Staianoplasticsurgery

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 patients who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant the service was consistently managed and well-led.

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 demonstrated a clear, shared vision and strategy, with a culture that prioritised patient‑centred care, openness and staff engagement.

Leaders ensured there was a shared vision and strategy and that staff knew, understood and supported the vision and values. Regular updates from senior leaders ensured staff felt informed and included.

Staff felt respected, supported, and valued. They were focused on the needs of patients receiving care and worked well together to ensure they achieved good outcomes for patients. Staff were positive and proud to work in the organisation.

Staff and leaders demonstrated a positive, compassionate, listening culture that promoted trust and understanding between them and patients using the service and were focused on good outcomes. Staff told us managers really listened to them and made changes where possible. Staff we spoke with were proud to work for this service.

The service was led by an inclusive leader who understood the context in which care was delivered and promoted a positive culture based on openness, honesty and integrity. Staff told us the leader was supportive and felt the service was well led, and patients achieved good outcomes.

The clinic was owned by the lead consultant surgeon who was also the registered manager. There was a clear structure in place showing the staff roles and responsibilities.

Leaders were visible and led by example, modelling inclusive behaviours, such as encouraging all staff to contribute to discussions and valuing different perspectives in decision-making. We were told they interacted with every patient. It was clear how important patient care was to the leaders. Colleagues reported that the leaders were excellent mentors, very capable and were conscientious and excellent colleagues.

Leaders were knowledgeable about issues and priorities for the quality of services. They led with passion and enthusiasm for the service.

The service fostered a positive culture where patients felt they could speak up and their voice would be heard.

The staff and leaders acted with openness, honesty and transparency. They encouraged staff to speak up and all staff were confident their voices were heard. Staff had a weekly meeting and they all felt any issues could be raised at this meeting. We were told all team members, including the leaders were approachable and they could raise concerns without fear of detriment

The service valued diversity in their workforce. The service had an inclusive and fair culture by ensuring equality and equity for patients who worked for them.

The team were a small team of 4 and described themselves as a “family”. Leaders ensured there were effective and proactive ways to engage with and involve staff. Staff felt empowered and were confident that their concerns and ideas resulted in positive changes to shape services.

The service did not have clear responsibilities, roles, systems of accountability and good governance. Staff acted on the information they had about performance and outcomes but risks within the clinic were not identified.

Governance systems were not effective in identifying the risks and shortfalls found during the inspection. There were no clinical governance meetings in place. The lead consultant chaired an annual medical advisory committee (MAC), with input from the nurse and the clinic manager. These meetings were intended to review complications, revision rates, outcomes and annual appraisals for each surgeon. However, minutes were brief and did not demonstrate detailed discussion or oversight of clinical outcomes. For example, one consultant had a revision rate of 21%, but there was no documented analysis of the reasons for this, the nature of revisions or how this would be monitored and improved. The lead consultant told us the discussions were minimal as there were no concerns to be discussed and they were happy with the patient outcomes.

Although the service held weekly team meetings, these were not minuted and did not include regular discussions of governance issues such as risks and audits. We were told these were discussed when issues arose. However, not all staff members could provide examples of identified risks or were aware of the risk register. Staff explained that, due to the small team, discussions took place informally during weekly meetings without an agenda or records. This reliance on informal communication meant not all staff were consistently sighted on key issues, including risks and audits within the service. Following the inspection, the manager told us the meetings were going to be minuted.

The service did not have an effective system for managing policies and procedures. There was no version control process in place, and not all policies included a review date or version number; where dates were present, several were over 3 years old. There was no formal policy review schedule, and although staff told us policies were updated when changes occurred, this was not evidenced. Policies lacked sufficient detail and clarity, and the service did not always follow its own guidance. For example, a clinic meeting policy required meeting minutes to be recorded; however, this did not occur and their fire policy stated an external fire risk assessment should be completed annually and there was no evidence this had taken place. We identified several policies that were out of date and inaccurate. Following the inspection the service were going to complete a full review of all of their policies to ensure they were dated, had version control and were up to date. We saw some policies which had been updated including the infection prevention and control audit.

Quality monitoring audits were not robust and failed to identify a number of concerns. The audits completed were minimal and did not cover all aspects needed to ensure the service was safe for patients. There was a lack of oversight of issues surrounding risk, health and safety, and infection control which were not picked up through regular audit.

There was a risk register for the clinic, but it did not contain all the risks for the clinic on it. For example, there were no risk assessments for the carpets, needlestick injuries, or a building fire risk assessment. Where risk assessments were complete, there were risk controls in place but these lacked detail. We were not assured that all staff were fully aware of the risks within the clinic and all necessary mitigations were in place to reduce potential harm to patients and staff. The service told us they were going to do a full review of all of the risk assessments within the clinic.

There was limited staff understanding of the duty of candour, which indicated gaps in governance and compliance arrangements.

There were good arrangements for the availability, integrity and confidentiality of data, records and data management systems. Information was used effectively to monitor and improve the quality of care.

The service had service level agreements, and these were well managed and reviewed regularly.

The service took steps to improve sustainability by reducing paper use and moving towards a paperless system, including the use of electronic consent forms. Recycling arrangements were in place for cardboard and plastics. Contingency plans were also established to ensure service continuity, including printing essential clinic lists in advance in case of system outages.

The service worked collaboratively with partners to ensure care was joined up and seamless for patients. Staff shared information and learning to support service improvement.

Leaders and staff were open and transparent, working with relevant external stakeholders to support care provision and service development. They also engaged with patients and professional networks to share learning and identify innovative approaches to improve outcomes.

The service focused on improvement across the service and actively sought feedback. Staff encouraged creative ways of delivering equality of experience, outcome and quality of outcomes for patients.

The lead consultant held a weekly social media question and answer session which was open and transparent. We were told there was good engagement from patients and prospective patients with this.

The service has strong external relationships that support improvement and innovation. The leaders engaged with external organisations such as the British Association of Aesthetic Plastic Surgeons (BAAPS) and Consortium uniting Aesthetic Plastic Surgery Clinic Owners (CAPSCO) which enabled regular peer discussion and a platform to share learning. The lead consultant was also interested in helping other doctors grow their private practice and participated in a weekly podcast sharing learning and encouraging improvement.

Leaders encouraged staff to speak up with ideas for improvement and innovation and actively invested time to listen and engage. There was a strong sense of trust between leadership and staff.

The service were pioneering a ‘see and treat’ service to simplify and accelerate the pathway from treatment to solution for minor operations. This was where patients could have their treatment the same day as their initial consultation for minor procedures.