The Mole 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 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 75 (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 people and their communities.All staff had contributed to the development of the practice vision and strategy, which was kept under review.

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.

Staff told us leaders in the service was approachable and responded to any concerns raised. Staff also told us leaders modelled the values of the service.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. Staff were aware of how to raise concerns both internally and externally.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

Policies and procedures to promote diversity and equality were in place. Adjustments had been made to ensure all staff were valued, for example, staff we spoke with informed us that adjustments were made to accommodate personal needs.

The service had clear responsibilities, roles, systems of accountability and good governance. The service delivered good quality, sustainable care, treatment and support. They acted on the best information about risk, performance and outcomes, and shared this securely with others when appropriate.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. Managers met with staff regularly to carry out appraisals and performance reviews. However, we found that consultants had not received internal appraisals, although all consultants had completed their NHS appraisals.

Staff could access all required policies and procedures. Managers held regular practice meetings with staff, during which they discussed clinical concerns and emerging risks. Managers clearly recorded any actions arising from these meetings and ensured they shared these with staff. Staff took patient confidentiality and information security seriously.

Feedback from people using the service was positive.

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

The service focused on continuous learning, innovation and improvement across the organisation. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people. They actively contributed to safe, effective practice and research. For example, the consultants accessed external seminars to keep updated with current practice and learning was implemented from this.

The service could demonstrate how it used complaints, incidents and feedback to improve.

The service had a continuous improvement planner in place, which was used to support ongoing monitoring and drive continuous quality improvement.