Seymour 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 there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities.

This is the first assessment for this service. This key question has been rated requires improvement. This meant there were widespread shortfalls in the service’s governance systems.

The service was in breach of regulation for governance at the service.

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.

The service had a shared vision, strategy and culture.

The provider had a clear vision for the service. The provider offered a wide range of surgical services with a focus on excellence and patient care. The services strategy and vision was:

“We prioritize patient safety and comfort, creating a compassionate environment for personalized care. Our goal is to make a positive impact on patients' lives, restoring health and well-being through innovative and patient-centered surgical solutions.”

Staff were aware of the vision and could explain how they were working to deliver high quality care.

The service had leaders who understood the context in which they delivered care, treatment and support. However, leaders did not always have clear lines of responsibility which led to gaps in necessary actions.

The service had a clear leadership structure which was made up of the company chief executive officer (CEO), who was also the registered manager and an operational manager. The CEO also acted as the medical director as they also had an anaesthetic background. However, the lines of responsibility were not clear. It was unclear who was responsible for specific tasks such as management of stock, rota management, incidents, staff training and appraisals and management of notifications to external bodies. Staff we spoke with were also not clear who was responsible for certain tasks and often used the CEO and operational manager interchangeably.

Leaders did however have a good understanding of the service they managed. They could clearly explain the procedures offered, operating models and how the teams were working to provide high quality care.

During our assessment, we saw the leadership team were visible, supportive and had good working relationships with staff. They told us they encouraged an open culture and actively sought staff feedback and opinion. Managers reported that they communicated and engaged with staff regularly which was corroborated by staff.

All staff spoke very highly of the leadership team and felt they were always approachable and actively involved in all aspects of the service. Staff told us they were encouraged to develop their knowledge and skills and were supported to attend training courses.

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

Staff reported that they felt comfortable speaking up and had no issue contacting the leadership team as they were extremely visible within the service. Staff reported that they gave feedback during team meetings however, the service did not provide meeting minutes to confirm. The service did not carry out an official staff survey to collate staff reviews. This meant that staff did not have an anonymous, open and honest forum to express their views and the service could not identify any themes from learning in response. However, the service had an in-date whistleblowing policy, which staff could access.

Leaders encouraged feedback from patients, carers and staff and used it to make improvements. Posters in the clinic showed that patients were offered the opportunity to meet with members of the provider’s senior leadership team if requested.

The service valued diversity in their workforce.

All staff we spoke with told us they felt respected, supported and valued. They also reported that they were able to work flexibly and that managers put reasonable adjustments in place for staff members to help support them in their roles. Staff were representative of different nationalities. We observed staff working well together and different backgrounds being celebrated. All staff had access to equality, diversity and inclusion training.

The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not always act on the best information about risk, performance and outcomes.

The service did not have a defined governance structure within the service and staff at all levels were not clear about their roles, responsibilities and accountabilities. The leadership team reported that all governance related matters were overseen by either the CEO or operational manager. However, roles, responsibilities and accountabilities were not identified in a policy. The lack of defined responsibility was reflected in the absence of meeting minutes, audits and poor risk management.

Leadership reported that they had quarterly team meetings due to the clinical activity being infrequent and lack of availability of medical staff. We observed a rolling agenda for these meetings, which included but was not limited to topics such as service and clinical focus, marketing, cancellations and team feedback and issues. However, the service did not provide meeting minutes to confirm whether these meetings took place or what was discussed.

Clinical and non- clinical performance was not always monitored through audits. The service did not provide audit data for medicines management, delays or cancellation and specific risk assessments such as national early warning score (NEWS). As a result, we could not be reasonably assured that risks were being identified in these areas and action was being taken in response.

The service did not always have appropriate policies and training in place. The service had a transfer of deteriorating patient policy, but this did not include the identification and management of sepsis. Staff training also did not appear to include training specific to sepsis. This meant that we could not be assured that staff could identify and manage deterioration prior to transfer.

Information governance systems were not always secure and could potentially compromise confidentiality of patient records. During the assessment we noted that the service laptop with patient information did not lock once put into sleep mode. This meant unauthorised personnel could access sensitive information if they gained access to the laptop. This was escalated to the operational manager who was unsure why the laptop was not locking and reported that the laptop was usually password protected. The service did not provide an update on whether this had been resolved.

On the day of assessment, the service did not have a defined risk register; however, post assessment the service created one. The risk register had 12 newly opened risks. The risk register included a title, description of risk, risk rating score, and any actions taken in response. However, none of the risks had a dedicated owner or a specific review date when the risk would be reassessed, and some of the actions were not detailed or measurable. Therefore, we could not be certain these risks were being managed as a priority.

The risks on the register included but were not limited to management of cash onsite, fire risk assessment, medicine storage and control of substances hazardous health (COSHH) storage. However, it did not include some of the risks we identified during the assessment such as the rain damage and the laptop confidentiality risk.

The service did not supply a business continuity plan. This meant there was no clear guidance for staff on how to manage and communicate unexpected events. For example, in the event of severe weather or a fire which could impact on the business being able to provide its usual service.

The service policies were all clear, detailed and easily accessible. The processes described within were all relevant to the service.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for people.

The service understood their duty to collaborate and work in partnership. The service engaged regularly with other organisations and similar service providers due to the various operating models bringing them together.

The CEO was also an active member of several external organisations including volunteer initiatives specific to the surgery, which allowed information sharing, discussions around best practice, and promoting service development.

The service focused on continuous learning through staff and patient feedback. However, there was no evidence of involvement in research, national audits or upskilling of staff.

The service did not provide evidence of involvement in research, national audits or staff development through further training or study days. However, leadership and staff reported that there was a focus on continuous learning and improvement throughout the service with patient experience at the forefront.