability, and learning, helping to ensure that Duty of Candour was applied appropriately whenever required.

We were shown a staff board which shared recent examples of incidents and learning for easy access and staff could read in their own time. The service had not had any formal complaints, but staff told us a frequent concern for patients was the lack of signage to the clinic and difficulties finding the service. The service had introduced appointment letters that included a map and detailed directions to assist patients in finding the clinic more easily.

At the time of our visit, the clinic had zero overdue incidents and a review of the last 12 months’ incidents showed that out of 14, the harm level was low and for 2 moderate harm. They were investigated and closed in line with policy.

We saw that all staff completed Adult and Paediatric Basic Life Support (BLS), and mandatory training with 100% compliance. Leaders monitored compliance and received reminders when updates were due, which helped ensure staff maintained the skills and knowledge needed to deliver safe care. At the time of the visit, the service had one surgeon, and the software system demonstrated 100% compliance with mandatory training.

We scored the service as 3. 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 people’s care pathways. 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 5 patient notes that we reviewed.

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. We observed three operations as part of the assessment.

The March Line Manager Monthly Brief noted the upcoming launch of Connected Care, a new partnership pathway for private cataract and refractive patients that aimed to improve continuity of care and strengthen collaboration with optometrists.

There was a process in place to transfer patients should they become unwell. Staff gave examples of how and when they had transferred patients to the local NHS Trust. Staff said after the transfer the clinic manager or reception staff would carry out a wellbeing call to make sure the patient was fine and if they required any support. The service had contacted emergency services for a patient's relative.

Theatre planning was completed in advance to ensure care plans were appropriate on the day of surgery and any concerns or queries could be highlighted and discussed at the huddle.

The service ensured patient records were always accessible. 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.

We scored the service as 3. 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.

Staff we spoke with understood their responsibilities relating to safeguarding and could confidently explain how they would identify patients at risk of abuse. Staff had completed safeguarding adults and children level 2 training and the compliance rate for the service was 100%. The clinic manager and lead nurse were both compliant with safeguarding level 3 training. The service had an in-date safeguarding policy detailing contact information for escalation. Staff had also completed Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards DOLs training and compliance for this was 100%.

The provider’s Area Head of Clinical Services was the safeguarding lead, held level 4 training, and was supported by an independent safeguarding network.

Staff knew how to identify adults and children at risk of, or suffering, significant harm, how to make a safeguarding referral and who to inform if they had concerns. Staff followed safe procedures for children visiting the service. There was a dementia lead who helped with advice and best interest meetings.

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. However, zero safeguarding referrals had been made in the 12 months before the inspection.

We scored the service as 3. The evidence showed a good standard. 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.

Staff prioritised the patients and made sure they were active participants in their own care.

Staff used a nationally recognised tool to identify deteriorating patients and escalated them appropriately. Staff responded promptly to any deterioration in a patient’s health. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

Patients we spoke with felt they had been fully informed regarding their planned care and were given opportunities to discuss concerns or raise queries with staff about their health. Staff carried out an assessment at admission to ensure there had been no changes since the preassessment.

Patients confirmed they had received a leaflet prior to their visit explaining the patient journey. We also saw staff giving patients a leaflet with post-surgery aftercare information.

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.

We followed 3 patients 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. We observed that staff were very kind and caring, enjoyed their work and were open and transparent.

Staff were able to respond promptly to any deterioration in a patient’s health. There was an on call system for nurses and optometrists, with protocols to escalate to a surgeon if required. Patients were provided with post operative information and had access to a phone line 24/7. The service had a policy in place for the emergency treatment of post-operative endophthalmitis (a severe, sight-threatening inflammation and infection of the internal eye fluids) and staff were aware of how to escalate patients if necessary. Nurses did extended training for escalation and ophthalmology. There were processes for first line resuscitation and calling emergency services. Staff were trained in intermediate and basic life support.

We scored the service as 3. The evidence showed a good standard. 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, ground floor commercial building. The environment followed national guidance and included an operating theatre, a dedicated laser room, a pre-theatre and post-theatre room, consulting rooms and a waiting area, each equipped to support safe and effective care. We saw that all the 16 staff were first aid trained.

