Sister Kate 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

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 is the first inspection for this service since its registration with CQC. This key question has been rated as good.

This service scored 71 (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, engagement, and understanding challenges and the needs of people and their communities.

Staff knew and understood the vision and values and how they were applied in the work of their service. The provider was committed to providing quality care for people within the local community and beyond.

The provider had previously worked in the NHS as an ear, noise and throat (ENT) nurse specialist. They had originally opened the service because of a shortage of competent, qualified ear wax removal clinicians in the local area. The ear care practitioner had worked alongside the provider in the NHS. The provider was content with the size of the service and the care delivered and had not got the desire to expand the business.

The provider had links to a forum for healthcare professionals providing earwax removal services who were registered with the Care Quality Commission. Staff also had links with Rotherham Ear Care and Audiology Service and attended annual updates as required.

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

Staff told us the provider was approachable and responded to any concerns raised and modelled the values of the practice. We saw the provider worked with local services to ensure people received the service they required.

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

Staff had access to a Whistleblowing policy. They told us they felt that they could speak up to raise concerns or make suggestions and were confident their voice would be heard and acted upon

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

Policies and procedures to promote diversity and equality were in place. Staff were aware of reasonable adjustments and had received training in equality and diversity.

The service 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 shared this securely with others when appropriate.

The provider supported staff, and staff we spoke with were clear on their individual roles and responsibilities. Regular clinical meetings were held, facilitating discussion and ongoing learning. Staff could access all required policies and procedures and took patient confidentiality and information security seriously.

However, the provider had not established governance processes that were appropriate for their service. Relevant risk assessments had not been completed, and the provider had not assured themselves that the landlord had carried out and acted upon the required health and safety assessments for the building and equipment. This included fire and legionella. Supervision was not recorded and appraisals and performance reviews had not taken place. Safe recruitment procedures were not followed, or staff vaccinations maintained in line with current guidance.

A limited number of audits had been completed, and those that had, did not include the date, location, or a clear scoring system to identify risk.

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

The provider offered both private and NHS appointments. They worked closely with local services, including a local college for young people with special educational needs and disabilities, care homes, a local GP practice and a nearby manufacturer. The local Integrated Care Board (ICB) carried out quality assurance visits to review the service provided to people eligible for NHS ear wax removal registered at a local GP practice. The ICB commented that the provider was professional and provided a good quality service. No issues were identified during the latest quality assurance visit. The service shared information with people’s GP practices as required.

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

The provider was a registered nurse, maintained their continual professional development and had completed their revalidation with the Nursing and Midwifery Council (NMC). Staff ensured their practice was up to date and current through attending annual updates with Rotherham Ear Care and Audiology Service.