Anglia Community Eye Service Limited operates ACES Thetford, which is one of four locations operated by this provider. The service is located in a healthy living centre, where ACES Thetford rents facilities dependent on demand. Facilities include one operating theatre, consultation areas, and a patient waiting area.

ACES Thetford offers a surgery service for patients aged 18 years and over. The main type of surgery performed is cataract surgery. The service offers day surgery only, performed under local anaesthetic. No laser refractive eye surgery is offered at the location. Surgery takes place on Thursdays, with dates scheduled in advance to meet patient need.

ACES Thetford also offers an outpatient service, including pre-operative outpatient consultations, laser eye clinics and general outpatient eye clinics. Outpatient clinics usually take place on Wednesdays, Thursdays and Fridays, with dates scheduled in advance to meet patient need.

We inspected the surgery and outpatient services using our comprehensive inspection methodology. We carried out the announced part of the inspection on 28 September 2017, along with an unannounced inspection on 09 October 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.

Services we rate

• 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 the following areas of good practice in relation to surgery:

• The provider had established processes in place for reporting and learning from incidents. We asked three nursing staff about incident reporting and all could describe what constituted an incident and how to report an incident. Staff discussed incidents at meetings and shared learning.
• All areas we inspected were visibly clean and tidy.
• 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 transported medicines securely and completed appropriate documentation of medicines administered.
• Nursing and medical staff kept detailed records of patients’ care. We reviewed seven patient records completed by staff in the surgery service and found these signed, 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. Information from the provider stated that 100% of staff had completed an appraisal in the last year.
• All staff had access to up to date policies and guidance and the provider had a process in place for updating policies. We reviewed a selection of policies and found they were version controlled, dated and included references to national standards, guidance and law.
• Staff audited patient outcomes, including visual improvements after surgery and rates of capsular rupture (a possible complication during cataract surgery). Information from the provider showed the consultant working at ACES Thetford had a capsular rupture rate of 0.5% (not adjusting for case complexity). This was lower than the benchmark of 2% set by the Royal College of Ophthalmologists.

• Staff treated patients with kindness and compassion. Staff spoke with patients before surgery to put them at ease and we saw a consultant ask a patient if they had any last minute questions before surgery.
• Patients we spoke with were consistently positive about the service. One patient commented that staff were “lovely and delightful” and told us “they make you feel you matter.”
• We received eight CQC comment cards from patients using the outpatient and surgery services. All eight gave positive feedback about the services.
• The provider offered surgery services all year round and surgery was scheduled six weeks in advance dependent on patient need.
• The service reported no complaints from April 2016 to March 2017. The provider had a process in place 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.
• The provider held governance meetings every two months at their main site. We reviewed four sets of meeting minutes dated from 27 October 2016 to 4 May 2017, which showed meetings included discussion of incidents, complaints and compliments and information governance.
• The provider monitored staff competency though appraisal, professional registration checks and monitoring of clinical outcomes.

However, we found areas for improvement

• Staff had not received the correct level of training in the safeguarding of children.
• Resuscitation equipment was available at the GP surgery in the healthy living centre where the service was located. However, staff did not have oversight of safety checks for resuscitation equipment before our visit. We raised this with senior staff and they assured us that regular monitoring of resuscitation equipment safety checks would be put in place.
• The provider did not audit compliance with the World Health Organisation (WHO) surgical safety checklist for cataract surgery and five steps to safer surgery. 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 and they told us they would start audits.
• The provider did not audit hand hygiene at this location but told us staff were audited at other locations owned by the provider, where they also worked. We raised this with senior staff at the time of inspection and they told us they would start audits at this location.
• Records dated June 2017 showed staff compliance with Mental Capacity Act training was 50%. Information from the provider showed that this training was scheduled.
• The provider’s risk register did not contain dates for entry, review or a named person for each action. This meant the provider did not have clear documentation of the ongoing management of each risk to the service.

We found good practice in relation to outpatients:

• Nursing staff could describe learning from incidents. The outpatient service reported four clinical incidents (all graded no harm) from April 2016 to March 2017. We asked three nursing staff about this and all could describe incidents that had occurred and learning from these incidents.
• A laser protection adviser (LPA) from a nearby NHS trust carried out annual checks on laser safety arrangements. The provider had a named laser protection supervisor, who was responsible for the implementation of laser safety arrangements.
• Patients we spoke with were positive about the outpatient service. One patient said the consultant was “exceptional” and another said their experience had been “excellent” and “staff treated me well.”
• Patients met with a consultant surgeon at their pre-operative appointment. This was the same surgeon that completed their surgery, promoting continuity of care for patients.
• Information leaflets for patients were available in the outpatient waiting area. These included “Yag laser capsulotomy,” “Bringing eye care to the community” and “Selective laser trabeculoplasty.”
• The provider shared information on outcomes of surgery with each patient’s GP and optometrist after surgery.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make some 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 the surgery and outpatient services. Details are at the end of the report.

Heidi Smoult

Deputy Chief Inspector of Hospitals