The Hair Dr, Leeds Private Hospital

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 assessed 7 quality statements from this key question. We looked for evidence there was an inclusive and positive culture of continuous learning and improvement based on meeting the needs of people who used services and wider communities. We checked leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

This is the first inspection for this service. This key question has been rated Requires Improvement.

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 did not have a clear shared vision, strategy and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement.

Leaders said they had a clear vision and strategy for the service which had been in place since 2024. Leaders articulated that they wanted to be a market leader in hair transplant. They also wished to expand the service to include more aspects of cosmetic surgery.

The vision and strategy included reference to transparency, diversity and inclusive care but did not include any mention of equity, equality, and human rights.

We observed posters which showed the values, vision, and mission statement for the service.

We saw no evidence of staff involvement in vision, strategy or values nor did any staff articulate how they were involved.

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, experience and credibility to lead effectively, or they did not always do so with integrity, openness and honesty.

Leaders told us that there was a positive staff culture, and that a recent staff satisfaction was undertaken and a report to the Governance Committee showed high satisfaction with structures and morale. We requested a copy of the completed survey, but this was not provided, we also failed to see where this had been shared with staff. Therefore, a positive staff culture was not evidenced sufficiently.

We reviewed the RMs file which had training certificates missing which meant that we did not have assurance that their records were accurate and up to date. Following inspection we were informed that this was due to a clerical error and up to date certificates were provided.

People did not always feel they could speak up and that their voice would be heard.

Staff said they would find it difficult to talk to the leaders about any concerns they had.

Staff also said that they felt that the CCTV and audio recording throughout the building impacted on their ability to speak freely and without fear of a negative consequence.

A Freedom to Speak Up (FTSU) Policy was in place. We reviewed a report from the service describing recent governance meetings, we saw there was no evidence of any discussion regarding FTSU themes and actions.

The Registered Manager said all staff can raise any risks or ask questions at the staff meeting, however, the minutes provided were bullet points only with no comments from staff. We saw no evidence within these minutes of staff bringing any concerns or issues to the meeting and there was no discussion regarding themes and actions from FTSU concerns.

Leaders told us staff were empowered to raise issues in a no blame culture. The staff handbook informed staff that there was a designated freedom to speak up champion who was independent of line management and the leaders had an open-door policy.

FTSU notices were in place around the building.

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

Leaders and staff demonstrated an understanding of equality, diversity, and inclusion. Staff received relevant training, and care was delivered in a culturally sensitive and inclusive manner, reflecting the diversity of both the workforce and the whole population.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. Staff did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Staff were clear about their roles and responsibilities; however, we were not assured there was regular opportunities to meet and learn from the performance of the service. We were told the service held monthly staff meetings where staff discussed clinical issues. On review of meeting minutes we saw that only a list of the issues/topics discussed was recorded with no detail of the discussion, therefore we did not receive assurance regarding what was discussed.

The service had a risk register which identified controls in place to mitigate against the impact from risks. However, this was not up to date with no date of entry and no review date allocated which could mean the service would potentially be exposed to unexpected hazards affecting people and staff wellbeing.

We reviewed leaders’ personal records and found an out-of-date DBS check and references that had not been checked. This did not provide assurance that all appropriate checks had been completed as described in both the provider’s recruitment policy and CQC regulations. We were provided with an up to date DBS check following inspection.

The Clinical Director had membership of appropriate organisations which were designed for surgeons not working in NHS. All training was up to date, and they had fulfilled their GMC revalidation requirements.

Leaders described the governance process for the service and provided minutes of Governance and Medical Advisory Committee minutes.

The staff handbook described in detail the clinical governance structure.

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

Leaders understood the importance of working in partnership. For example, the service shared information about people’s treatments with their GP’s. If people were required to visit other health providers, the service provided information for them to take which explained the procedures they had undergone.

The service had a focus on continuous learning, innovation and improvement across the organisation and local system. Staff did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. Staff did not always actively contribute to safe, effective practice and research.

The governance process which was in place provided a structure for developing and learning.

The service detailed an extensive audit programme covering a multitude of different areas to monitor and drive improvement. We requested copies of audits throughout the assessment process and were not provided with sufficient examples to evidence that the audit programme was effective.

The service acknowledged it would like to undertake research and development but are currently not doing so.

Training was provided in house by the surgeon or through an online platform. All staff were up to date with their training.