CHEC - Kings Norton

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• 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 service had an inclusive learning culture to improve safety. Staff felt able to challenge issues with the senior team and were listened to. There were sufficient staff on duty for the number of patients. Staff worked with the patients and those that cared for them to manage identified risks.

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

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. There were four incidents reported by staff in September 2025. These covered a range of issues including staffing and administrative errors. Each incident had been investigated and practice had been amended or actions were taken.

There were processes to ensure that lessons were learnt to identify and embed good practice. Staff were aware of these and other incidents occurring at other locations through a system of flash alerts. Flash alerts detailed the issue that had occurred and learning that occurred following review. These information sheets were generated when an incident occurred in any part of the organisation which could promote learning in other locations. Staff knew how to report incidents and felt able to do so. Staff were open and transparent with patients and fulfilled the duty of candour requirements. An example of this included a change in lens manufacturing which led to a new injector to be used. While staff had training on the use of this injector, they still struggled with it, which led to an incident. A debrief was held post procedure and further training given. The patient was informed of the incident and actions taken.

The service had 14 incidents relating to endoscopy services between April and September 2025. These were mostly in relation to the transcribing of histology reports. The service had issued a flash alert in response to this and staff were reminded during the daily huddle and team meetings of the importance of accurate transcription. Staff reported incidents to ensure changes were made and managers were informed, and actions were taken. For example, a recent incident included the inability to process the flexible endoscopes in the required time frame. Staff reported this so that managers were able to monitor the usage of the decontamination area. They also reported when there was only one person working in the decontamination area.

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 undertook service on behalf of the NHS. They worked with partners in care, such as the NHS, GP’s and optometrists, 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 before admission. They made sure there was continuity of care, including when people moved between different services. Staff ensured patients received a timely follow up appointment and shared information about the patient to ensure continuity of care.

Staff ensured histological findings from endoscopy procedures were referred to the most appropriate person 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, the 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 level three safeguarding adults training. The chief nurse was trained to level four 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 not needed to make a safeguarding referral but understood the process. If there were other concerns about a patient‘s welfare staff would liaise with the patient’s GP. The service shared concerns quickly and appropriately. We heard about a patients who was referred back to their GP for further support.

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 undertaken. If necessary, a further discussion with the consultant were had. 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 to have transportation home provided. The service could provide this if required. At this time an explanation of their treatment would be given. Staff ensured that patients understood what to expect. For patients whose first language was not English the service was able to provide information in an acceptable format.

The service used the National Patient Safety Association and the Royal college of surgeons guidance to ensure that patients were operated on in a safe manner through appropriate marking of the site for surgery. The service used the World Health Organisation surgical checklist which ensures staff have all the relevant information and undertake appropriate checks to ensure patients safety during the operation. 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 number patients could use to contact a member of the medical team 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. However, this had not been required to date for patients undergoing eye surgery.

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 environment had been adapted to meet the needs of the service and those who used it. Corridors were wide and could meet the needs of disabled users. The service had installed sensor taps to minimise the risk of infection transference.

Clinic areas were wipe clean and we saw cleaning schedules were up-to-date and completed. A fire plan was easily available within the clinic and oxygen cylinder locations were identified. 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 the vision in the eye for people who had previously had cataract surgery and a membrane in the eye had become cloudy. The laser treatment (Yttrium Aluminium Garnet) is commonly known as YAG treatment. The clinic had a laser room where they used a YAG laser for procedures. This had appropriate signage in place. There was a laser protection officer who monitored use and provided information to the local team about the care and use of the laser.

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. We reviewed the decontamination of flexible endoscopes and found that the staff had the appropriate equipment to do this. The endoscopy decontamination suite cleaned flexible scopes for other sites in line with national guidance. They had turnaround times in to reduce the risk of infection. When these could not be met it was recorded as an incident.

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 and storing 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. We saw that staff used a detailed logbook to track each endoscope and associated equipment. The service had appropriate contracts for the testing of water used and for servicing of all the equipment.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. There were no vacancies at the service. There had been three leavers in the last 12 months. This was for a variety of reasons; some went into further education, others felt that it wasn’t the role for them. The registered manager spoke to all staff about their rationale for leaving.

Staff were skilled in undertaking the roles they fulfilled. Training was given to support staff to develop, for instance one person started as a receptionist and was now undertaking training to be an optical assistant. There were defined pathways to develop staff and competency assessments to ensure the skills of staff. Staff worked together well to provide safe care that met people’s individual needs. They covered each other’s shifts in times of staff sickness, and the service would be supported by sister sites to deliver services. Similarly, staff would go to other sites if they were needed. This meant the service did not use agency staff, and staff were familiar with working patterns.

Staff had received and were up to date with appropriate mandatory training with 100% compliance. The training was appropriate for the patient group using the service and included topics such as dementia training. The service had consultants with practicing privileges who had substantive NHS practices. This was monitored centrally at the organisation. Employed staff had appraisals every three months but felt able to discuss development at any time. Staff set their own objectives for the next 12 months.

Staff were experienced and qualified and had the right skills and knowledge to meet the needs of patients undergoing eye surgery. The service gave staff an appropriate induction and ensured that they had the appropriate competencies. Staff appraisals were held every three months at which point the staff members own objectives would be reviewed. Medical staff were either appraised in their NHS practice or by the chief medical officer acting as their Responsible Officer. The managers dealt with poor staff performance promptly and effectively.

Staff were trained and assessed as competent in endoscopy practice. Some staff attended a specialised training school and undertaken a four day decontamination management training course. We found that the endoscopy technician had a good knowledge of endoscopy practices.

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 would arrange repairs. Staff told us this was done promptly. We saw evidence that equipment was tested and kept clean. Cleaning schedules were robust and records were up-to-date. They detected and controlled the risk of infection spreading and shared concerns with appropriate agencies promptly.

Cleaning staff utilised the NHS colour coding for mops and buckets so that high risk areas were cleaned with different 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. While there were no procedures being undertaken on the day of our inspection staff were able to describe appropriate hand washing practices. Audits undertaken in respect of infection prevention and control demonstrated a good compliance with regular cleaning, deep cleaning, hand hygiene 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. At this service this included issues such as maintaining a clutter free environment which had been highlighted in August as requiring improvement but this had been addressed by the September audit.

The endoscopy decontamination suite cleaned flexible scopes for other sites. They had defined turnaround times to meet which reduced the risk of infection. When these could not be met this would be recorded as an incident. This had happened once at this site. There were set sterilisation standards and checks which were being followed to ensure all the scopes were processed in line with national guidance.

Staff had the appropriate equipment to decontaminate scopes. These were maintained through a contract with the supplier. Decontamination of the scopes was split appropriately into the dirty and clean areas. The service was not yet Joint Advisory Group (on Gastrointestinal (GI)) Endoscopy accredited but were working on obtaining this in the near future. 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 although the compressor may cause a manual handling challenge due to its location and the need to carry heavy salt sacks past it.

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 using a keypad for extra security. The service occasionally used private prescription pads. These were stored in the clinic manager’s office and only they held the key to this cupboard. The use of this key was documented. 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. Bowel preparations were given to patients and their manner of taking was explained. Dietary advice and support was provided in writing and verbally to patients.