St Clare Medical Centre

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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 and fair culture.

This is the first assessment of this service. We rated this key question as requires improvement; this meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care. We found that governance arrangements were not fully effective because some policies were not written in a comprehensive manner and did not reflect the current configuration of the service.

The service was in breach of regulation 17 for good governance as the information they held about their processes was not up to date, accurate and properly analysed and reviewed.

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 scored the service as 3. The evidence showed a good standard. 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 using their services.

The manager told us about their vision for the future of the service and how they were planning to achieve this. The manager highlighted the importance of each staff member under his employment in the delivery of these plans. Staff understood the provider’s vision and values and could explain how these were applied in their daily work. Staff told us they felt respected, supported, and valued. They were focused on meeting patients’ needs and could describe how they worked to deliver high-quality care. Staff told us they had opportunities to contribute ideas for improving the service. Staff who looked after post-surgical patients told us they could contact the surgeon directly if they needed advice, and next steps could be decided during those calls.

We scored the service as 3. The evidence showed a good standard. The service had inclusive leaders at all levels who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The manager demonstrated understanding of the services they managed and could clearly explain how teams worked together internally and externally to deliver high-quality care. To strengthen governance, the service appointed an external consultant who supported the service in matters of governance, recruitment, complaints, compliance, policies and procedures.

Staff told us senior staff were visible and approachable for both patients and them. We observed a positive culture where staff worked well together as a small, cohesive team and felt supported by management.

We scored the service as 1. The evidence showed significant shortfalls. People did not have clear processes to follow to speak up and be assured their voices would be heard.

The service did not have a Freedom to Speak Up Guardian or a designated individual for staff to approach when they wished to raise concerns. In addition, there was no policy outlining the process for staff to follow should they need to speak up. Staff told us they felt supported and able to escalate concerns to the manager, but there was no process in case staff needed to raise concerns about management.

However, the service fostered a positive culture where patients felt confident to raise concerns and knew their voice would be heard. Managers and staff had access to feedback from patients and used this information to make improvements. Patients and staff could meet with the manager to share feedback directly. The service actively encouraged openness.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The manager made reasonable adjustments to support staff in carrying out their roles. At the time of the inspection the service did not undertake any NHS work.

We scored the service as 2. The evidence showed some shortfalls. 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 share this securely with others when appropriate.

We found some of the service’s policies were not written in a comprehensive manner and contained wording which did not reflect the configuration of the service. Many of the provider’s policies included references to roles and committees not part of the organisation. This could lead to confusion among staff and result in ineffective governance arrangements. Some policies lacked purpose, scope and comprehensive, practical guidance to support staff to respond in a timely manner in matters of patient safety. This increased the risk of delayed or inappropriate escalation of care.

However, staff we spoke with had clear roles and responsibilities, and systems of accountability. These processes were used to manage and deliver high-quality, sustainable care. The manager and staff collaborated to strengthen their processes, procedures and an audit trail with the help of an external consultant hired for this purpose. Staff demonstrated clear oversight of which audits were completed and how the resulting data informed decisions on business planning, surgical scheduling, and staffing requirements. The service explored establishing a service level agreement with the nearest NHS hospital to facilitate emergency patient transfers. However, this was deemed unfeasible because patient transport services were managed by a separate organisation rather than the hospital itself.

The service maintained a risk register which included business risks. Risks and performance were discussed during staff meetings. Staff concerns aligned with those on the register, and we saw evidence of mitigation measures being implemented. The registered manager demonstrated comprehensive oversight of risks, which reflected those recorded and mentioned by other staff members.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

The service collaborated with GPs when required to ensure patients underwent the necessary tests and were medically cleared for surgery. It also communicated with the patient’s GP if any concerns arose during the pre-operative assessment or the procedure itself. Additionally, the manager worked across other sites under practicing privileges offering cosmetic surgery and shared learning and best practices between these different providers. The service told us they compared themselves against information obtained from the Private Healthcare Information Network (PHIN) with regards to similar providers of cosmetic surgery services.

We scored the service as 3. The evidence showed a good standard. The service focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contribute to safe, effective practice and research.