The Newcastle Clinic

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 assessed all 7 quality statements from this key question for the service. This means 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 for this service. This key question has been rated requires improvement. This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of legal regulations in relation to good governance as systems and processes to monitor and improve services were not always effective.

The service was in breach of legal regulations in relation to fit and proper persons employed as they did not operate robust recruitment and ongoing monitoring processes to ensure staff had the right qualifications, competence, skills and experience for the work to be performed by them.

This service scored 36 (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 did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not understand the challenges and the needs of people and their communities.

The service did not have a formal vision and strategy policy in place. Staff and leaders were unaware of any vision or strategy. Therefore, could not understand how their role helps in achieving vision or strategy. Staff were unable to list the values that underpinned the service.

Staff were unable to provide any examples of engagement with NHS providers, referring clinicians or patients to shape the future or make changes to the service.

Staff told us they had no opportunity to contribute to discussions about the strategy for their service.

Staff spoke positively about working in the department. They told us that they loved working at the service, and they felt supported by their peers but felt the provider had left them isolated with little or no communication, leadership or direction. They told us they had been without a registered manager for over 12 months and were unclear who was leading the service in the interim.

The service did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment, and support, or who embodied the culture and values of their workforce. Leaders did not have the skills, knowledge, experience, and credibility to lead effectively.

Staff told us they did not see the company Director regularly, so they were unsure if their voices or feedback was heard at that level. On the day of the visit, the service underwent a change of company Directors.
Staff and leaders told us they did not have job descriptions. Not all staff were clear about their roles and accountabilities, and it was clear that staff did not meet regularly to discuss and learn from the performance of the service.

The service had no registered manager in post, but the clinical lead had applied for the role. However, because they were the only current permanent radiographer it was unclear how they would fulfil the role. The service had a nominated individual in post, but they only worked 1 day per week and performed a clinical role, and they told us they had little time for management tasks.

Leaders did not understand their management responsibilities in relation to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. They did not fully understand the risks to the service and had no clear oversight on safety, governance and performance issues and quality monitoring.

Staff and leaders told us there were no leadership development opportunities.

People did not always feel they could speak up and that their voice would be heard.

The service did not have a freedom to speak up policy. We did not see how staff were encouraged to raise their concerns. This was not physically promoted in the service. For example, we did not see any posters on the walls or in the staff areas.

Most staff told us they felt confident they could raise any issues with their manager and that managers listened to them. However, they felt that their concerns were not listened to by the owner of the service

There had been 3 whistle blower concerns received by the Care Quality Commission relating to this service during the past 12 months in relation to the governance and management of the service.

The service did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The service did not have an equality, diversity and inclusion policy and they could not evidence how it would be incorporated into their recruitment processes.

The service did not carry out annual staff surveys to gain feedback from various staff groups about their experiences.

Equality and diversity training was mandatory for all staff. However, unvalidated mandatory training compliance data showed equality and diversity training to be at 33%.

Most staff told us the service had an inclusive working culture, and they were treated with respect and equity. All the staff we spoke told us they had not experienced any instances of unfair treatment, discrimination or harassment.

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, or share this securely with others when appropriate.

The structures, processes and systems of governance were not effective to support improvement and the safe delivery of the service. There was an informal and limited governance structure. There were no daily safety huddle meetings, routine clinic staff meetings, clinical governance and performance meetings or MAC committee meetings to review information.

The service did not have a formal policy or process detailing how fit and proper persons checks were undertaken for directors and staff. The fit and proper persons files for the 2 company directors could not be located and leaders could not confirm checks in line with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 5 requirements for fit and proper persons; directors had taken place.

We reviewed 8 staff recruitment files during our assessment. We found that the service did not follow its own recruitment policy and there were significant gaps in every staff recruitment file we viewed including but not limited to missing DBS certificates, qualifications, employment histories, health declarations and identifications.

There were limited and insufficient processes to ensure doctors working under practising privileges had the necessary skills, knowledge, and experience, or were safe to work in the clinic. The service did not follow its own recruitment policy and had no medical advisory committee (MAC) in place to authorise the formal granting of practicing privileges and there was no documented evidence in staff files.

Staff did not participate in quality monitoring and audit processes. They told us their performance was not routinely monitored and that no clinical audits had been undertaken since 2023 to aid learning and improvement within the service.

Leaders did not understand the key risks to the service and did not maintain a risk register. Staff were not aware how to record and escalate key risks.

The service was not signed up to receive Central Alerting System (CAS) safety alerts that would help ensure up-to-date guidance was followed. CAS alerts are web-based safety alerts, including National Patient Safety Alerts sent to NHS and other healthcare providers.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people.

People told us care and treatment was well co-ordinated between the service, their referring clinician and partnering NHS trusts. They felt there was timely communication and sharing of information about their care and treatment between the services.

People spoke positively about being able to access treatment within their local area and told us this was convenient and reduced travelling times.

Other partners who worked with the organisation told us they had no concerns raised with them regarding the service.

The service did not focus on continuous learning, innovation and improvement across the organisation. They did not encourage creative ways of delivering equality of experience and outcomes for people. They did not actively contribute to safe, effective practice.

Leaders did not have a good understanding of how to make improvements happen. Staff were not supported to develop their skills around improvement and innovation.

Staff and leaders did not engage with external work, for example embedding evidence-based practice in the service.

The service did not have processes in place to ensure learning happens when things went wrong. Leaders did not encourage reflection or collective problem-solving.

Leaders did not have a robust process for ensuring mandatory training was completed or to ensure bank staff had completed mandatory training.

The provider had removed all funding for training from staff.