Balance My Hormones

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

At our last assessment, we rated this key question as Good. At this assessment, the rating remains Good.

This service scored 68 (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 shared vision, strategy and culture. This was based on transparency, equity, inclusion, engagement, and understanding challenges and the needs of patients and their communities.

Staff had contributed to the development of the practice vision and strategy, which was kept under review.

The provider had recruited to ensure that clinical leadership was in place, and it was working with staff and peers to address future challenges.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment, and support, embodying the culture and values of their workforce and organisation. Although leaders had the skills, knowledge, experience, and credibility to lead effectively, and the provider had sufficient managerial and clinical leadership capability, the quality and safety of some clinical care components were not effectively monitored, which we have identified as areas for the provider to improve.

Clinical leadership and non-clinical staff conducted a doctor's clinical record-keeping audit to ensure specific metrics were recorded in patients' clinical records. However, the audit design could not distinguish between initial and follow-up consultations, affecting the clarity of information recorded. The provider stated that psychological history was revisited at each consultation. However, audits indicated 80% of consultations for two doctors did not have any psychological history recorded. We have identified clinical record-keeping auditing as an area for the provider to improve.

Auditing of clinical care and treatment was limited to patient-reported outcomes and lacked discussion of findings, potential improvements, recommendations for changes, or re-audits to assess impact. This meant the provider was not routinely using audit to improve patient care. We have identified the auditing of clinical care as an area for the provider to improve.

Management staff capability was appropriately deployed to oversee the quality and safety of management processes and outcomes, in conjunction with senior leadership and non-clinical staff.

Staff reported that leaders in the service were approachable and responded to any concerns raised. Staff suggestions for improvements were listened to and implemented where appropriate. Staff felt valued, listened to, and supported by their colleagues, as well as the leadership and management teams.

Immediately after our assessment, the provider sent evidence of an action plan designed to improve the clinical care and treatment component of auditing.

The provider had a freedom to speak up protocol and fostered a positive culture where patients and staff felt they could speak up and their voice would be heard.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for patients who work for them.

Some arrangements to ensure clear responsibilities, systems of accountability, and good governance were in place. Non-clinical managerial arrangements to implement or sustain necessary improvements were effective. However, clinical governance, identified as an area for improvement following our October 2022 assessment, had not fully improved in line with best practice guidelines. We have identified clinical governance systems and processes as an area for the provider to improve.

All staff we spoke with were clear on their individual roles and responsibilities. Management staff were updating the provider’s organisational chart to reflect changes since the service had experienced considerable growth and transitioned into a fully integrated digital healthcare service. The provider demonstrated it was able to extract clinical and other data intelligence from its IT systems to implement and track improvements, including in patient outcomes, in line with service growth.

The provider demonstrated it was able to extract clinical and other data intelligence from its IT systems to implement and track improvements, including in business processes and patient outcomes, in line with service growth.

Managerial and some clinical oversight arrangements to implement or sustain necessary improvements were effective. This included business continuity planning, and improvements relating to our previous inspection and during this assessment process. We noted improvements in areas such as safety alerts, GDPR, arrangements for patient translation services, safeguarding, recruitment of clinical lead staff, and implementing procedures for potential patients that may need translation services or have a learning disability.

There were regular clinical and other meetings where learning was shared, and improvements agreed upon. The provider implemented a framework to ensure essential issues were considered at meetings and agreements noted to ensure follow-up.

The provider had recently evolved and integrated non-clinical staff in-house as part of the patient care journey. However, clinical leadership did not (or did not always) assess and monitor the quality and safety of the patient/non-clinical staff component of the care pathway, to identify and manage risks.

Although there was a protocol for non-clinical staff to follow, not all non-clinical staff managing patient’s communications were aware of it, and it did not contain essential guidance on urgent and emergency symptoms or arrangements for direct involvement from a doctor. We have identified clinical oversight to monitor and assess the patient/non-clinical staff component of the care pathway as an area for the provider to improve.

The provider made statutory notifications to the CQC as required or in line with best practice. Staff were in the process of ensuring their CQC rating was displayed on their website in line with legal requirements, following the provider recently evolving into a fully integrated digital service.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for and with its patient community.

The provider had a significant presence on social media, posting information and videos that complement the guidance leaflets accompanying injectable testosterone delivered to patients. These videos demonstrated the method of administering the injection.

Positive patient feedback highlighted prompt medication delivery and excellent support, with easy contact options and responsiveness to policy changes and medication shortages, indicating the provider had effective systems to work seamlessly with its in-house pharmacist, patients, and medicine suppliers.

The provider considered patients at risk of not affording the annual fee due to the cost of living crisis and changed its system to allow monthly payments without any extra cost.

Although there were shortfalls in clinical governance systems and processes, we considered that since the previous inspection on 10 July 2023, the service had experienced considerable growth, and had transitioned into a fully integrated digital healthcare service and was committed to continuous learning, innovation, and improvement.

The provider encouraged creative ways of delivering equality of experience, outcomes, and quality of life for patients. The provider's further plans for learning, improvement, and innovation included forming further partnerships with other services, establishing a Caldicott Guardian, exploring ISO 2000 certification, developing a clinical support plan for new patients, and sustaining a strong social media presence. The provider had established procedures and processes to support patients requiring assistance with injections, that they told us included home visits for patients needing assistance with injectable testosterone dose administration.

The provider informed us that, in relation to injectable testosterone replacement therapy, a “one ampoule, one dose” approach was used. This was to manage and mitigate the safety risks associated with patients decanting testosterone into empty containers, enhancing patient care and safety.