CES Medical - Headcorn

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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

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 patients who use the service 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.

This is the first assessment for this service. This key question has been rated outstanding. This meant patient’s needs were met through outstanding organisation and delivery.

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.

The service had a clear shared vision, strategy and culture that built on the organisational vision and strategy. 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 patients and their communities.

The service had a vision for what it wanted to achieve and a strategy to turn it into action. This vision reflected the overarching provider aims and objectives. Staff knew how their work contributed to achieving targets. Leaders were passionate about providing high quality eye care for the local community. Their mission was to provide ‘global care for local people.’

The provider demonstrated a strong commitment to valuing staff and promoting inclusion through systems that supported equality, wellbeing and reasonable adjustments in line with the Equality Act 2010. Leaders proactively identified and responded to staff needs through discussions at recruitment, supervision, return‑to‑work meetings and regular staff surveys, ensuring they reviewed and adapted adjustments as required. A wide range of reasonable adjustments were available, including flexible working arrangements, physical workplace adaptations, assistive technologies and tailored wellbeing support, with evidence these had been implemented in practice. Policies promoting dignity at work, zero tolerance of bullying and harassment, and robust Freedom to Speak Up arrangements supported a positive and inclusive culture. Leaders actively used staff feedback to inform wellbeing initiatives and continuous improvement, demonstrating a responsive approach to workforce engagement and support.

Staff felt respected, supported and valued. Staff reported that the leadership culture was inclusive, and they felt valued and respected. Relationships between staff of all grades were positive, with strong teamwork and collaboration. Staff described the leadership team as ‘tightknit and supportive.’

Staff felt motivated about the future and planned changes for the service. The provider had clear systems to ensure staff understood their roles and accountability. All staff held signed job descriptions, supported by a clearly defined management structure and robust induction. Role clarity was reinforced through supervision, appraisal and role‑specific training, with compliance monitored through governance arrangements. These systems supported safe practice and effective oversight.

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 always did so with integrity, openness and honesty and understood the impact their behaviours and leadership had on patient outcomes and experience.

Leaders had a range of experience, skills and abilities to run the service, and they understood and managed the priorities and issues the service faced. Leaders were visible and approachable in the service for patients and staff. Staff felt leaders supported them to develop their skills and take on more senior roles. Leaders modelled behaviours that supported wellbeing such as maintaining healthy working hours, taking breaks away from the clinic and only sending emails during work time.

The service had effective leadership and governance arrangements in place, with senior leaders appointed through a structured recruitment process and supported by comprehensive Fit and Proper Persons checks. Leaders maintained ongoing assurance through regular appraisals, supervision and role‑appropriate training. These systems supported clear accountability, regulatory compliance and effective organisational oversight.

Leaders took incidents seriously and knew how to deal with concerns when raised which promoted a positive culture in the service. Leaders attended the wards and departments to assess for themselves how the service was running.

Leaders demonstrated an open and reflective approach to understanding staff experience through a comprehensive staff survey. The last survey was in 2025 and had a 91% response rate, providing assurance that staff felt able to share their views. Results showed strong overall engagement, with most staff reporting they generally looked forward to work, indicating a positive organisational culture. The 2025 staff survey has now been completed, and the results are currently being analysed.

Leaders also acknowledged and analysed areas of pressure, including staffing levels, workload demands, clarity of roles, resourcing constraints and perceptions of influence over decision‑making. Importantly, these issues were not minimised and were translated into a clear action plan focused on workforce sustainability, communication, role clarity and retention. Senior leaders identified staff engagement as a strategic priority and committed to practical improvements such as reviewing benefits, developing clearer hybrid working arrangements, strengthening local management capability and improving access to equipment and resources. This demonstrated that leaders used staff feedback to drive continuous improvement, support staff wellbeing and ensure the service remained well‑led, resilient and responsive.

