13 High Street

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 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 good.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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 patients and their communities.

The provider knew and understood their vision and values and how they were applied in the work of their service. The provider was committed to providing quality care for patients within the local community and beyond and had built up links with 2 local GP practice and the local pharmacy.

The provider based their values on the 6 C’s of care, which were: care, compassion, competence, communication, courage and commitment.

The provider had links to a forum for healthcare professionals providing ear wax removal services who were registered with the Care Quality Commission. The members of the forum supported each other by sharing information on relevant articles or research they had read. The provider also had access to support and guidance through the National Weight LossProgramme in relation to weight management.

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 provider was a sole trader, and the only person working in the service. The provider had the skills, knowledge and experience to perform their role, and had a good understanding of their service. They were visible in the service and approachable for patients. We observed a good rapport between the patients, relatives and the provider.

This quality statement is not relevant for this service. The provider was a sole trader. They were the only person working in the service. However, information about whistleblowing was available.

This quality statement is not relevant for this service. The provider was a sole trader. They were the only person working in the service.

The service had clear responsibilities, roles, systems of accountability and good governance. They used these to manage and deliver good quality, sustainable care, treatment and support. They acted on the best information about performance and outcomes and shared this securely with others when appropriate. However, governance processes needed to be strengthened around obtaining assurance from the landlord around health and safety.

The provider had processes for managing and monitoring the service, which ensured it ran effectively. This included policies for governance and management, incidents and complaints, audits, and health and safety.

The provider had systems in place for managing and learning from incidents, complaints, feedback and audits. The provider was a sole trader, and the only person working in the service. They carried out audits to enable them to monitor and improve the service.

The provider was clear on their roles and responsibilities and scope of practice. They ensured a patient’s GP would be contacted if needed, with the patient’s consent. Policies and procedures were reviewed regularly.

Patient information was stored securely online. The provider was registered with the Information Commissioner’s Office (ICO) and had a valid Data Protection Registration Certificate.

The provider had systems for the management of risk, issues and performance. They ensured that the necessary health and safety assessments were carried out and implemented within their service. However, they had not assured themselves that the landlord had carried out and acted upon the required health and safety assessments for the building and equipment. This included fire, legionella and checking of emergency medicines and equipment. Evidence to support this was provided following our assessment.

The provider had not updated their Statement of Purpose to including weight loss treatments or notified the Care Quality Commission (CQC) via a statutory notification. In addition, the hyperlink on the provider website to the CQC website required updating to link to the registered service.

The service understood their duty to collaborate and work in partnership, so services work seamlessly for patients. They shared information and learning with partners and collaborate for improvement.

The provider had built up relationships with 2 local GP practices, and shared information about specific patients when necessary. The provider shared learning with other practitioners, to promote and develop good practice.

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 patients. They actively contributed to safe, effective practice and research.

The provider had completed quality improvement work related to patient notes and the recording of consent and history taking, and trauma as a result of ear wax removal. The provider was also a registered nurse, maintained their continual professional development and had completed their revalidation with the Nursing and Midwifery Council (NMC).