CES Medical – Tunbridge Wells

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 safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. Staff arranged safety processes before surgical procedures and operations and worked together to ensure the right patient had the correct operation. Medicines were managed safely. Patients were safe from neglect, abuse and discrimination. Patients gave informed consent prior to procedures.

This is the first assessment since registering to provide a regulated activity. Patients 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.

The service had a strong, proactive and positive culture of safety, based on openness and honesty. Incidents were reported, investigated, and learning was shared with teams and used to reduce the risk of recurrence. Staff felt able to raise concerns and told us leaders responded appropriately when issues were identified We saw evidence of how learning was shared through safety huddles, team briefings and meeting minutes. Learning from incidents was shared widely across the other CES locations

The service had an up-to-date incident reporting policy aligned with national guidance and used recognised investigation methods. There was a timeline to implement training in Patient Safety Incident Response Framework (PSIRF). The Patient Safety Incident Response Framework (PSIRF) is the NHS approach to responding to patient safety incidents, focusing on learning, improvement, and reducing the risk of future harm rather than assigning blame. The provider submitted policies for accident and incident management and confirmed its transition to the Patient Safety Incident Response Framework (PSIRF), supported by planned staff training in July and August 2026. At the time of assessment, PSIRF had not yet been implemented, and no PSIRF investigations had been undertaken.

Staff recognised and reported incidents and near misses. Staff survey results supported this, with 90% of respondents saying they felt secure raising concerns and confident that concerns would be addressed Records and we viewed showed consistent use of the reporting system. For example, staff reported equipment issues such as a faulty lens on the day of surgery. The service used a paper-based reporting system and an electronic trend and theme monitoring process.

There was a well-established learning culture, with systems to identify and act on learning from incidents, complaints, audits and patient feedback. Learning logs and governance records showed actions were monitored, followed up and embedded into practice.

The service was open and transparent when things went wrong. Staff apologised to patients and provided appropriate support in line with duty of candour. There were zero Never Events reported in the 12 months preceding the assessment. A Never Event is a serious patient safety incident that is largely preventable because national guidance or safety measures are available and should have been implemented to prevent it from occurring.

Mandatory and role-specific training was in place, with high levels of compliance. Staff were trained to meet the needs of patients, including those with mental health conditions, learning disabilities and dementia.

The service worked closely with patients and healthcare partners to ensure care was safe and well-coordinated across all stages. Staff supported smooth transitions between teams and providers, and we saw evidence that transfers and discharges were managed safely and effectively. We reviewed the transfer and discharge protocol alongside patient records, which confirmed these processes were followed in practice.

Patients were assessed prior to attending the service. Staff used this information to plan care safely and ensure patients’ needs could be met. Clear admission criteria were in place, and we saw evidence from the admission policy and pre-assessment records that these were applied consistently. We also observed pre-assessment processes during the assessment, which reflected these requirements in practice.

Staff provided patients with clear information about tests and investigations and involved them in decisions about their care. Communication was clear and supported patient understanding.

Patient records were managed in line with national standards. Records were secure, accurate, complete, and contemporaneous. and accessible to staff when needed.

There were systems and processes to support patients who needed to return to theatre for additional clinical treatment. The service demonstrated good clinical outcomes. Over a 4-month period, complication rates were low (0–0.94%), with 2 complications recorded and 1 return to theatre, Laser treatments showed 100% compliance with safety checks, demonstrating strong clinical oversight.

The service worked with patients and partners to keep people safe from harm, abuse and discrimination. Staff understood their safeguarding responsibilities and acted promptly when concerns arose. Staff told us they could recognise the signs of safeguarding concerns, and we saw safeguarding information available on site alongside an up-to-date policy aligned with national guidance.

Staff received safeguarding training appropriate to their roles. Training compliance was 100% for both clinical and non-clinical staff in safeguarding adults (levels 1 and 2) and safeguarding children (levels 1 and 2), to protect children who attended the service with their parents or carers who were receiving treatment. This demonstrated that staff had the knowledge required to identify and respond to safeguarding concerns.

