Life Through The Lens - Stoke 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

This means 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.

At our last assessment we rated this key question as Requires improvement. At this assessment, the rating has remained Requires improvement.

This key question has been rated 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.

Service users did not have official support on how to give feedback. Areas of concern identified in 2029 had not been acted on. There was no governance system in place.

Staff told us they had the opportunity to contribute to discussions involving the service as they could speak to the registered manager on the telephone if they had any ideas they wished to share with them.

Staff had access to the equipment and information technology needed to do their work.

Staff engaged with local hospitals and told us they had a good working relationship with them. Staff understood the importance of linking in with local hospitals.

We heard from staff about some Innovations that were taking place in the service. For example, they no longer charge if a patient is unhappy with a scan or if it needed to be repeated.

The service was in breach of regulation for governance.

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 have a shared vision, strategy and culture that is based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding and meeting the needs of people and our communities.

We scored the service as 2. The evidence showed some shortfalls. The service did not have a clear shared vision, strategy, and culture which was based on transparency, equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities.

The service did not have a strategy or vision. However, there was a Life Through The Lens statement of purpose which stated that the service provided private ultrasound scanning services prioritising safety, dignity and professionalism as well as delivering high-quality imaging and compassionate care in line with regulatory standards.

Staff told us they had the opportunity to contribute to discussions involving the service as they could speak to the registered manager on the telephone if they had any ideas they wished to share with them. There were no specific values highlighted to staff or service users within the service.

We have inclusive leaders at all levels who understand the context in which we deliver care, treatment and support and embody the culture and values of their workforce and organisation. They have the skills, knowledge, experience and credibility to lead effectively and do so with integrity, openness and honesty.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have inclusive leaders at all levels who understood the context in which they delivered care, treatment, and support, or who embodied the culture and values of their workforce and organisation. Leaders did not have the skills, knowledge, experience, and credibility to lead effectively, and they did not do so with integrity, openness, and honesty.

The registered manager was unavailable to speak with us prior to, at the time of the inspection or following the inspection. They told us they were unavailable and were looking to appoint a new registered manager. We offered the registered manager the opportunity to speak with us on 3 separate occasions, but these were declined.

The registered manager was not visible in the service and approachable for service users and staff. There were no leadership development opportunities, including opportunities for staff.

We create a positive culture where people feel that they can speak up and that their voice will be heard.

We scored the service as 1. The evidence showed significant shortfalls. People did have avenues they could speak up and ensure their voice would be heard.

Service users and their family did not have official channels to give feedback on the service they received in a manner that reflected their individual needs.

The registered manager and staff had access to the feedback from service users on social media but did not collate it or use it to make improvements. This is important as not all service users would wish to post feedback on a public forum.

Service users and families were not involved in decision-making about changes to the service.

Service users and staff could not easily meet with the registered manager to give feedback as they were rarely at the service due to other commitments.

We value diversity in our workforce. We work towards an inclusive and fair culture by improving equality and equity for people who work for us.

We scored the service as 1. The evidence showed significant shortfalls. The service did not value diversity in their workforce. They did not work towards an inclusive and fair culture by improving equality and equity for people who work for them.

There were no equality and diversity champions within the service. The provider did not undertake equality monitoring of staff within the service to ensure it is diverse in its make-up and representative of the patient group.

Staff were able to apply to work flexibly to account for personal circumstances such as caring responsibilities and health issues.

There were no policies in place relating to staff wellbeing.

We have clear responsibilities, roles, systems of accountability and good governance to manage and deliver good quality, sustainable care, treatment and support. We act on the best information about risk, performance and outcomes, and we share this securely with others when appropriate.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have clear responsibilities, roles, systems of accountability, and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

The rating from the last CQC inspection in 2019 was not displayed in the clinic or on the website. We also found areas that we identified in 2019 had not been acted on.

There were no clear governance systems in place. Staff did not undertake or participate in local clinical audits. There were no team meetings, recorded processes for Disclosure and Barring Service checks (DBS), mandatory training schedules, supervision, appraisals, or inductions for new staff. There were no audits available for us to review.

There was nothing in the policy to specify that staff needed an enhanced criminal record check as the service had visiting children.

The staff files put together for our inspection did not have all the sonographers DBS files in them. Therefore, we were not assured there was any oversight on this. We included this in the Section 29 warning notice enforcement action we served against the provider.

Staff did not maintain or have access to a risk register. There was no clear policy to escalate concerns when required. There were no risk assessments in place.

The service did not have any plans for emergencies – for example measles or a flu outbreak. Information was not in an accessible format and did not identify any areas for improvement.

There was no oversight or scrutiny of policies. Polices were available but were limited in detail, missing, of poor standard or contained incorrect information. We were told the policies had only been made available on site recently when the inspection had been announced and had not previously been available for staff to read.

Staff had access to the equipment and information technology needed to do their work.

Information governance systems included confidentiality of patient records. Staff were knowledgeable on the retention of records. There was a Record Keeping and Data Protection policy. The policy noted an annual record keeping audit should take place however this did not happen.

Images were archived on the ultrasound machine. Staff told us they thought the registered manager backed up the images; however, we did not see any evidence of this.

Following the inspection, we asked for a copy of the action plan from our previous inspection in 2019, this was not provided. Several concerns raised during our last inspection had not been acted on for example concerns relating to cleaning schedules and lack of access to translation services.

We understand our duty to collaborate and work in partnership, so our services work seamlessly for people. We share information and learning with partners and collaborate for improvement.

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.

Staff engaged with local hospitals and told us they had a good working relationship with them. Staff understood the importance of linking in with local hospitals.

We focus on continuous learning, innovation and improvement across our organisation and the local system. We encourage creative ways of delivering equality of experience, outcome and quality of life for people. We actively contribute to safe, effective practice and research.

We scored the service as 2. The evidence showed some shortfalls. The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

Staff were not given the time and support to develop opportunities for improvements and innovation and this led to changes in care delivery. However, both staff gave examples of how the service could be improved that they had shared with the registered manager.

Staff did not have any opportunities to participate in research.

Staff did not use any quality improvement methods.

Staff did not participate in national audits relevant to the service and learned from them.

We heard from staff about some Innovations that were taking place in the service. For example, they no longer charge if a patient is unhappy with a scan or if it needed to be repeated.