Face Perfect Clinic

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

This is the first assessment for this service since its registration with CQC. This key question has been rated as Inadequate. We have identified a breach of regulation 17 (good governance).

This service scored 36 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture, and had set out its values which incorporated ethical working and continuous learning, however we found this had not always been implemented in practice and that capturing, sharing, discussing and embedding learning was an area needing significant improvement.

There was a business plan which included a review of the needs of patients who used the service, as well as plans for future service development.

However, the concerns identified during the assessment indicated that staff and leaders did not ensure any risks to delivering the strategy were understood and addressed. The provider did not monitor and review progress against delivery of the strategy.

The concerns identified during the assessment meant that leaders could not demonstrate they had the capability to ensure regulated activities were delivered to patients appropriately, safely, and to the expected standards.

Leadership was not effective. Leaders could not demonstrate that all staff had the skills, knowledge, experience and credibility to deliver safe and effective care, and that they followed best practice guidelines.

Staff told us that managers were visible and approachable and that they felt supported by them.

Staff we spoke with and received feedback from told us they knew how to raise concerns and felt confident to do so. There was no evidence of incidents being reported, documented and investigated appropriately.

There were systems and processes in place to support the safety, equitable treatment, and well-being of staff. Staff received training in equality, diversity, and inclusion. Staff told us they worked in an inclusive and fair way and supported one another to deliver services effectively. This included, for example, supporting flexible working arrangements.

The provider was unable to demonstrate that clear and effective governance, management, and accountability arrangements were in place.

Systems for identifying, acting on, and learning from incidents were not effective. There was no documentation of incidents which meant that monitoring of themes, learning, and the progress of any investigation could not be carried out.

Policies and standard operating procedures were not always sufficiently clear or comprehensive. In some cases, there were discrepancies between what was stated in policy and what was happening in practice. Some policies and procedures lacked adequate clinical guidance to support staff to safely prescribe and monitor patients’ health.

The provider did not maintain an accurate, complete and contemporaneous record in respect of each patient. This included no record of prescriptions in some patient’s records. This increased the risk of harm to patients as records did not accurately reflect the treatments and advice they had received, and clinical information was not present to allow prescribers to make informed prescribing decisions.

There was no process in place to ensure that legal and professional responsibilities to share information appropriately were adhered to. This included sharing information with the patient’s GP.

The provider did not establish effective systems to assess, monitor and improve the quality and safety of the service. Audits did not effectively identify where policies were not being adhered to, and it was not clear what action had been taken where issues were identified.

There was a lack of oversight of staff training needs and ongoing staff compliance checks including DBS renewals and professional registrations.

The provider had started to take action following our feedback and concerns from this assessment. This included making changes to policies and arranging additional staff training, however further work and time was needed to strengthen this and to allow for these policies to be fully implemented and embedded into practice.

The provider did not collaborate or share information with relevant external stakeholders, in order to support care provision, service development and joined-up care.

There was a programme of audits in place which included record keeping, medicines management, and hand washing, however these were not seen as effective. For example, audits were not comprehensive, did not always identify issues, and did not contain information on action taken where issues had been identified.

There was a lack of process to ensure that learning and improvement was captured when things went wrong, as incidents were not appropriately identified, recorded and investigated.

There were systems in place to gather and review patient feedback. Staff were encouraged to learn and develop in their roles, for example through attendance at external training courses.