108 Medical Limited - Harley Street

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. 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. 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.

The service was previously inspected under the old methodology in 2013 and was assessed as meeting all standards.

This is the first rated assessment for 108 Medical Limited – Harley Street service. This key question was rated good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 75 (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, equality and human rights, diversity and inclusion.

The service developed a strategic vision and objectives for 2025. Leaders described the service’s strategic vision for the year and said they had listened to staff, they had done this through staff forums for staff to share views and ideas for the future direction of the service.

Staff forums were in place to share information with staff and provided staff with an opportunity to become familiar with the vision and strategy of the service.

Staff we spoke with were positive about working in the service. Staff told us they were treated fairly and felt like being amongst family not colleagues. Staff consistently told us the happiest element of working in the service was teamwork and support from management.

The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff said there was consistent and visible leadership, who regularly communicated with staff. Staff respected the leadership team and spoke positively of collaborative work in all aspects of work. Senior staff supported their teams to be ambitious and persistent in their career goals. They helped staff to flourish in new roles through targeted personal and professional development training.

We noted that leaders of the service were clear and understood the remit of their roles and the scope of their responsibilities. The leadership of the service demonstrated an understanding of the challenges to quality and sustainability of the service.

The clinic manager told us there were systems to review the performance of the leaders and to continually develop their skills and improve the service, This was done through professional development training courses, conferences and workshops attendances.

Both clinical and non clinical staff we spoke with told us they were happy with their manager. Staff said, they had monthly supervision meetings with their managers and described the supervision and annual appraisal processes as useful. Staff set their own annual goals and reviewed progress during the year. Leaders acted on staff survey results to make improvements. For example, the manager told us how they developed and managed the staff rota to ensure the clinic is staffed safely as a result of patient feedback.

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

Leaders and staff understood the importance of staff being able to raise concerns without fear of retribution. Freedom to speak up notices were noted across the service to encourage staff to share their concerns. Staff we spoke with told us they had not needed to use the service as they had been able to raise concerns within their teams directly, and these concerns had been listened to and dealt with. For example, staff raised concern about breaks, which led to the introduction of flexible, self-managed breaks. All the staff we spoke with told us they worked in a culture were speaking up was encouraged and valued.

The service had policies to support people to raise concerns and for their concerns to be acted upon, these policies included a complaints procedure, incident reporting, sharing the investigation of incidents, and duty of candour and staff were aware of these policies.

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

Staff said they felt respected, empowered, and supported by colleagues and managers. All staff we spoke with told us the service valued diversity in their workforce and had embedded an inclusive and fair culture by improving equality and equity for its staff. Most staff told us there was a positive culture of diversity, equality and inclusion within the workforce. The clinic manager told us there was a positive culture of equality, diversity and inclusion across the workforce and that there was diversity across staff groups that matched the diversity of the patient group population. We were told training was available for all staff in equity, diversity and inclusion' (EDI). This was a mandatory requirement for all staff. Training compliance data showed a 98% completion rate for EDI training.

There was a policy and standard operating process for equity, diversity and inclusion. The policy supported recruitment from diverse backgrounds. Staff were able to request flexible working arrangements to work flexibly e.g. flexible working agreements to accommodate their personal circumstances such as caring responsibilities and health issues. Managers put reasonable adjustments in place for staff members to help them carry out their work.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They act on the best information about risk, performance and outcomes, and share this securely with others when appropriate.

The service had a documented governance structure with roles and responsibilities outlined for all staff to follow. A review of documents submitted following our visit showed the service had structures, processes and systems of accountability to support the delivery of the service. This included a meeting structure which gave senior leaders and managers regular opportunities to discuss operational issues. Staff were clear about their responsibilities to escalate risks and issues to the management. The reporting structure demonstrated how staff and patients feedback was escalated and included pathways to demonstrate how information was fed back down to staff.

The clinic manager told us that governance processes were used to support learning, improvement and promote innovation. We noted that, the management had a range of data and information available to understand the service’s performance. This was shared with staff groups, including clinical staff, so that the service could be developed, and improvements could be made. For example, the clinic manager shared performance data with the MAC members through governance meetings. This was to ensure MAC had oversight of their performance. The performance data showed where progress had been made and where there were new challenges so the teams could see what areas they needed to be most responsive with.

The governance assurance framework was supported by the medical advisory committee (MAC) meetings and clinical governance committee meetings. We reviewed the minutes of these meetings for the past six months and there was evidence of the actions taken to address compliance within the services. Management of risk, issues and performance was discussed at MAC meetings and staff had access to the risk register for ongoing monitoring of risks and performance.

They were quarterly governance meetings that all key staff attended including representatives from finance, booking, and quality and safety. Minutes of the meeting reviewed showed key areas of performance, risk, quality, safety, culture and workforce were discussed at these meetings. Areas of concern were identified, and actions were taken to learn and improve.

The service provided information relating to radiation governance arrangements. The service held Radiation Protection Committee (RPC) meetings every month. The meeting was attended by the senior management team and clinical imaging staff, Radiation Protection Supervisor (RPS), Lead Radiologist and Radiation Protection Advisor (RPA). The agenda for this meeting included safe radiation doses and diagnostic reference levels. The appointment of RPA and RPS and the availability of Local Rules was a legal requirement where there were controlled areas of radiation. The RPS role ensured the local rules were enforced to keep patients and staff safe.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

Senior leaders of the service engaged with a local acute independent hospital and other referring clinicians. They shared clinical expertise and recent innovations to support their services.

Patients told us they had been referred to the service by their friends or through a web search, and they said, they had received information from the service with a date of their appointment. People confirmed they had been asked to confirm information about themselves, the procedure and their health prior to their diagnostic test. Patients said following their diagnostic test they had a further appointment booked with their consultant who would discuss their results and if required any further treatment.

The service focused on continuous learning, innovation and improvement across the organisation.

Staff told us there was a culture of learning and improvement within the service. The clinic manager valued the contribution, abilities and professional development of each staff and provided them with opportunities in clinical specialties and leadership development.

There was a service wide quality improvement plan that identified areas of improvement through review of guidelines and audits. This supported the delivery of evidenced based care and treatment to patients. Quality improvement programmes related to day-to-day practice such as ensuring documentation guidelines were followed and the booking process followed the providers policy documentation and record keeping.

Staff were involved in developing and evolving improvement strategies for specialist services to improve patient care, including access to treatment options. Staff felt the managers were open to suggestions for improvement and facilitated improvements suggested by staff. For example, managers agreed to make changes to pre-assessment forms following staff suggestions from staff.