Archived: The Pemberdeen Laser Cosmetic Surgery Clinic Limited

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 there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. However, we could not find evidence of this. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities. However, we found significant shortfalls in the service provision.

The key question was previously rated as requires improvement. This key question has been rated inadequate. This meant there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of regulations for people’s safe care and treatment the premises and equipment used within the building, staffing , the ways people’s medicines were managed safely and the governance at the service. We requested further information from the provider to address these concerns.

CQC has taken regulatory action in relation to the concerns that we found. We may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The evidence showed significant shortfalls. The service did not have a shared vision, strategy and culture based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. We asked the clinic manager for the statement of purpose, a document outlining what the service provides and their aims and objectives, they stated that the service did not have one. We asked for a copy of the services vision, values and or mission statement and were told they did not have one. However,staff could explain how they were working to deliver quality care to the standards of the staff working at the service.

The evidence showed some shortfalls. Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, or experience to lead effectively. Senior leaders at the time of the inspection were non clinical and therefore whilst they understood the services and the regulations there was no one with clinical oversight of the service. There were limited opportunities for leaders or staff to develop. There was limited evidence of how staff were included to develop services although staff felt valued and respected buy leaders.

The evidence showed some shortfalls. The service fostered a positive culture where staff told us that they felt they could speak up and their voice would be heard. However,patients and carers were not given opportunities to give feedback on the service they received in a manner that reflected their individual needs. Patients and carers were not involved in decision-making about changes to the service. There is a freedom to speak up policy but we did not see this and staff could not access this policy.

The evidence showed significant shortfalls. The service was unable to demonstrate it they valued diversity in their workforce. The recruitment policy indicated that the service worked towards an inclusive and fair culture by improving equality and equity for people who work for them. However, there was a lack of evidence in the recruitment files of the small number of staff which were employed by the service. The "Bank Recruitment and HR Requirements" policy did not reflect the opportunities for staff to be recruited in an equal way or that the service valued diversity. There we no equality and diversity champions within the service. We saw no flexible working agreements to account for personal circumstances such as caring responsibilities and health issues. The provider did not undertake equality monitoring of staff within the service to ensure it is diverse in its make-up and is representative of the patient group.

The evidence showed significant shortfalls. 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. There was a Quality, Governance, Patient Safety and Risk committee whose agenda and minutes contained a framework of essential information. However, there had only been one meeting which did not have representation from all areas of the service. The minutes of this meeting were provided but no supporting evidence of the audits being undertaken. When asked, the clinic manager stated that they had not undertaken a patient records audit, yet the outcome of this was discussed at the meeting at which they were present. We were sent a blank medical records audit form as evidence that this had been completed. There was no learning identified from this meeting and it was not clear how this information was shared with the wider team. Staff did not participate in local clinical audits nor were they aware of any of the risks we identified apart from the out of date medication which we alerted staff to. Staff told us that information from the senior leadership team came to them via a group text message.

Our inspection identified a number of concerns and breaches of regulation that put people at risk. The provider’s governance processes had not identified these issues or improved them.

The evidence showed significant shortfalls. The service did not always understand their duty to collaborate and work in partnership, so services work seamlessly for people. They shared information with and from the third part provider that conducted assessments of patients. However, there was no evidence that there was sharing of leaning to drive improvements in patient selection or quality of care between parties. There were no contracts with providers of services to support the hospital in providing safe and effective care. Therefore, there were no feedback mechanisms in place to share learning or improvements required to enhance patient care.

The evidence showed significant shortfalls. The service did not focus on continuous learning, innovation and improvement across the organisation and local system. There was no evidence that the service encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research. It was unclear how the service provided opportunities for staff to develop and learn about improved practice. Most staff could not explain how they were assured that their practice was up to date.