ACES (Cromwell Road)

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

We rated safe as good. We assessed 5 quality statements. There was a positive learning safety culture where events were investigated, and learning was embedded to promote good practice. Staff were open and honest when things went wrong or could be a risk. Staff completed and updated risk assessments for each patient and removed or minimised risk. Staff identified and quickly acted upon patients at risk of deterioration. Staff understood how to protect patients from abuse. Staff had training on how to recognise and report abuse and they knew how to apply it. The environment was safe, well maintained and met peoples’ needs. The design of the environment followed national guidance, and the service had suitable facilities to meet the needs of patients and their families. However, the service did not always have safe systems for appropriate and safe handling of medicines. Following our inspection, the service told us of improvements they made in their medicines management. We have requested an action plan to address these issues and ensure compliance with standards.

This service scored 72 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff were confident to report incidents, and they told us they felt supported by managers when things went wrong. Staff told us they knew what they should report and when. The service’s formal reporting system was easy to use. Staff and leaders saw incidents as an opportunity to learn and improve.

The service managed patient safety incidents well. Staff had effective systems to raise concerns both formally and informally. Reports were analysed and urgent actions taken by leaders to manage or remove risks.

We did not look at Safe systems, pathways and transitions during this assessment. The score for this quality statement is based on the previous rating for Safe.

The service had clearly defined and embedded systems, processes, and procedures to keep people safe and safeguarded from abuse. The service had an up-to-date safeguarding policy with clearly defined roles and responsibilities for staff regarding safeguarding and the safeguarding referral process. Staff knew how to identify people at risk of, or suffering, significant harm and worked with other agencies to protect them. Staff told us they knew how to make a safeguarding referral and who to inform if they had concerns.

Leaders used a safeguarding training matrix to ensure staff were trained to the appropriate level. Staff we spoke with understood how to report safeguarding concerns, the service had a safeguarding lead and appropriate policies and processes in place to manage safeguarding concerns.

People were given information and support to help them understand the risks involved in treatment, and staff recorded any additional needs to reduce risk. Staff supported patients to take a balanced and proportionate approach to risk and respected the choices people made about their care. Staff told us they completed risk assessments for each patient, using a recognised tools, and reviewed this regularly.

The service had up-to-date policies and procedures to support staff when assessing patient needs. The service used patient risk assessments that were person-centred, proportionate, and regularly reviewed to identify additional areas of needs. There were policies and procedures in place to verify patient identity and manage the deteriorating patient.

Staff told us they had access to all the equipment they needed which was maintained and serviced to ensure it was safe to use. The environment was purpose built to meet the needs of the people who used the service and leaders used innovative security systems to secure equipment and the environment. Staff told us they completed checks on emergency equipment. The service had policies and processes in place to manage emergencies or a deteriorating patient.

The environment was purpose built to meet the needs of the people who used the service and leaders used innovative security systems to secure equipment and the environment. Staff completed checks on emergency equipment and the service had policies and processes in place to manage emergencies or a deteriorating patient. The environment was visibly clean and free from clutter. The service reception area was bright, welcoming and spacious with appropriate and plentiful seating. There was clear signage with high contrast colours to help people with vision impairment. Patients could access toilets which were visibly clean and free from odour. Patients had separate waiting areas in the main reception area, to promote privacy dependent on the clinic they were attending. People were kept safe while waiting to be seen or receive treatment. The theatre, laser and medicines storage areas were security access protected. Staff cleaned equipment after patient contact and labelled equipment to show when it was last cleaned. Staff disposed of clinical waste safely.

The service fire safety and other emergency systems were tested and maintained and there was a planned preventative maintenance schedule and contracts for the removal of waste and equipment maintenance. The service had an up-to-date policy for the care of devices and equipment and air management in theatres. The service had processes for checking emergency equipment and up-to-date resuscitation policy and guidance on the use and management of emergency equipment.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

We did not look at Infection prevention and control during this assessment. The score for this quality statement is based on the previous rating for Safe.

Staff interacted with people kindly and provided support to people when medicines were administered. We reviewed peoples records and saw evidence that they had consented to their treatment before their surgery. There were processes in place to obtain a comprehensive medical history from and share information about the procedure to the GP. However, we saw that when people were treated with off-license medicines , the consent form did not contain the information required for people to understand the reasons why they needed to be treated with this. Off-license medicines are medicines that are being used in a way that is different to that described in the licensing process, for example using a medicine for a different illness or a different dose to that stated in the license.

Staff told us they had regular educational sessions held by the ophthalmologists. We requested medicines training completion records and at the time of the assessment, the medicines training and competency for staff were not up to date. However, after the assessment, we received information from the provider which showed that 95% of staff had received medicines training about one week after we were on site.

Medicines were stored securely and safely, and temperatures were monitored where they were stored, to ensure their safety when used. Prescription forms were stored securely, and logs were kept when they had been used. However, staff did not follow the provider policy to monitor their use and investigate when prescription logs were incomplete. This is required to reduce the risk of misuse.

Staff understood the processes to report incidents and lessons learned were shared internally and nationally within the organisation. Records were kept when actions were taken in response to patient safety alerts. When people were given prescription only eye drops to take home, staff labelled these within the service. However, we saw that the labels did not follow legal requirements. The discharge documents did not accurately reflect the medicines people were given. We reviewed 3 peoples records and observed that the information given to them contained a list of pre-printed eyedrops which they had not received, which could cause confusion for people. We saw that there were processes in place to check that people had their medicines before they went home, and staff signed to say they had completed these. However, during the assessment we saw that a person had left the service without their eye drops. Upon review of the discharge documents, we saw that the record had been signed by staff. This meant that the record was inaccurate. Following our on-site assessment, leaders of the service told us they introduced a new process for recording the use of prescription forms. They also put in place a plan to carry out a quarterly audit of prescription forms. Additionally, following our feedback around concerns of labelling, leaders in the service recognised the need to design a new medicines audit. The medicines audit would include labelling and observation. As part of our process to drive improvement, we have requested the service to provide CQC with an action plan.