The service had a clear and structured leadership development and succession strategy in place, which was reviewed annually at director level. Succession planning covered all key leadership roles, with identified deputies and development plans to ensure continuity and sustainability. Leaders were actively developed through a tiered programme, combining internal training, mentoring and external sector‑specific development. Contingency arrangements were in place to manage unplanned leadership absence, providing assurance that effective leadership and governance would always be maintained.

The service fostered a positive culture where staff knew they could speak up and their voice would be heard.

Staff and leaders acted with openness, honesty and transparency. Leaders encouraged staff to raise concerns and offer ideas; the culture allowed staff to be confident their voices were heard. The provider had clear channels of escalation which included human resources and leaders within the organisation. There was a Freedom to Speak Up (FTSU) and whistleblowing policy for staff to follow.

The provider promoted an open, inclusive culture and actively encouraged and supported staff to speak up. Robust FTSU and whistleblowing arrangements were in place, including a named FTSU Guardian, anonymous reporting options and a clear commitment to no detriment for raising concerns. Staff received training on equality, diversity, whistleblowing and human rights as part of induction and ongoing learning, supporting confidence to raise issues.

Regular staff surveys showed most staff reporting felt they were able to raise concerns and believed incidents and unsafe practice would be addressed and learned from. Leaders reinforced this culture through regular engagement, wellbeing discussions, and reasonable adjustments. They used clear human resources processes to address behaviour that did not align with organisational values, demonstrating a fair, transparent, and learning‑focused approach.

Staff told us they felt able to raise concerns and believed they would be supported, without fear of detriment. When concerns were raised, leaders investigated sensitively and confidentially. The local senior leadership and provider level leadership were made aware when whistleblowers had raised serious concerns. Risk registers and management reports contained analysis of concerns over time and associated action plans.

The service valued diversity in their workforce. It had an inclusive and fair culture which had improved equality and equity for staff.

Leaders acted to improve any disparities in the experiences of staff with protected equality characteristics. Leaders demonstrated a strong commitment to equality, diversity and inclusion, with clear systems in place to promote fairness and reduce discrimination across the workforce. Workforce diversity was actively monitored using data aligned with protected characteristics, and recruitment practices were designed to minimise bias through structured, competency‑based interviews, anonymised shortlisting and diverse recruitment panels. Equality and diversity training formed part of staff induction, with additional inclusive leadership and unconscious bias training provided for recruiting managers. Leaders undertook annual pay equity reviews and engaged with staff from under‑represented groups through regular one‑to‑one discussions. Flexible working was promoted as standard, supporting work‑life balance and inclusion. All organisational policies included equality impact assessments, providing assurance that equality considerations were embedded in decision‑making and governance processes.

Leaders took steps to remove bias from practices to ensure equality of opportunity and experience for the workforce within their place of work, and throughout their employment. Staff told us they had opportunities to apply for project work, new roles and to undertake external studies through an open application process.

The service acted to prevent and address bullying and harassment at all levels, for all staff, with a clear focus on those with protected characteristics under the Equality Act 2010 and those from excluded and marginalised groups. Staff felt everyone was treated fairly and they felt able to report behaviour or attitudes which were negative in style.

The provider demonstrated a clear and proactive commitment to promoting race equality and inclusion across the workforce. A Race Equality Action Plan was in place, alongside the introduction of the NHS Workforce Race Equality Standard (WRES), with arrangements to monitor recruitment, progression and staff experience by ethnicity and to review annual WRES data to track progress and address disparities. Leaders used staff survey feedback to inform targeted actions, including outreach to more diverse candidate pools, mentoring for ethnic minority staff, staff networks to support safe conversations, and anti‑racist training to reduce bias in recruitment and performance management. Robust FTSU arrangements and policies, aligned with the Equality Act 2010, supported fair treatment, accountability, and a culture that challenged bullying and discrimination.

Staff with disabilities were offered reasonable adjustments to support them to carry out their roles well. For example, there was the opportunity to work remotely and have condensed hours as part of a reasonable adjustment.

