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

Well-led – this means 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. This was a focused assessment, and as such it did not include a review of all areas of the service. The evidence gathered during this assessment was not intended to support a reassessment of the overall rating; therefore, the overall rating remains unchanged. At our last assessment we rated this key question requires improvement. At this assessment the rating has remained requires improvement.

A quality assurance framework was in place, including audits and policy reviews. Managers used audit results to guide decisions and improve care. However, governance processes were not consistently followed and had resulted in documentation errors.

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.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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

This assessment found the provider to be in breach of 1 legal regulation relating to staffing requirements. The provider did not have an effective quality assurance and governance system in place to ensure the people who used the service were not at risk of harm.

Patient notes were paper based. We looked at 1 patient record and saw evidence of unsigned consent forms, incomplete nursing notes that were not signed or dated and incomplete patient observation records.

Governance systems were not operating effectively to provide sufficient assurance. For example, gaps were identified in staff recruitment records, including professional registration details, which senior leaders were unaware of until raised during the assessment. In addition, all 3 staff files reviewed had been signed off as compliant, but omissions were found in each. These issues were identified during our assessment but had not been recognised through the provider’s own governance and oversight processes. Following the assessment, the provider took immediate action to mitigate risks and strengthen systems to protect patient safety. We will follow up the changes made at the next assessment of the service.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.