Staff had access to emergency equipment for example a resuscitation trolley, first aid kit and an endophthalmitis kit (a serious internal eye infection), they were checked monthly and clearly labelled. The service was fully equipped, and staff told us they had been trained for emergency situations. Equipment was serviced as per the manufacturer’s guidance.

The service ensured medical devices had scheduled service checks and equipment had annual calibration testing. We checked 2 electrical items in theatre and found both had 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 theatre 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. We observed that 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. We saw that the service used The World Health Organisation (WHO) Surgical Safety Checklist Policy (including Lens Check Procedure), to ensure all staff understood the procedure to follow in completing The National Safety Standards for Invasive Procedures (NatSSIPs Eight).

We saw that 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). The service followed relevant guidance, including the Medicines and Healthcare products Regulatory Agency (MHRA)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 storeroom and found all items were in date.

We saw that the clinic 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).

The service had an up-to-date fire risk assessment (March 2026), fire plan and evacuation procedure, with documented escape routes, fire exits, firefighting equipment, fire detection and alarm systems. The service also held a current Emergency Lighting Periodic Inspection and Testing Certificate from December 2025, which reported no defects

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 scored the service as 3. The evidence showed a good standard. 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.

Staff were experienced, qualified and had the right skills and knowledge to meet the needs of patients. Managers gave all new staff a full induction tailored to their role before they started work. It included objective setting and orientation around the whole site and all patient pathways.

One to one meetings progressed from weekly to monthly to quarterly objective meetings and annual performance reviews. Managers made sure staff attended team meetings or had access to full notes when they could not attend.

The service employed 16 members of staff. A new manager had recently been in post at the time of the assessment, therefore the appraisal rate was 69%. The manager alongside the Area Head of Clinical Services were working to improve the appraisal rate by reinstating regular 121s and quarterly appraisal meetings.

Staff also participated in annual appraisals, during which they reviewed their performance and worked with their manager to set personalised objectives that supported the effective delivery of evidence-based care. In addition, staff had access to regular team meetings to support communication, learning, and service development.

The manager identified the learning needs of staff and provided them with opportunities to develop their skills and knowledge. They ensured that staff received the necessary specialist training for their roles. For example, the infection prevention and control (IPC) lead received additional IPC‑specific training, to support their responsibilities.

All staff had access to a variety of professional development opportunities such as training events, external and internal courses, educational lectures and seminars.

The service had a training programme with opportunities for all staff which included full funded apprenticeship. Two members of staff were undertaking apprenticeships at the time of the assessment. As part of Optegra’s contract with the ICB/NHS, they had an agreement to support trainee doctors from each local ICB site in developing their cataract surgery training.

We saw that the service had enough staff to keep patients safe. Safe staffing levels were set and monitored for safety. It included two alternating scrub nurses which meant one was free to prepare for the following procedure. A health care technician offered floating support to the theatre team and patients. There was a low turnover of staff and low sickness rate. We looked at data and saw that sickness and unplanned leave rates were low compared to other Optegra services typically below 5% and spiking to 11% in December 2025. We looked at 4 staff records on the service’s secure platform and saw that records contained pre-employment checks, appraisals, absence and leave records and training records.

Absence levels were reviewed quarterly as part of the Performance and Development Review (PDR) process. Where any concerns or patterns of absence were identified, managers worked closely with the individual to explore appropriate support and implement any reasonable adjustments that were required. This process was supported by Optegra's Absence Management Policy, with advice and guidance from the HR team provided where necessary.

The service had enough medical staff to keep patients safe. We saw that there was a safe process for granting practising privileges which was authorised by the medical advisory committee. Practising privileges were renewed annually so documents were checked on this basis. All medical staff had appropriate qualifications or were on the GMC specialist register in ophthalmology.

The site kept a record of their clinical competencies, and we saw compliance was 100%. New staff told us they had undergone an induction when they first joined the team and were given time and support to complete their competencies before working independently in their roles. One of the senior nurses was responsible for managing the staff rota and made sure any gaps in the rota were filled a month in advance. They told us staff were often willing to help with filling gaps which meant the service could continue running effectively.