Staff knew how to raise concerns and access safeguarding support. Clear guidance was available, and safeguarding leads were accessible for advice. Staff were able to describe who they would contact if they identified a safeguarding concern. Leaders maintained oversight of safeguarding through governance processes and ensured concerns were appropriately managed.

We saw evidence of a safeguarding referral made by the provider at another location, which demonstrated that safeguarding processes were understood and applied in practice.

The service worked with patients to understand and manage risks. The service used a clearly defined acceptance criteria to assess people's needs before admission. This enabled staff to determine whether the service could safely and effectively meet those needs and provide appropriate care and treatment.

Patients had all their risks considered when entering the service which supported a holistic approach to care delivery. Records we viewed showed a consistent approach to these assessments and included assessing the risks associated by laying still to safely tolerate cataract surgery. We also saw evidence of a patient being assessed and then referred onwards for an additional procedure to enhance their overall clinical outcome.

There was a process for patients to follow out of hours should they become worried or have any questions or concerns about their treatment/recovery. Staff provided patients with clear written and verbal information, including guidance on when and how to seek help, supporting them to identify and respond to potential risks. We saw this reflected in the discharge information given to patients.

We spoke with patients during assessment who told us they felt listened to, understood the risks, and were involved in decisions about their care and treatment. This demonstrated that patients were supported to actively participate in managing risks associated with their care.

We observed consultations where staff clearly explained conditions, investigations and treatment options, and worked with patients to agree care plans that considered safety and individual circumstances. During one consultation, the consultant listened carefully, took a full history, and asked permission before examining the patient’s eyes. The consultation took the patient’s age, mobility, support needs and preferences when discussing options, demonstrating how patients and carers were involved in decisions about managing risks and planning care safely.

They clearly explained their findings and checked the patient’s understanding throughout. Patients left consultations with a clear understanding of their next steps, ongoing care, and how to manage any risks following treatment.

The service detected and controlled potential risks in the care environment. Leaders and staff ensured that equipment, facilities and technology supported the delivery of safe care and took action to mitigate risks when identified. We saw an example of equipment failure and appropriate measures were taken to reduce the risk of disruption to patient care.

The service ensured the safe use of specialist equipment in line with national guidance. Staff followed local safety procedures, and only trained and authorised staff operated equipment under appropriate supervision. We saw evidence of training and local rules to support safe practice. The service had external oversight and audit processes and acted on recommendations to improve safety.

Leaders maintained oversight of equipment safety and availability. The service carried out routine audits, shared findings with staff and ensured timely repair or replacement of equipment. The service maintained an asset register and had systems in place to monitor equipment safety and ensure equipment was appropriately maintained and calibrated. Staff told us they had access to the equipment needed to provide safe care.

The design, maintenance and use of facilities supported patient safety. The provider had site maintenance arrangements and carried out health and safety risk assessments. We saw evidence of electrical safety checks and fire extinguisher servicing within the last 12 months. Fire safety systems were maintained and regularly checked.

Staff were trained to use equipment safely and managed clinical waste in line with policy. Waste was appropriately segregated and labelled, and sharps were handled safely to reduce the risk of injury. There was a service level agreement (SLA) for waste management, including sharps disposal.

The service stored hazardous substances safely and ensured staff had access to relevant safety information. Substances were stored securely with restricted access via keypad entry. Although we found the COSHH cupboard was broken on the day of inspection, this was promptly reported and action taken to address the issue, demonstrating responsive risk management.

The service had emergency equipment available, well maintained, and ready to use. This included a defibrillator, and records showed that staff carried out routine checks. Staff had received appropriate training to use the equipment.

However, staff did not record the seal number of the emergency trolley during these checks. This meant the service could not be sure the trolley had not been tampered with. During the assessment, we found the call bell in the patient recovery area was unplugged. This was raised with staff at the time and rectified immediately.

The service ensured there were enough qualified, skilled and experienced staff to provide safe care that met patients’ individual needs. We saw evidence of a safe staffing policy aligned with Association for Perioperative Practice (AfPP) guidance. Staff worked well together and understood their roles in delivering safe care, which we observed during patient pathways and interactions across the service.

