Community Health and Eyecare Limited (CHEC - Worcester)

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 means we looked for evidence that people were protected from abuse and avoidable harm. The provider did not always have a proactive and positive culture of safety based on openness and honesty. Staff reported incidents but were unaware of the learning from the investigation that took place. Lessons were not always learnt to continually identify and embed good practice.

This is the first assessment for this newly registered service. This key question has been rated Good. This meant people were safe and protected from avoidable harm.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider did not always have a proactive and positive culture of safety based on openness and honesty. Whilst staff reported incidents, and these were investigated they were unaware of the outcomes of the incident investigations. Lessons were not always learnt to continually identify and embed good practice. There were 24 incidents reported by staff between April and July 2025. These covered a range of issues including surgical complications and administrative errors. Each incident had been investigated and practice amendments or actions taken. There were some processes in place to ensure that lessons were learnt to continually identify and embed good practice. However, staff were not always aware of these and other incidents. A system of Flash Alerts were generated when an incident occurred in any part of the organisation, which could promote learning in other locations. Staff were not always aware of what these were as team meetings had not been taking place. Staff knew how to report incidents and felt able to do so. Leaders were open and transparent with patients and fulfilled the duty of candour requirements.

The endoscopy service had 7 incidents relating to endoscopy services from April to August 2025. These were varied and related to the organisation of endoscopy lists, bowel preparation and decontamination issues. A recent incident resulted in the lead for endoscopy services providing extra training for staff.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. The service mainly delivered services on behalf of the NHS. They worked with partners in care to ensure patients were offered the most appropriate service that met their needs. The service provided a preassessment clinic for all procedures which assessed that the clinic could meet the patient’s needs. They made sure there was continuity of care, including when people moved between different services. When patients were referred to other services, the staff ensured they received a timely follow up and shared information about the patient to ensure continuity of care.

Endoscopy staff ensured histological findings were referred to the most appropriate individual or department, both internally and externally. They made sure there was continuity of care, including when people moved between different services through ensuring that patients with cancerous lesions were followed up within the national two-week pathway expectation. When patients were referred to other services, staff ensured they received a timely follow up and shared information about the patient to ensure continuity of care.

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. All staff were trained to the competencies of level 3 safeguarding adults training. The chief nurse was trained to Level 4 and was available for support. Each clinic room had a QR code which could be scanned to access further support for staff. The team had previously referred a patient to safeguarding services as they were concerned for their welfare. If there were other concerns about a patient‘s welfare staff would liaise with the patient’s GP. An example of this was when a patient arrived in the clinic with a bump on their head. Staff sensitively enquired how this had occurred. It was determined the patient had fallen following alcohol consumption during a night out. Staff demonstrated appropriate awareness of potential risks associated with this situation.

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. Patients attending for surgery had a preassessment appointment at which point any concerns were identified and risk assessments were undertaken. If necessary, a further discussion with the consultant took place. This included patients living with dementia or those that had mobility issues. For patients having cataract procedures the process was explained along with the need for transportation to take the patient home following the procedure. The service could provide this if required. At this stage, the treatment plan would be explained to the patient. Staff ensured that patients were fully informed about what to expect. Staff were able to appreciate when patients did not fully understand their procedure and may have lacked the capacity to consent. They highlighted a patient who had been referred back to their GP as they were living with dementia, and staff could not ensure they had understood the procedure or what would be required of them. For patients whose first language was not English the service was able to provide information in an acceptable format.

The service used the World Health Organisation surgical checklist which ensures staff have all the relevant information and undertake appropriate checks to ensure patient safety throughout their procedure. The staff also had a brief before and after surgery to ensure that all staff in the operating theatre were aware of the individual safety needs of each patient and that the correct equipment was ready for the operation. Post Surgery debriefs highlight any issues and seek to learn from the operating session. There was an out of hours telephone number that patients could use to contact a clinician for advice and support. A member of the operational team was also on call to facilitate urgent appointments during clinic operating times. There was a deteriorating patient protocol for patients who had deteriorated post-surgery. This had been enacted correctly in June 2025 and staff followed up with the patient when appropriate.

The service detected and controlled potential risks in the care environment. They mostly made sure equipment, facilities and technology supported the delivery of safe care. The environment had been adapted to meet the needs of the service and those who used it. We reviewed the resuscitation trolley and found that this had been checked weekly in July. We checked its contents and found some consumable equipment out of date or missing. In the bottom drawer there was some additional equipment that was not on the checklist for staff. We also noted that the oxygen bag was stored on the floor in the corridor. The fridge temperatures were monitored and cupboards containing medicines or substances hazardous to health were locked.

Corridors were wide and could meet the needs of wheelchair users. The service had installed sensor taps to minimise the risk of infection transference. Surfaces within the clinic areas were wipe clean and cleaning schedules were up-to-date and completed. A fire plan was easily available within the clinic on which oxygen cylinder locations were identified. This assists the fire service to locate these in the event of a fire and to reduce the risk of an explosion. The design of the environment followed national guidance. There was a dedicated theatre with appropriate facilities where surgical procedures were carried out.