The service had clear responsibilities, roles, systems of accountability and effective governance. Staff used these to manage and deliver high-quality, sustainable care, treatment and support. Staff always acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

The provider had a clear and effective governance structure with defined lines of accountability at all levels of the organisation. Board‑level oversight was provided by the directors, with operational accountability held by the Registered Manager and Clinical Lead, and site‑level responsibility assigned to named lead clinicians. Individual professional accountability was supported through practising privileges. The governance structure was reviewed annually, providing assurance that leadership arrangements remained appropriate, current and effective.

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 directors of the organisation met with clinicians monthly as a board and the site leads met monthly to discuss governance.

Leaders demonstrated effective governance arrangements through regular, structured compliance meetings with clear senior oversight and multi-disciplinary attendance. Risks to safety and regulatory compliance were proactively identified across sites, including medicines management, fire safety, water safety, and controlled drugs, with clear action plans agreed, ownership allocated, and progress monitored. There was evidence of a learning culture, with gaps in compliance openly acknowledged and targeted support and oversight put in place.

Leaders demonstrated awareness of how resource and financial constraints impacted compliance and appropriately escalated these risks to senior management. They strengthened systems by introducing standardised logs, digital temperature monitoring, audit trails, and shared documentation through a web‑based platform, which supported transparency and accountability. They used monthly meetings, clear escalation routes, and preparation for external inspections to ensure quality, safety, and regulatory requirements were actively overseen and continuously improved.

The clinical leadership team approved doctors’ practising privileges and reviewed the clinical outcomes of individual clinicians. When concerns about performance arose, the team followed established processes and shared information with professional bodies when required. As a condition of practising privileges, all clinicians demonstrated completion of a minimum of 50 hours of continuing professional development (CPD) each year. The service reviewed CPD evidence during the annual practising privileges renewal.

Staff at all levels were clear about their roles and accountabilities. Staff had job descriptions, and these set out expectations and responsibilities. Where senior staff had designated tasks related to audit and monitoring quality of services, they understood what was required of them.

Staff could find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements. The information systems were integrated and secure. Data or notifications were consistently submitted to external organisations as required.

Leaders made sure they discussed accurate information and shared this with key staff. For example, they shared information via operational meetings every Monday morning and a staff bulletin.

The service clearly identified risks and used a formal log to keep oversight and manage mitigations or resolve them. Staff contributed to decision-making to help improve sustainability and improve quality of care. The top 3 risks on the provider’s risk register were information technology infrastructure, the reduction in tariffs paid for procedures and maintenance of medical equipment. The risks were rated and reviewed regularly.

The service demonstrated effective leadership and governance through robust risk management and clear board oversight. A comprehensive risk register was maintained, reviewed monthly at clinical governance meetings and escalated appropriately to board level, ensuring senior leaders had oversight of organisational risks. There were no high‑level risks scored at 12 or above, demonstrating effective mitigation and control measures in place. Identified risks were primarily low to moderate and were actively monitored, with evidence of stability over time and no new risks emerging at recent governance meetings. This approach showed that leaders had strong systems to identify, assess, manage and review risks, supporting safe, sustainable and well‑governed care delivery.

Audit processes and the outcomes were used to ensure quality of services was maximised. Where improvements were required, leaders ensured action plans and the monitoring of these led to positive changes. The provider had an extensive audit cycle of clinical and non-clinical audits that drove improvement in the service.

The service had plans to cope with unexpected events and had a business continuity plan, which included major incident plans. The service demonstrated effective planning and risk management arrangements to ensure continuity of care. Leaders had identified and assessed risks associated with fluctuations in demand, staffing disruption, equipment failure and environmental factors, with these risks recorded and monitored through the risk register. A comprehensive business continuity plan was in place, supported by clear action cards, which addressed potential scenarios including major staff absences and critical equipment failure. These arrangements provided assurance that leaders could respond promptly to disruption and maintain safe, effective service delivery.

The service had not reported any data breaches and systems were secure. The service handled patient identifiable information correctly. We reviewed several service level and provider policies and found these were up to date and readily available to staff. Leaders had oversight of the accuracy and validity of each policy.