The service employed staff with the right qualifications, skills and experience to keep patients safe and provide appropriate care and treatment. We reviewed staff recruitment and pre-employment checks and found these were completed in line with the provider’s policy. Staff received their shift patterns in advance and told us they could request changes where needed, supporting safe and effective workforce planning.

We reviewed a sample of staff records, including pre-employment checks, appraisals, absence records and training records, and found these were complete and up to date. Access to staff records was appropriately restricted depending on role, ensuring confidentiality and information governance requirements were met.

New staff completed a structured induction programme relevant to their role before starting work. Managers supported staff through appraisals and ongoing oversight to maintain standards of care.

Staff spoke positively about working for the service and told us they felt supported in their roles. Staff confirmed they were able to take appropriate breaks during shifts, which supported their wellbeing and ability to provide safe care.

The service supported staff learning and development. Managers identified training needs and provided access to training to ensure staff maintained the skills and knowledge required for their roles. The service monitored mandatory training compliance through established oversight systems, and staff were up to date with their mandatory training requirements

Managers ensured staff had access to team information, including when they were unable to attend meetings. This included sharing updates through internal communication systems.

The service ensured clinical staff working under practising privileges were appropriately assessed and met required standards. We saw practising privileges documentation for consultants and systems for ongoing monitoring.

Surgical and clinical decisions were made by appropriately skilled and experienced clinicians, and patients were clear about who was responsible for their care.

The service used bank staff to support care delivery. The most recent results showed that staff were generally positive about their roles and felt proud to work for the service. The survey also identified some areas of pressure, including workload and staffing, which leaders were aware of. Leaders had developed an action plan to address these concerns and support improvements in staff experience and wellbeing.

The service had systems to manage infection prevention and control. Infection risks were assessed and managed through policies, audits and routine monitoring. Staff used appropriate equipment and control measures to protect patients, themselves and others from infection. Clinical areas, including theatres, were visibly clean, well maintained and supported safe care.

We observed staff following hand hygiene guidance, using appropriate personal protective equipment (PPE) and clean equipment between patients. In theatres, processes were followed to minimise the risk of infection, with staff working in line with the national standards.

The provider had an up-to-date infection prevention and control policy aligned with national guidance. A comprehensive audit programme included monthly hand hygiene, environmental cleanliness and cleaning audits, alongside Aseptic Non-Touch Technique (ANTT) competency observations and quarterly health and safety walkabouts. Compliance over the previous six months was consistently high, with 100% compliance for hand hygiene, environmental cleanliness and ANTT practice. Action plans were triggered for any audit below 95%, with escalation processes, although no areas required escalation during this period. This demonstrated effective monitoring and oversight of infection control practices.

The service also had arrangements for environmental safety, including water safety testing such as Legionella monitoring, and records demonstrated compliance with the required testing and monitoring schedules. There was a service level agreement for the decontamination of instruments, supporting the safe processing of equipment.

However, infection prevention and control standards were not fully consistent across all areas. The recovery area and laser room did not have access to handwashing facilities with running water and soap, relying instead on alcohol gel.

The service ensured medicines and treatments were safe and met patients’ needs. Staff involved patients in planning their care and explained any changes to treatment. Patients told us they understood their medicines and felt involved in decisions.

There were effective systems to safely prescribe, administer, record and store medicines. Stock checks were carried out regularly, and records showed medicines were managed safely and appropriately.

The medicines management policy was up to date, specific to the service and aligned with national guidance. Regular audits were carried out to monitor safe practice.

We reviewed prescription records and found they were clear, complete and up to date. Staff reviewed medicines as part of ongoing care and provided advice where needed.

The service had clear guidance to support safe medicines use in specialist areas. This included procedures for the use of off-label medicines in ophthalmic surgery, antimicrobial guidance to support appropriate antibiotic use, and standard operating procedures (SOPs) for the safe administration of topical medicines by non-registered staff. Records showed non-registered staff had completed competency assessments and were appropriately supervised by a registered member of staff.

Leaders monitored national patient safety alerts relating to medicines and acted where required, ensuring learning was embedded into practice.