The Fertility & Gynaecology Academy

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• 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

There were governance shortfalls, including lack of oversight of staff training and compliance with schedule 3 of the Health and Social Care Act. Leaders lacked consistent oversight of operational risks, and they did not use the risk register to understand the ongoing risk to the service. Equality impact assessments of polices had not been undertaken. However, leaders were visible and approachable and understood their responsibilities under the HFEA regulations.

The last assessment of this service on 16 January 2014 was under an old methodology and was not rated. This is the first time this service had been rated. We rated well led as requires improvement.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

The service did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

The service did not have a formal vision and strategy for the clinic therefore could not share their vision with staff. The registered manager told us they planned to continue as they were, providing patients with the current service and there were no plans to extend this in the future. They did not have an action plan showing how they would build a culture based on equity and equality and engage with staff and patients to do so.

Leaders did not have oversight of risks to the service or understood the regulatory requirements to comply with legislation.

Leaders did not have a good understanding of the risks within the service or the actions being taken to mitigate these. The senior leaders were not aware staff had not completed their mandatory training and did not understand the risk this posed or take immediate action to resolve the concerns.

Leaders did not demonstrate consistent insight into the operational risks impacting on their frontline services. Systems to identify and manage risks were not consistently used and meant risks were not identified. There were shortfalls in governance which impacted on how leaders-maintained oversight of the quality and safety of services. For instance, the lack of oversight of recruitment led to basic background checks not being carried out. These concerns were not recognised as risks and no action was taken to mitigate the risk.

Leaders were visible in the service and approachable for patients and staff. Staff told us they were able to speak with the registered manager to discuss concerns, ideas or development opportunities.

The service had a whistleblowing policy which provided staff with details of reporting channels, so they knew who to raise their concerns to. It outlined a timeframe for acknowledgement of the concerns raised but not a timeframe for concerns to be investigated. The policy stated that staff would remain anonymous and protected against retaliation. However, it did not cite national guidance which might provide additional assurance to staff.

Staff we spoke with told us they felt comfortable reporting any incidents or concerns and that leaders were approachable. This showed incident reporting was embedded with staff and they were not afraid to raise concerns.

The service did not have a freedom to speak up guardian.

The service had a multicultural and diverse workforce that was representative of the patient body. Not all staff had completed equality and diversity training.

All nursing staff employed were foreign nationals and had the appropriate documentation in place showing their right to work in the UK. The 2 healthcare assistants were registered nurses overseas and were working on gaining their UK registration in order to work as a registered general nurse. Leaders supported and sponsored staff to do this and staff told us they were given time and supported to achieve this.

The service employed staff from different backgrounds and as a small body of staff, it was culturally and ethnically diverse which was reflective of the diversity in the patients accessing the service. Staff in the clinic spoke many different languages and could help put patients at ease when they were able to speak with someone in their own language.

It was reported staff received equality and diversity training as part of their mandatory training, however staff had not completed this meaning staff may not fully understand what it meant to work in a fully equitable service and how this might impact patient care.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Staff and leaders told us performance and learning was shared at staff and governance meetings. We requested to see the minutes of these meetings to review how information was shared but these were not provided. Therefore, we were not assured regular meetings took place with a standard agenda allowing for updates, learning and performance to be discussed with staff.

We were not assured leaders had oversight of the risks to the service. A risk assessment tool was used to identify risks however there was only one risk identified around the introduction of an online document sharing service. This was due to be completed in July 2021. It had not been updated to reassess the risk or remove it if necessary. No other risks had been identified which was not consistent with the risks we identified, for example the lack of disclosure baring service checks on staff employed. This meant leaders were not using governance tools effectively in order to improve the service.

The service had audit calendars listing different audits to be undertaken, their frequency and when they were due. The quality manager had oversight of this and maintained the records which showed all audits due in January 2026 had been undertaken. The nursing audit schedule listed the audits nursing staff had to undertake, including handling of clinical equipment and record keeping. It was clear when the audit was due, referenced the policy or SOP it was aligned to and whether it was required for compliance with regulators. However, the audit of the resuscitation equipment showed that medications were in date and the equipment was functional. This is not what we found during out inspection where we found the resuscitation trolley was broken and medication was out of date.

The service had a non-clinical emergencies SOP which outlined what action staff needed to take and who to contact. Names and numbers of leaders were listed, and it was clear for staff how to escalate concerns. The business continuity plan detailed what action would be taken in the event of the premises having to close unexpectedly. There was a contract in place with a local provider who were a HFEA licensed centre to provide a continuation of service.

The service did not work with partners or communities regarding activity regulated by the CQC.

Leaders told us they had reciprocal agreements with partners to provide a continuous service in the event of an unexpected clinic closure. Leaders understood the risks and impact on patients if facilities failed or appointments delayed. Agreements were in place with other licensed providers meaning patients’ treatment was prioritised. However, this was not activity regulated by the CQC.

The service focused on continuous learning and improvement across the organisation. They did not always encourage or actively contribute to safe and effect research.

The clinic learned from incidents and complaints in order to improve the service. The incidents and complaints received over the last 12 months were not about activity regulated by the CQC, however staff were able to tell us about improvements the service had made to improve the experience for patients. For example, the service shared learning with staff about the importance of checking patients’ identification so that it matched the information on the patient registration forms. This was after an incident where a patient used a different name to that on their identification. This had potential impact on sharing information with other providers and gaining access to test results. We were told learning was shared at a staff meeting where they were reminded of the importance of checking identification and that patient registration could only be completed once identification had been checked. However, we were not sent minutes of staff meetings showing evidence learning was shared.

The service participated in national audits as part of their regulated activity under HFEA. Leaders told us they received updates from HFEA and when they needed to take action, the quality manager would inform the registered manager and together they would work to ensure all updates were completed and improvements were made. The provider did not take part in any national audits regarding activity regulated by the CQC and were not able to show any quality improvements made as a result of audits undertaken.

The service did not participate in research themselves, but leaders told us they attended conference to keep up to date with new and innovative ways to work. Meaning leaders could review current practices and introduce new ways of working when they believed change was needed, however, they did not provide any examples of them doing so.