Renew Skin & Health Clinic Limited Ltd

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

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care. We checked that leaders proactively supported staff.

This key question has been rated requires improvement. This meant there were shortfalls in service governance. Leaders did not assure the delivery of high-quality care.

The service was in breach of legal regulation in relation to the quality of the governance of the service.

This service scored 61 (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 formal strategy to support the vision for the service.

The vision of the service was to provide competitively priced cosmetic and other health care services to the local community. There was a strategy to support the vision that managers told us about however, this was not written down. The strategy focussed on the development of a service which enabled people to access competitively priced treatment without long waits.

Staff told us they worked in a supportive environment where there was mutual respect for each other’s culture and background. They said they helped each other out at busy times. One person said, “I feel safe at work, sometimes I work alone but I am very safe. [Name] will check in on me and make sure I'm okay.” Another member of staff who said they felt well supported said, “I can talk to [name] about how I'm feeling, they will take an interest and take actions if anything is needed.”

Leaders did not always have the skills, knowledge, and experience to lead effectively.

The registered manager had online management training but did not have the experience skills and knowledge to manage effective governance processes. However, they demonstrated a willingness to learn and improve. In the time between our 2 visits, they had implemented some changes to improve governance.

Staff told us leaders were visible and approachable. Leaders worked alongside staff.

One member of staff told us “they took a personal interest in my situation when I had some difficult things going on.” and “I have high regard for both of the managers.”

The service fostered a positive culture where people felt they could speak up and their voice would be heard. However, there was not a formal process for staff to use a speaking up service at the time of our inspection.

Staff told us they would be able to raise any concerns they had with managers. They also told us they had access to a dedicated raising concerns hotline through their previous human resources provider. They said they had a brand new outsourced human resources provider. They were waiting for the new staff handbook, and assumed rather than knew if they would continue to have access to a facility where staff could speak up safely.

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

Managers told us that staff came from a range of different countries and had a range of ethnic backgrounds and experiences. They told us they celebrated all the different cultural and religious festivals together.

Staff told us they were treated equally and fairly. They said they valued each other’s differences and worked together well as a team for the benefit of patients.

Staff said they were able to work flexibly when they needed to attend important personal appointments.

The service did not always have appropriate systems of accountability or good governance. Staff did not always act on the best information about risk. However, staff had clearly defined roles and responsibilities.

The structures, processes and systems of governance were not always effective to support improvement and the safe delivery of the service. There was an informal and limited governance structure.

There were limited and insufficient processes to ensure doctors working under practising privileges or the technicians who supported hair transplant surgery had the necessary skills, knowledge, and experience, or were safe to work in the clinic.

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 did not have a risk register. There was a risk assessment file but this did not provide oversight of the main risks effecting the provider. This meant the likelihood and potential impacts of a range of risks to the safety of the service were not clearly defined and consequently there were no mitigating actions.

We saw evidence some audits were undertaken. However, systems were not always used to effectively monitor and improve the compliance with audits. For example, the outcome of audits had not been mapped to historical audit data to help drive improvement, and there were not any action plans to demonstrate how improvement in compliance was going to be delivered and in what timeframes. For example, checks on the environment and infection prevention and control audits had taken place and records had been kept, but they had not been collated to demonstrate if there were themes or trends in issues requiring improvement.

However, when we returned to the clinic for our second visit, we saw development in the management of audits and a new structure of meetings designed to improve the governance of the service and ensure safe patient care. These meetings included a risk management meeting, a meeting for incidents and action plans, and a general governance meeting designed to cover a range of topics including safer recruitment.

The provider had a service level agreement to purchase pathology services from a local trust. We saw the service level agreement was up to date and stored safely. There were systems to ensure servicing of equipment took place within manufacturers guidelines.

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

Staff and leaders understood the importance of working in partnership. For example, doctors shared information about risk, and about the diagnosis of conditions that required treatments outside of the scope of the clinic with patients' GPs. For instance, if the clinical pathology of a lump or bump diagnosed disease that required specialist intervention, this would be referred to the GP.

The service focused on continuous learning, and staff encouraged creative ways of improving quality of life for people.

Staff had monthly teaching sessions focused on improving their knowledge and skills about the procedures and treatments offered in the clinic to enhance patient care.

Staff told us they were encouraged to innovate. An example of this was looking at ways to reduce the use of paper to become a more sustainable service. A member of staff was actively engaged in researching data handling tools for patient files to reduce the use of paper in patient records.

We saw the service was committed to learning and improvement. We gave feedback following our first visit regarding the governance system and saw at our second visit they had made improvements to this, by creating a new governance structure and improving the auditing process. We were given assurances changes to the recruitment process for staff employed under practicing privileges had been made, and a new process for the employment of technicians to support hair transplants would be introduced.