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

We looked for evidence that leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture

At our last assessment, we rated this key question as inadequate. At this assessment, the rating has changed to good.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

At our last assessment, we found the provider's vision and commitment to continuous improvement were not always reflected in practice. During this assessment, we found improvements had been made, with a positive culture that supported learning, quality improvement and the delivery of person-centred care. 

The provider had established a clear vision and set of values which focused on providing safe, effective and person-centred care. Staff were aware of the provider's vision, strategy and objectives and were able to describe how these influenced their day-to-day practice. There was a strong culture of ethical working, continuous improvement and learning throughout the service. Staff told us that learning from incidents, patient feedback and audits was regularly shared and discussed, helping to drive improvements in the quality of care provided.

The provider was visible and approachable, and staff told us they felt involved in the development of the service and supported to contribute ideas for improvement. The provider maintained a business plan which considered the needs of patients and identified opportunities for future growth and development. Staff consistently described a positive and open culture where they felt respected, valued and able to raise concerns or share feedback. This supported the delivery of the provider's vision and helped to promote continuous improvement across the service.

At our last assessment, we found leaders could not always demonstrate effective oversight of the service or provide assurance that care was delivered in line with expected standards. During this assessment, we found improvements had been made, with effective leadership arrangements and clear oversight of governance, quality and staff development. 

The provider demonstrated the skills, knowledge and experience required to ensure regulated activities were delivered safely and in line with expected standards. Leadership and management arrangements were effective, with clear oversight of clinical governance, risk management and staff development. Leaders had established systems to ensure staff were appropriately trained, received regular clinical supervision and annual appraisals, and maintained the competencies required for their roles. Best practice guidance was promoted and embedded within the service to support the delivery of safe and effective care.

Staff spoke positively about leaders and told us they were visible, approachable and supportive. They felt comfortable raising concerns, seeking advice and sharing ideas for service improvement. Staff told us leaders listened to feedback and acted where appropriate. There were clear roles and responsibilities within the leadership team, and leaders used information from audits, incidents, complaints and patient feedback to monitor performance and drive improvement. This supported an open and inclusive culture where staff felt valued and supported to provide high-quality patient care.

Staff told us they felt able to raise concerns and were confident that these would be listened to, investigated and acted upon where necessary. They described an open and supportive culture where they could speak up without fear of negative consequences. The provider had identified a Freedom to Speak Up Guardian, and staff were aware of who this was and how they could access support if required.

The provider promoted open communication and encouraged staff to share concerns, feedback and suggestions for improvement. There were systems in place for recording, reporting and investigating incidents, and staff were able to describe the processes they would follow. Incidents and learning were discussed during team meetings to promote shared learning and support improvements in practice. Staff told us leaders were approachable and responsive, and they felt their views were valued and taken seriously. This supported a culture of openness, transparency and continuous improvement.

The provider promoted equality, diversity and inclusion within the workplace and had systems in place to support the wellbeing, safety and fair treatment of staff. Staff completed equality, diversity and inclusion training as part of their mandatory training programme and understood their responsibilities in promoting inclusive and respectful practices. Staff told us they worked within a positive and supportive team environment where everyone was treated fairly and with respect, regardless of their background or role.

Staff described an inclusive culture in which they felt valued and supported by leaders and colleagues. They told us the provider considered their individual circumstances where possible and supported flexible working arrangements to promote work-life balance. Staff said they were encouraged to share their views and felt confident that these would be listened to and acted upon where appropriate. This helped create a positive working environment that supported staff wellbeing and enabled them to provide effective care to patients.

At our last assessment, we found governance and oversight systems were not always effective in identifying risks, monitoring performance and ensuring safe care. During this assessment, we found improvements had been made, with clear governance arrangements and effective systems to support oversight, accountability and continuous improvement. 

The provider had established clear governance, management and accountability arrangements which supported the delivery of safe, effective and sustainable care. Leaders maintained oversight of service performance through a programme of audits, incident reporting, complaints management, staff supervision and patient feedback. There was a clear audit programme in place, and leaders were able to demonstrate how findings were used to identify improvements, implement actions and monitor progress. Risks to the service were identified, recorded, reviewed and mitigated through effective risk management processes.

Policies and procedures were comprehensive, regularly reviewed and reflected current practice and relevant guidance. Staff understood their governance responsibilities and were able to explain reporting and escalation processes. Leaders were able to demonstrate learning and improvements resulting from audits, incidents and complaints, with outcomes shared across the team where appropriate. The provider also maintained business planning and succession arrangements to support the future sustainability and continued development of the service. These systems supported effective oversight and continuous improvement across the clinic.

At our last assessment, we found the provider did not consistently work with relevant external stakeholders to support joined-up care. During this assessment, we found improvements had been made, with effective arrangements in place to support communication and information sharing with other healthcare professionals where appropriate.

The provider worked collaboratively with external stakeholders to support the delivery of safe and joined-up care. Processes were in place to share relevant information with people’s GPs and other healthcare professionals, where consent had been obtained, to support continuity of care. Leaders recognised the importance of partnership working and were able to demonstrate how communication with external organisations supported patient safety and treatment outcomes. These arrangements helped ensure patients received coordinated care and that relevant information was shared appropriately to support their ongoing healthcare needs.

At our last assessment, we found systems for capturing learning, identifying improvements and driving service development were not always effective. During this assessment, we found improvements had been made, with effective processes in place to support learning from audits, incidents, complaints and patient feedback. 

The provider had effective systems in place to support learning, improvement and innovation. A programme of audits was in place, including audits of clinical records, medicines management and infection prevention and control. Audits were comprehensive, identified areas for improvement where required and included evidence of actions taken and outcomes achieved. Leaders were able to demonstrate how findings from audits, incidents, complaints and patient feedback were used to improve processes and enhance the quality and safety of the service.

There were clear processes for identifying recording, investigating and learning from incidents. Learning was shared with staff through team meetings and other governance processes to support continuous improvement and reduce the risk of recurrence. The provider actively sought feedback from patients and used this information to inform service development. Staff were encouraged and supported to develop their skills and knowledge through training, clinical supervision and attendance at external courses, helping to promote a culture of learning and continuous improvement across the service.