The service had robust governance and oversight arrangements in place, supported by a structured programme of performance monitoring and assurance. The governance lead produced a comprehensive monthly key performance indicator report covering quality, patient experience, operational performance, workforce and finances. The Registered Manager signed this off. Performance was reviewed at monthly Clinical Governance Committee meetings and escalated to directors quarterly, ensuring effective board‑level oversight.

The service clearly understood and carried out their duty to collaborate and work in partnership, and services worked seamlessly for patients. Staff always shared information and learning with partners and collaborated for improvement.

Staff and leaders at the service collaborated with relevant external stakeholders and agencies to improve care and treatment for patients using the service. For example, the service demonstrated strong partnership working through active and sustained engagement with the local NHS Integrated Care Board (ICB) and wider system partners. Leaders contributed to local provider forums, specialist eye care groups and ICB consultations, supporting the design and delivery of community ophthalmology pathways, particularly for glaucoma care. The service aligned its provision with local system priorities, including reducing health inequalities, supporting an ageing population and integrating primary and community care through shared‑care arrangements with community optometry providers. Effective information sharing and referral processes were in place via an electronic referral service, supporting safe onward referral and continuity of care. This collaborative approach supported joined‑up care, improved patient outcomes and effective system integration.

Leaders and staff actively and openly engaged with patients, staff, equality groups, the public and local organisations to plan and manage services. A poster with a photograph and name of the leaders was displayed in the waiting room of the clinic. This meant visitors knew who to contact if they wished to discuss any feedback.

The provider actively involved patients, carers and referrers in shaping services through structured feedback mechanisms, including Friends and Family Test results and direct engagement. Feedback was used to inform service redesign, with patient workshops held to improve care pathways and plans in place to extend this approach to glaucoma services, ensuring care remained patient‑centred. Leaders responded to system partner feedback by clarifying referral pathways through the development of a referral process for local optometrists and by introducing a new ocular plastics clinic to address identified access delays. The provider also strengthened support for patients with visual impairment through partnership working with voluntary organisations. Planned engagement activities demonstrated a commitment to inclusive participation, with targeted involvement of diverse service users across local communities.

The service had a focus on continuous learning, innovation and improvement across the organisation and local system. Staff often encouraged creative ways of delivering equality of experience, outcome and quality of life for patients. Staff contributed to safe, effective practice and research.

The provider actively engaged staff at all levels in the planning, delivery and continuous improvement of services. Staff were encouraged to share their views through regular team meetings, supervision, one‑to‑one discussions and staff surveys, with feedback documented, reviewed and acted upon where appropriate. Leaders promoted an open and psychologically safe culture, supported by whistleblowing and incident‑reporting processes, ensuring staff felt confident to raise concerns and contribute to learning and improvement. Training, development opportunities and recognition of staff contributions further supported engagement and a positive, inclusive working culture, ensuring staff voices were valued and reflected in service delivery.

The provider had effective systems for staff development and accountability. All staff received annual appraisals, with 100% completed in 2026, supported by regular clinical supervision and strong leadership focus on engagement and development.

Several staff we spoke with had a good understanding of quality improvement methods and had been trained in this area of work. We were told about some of the areas of work which they had focused on, which included improvements made in the cataract patient pathway. The pathway was streamlined to reduce patient visits to the clinic and ensure all consultants’ practice mirrored national guidance.

Staff were supported to develop their skills in improvement and innovation and to pursue areas of interest within the service. A roundtable workshop involving all staff identified opportunities to improve both the service and patient experience. This led to streamlining the cataract pathway and introducing virtual follow-up appointments for some patients, reducing the need for in-person visits.

Leaders were also developing a bespoke digital readiness platform to provide real‑time oversight against CQC Quality Statements, supporting proactive identification of gaps against the regulations and continuous improvement. These systems demonstrated clear accountability, effective escalation and strong leadership assurance.