Vision of Hope

On this page

• 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 service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first assessment of this service since CQC introduced ratings.This key question has been rated as requires improvement. The service was in breach of legal regulation in relation to good governance.

This service scored 61 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a vision which was shared with people using the service.

The provider was able to describe the vision in relation to transparency, equity, equality and inclusion. They aimed for the service to provide an effective complementary service to people following a life-changing diagnosis, with a holistic focus on nutrition, emotional needs and wider lifestyle factors. This approach was reflected in the name of the service: ‘The Vision of Hope Clinic’.

The service was operated by an individual provider who was a medical doctor. They had not put in place effective systems and processes to support service delivery. However, they understood the context in which they delivered care, treatment and support.

The provider had failed to identify and address gaps in governance and emerging risks despite this being a key leadership responsibility. However, they were committed to providing a compassionate and supportive service for people at a difficult time in their lives. People using the service described the provider as compassionate and capable.

The service did not employ any staff or contractors. The provider told us they would raise concerns if they became aware of any safety issues in relation to other agencies or services.

The service did not employ any staff or contractors.

Policies and procedures to promote workforce diversity and equality were in place should this change, although these had not been reviewed since 2019.

The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes.

The service did not have established processes to ensure policies contained relevant and up to date information. The service had a suite of policies and procedures which set out responsibilities, roles and systems of accountability. However, many policies had not been recently reviewed. For example, the service had a policy and system to record incidents, near misses and safety events but this had not been reviewed since January 2019.

The service did not have effective oversight of risk in the care environment. The provider had not carried out a fire risk assessment which is a legal requirement, although we noted that the fire extinguishers had been checked in the last 12 months. There were no documented risk assessments in relation to health and safety, premises and Legionella. Additionally, the service did not have effective oversight of infection prevention and control. There was no recent infection prevention and control audit.

The service did not have a policy to demonstrate what training was required to support the management of the service and the safety of people. There was no evidence to demonstrate if additional training was considered to support the provision of services or the frequency with which completed training should be updated. For example, safeguarding training was not up to date in line with guidance for clinicians.

The service had not documented specific treatment protocols enabling these to be systematically audited. The provider was not collecting systematic data on performance or outcomes aside from feedback from people using the service.

The service could not always evidence they had appropriate processes to support information governance. The service could not evidence information governance training had been considered or undertaken. Additionally, we were not fully assured that the electronic records system and digital communications were appropriately encrypted or protected. The service policy covering information governance (dated January 2019) stated that all emails containing confidential or personal information must be encrypted. We requested additional information about these arrangements, but this was not provided during or after our assessment. However, paper records were kept securely, and people’s identity was verified during remote consultations.

The service understood their duty to collaborate and work in partnership when appropriate. For example, to share relevant information with people’s usual GP (with consent) or in relation to people at risk of abuse.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not actively contribute to safe, effective practice and research.

Service development was driven by a focus on improving the experience of people using the service, meeting their goals and their satisfaction with outcomes. The service did not carry out more systematic audits or reviews of outcomes, performance or prescribing. The provider maintained their own professional development through self-directed reading. They had not arranged any formal supervision aside from their annual independent clinical appraisal.