The service treated patients with a laser procedure to improve vision for patients who had previously undergone cataract surgery and developed a cloudy membrane in the eye. This treatment known as Yttrium Aluminum Garnet (YAG) laser therapy, was carried out in a dedicated laser room equipped with appropriate signage. A designated laser protection officer oversaw the use of equipment and provided guidance to the local team regarding its safe operation.

The endoscopy service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Flexible endoscopes were sent off site for further decontamination. Staff had the appropriate equipment to decontaminate endoscopes on site prior to packaging ready for cleaning at the specialist unit. This service had established turnaround times to reduce the risk of infection.

There was a dedicated procedure room with appropriate facilities where endoscopy procedures were carried out. The provider had suitable decontamination equipment and safe storage cabinets for their endoscopy equipment. This was located in a dedicated room for specialist washing, drying, decontaminating endoscopy equipment. The adjacent storage and decontamination rooms enabled equipment to flow through the procedure room from ‘clean to dirty’ (used) which ensured continued infection prevention and control management.

There was a tracking and traceability system for endoscopes which included usage, cleaning, decontamination drying and storing. Staff used a detailed logbook to track each endoscope and associated equipment.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. There were 2 vacancies at the service. Between October 2024 and July 2025, 10 members of staff had left the service for various reasons. Staff left for a variety of reasons, including further education, and role suitability.

Staff possessed the necessary skills for their roles, and the service invested in training to promote career progression. For instance, one team member progressed from patient coordinator to deputy manager. Clear pathways were in place to support staff development. Team members worked together well to deliver safe care that met people’s individual needs. Staff provided cover during sickness, and sister sites offered additional support when required. Similarly, staff at this location assisted the other sites when needed. This approach eliminated the need for agency staff and ensured familiarity with established working patterns.

Staff had completed the required mandatory training. However, the October 2025 report demonstrated that several areas were below 80% compliance. This included training on modern slavery, freedom to speak up, dementia awareness and duty of candour. Overall compliance across all training modules was 93%. The training provided was appropriate for the patient group using the service and included topics such as conflict resolution. All staff were trained in basic life support, with 2 staff members holding intermediate life support. Consultants working under practising privileges maintained substantive NHS roles.

Staff were experienced, qualified and equipped with the right skills and knowledge to meet the needs of patients undergoing eye surgery. The service provided an appropriate induction and ensured staff maintained appropriate competencies. Staff appraisals were undertaken to review individual objectives. Medical staff were appraised either through their NHS practice or by the Chief Medical Officer acting as their Responsible Officer. Managers addressed poor performance promptly and effectively.

The service assessed and managed the risk of infection. The environment was visibly clean and well maintained. The service had their own maintenance staff who arranged repairs. Staff told us this was done promptly. Equipment was tested and kept clean between patient use. Cleaning schedules were robust and records were up to date. The service detected and controlled the risk of infection spreading through audit and shared concerns with appropriate agencies promptly.

Cleaning staff followed the NHS colour coding protocols for mops and buckets, ensuring that high risk areas were cleaned with separate equipment to low-risk areas. This assisted with the prevention of cross infection. Clinical waste was disposed of through a contract with a company providing specialised waste transferal. Disposable items were used when appropriate to reduce the risk of cross infection. Staff were able to describe appropriate hand washing practices. However, the latest hand washing audit demonstrated that opportunities for hand washing were not always undertaken. Re-auditing demonstrated good compliance. Audits undertaken in respect of infection prevention and control demonstrated a good compliance with regular cleaning, deep cleaning and Standard Infection Control Precautions (SICPs) were undertaken regularly and demonstrated that the service met the organisations targets. Where there were deficits action plans were in place to addresses this. An example of this is the hand hygiene audit.

Endoscopy staff had the appropriate equipment to decontaminate. These were maintained through a contract with the supplier. Decontamination of the scopes was split appropriately into the dirty and clean areas. We reviewed data on the water quality results and these were within the expected level. There was a process to follow when results were out of the accepted range. A deep clean was carried out of this area once a month. We saw evidence of this cleaning which was signed and dated by staff undertaking the cleaning. We reviewed the equipment required for reverse osmosis and found this to be well maintained.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. Medicines were stored in locked cupboards and staff could describe processes for removing and documenting their use. The medicines room was in a temperature-controlled part of the building and was accessed by a keypad for extra security. The Control of Substances Hazardous to Health (COSHH) cupboard was easily identified and contained within the temperature-controlled medicines room. The medicines fridge was checked daily when someone was on site. An explanation was given to patients when prescribed alternative medications and this would be indicated in the letter for the GP.

There had been one incident relating to the management of controlled drugs where these had been inappropriately disposed of. The incident was reported and the home office informed. A new procedure was put in place to ensure that controlled drugs were destroyed in the appropriate way and the correct licenses held by the clinic. Medicines which were not used during procedures but drawn up were placed in a special container containing neutralising granules.