ACES (Cromwell Road)

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We rated effective as good. We assessed 2 quality statements. Staff comprehensively assessed people, so the care and treatment provided met their needs. This included both their mental and physical health and any personal circumstances that needed to be considered. Staff worked in a strong culture of evidence-based practice. Managers checked to make sure staff followed guidance. Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent.

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.

We did not look at Assessing needs during this assessment. The score for this quality statement is based on the previous rating for Effective.

Staff used the service’s systems to follow the latest guidance and evidence-based practice. The service kept its database of guidance and policies up to date. Staff used information given regularly in safety briefings and newsletters to implement new guidance or changes to existing procedures. They used effective tools for assessing patients and acted on any indicators of concern.

The service’s intranet contained a comprehensive range of up-to-date policies and standard operating procedures which reflected current best practice. Staff accessed guidance for collaboration with multi-agency teams and for delegation of clinical tasks to ensure the right people delivered evidence-based care and treatment. Managers had a dedicated audit schedule and associated action plans to ensure quality and standards met national and local guidance. Key elements of the audit were focused on the patient experience and quality to improve safety and outcomes. The service audited compliance with the World Health Organization (WHO) surgical safety checklist. This checklist was developed after extensive consultation aiming to decrease errors and adverse events and to increase teamwork and communication in surgery. Staff undertook quarterly WHO surgical safety check list audits. We reviewed audits between September 2024 to January 2024 which showed the service routinely achieved above 98% compliance. The service has responded to the recommendations of the Getting It Right First Time (GIRFT) Ophthalmology Report (2019) and told us it was focused on reducing variation in care, improving clinical efficiency, and enhancing patient outcomes. The service regularly conducts audits in line with GIRFT’s call for data-driven improvements, ensuring clinical practices are evidence-based and continuously refined. The service monitors complication rates and patient outcomes to identify areas for improvement and adopt best practices.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Monitoring and improving outcomes during this assessment. The score for this quality statement is based on the previous rating for Effective.

Staff received training on the service’s policies in relation to patient consent and capacity. Staff understood how and when to assess whether a patient had the capacity to make decisions about their care. Staff gained consent from patients for their care and treatment in line with legislation and guidance. There was a detailed assessment and referral process for each patient. Staff told us they sought oral and written consent throughout the patient’s treatment journey. Staff made sure patients consented to treatment based on all the information available.

The service had systems and practices in place to ensure people understood the care and treatment being offered or recommended. Staff received training on consent and capacity and the service had up-to-date policies to provide staff with appropriate guidance. Staff recorded consent clearly in the patients’ records.