CES Medical - Headcorn

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

Surgical services provided at this location included cataract surgery completed as an outpatient.

The service had a good learning culture and staff and patients could raise concerns. Managers investigated incidents thoroughly and shared lessons learned and identified improvements with staff. Staff understood local safeguarding arrangements and safe systems of working and kept patients protected and safe.

There were enough staff with the right skills, qualifications and experience to ensure high quality care and treatment. Managers made sure staff received training and had regular appraisals to maintain high-quality care.

Staff managed medicines safely. Staff understood and managed risks from the environment. The facilities and equipment met the needs of patients, were clean and well-maintained and any risks were mitigated.

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 evidence showed a good standard. 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. Lessons were learnt to continually identify and embed good practice.

The provider maintained a monthly incident trend report that monitored incidents by category, level of harm, themes, actions taken, and how learning was shared and embedded across the service. Staff reported incidents and near misses through the group incident reporting system in line with the incident reporting policy.

The service had an up-to-date incident reporting and review policy. Leaders were undertaking training in the Patient Safety Incident Response Framework (PSIRF), the NHS’s mandatory approach to responding to and learning from 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 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. Leaders used feedback and events to drive continuous improvement and safer care. They shared learning across sites to promote consistency and prevent recurrence.

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.

The service analysed incidents to identify trends or themes and potential links to individual practitioners. Records we reviewed showed robust discussion and actions taken in management meetings. When an incident occurred, staff documented it and submitted it to the Operations Manager. The Operations Manager reviewed the incident, and the team discussed any learning points and required actions at the weekly operations meeting. Leaders shared learning through the clinical governance committee, team meetings, and direct staff briefings, and embedded improvements by updating relevant standard operating procedures (SOPs) and checklists and undertaking re-audits.

Staff understood the duty of candour. The NHS Duty of Candour is a legal and professional obligation requiring health and care providers to be open and honest with patients or families when something goes wrong that causes moderate or severe harm, or death. It requires an apology, a thorough investigation, and a detailed explanation of findings to be shared promptly, aiming to improve safety and foster a learning culture rather than a blame culture. Staff were open and transparent and gave patients and families a full explanation when things went wrong. Staff received feedback from investigation of incidents, both internal and external to the service.

The service provided mandatory training in key skills to all staff. Managers monitored mandatory training and alerted staff when they needed to complete updates. Once staff had completed their induction the mandatory training program offered training over a 12-month cycle. This ensured training expired at different times and staff could be released from work to complete the training.

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. Staff assessed patients before attending the clinic and carefully considered the findings when planning their care and treatment. Clear admission criteria were in place for all patients, which outlined the service’s limitations and helped minimise risks by excluding those whose needs could not be safely met. For example, the service did not accept patients with significantly restricted mobility as they did not have manual handling equipment available. Patients requiring tests and investigations were given enough information to enable them to understand the procedure. We observed a consultation where the clinician clearly explained the investigations and agreed a treatment plan together with the patient.

The service used a mixture of electronic and paper-based patient records and kept these securely. The information technology connectivity was consistently available across the service to meet the needs of staff completing the records. The provider managed records in line with the NHS Records Management Code of Practice. Staff stored records securely with restricted access, retained them for required periods, and disposed of them through secure destruction. The information governance lead reviewed compliance annually, and the registered manager completed monthly audits to ensure adherence to the policy.

The service worked with patients and healthcare partners where required, to understand how best to keep people safe, what it meant for individuals and the best way to achieve that. Staff concentrated on protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

Training aligned with the Intercollegiate Safeguarding Competencies. Data showed that all staff had adult and children’s safeguarding training to level 3. Although the service did not provide treatment to children, leaders recognised the importance of safeguarding and ensured staff completed Level 3 safeguarding children training. This helped staff identify and respond appropriately to any safeguarding concerns involving children who may attend the service with a parent, carer, or other adult.

The service had current safeguarding policies, and these reflected the national guidance for adults and children, including visitors. Staff knew how to make a safeguarding referral and who to inform if they had concerns. Staff accessed external safeguarding advice during working hours and knew how to contact the service. There was a named nurse and named doctor for adult/child safeguarding. Each clinical room had a flowchart showing staff the process to follow if they suspected a safeguarding concern. The flowchart was reviewed regularly and had the correct current guidance to follow.

Staff knew how to identify adults and children at risk of, or experiencing, significant harm and worked with other agencies to protect them. Staff could give examples of how to protect patients from harassment and discrimination, including those with protected characteristics under the Equality Act 2010.

The service worked with patients to understand and manage risks by thinking holistically. Staff provided care to meet patient’s needs which was safe, supportive and enabled patients to do the things that mattered to them.

