Optegra Maidstone

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• 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.

The service was well led, with experienced and supportive leaders who promoted a positive, inclusive and transparent culture. Staff felt valued, respected and confident to raise concerns, supported by effective communication, strong governance arrangements and high training compliance. The provider demonstrated a commitment to equality, diversity and inclusion, worked collaboratively with external partners, and supported staff development. Continuous improvement was driven through audits, innovation, research and technology. Leaders used performance data effectively, strengthened information governance following data breaches, and maintained systems for managing risks, incidents and organisational learning, although some risk-register scoring required greater clarity.

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.

We scored the service as 4. The evidence showed an exceptional standard. The service had a very clear shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and an exceptional understanding of the challenges and the needs of people and their communities.

The service had a clear vision and set of values that aligned with the provider's wider vision and strategy. It aimed to deliver a patient centred service where quality, safety and compassion supported exceptional care. The service promoted diversity, inclusion and continuous learning, and aimed to ensure every patient felt respected, valued, listened to and supported throughout their care journey. Local goals focused on preparing for regulatory review, strengthening leadership, developing clinical staff, improving patient flow and enhancing the workplace culture. Staff at Optegra Maidstone developed these goals collaboratively during a training day, where they identified priorities that were important to them both as a team and as individuals.

The service monitored progress against its delivery of the strategy and local goals through regular service performance meetings and results were presented to the provider wide governance team. We looked at Pathway Meeting documentation attended by the clinic manager and operational leads from across Optegra. The service monitored progress against strategic objectives and local performance targets. We found that staff understood the service’s vision, values and strategy and their role in achieving them.

Staff we spoke with during the inspection felt supported, respected and valued. The culture was centred on the needs and experience of people who used services. The service promoted its values through onboarding processes and corporate induction that included meeting the chief executive. Staff felt positive and proud to work in the organisation.

The service had a culture which encouraged openness and honesty at all levels within the organisation, including with people who use services.

All staff we spoke with demonstrated a clear understanding of the local vision and values, particularly in relation to delivering compassionate, person centred care. For example, one member of staff described their aim as creating an environment where patients felt safe and supported. This reflected a shared commitment among staff to meeting patients’ emotional as well as clinical needs.

Staff reported that they felt comfortable raising concerns and were confident that their views would be heard and acted upon. They described local managers as approachable, responsive, and supportive, contributing to a culture of openness.

There were several staff information boards on display, including a governance board and a team board that shared the core values. These boards were actively maintained by individual staff members who spoke with pride about their ownership and use.

We found that there was an overwhelming sense of team cohesion and a positive workplace culture across departments.

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.

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.

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

The service’s manager, was also the CQC Registered Manager, had been in post since March 2026. Staff confirmed their presence on-site 3–4 times per week and described having open and direct access, with regular engagement and visibility across departments.

Staff felt supported by the Area Head of Clinical Services (AHOCS). Some staff were able to name members of the UK leadership team.

The service manager demonstrated good insight into the challenges faced by staff, maintained an open-door policy, and conducted daily rounds to remain a visible and accessible leader.

There was strong evidence from staff interviews to support the view that leadership was capable, compassionate, and inclusive. We spoke with 4 members of staff and 3 leaders and they said that “working for Optegra was like a breath of fresh air, as this was a listening organisation”. Staff also said that “everyone was on the same page, and that leaders were approachable”.

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.

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

Senior leaders provided strategic oversight remotely and maintained regular contact with the hospital through scheduled performance and clinical governance meetings.

Staff told us they found leadership easy to access and communication open, consistent, and supportive. The service had a clear approach to succession planning and staff development. Staff were supported through development opportunities, including involvement in projects, attendance at senior meetings, and additional responsibilities. Leaders told us this approach helped develop talent from within and supported future succession planning.

In 2025, Optegra launched their Future Leaders programme, designed to identify and develop high-potential talent within Optegra. The programme currently included 10 employees, each of whom had been assigned a mentor from the leadership team and was being supported to build a personalised development plan (PDP). This approach ensured Optegra continued to develop talent from within and create strong succession plans for the future.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

Staff we spoke with were aware of the Freedom to Speak Up (FTSU) Champion, and the service’s manager confirmed the Champion had received appropriate training. The service’s FTSU champion attended monthly freedom to speak up meetings lead by the organisation's guardian and supported by a HR representative. These meetings gave the champion the opportunity to discuss local concerns, share learning with their peers and get guidance from senior leaders. The champion locally met with the clinic manager to discuss concerns, however, locally there had been no freedom to speak concerns raised with the champion in the last 12months.

Staff consistently reported feeling able to raise concerns freely, with confidence that they would be listened to and supported. There was a FTSU and whistleblowing policy for staff to follow.

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.

We scored the service as 3. The evidence showed a good standard. 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 2025 employee engagement 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.

We scored the service as 3. The evidence showed a good standard. 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 operated effective governance processes through various committees and on-site activities. There was a range of information collected, monitored and communicated internally at the relevant committee meetings and then fed upwards to the provider.

The service had effective governance structures, processes and systems of accountability to support the delivery of the strategy and good quality sustainable services. There were local and corporate governance structures that provided assurance, based on up-to-date information. Local governance reported into provider level governance for safety and quality. We looked at minutes of the Quality Improvement Learning Team (QILT) Panel meetings for September 2024 and April 2025. These meetings provided a structured forum to discuss learning from complaints and incidents reported during the previous week across all Optegra sites. This supported wider learning and ensured that actions were shared, particularly where improvements needed to be adopted across multiple locations.

