Archived: The Sanctum

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• 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 inadequate.

We assessed 7 quality statements from this key question.

We found concerns in all 7 quality statements which included Freedom to Speak Up, governance, management, and sustainability, learning improvement and innovation, capable, compassionate, and inclusive leaders, and partnerships and communities.

We found 2 breaches of the legal regulations, relating to safe care and treatment, good governance.

There were no clear and effective governance, management and accountability arrangements, which resulted in the significant concerns identified during the assessment. The provider took account for the actions, behaviours and performance of themself and other staff, but they were unaware of some of the issues due to a lack of governance oversight. The provider was open and transparent with us on the day of, and the days following our inspection. They could not demonstrate that they worked in partnership with key stakeholders, when required to support joined-up care.

This service scored 18 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The concerns identified during the assessment meant the provider could not demonstrate they had the capability to ensure regulated activities were offered to people appropriately. The findings suggested leadership was not safe or effective, which compromised staff working at the service and which may have affected the quality-of-care people received. They could not demonstrate that they were aware of, and followed, best practice guidelines.

The policies and procedures provided to us by the provider on the day of the assessment were not service-specific and did not contain the level of detail we would expect to see in order to provide staff with the guidance to carry out their roles effectively.

There was no identified Freedom to Speak Up Guardian outside of the service. There was no evidence of processes to support staff in line with a named freedom to speak up guardian.

Issues identified during the assessment were not raised with us by staff.

The provider was unable to demonstrate through discussion or by the records made available to us that they had clear and effective governance, management, and accountability arrangements in place. They demonstrated a disregard for the safety of staff and people using the service and staff, confidentiality, and information security.

The provider told us they did not hold formal staff meetings. No records of staff meetings were available. Staff confirmed this. We were told that daily informal staff meetings took place.

There were no clear and effective governance, management and accountability arrangements, which resulted in the concerns identified during the assessment. However, when we raised our concerns with the provider, they took account for the actions, behaviours and performance of themself and other staff.

Policies and procedures and identified lead members of staff that contributed towards the governance of the service were in place but not embedded into practice. The service was not following its own policies and procedures in relation to significant events, medicine management, emergency equipment, recruitment of staff, or infection prevention and control.

There was assurance that staff were competent to carry out regulated activity because there were no systems of oversight for recruitment, training, competency, and appraisal.

Whistleblowing and freedom to speak up arrangements were detailed in the provider’s policy, but they were not service specific, and it was not clear whether staff knew of these arrangements.

Information was not used effectively to monitor and improve the quality of care.

Our assessment found the care and treatment people received did not meet the expected standards relating to partnership and communities.

The provider was open and transparent on the day of our inspection, and where follow-up communication was required in the days following. However, the lack of recording of significant incidents, complaints, staff supervision and learning meant the provider could not demonstrate that they shared learning with other services, which had the potential to lead to better outcomes for people.

Staff we spoke to told us they were encouraged to upskill themselves in their aesthetics role within the service. We saw that staff were actively training to master their skills in aesthetics. However, we did not see accurate and up-to-date training evidence which would have contributed to the safety of the delivery of regulated activity at the service.

The provider told us they relied on staff having completed what they deemed as mandatory training for areas including (but not limited to) safeguarding, health and safety, anaphylaxis, basic life support and information governance in their other employment but did not consistently seek confirmation that this training had been completed.

There was a lack of processes to ensure that learning happened when things went wrong, and no system in place for the sharing of good practice. Leaders did not actively encourage reflection and collective problem-solving.