There was a policy for staff to follow that ensured patients were suitable for treatment in its day surgery service. Staff checked each patient's health, the type of procedure they needed, and whether they could safely have treatment under local anaesthetic. If a patient needed more complex care, staff referred them to a hospital better equipped to meet their needs.

Every surgical patient received a pre-operative assessment before their procedure. Staff recorded vital information, including medical history, allergies, medications, the planned procedure, and consent. Staff checked that assessments had been completed before surgery. They also regularly audited patient records to ensure staff followed the correct process. The provider operated a 24-hour ophthalmology emergency telephone service, enabling patients to access clinical advice from consultants following discharge after surgery. Consultants participated in a fair rotational on-call system, ensuring continuity of care, timely clinical support, and clear accountability. Staff provided patients with written and verbal discharge information, including clear guidance on when and how to seek urgent help, and responded to all emergency calls within 30 minutes, prioritising urgent clinical concerns to maintain patient safety.

We spoke with 10 patients during our assessment, all of whom told us they felt listened to, that risks had been clearly explained, and that they were involved in decisions about their care and treatment. For example, we observed a consultation with a patient diagnosed with glaucoma, a group of eye conditions that damage the optic nerve, often linked to increased pressure within the eye. The clinician provided a clear and detailed explanation of the condition, the procedures involved, and the treatment options available. A plan of care was agreed collaboratively with the patient, who left the clinic with a confirmed date to return for treatment.

The service detected and controlled potential risks in the care environment. Leaders and staff took steps to make sure equipment, facilities and technology supported the delivery of safe care. Where they were unable to do so, they mitigated the risks.

The design of the environment followed national guidance around the built environment. Where required, areas were secure and protected patients. Access to the area was restricted to authorised staff through a keypad entry system.

Staff completed daily safety checks of specialist equipment. Resuscitation equipment for adults and children was readily available throughout the clinic.

The minor operations room was clean and fully equipped to provide ophthalmic procedures. The staff used Local Safety Standards for Invasive Procedures (LocSSIPs) to make sure care was safe. LocSSIPs are locally developed, adapted standards based on national guidelines designed to reduce risk and improve patient safety during treatment. The service used single use equipment to perform surgery and disposed of them safely.

The provider managed surgical instrument decontamination in accordance with HTM 01-01 and the Decontamination Policy. The service kept instrument traceability to patients and procedures, used single-use devices appropriately, and carried out regular equipment validation and testing.

Leaders maintained oversight of equipment to ensure it was safe and ready to use. They completed equipment audits and shared outcomes 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. The service ensured repair or replacement of broken or missing equipment effectively.

The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use equipment and disposed of clinical waste safely, both inside and outside the building. They segregated and labelled waste in accordance with their policy. The service manged sharp implements safely to minimise sharps injuries. Fire safety equipment was available and had been serviced. Fire exits were clearly signposted and free from obstruction.

The service stored hazardous substances safely and made information about products available to staff. They stored substances controlled under Control of Substances Hazardous to Health (COSHH) in a locked cupboard. Access was controlled by a digital code lock and restricted to authorised staff. COSHH is UK law requiring employers to control substances that can cause ill health. There was a first aid kit available at the reception of the clinic and staff had been trained in first aid. All items in the first aid kit were sealed and in date ready to be used.

The service made sure there were adequate numbers of qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked well together to provide safe care which met patient’s individual needs.

The service had enough clinical staff and support staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Staff received their rotas in advance and could request changes to accommodate their personal circumstances.

We reviewed 5 staff records on a secure web-based platform. Each staff member could only access their own record while managers could access multiple records depending on their role within the organisation. Staff records contained pre-employment checks, appraisals, absence, leave records and training records.

New staff received a full induction tailored to their role before they started work. Training on the induction program was aligned to NHS skills for health training. Managers supported staff to develop through constructive recorded, annual appraisals and constructive clinical supervision of their work. The service did not employ agency or bank staff.

Staff spoke positively about working for the service and did not express any intention to leave. Although the service had some existing vacancies, turnover and sickness rates were low. Staff told us they felt the service was safe, and they were able to take appropriate breaks during their shifts.

The service supported the learning and development needs of staff and made sure they received any specialist training for their role. Managers identified training needs their staff had and gave them the time and opportunity to develop their skills and knowledge. Clinical staff completed training on recognising and responding to patients with mental health needs, learning disabilities and dementia. All staff completed the required training courses with a high level of attendance and compliance. Overall compliance reached 100% across non-clinical and clinical staff. Staff fully complied with all mandatory training, while attendance for Preventing Radicalisation was slightly lower for clinical staff. A small number of courses remained in progress or were scheduled for later delivery, but arrangements were in place to ensure full compliance.