Staff at all levels were clear about their roles and understood what they were accountable for, and to whom. The service had a structure in place to govern and manage relationships with partners and third-party providers. A governance board was displayed in the staff area. The area head of clinical services undertook a practicing privilege annual review for the consultant surgeon working at Optegra Maidstone, a process by which they oversaw the scope of clinical activities that the consultant surgeon was authorised to perform. They also checked mandatory training, indemnity insurance and evidence of General Medical Council (GMC) registration.

A comprehensive risk register was reviewed monthly through clinical governance processes and escalated to Board level as required. Review of the April 2025 risk register identified no high-level risks (score 12 or above), with existing low to moderate risks effectively managed and monitored. Leaders demonstrated robust risk oversight, with operational and patient safety risks escalated appropriately.

The service had an effective internal incident‑reporting system, and leaders shared learning across teams. Every member of staff had an account and could report an incident. Incidents were reviewed locally and at Optegra wide Quality Improvement meetings if not completed earlier as part of their Patient Safety Incident Response Framework (PSIRF). These meetings provided a structured forum to discuss learning from complaints and incidents reported during the previous week across all Optegra sites. This supported wider learning and ensured that actions were shared, particularly where improvements needed to be adopted across multiple locations.

Recently completed 72-hour reports and patient safety incident investigations were also presented at these meetings. This helped to disseminate learning and any resulting actions to the relevant teams. This approach to sharing learning was well established and embedded across the organisation. It had been particularly beneficial for sites such as Maidstone, where there may be fewer serious incidents, as it enabled proactive learning from events at other sites.

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.

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. For example, the introduction of the widescreen TV in theatre, which was implemented following a wrong lens never event at another site. This led to mitigation actions being incorporated through policy changes and the sharing of learning across the organisation. The service monitored implementation of such actions through processes including clinical reviews, which identified any areas of non-compliance.

The governance team completed annual site reviews, which highlighted areas of good practice as well as opportunities for improvement. Trends and themes of learning identified through these reviews was shared with Optegra’s leadership team either to be identified on the corporate risk register depending on the seriousness and risk or for immediate support to improve services. Staff completed local monthly audits and senior leaders audited cataract complications at a provider level.

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 governance structure operated at a provider level, with the Clinical Governance Steering Group acting as the central hub. Sub‑committees included, 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 service manager and provider’s Area Head of Clinical Services monthly bulletins, outputs from meetings, and, for urgent matters, through ‘after incident reviews’ and ‘Flash Alerts’.

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

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

We scored the service as 3 The evidence showed a good standard. 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. For example, the service actively participated in the local healthcare community: regular continuing professional development (CPD) events were held and well attended.

The service’s manager described collaborations with GP practices and local optometrists, including site visits to observe referrals and surgical processes.

Patient and staff views and experiences were gathered and acted on to shape and improve the services and culture. The service conducted a regular patient survey and had ways for patients to provide comments and suggestions in a discreet way. Comments left on review websites were monitored and responded to. Patient feedback was also presented in pathway meetings with the ICB.

Staff were engaged with through staff meetings, one to one meetings, annual engagement survey and inclusivity and diversity events.

Data from the 2025 Employee Engagement Survey showed the site had a good score for confidence in management (65%), pride (90%) and wellbeing risk index (65%). Staff we spoke with said although they enjoyed their jobs and loved their team.

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

We saw examples of various provider wide innovation and improvement initiatives which aimed to utilise closer working with industry partners to adopt the latest technologies related to cataract surgery in all provider location.

Optegra had redesigned its cataract pathway to improve patient experience and safety and optimise the time taken to complete the process. The redesigned pathway ensured the service was routinely available to all NHS patients who met the eligibility criteria. This innovative steroid injection approach was designed to make recovery simpler, more comfortable, and easier to manage at home. 

Maybe additionally? The redesigned pathway ensured the service was routinely available to all NHS patients who met the eligibility criteria.

We were shown the recent patient video discharge process. Post surgery all patients were provided with an electronic device to watch their discharge aftercare video to support independence, recovery and give advice regarding preventing eye loss. We observed patients being given the video with instructions to watch before surgery, they were also given a booklet with the same information that they were also able to access via the patient portal.

Optegra embraced the opportunities presented by technology and AI, investing in innovative solutions to provide pre- and post-operative checks for NHS cataract patients. The organisation introduced IRIS, its AI Virtual Assistant, to streamline NHS cataract care, reduce administrative tasks, and improve patient outcomes.

Leaders promoted continuous learning, improvement and innovation. Staff were given opportunities to conduct improvement projects and suggest new ways of working. The service had established systems in place which encouraged the review and improvement of policies and processes. All policy documents required review no later than three years after their initial approval and underwent regular reviews on the same basis thereafter. The organisation reviewed documents more frequently when changes in legislation or service requirements necessitated it. Policy authors were responsible for ensuring that they reviewed documents in line with their review dates.

The service had developed new strategies to develop services such as NHS cataract pathways which were now being rolled out to other provider locations. The service participated in national audits such as the Royal College of Ophthalmologists National Ophthalmology Database Audit. The service directly contributed to research by undertaking research studies in partnership with industry manufacturers. We saw various examples of published work in scientific journals.

Optometry corporate events were held at the service including continuous professional development events for optometrists.

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.

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. Both of the service’s optometrist had completed the training. 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 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.