The service had staff with the appropriate training and qualifications to operate the Yttrium Aluminium Garnet (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 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.

In addition, formal meetings known as training days were held every 2 months. These sessions covered a range of agenda topics, including operational performance, risk management, organisational updates, complaints, incidents, patient safety, quality improvement, and regulatory requirements. They also provided dedicated time for staff to complete mandatory training and maintain their professional knowledge and competencies.

We scored the service as 3. The evidence showed a good standard. 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.

We observed that staff followed infection control procedures throughout, including hand washing and the use of personal protective equipment (PPE). Staff worked effectively to prevent, identify and treat surgical site infections.

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). This result demonstrated effective infection‑control measures and safe surgical practice across the year. Data showed the service had a 0.3% post infection rate against a National Ophthalmology Database benchmark of 0.9%. All surgical site infections were reported through the governance process for learning and included assigning for root cause analysis and review by the medical advisory committee.

The service was contracted to provide cataract surgery by the local integrated care board (ICB) and themes were reported in joint review meetings for quality and performance. The service audited decontamination and clinical waste, environmental hygiene, hand hygiene and scrub procedures. Results from all audits showed between 93% to 100% compliance for May 2025 to April 2026. For example, we looked at the data for the Scrub Procedures Hygiene Audit November 2025 and Hand Hygiene Audit March 2026 and saw that the compliance rate for both was 100%.

We observed that 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. We noted that staff followed the "Five Moments of Hand Hygiene," established by the World Health Organisation (WHO), critical guidelines for healthcare workers to prevent the spread of infections.

Managers monitored adherence to the IPC policy through regular audits, which showed overall IPC compliance between 93% and 100%, for May 2025 to April 2026.

We saw that clinical areas were clean and had suitable furnishings which were clean and well-maintained. Everywhere was found to be dust free with no clutter. We reviewed cleaning records and found they were up-to-date and demonstrated that all areas were cleaned regularly. This included disinfection between patients in theatre. Staff cleaned theatre and laser rooms when in use. Cleaning was carried out on surgical instruments before being sent for sterilisation under contract with a suitable provider. A professional deep clean of theatre and all areas took place in November 2025.

We saw that 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.

We saw that 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. 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. They completed all required checks for all surgical trays, and consistently logged serial numbers and confirmed the correct instruments were available.

The clinic 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 could seek infection control advice from the IPC lead nurse when needed.

We scored the service as 3. The evidence showed a good standard. 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.

On assessment we reviewed the medicines management policy, which was a national policy which applied to all locations. Each location had a policy that covered only the medicines used at the location. The policy was reviewed regularly and was version controlled to ensure that staff had the most up to date guidance.

Staff followed established processes to prescribe and administer medicines safely and in line with legislation. Prescriptions were completed accurately, signed by prescribers, and contained all required patient and prescriber details. Medicines records were maintained appropriately, and patients received advice on any changes to their medicines.

The Area Head of Clinical Services was the Controlled Drugs Accountable Officer (CDAO). Controlled drug records matched stock levels, access was restricted to authorised registered staff, and the key was held securely by the lead nurse. The service had appropriate arrangements, policies, and risk assessments in place for the prescribing, storage, and management of controlled drugs.

The last external audit carried out in June 2025 had no recommendations. The auditor reported that the site had maintained high standards of medicines management and met all relevant requirements.

During our visit staff were observed explaining the function of the different eye drops before administering them to patients. Patients were given the opportunity to ask questions, and information was provided in writing.

The service used effective systems and processes to safely prescribe, administer, record and store medicines. Medicines were stored securely in locked cupboards and refrigerators within the storeroom. Staff regularly monitored medicine fridge temperatures and were able to explain the actions they would take if temperatures fell outside the recommended range, including the disposal of affected medicines where necessary. A standard operating procedure was displayed above the fridge, providing clear guidance on correct storage requirements. This demonstrated that staff understood how to manage medicines safely and protect people from harm.

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.

For cataract patients, drop-free cataract surgery was now their standard and preferred treatment pathway. This was designed to make recovery simpler, more comfortable, and easier to manage at home.