Managers made sure staff attended team meetings or had access to the information shared when they could not attend. They shared notes from team meetings and other general information on notice boards.

Records showed that visiting clinicians were subject to a full assessment through the practice privilege process. They were required to provide evidence of appraisal and re-validation.

Surgical procedures and clinical decisions were carried out by doctors with appropriate seniority and speciality training. Patients were clear who the doctors involved in their treatment were.

The evidence showed a good standard. The service assessed and managed the risk of infection.

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 the equipment and the premises visibly clean. As well as regular cleaning in between patient appointments, an external commercial cleaning company, which specialised in medical premises, cleaned the clinic every day.

The provider maintained cleanliness in the operating theatre and clinical treatment areas in accordance with the Infection Prevention and Control Policy, national infection prevention and control guidance, including HTM 03-01 for ventilation and the NHS National Standards of Healthcare Cleanliness, and the Royal College of Ophthalmologists' standards for ophthalmic surgical environments.

The provider signed up to the NHS England Commitment to Cleanliness Charter, confirming its commitment to high standards of cleanliness and hygiene. The charter set out clear expectations for maintaining clean, safe environments and supported patient safety through strong infection prevention and ongoing monitoring of cleanliness standard.

Clinic and treatment areas were visibly clean and well-maintained, free from clutter and had suitable furnishings. All clinical rooms had clinical handwashing sinks for staff to use in line with Health Building Note 10. Health Building Notes give best practice guidance on the design and planning of healthcare buildings. We saw staff regularly washing their hands and decontaminating equipment in between patient use.

The provider had an infection prevention and control (IPC) policy and supporting guidance accessible to staff. The provider’s guidelines reflected national IPC guidance. Staff had access to expertise in infection control as needed.

There was a programme of IPC audits including for example, hand hygiene and environment audits. The service performed well in local IPC audits. In the most recent audits, the scores showed compliance with IPC measures in all clinical areas.

Staff followed the infection prevention policy and national guidance to reduce the risk of surgical site infections. Staff used sterile techniques, completed safety checklists, gave patients advice on caring for their eye after treatment, and monitored patients for signs of infection. The service reported no surgical site infections or cases of endophthalmitis (a rare but serious infection inside the eye that can threaten sight if not treated quickly) in the previous 12 months.

Staff cleaned equipment after patient contact and labelled equipment to show when it was last cleaned. Staff told us they always cleaned the equipment in front of the patient to emphasise how important preventing the spread of infection was to them. A professional cleaning company cleaned the clinic at the end of each working day.

There were processes to enable staff to respond to IPC risks, such as transmittable infections. Staff followed infection control principles including compliant handwashing and the use of personal protective equipment (PPE) as outlined in the service’s PPE standard operating procedure.

There was appropriate testing of water outlets to detect any incidents of Legionella. These tests had shown variable water temperatures and as an action the team enhanced their surveillance to detect Legionella. Legionella is a type of bacteria that can grow in water systems and can cause a serious lung infection called Legionnaires’ disease when people breathe in contaminated water droplets.

Staff supported IPC measures by following the uniform policy. They did not wear nail varnish and jewellery, and staff in clinical areas were bare below their elbows to allow for full hand decontamination.

The service made sure that medicines and treatments were safe and met patient’s needs, capacities and preferences. Staff involved patients in planning, including when changes happened.

The service used systems and processes to safely prescribe, administer, record and store medicines. After the procedure, staff gave patients an antibiotic eye treatment as standard to prevent infection, with an alternative used if the first option was not suitable. Patients used it for 5 days, in line with national guidance and normal UK eye care practice.

Staff monitored the use of antibiotics through audits and governance meetings to ensure they followed the agreed procedures. Where needed, clinicians gave antibiotics during cataract surgery to help reduce the risk of infection.

On assessment we reviewed the medicines management policy. 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 systems and processes to prescribe and administer medicines safely. They managed medical prescriptions in line with legislation. We saw prescribers wrote prescriptions in permanent ink and signed them. Prescriptions contained the patient's name/address, date, prescriber's address, and prescriber type.

Doctors reviewed each patient’s medicines on admission and provided advice to patients and carers about any changes. Staff completed medicines records accurately and kept them up to date.

There was effective governance of medicines. Prescription pads were issued to consulting rooms prior to clinics commencing, with each use recorded on an audit sheet. Staff securely locked away unused prescription sheets after clinics. They recorded all medicines in a medication log and stored them safely in a locked cupboard. Clinic managers oversaw medication usage, monitored stock levels, and managed ordering to ensure safe and appropriate supply.

Leaders monitored Medicines and Healthcare products Regulatory drug alerts, assessed the relevance to the service and shared if needed.