ACES Fakenham is operated by Anglia Community Eye Service Ltd (ACES). Facilities include one operating theatre and a patient waiting room. The service has no inpatient beds.

The service provides cataract eye surgery for adults only.

We inspected this service using our comprehensive inspection methodology. We carried out an announced inspection on 12 September 2017.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

We rated this service as good overall.

• Although some elements of it require improvement, the overall standard of the service provided outweighs those concerns. We have deviated from our usual aggregation of key question ratings to rate this service in a way that properly reflects our findings and avoids unfairness.

We found good practice in relation to surgical care:

• The provider had established processes for reporting and learning from incidents. All staff could describe what constituted an incident and how to report it. Staff discussed incidents at meetings and shared learning.
• All areas we inspected were visibly clean and tidy.
• Nursing and support staff kept equipment clean and followed infection control processes.
• Staff had a system for recording implants used in theatre. Nursing staff logged lens implant stickers and batch numbers in patients’ care records.
• Nursing and medical staff stored medicines securely and completed appropriate documentation of medicines administered.
• Nursing and medical staff kept detailed records of patients’ care. We found patient records weresigned, dated, and legible. All records included the patient’s details and surgical notes, including clear documentation of the site of surgery and post-operative instructions.
• Nursing and medical staff completed the World Health Organisation (WHO) surgical safety checklist for cataract surgery and five steps to safer surgery for all patients. This is a safety checklist used to reduce the number of complications and deaths from surgery.
• Managers completed annual appraisals for all staff. Allstaff had completed an appraisal in the last year.
• The service managed staffing effectively, ensuring it maintained appropriate levels of staff with the right skills and experience to keep patients safe and to meet their care needs.
• The patient waiting area was comfortable and well maintained.
• Nursing and medical maintained the privacy and dignity of patients.
• Patient feedback provided by the provider and at the time of the inspection about the service was consistently positive.
• Nursing and medical were kind and compassionate in their interactions with patients.
• The service reported no complaints from April 2016 to March 2017. The provider had a process for managing and responding to complaints.
• All Staff we spoke with were positive about leadership of the service and told us leaders were visible and approachable.
• Senior staff had oversight of risks to the service. The provider had a risk register, which included identified risks, mitigation strategies and actions.
• The provider held governance meetings, board meetings and team meetings wherethe provider discussed incidents, complaints and compliment, information governance and staff competence.
• The provider monitored staff competency though appraisal, professional registration checks and monitoring of clinical outcomes.

However, we also found the following areas of practice that require improvement:

• Mandatory training completion was below acceptable levels, especially in regard to safeguarding children, manual handling and Deprivation of Liberty Safeguards (DoLS).
• Staff did not audit compliance with the WHO checklist. This meant senior staff did not have assurance that these safety checks were always completed. We raised this with senior staff at the time of inspection.
• Safeguarding leads were not trained to the correct level for the safeguarding of children, in line with the Royal College of Paediatrics and Child Health safeguarding Children and Young People: roles and competence for health care staff, Intercollegiate Document.

Following this inspection, we told the provider that it that it should make improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with one requirement notice that affected ACES Fakenham. Details are at the end of the report.

Heidi Smoult

Deputy Chief Inspector of Hospitals

Evidence was seen of discussions with each person who used this service and that clear explanations had been given about the treatment being provided. This meant that people’s privacy, dignity and independence were respected.

We reviewed six treatment records in detail and these showed us that people received treatment in line with the best practice guidelines as issued by the National Institute for Clinical Excellence (NICE) and by the Royal College of Ophthalmologists. This meant that individual care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare.

Those training records seen demonstrated that all staff had received current safeguarding training. This meant that the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

The service had a current complaints policy dated January 2013. This policy was noted to be comprehensive and showed us that response time scales and other clear protocols were in place for the management of any complaints received. This meant that there was an effective complaints system available.

The treatment records seen were accurate and reflected the specific intervention carried out by the respective surgeon. This showed us that people were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained.

Everyone we spoke with confirmed that they were aware of the treatment that they were getting and had given their informed consent to receiving this specialist care. This showed us that before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes. Everyone we spoke with confirmed that they were satisfied with the care and treatment that they were receiving. This showed us that people experienced care, treatment and support that met their needs and protected their rights.

We saw evidence of collaborative working and of a wide range of referrals to the service by local General Practitioners and Opticians. This demonstrated to us that people’s health, safety and welfare was protected when more than one provider was involved in their care and treatment, or when they moved between different services.

We saw that preventative maintenance records were in place for all of the equipment provided by, and used by this service. This showed us that people were protected from unsafe or unsuitable equipment. The provider had been audited by the local Primary Care Trust (PCT) in line with their contract monitoring and payment by results quality framework. The results seen demonstrated that the provider was in compliance with the quality thresholds identified by the PCT. this showed us that the provider had an effective system to regularly assess and monitor the quality of service that people received.