Pall Mall Medical Diagnostic Treatment Centre

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

Leaders were not always visible in the service. Leaders did not engage with staff to develop the organisation’s new vision and values. However, staff we spoke to felt supported to give feedback. People with protected characteristics felt supported.

This service scored 50 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The majority of managers and staff we spoke with were able to describe the vision and strategy of the organisation. The vision and values were promoted throughout the organisation. Staff told us their appraisals were based on and followed the service’s values.

Service leaders told us they were in the process of introducing some new “heart” values which they were planning on sharing with the staff. The leaders had not engaged with staff members, or collaborated with people who used the service, to develop the new values. Service leaders told us they were planning to launch and present the new values to the staff during the upcoming Christmas Party.

The service had a 12-month service improvement plan which had been updated in September 2024. This included a focus on embedding best practices and a commitment to compliance and positive patient experiences. The plan involved consistently monitoring the two new services that they hoped to introduce weight loss and gender affirmation surgeries.

The provider shared examples of positive feedback within staff surveys.

Following our site visit service leaders added an addendum to their service plan to improve areas we had addressed during our inspection such as governance, fire safety, environment and equipment, cleanliness, medicines management, IT security and records.

Staff we spoke to told us leaders at a local level were visible and lead by example modelling inclusive behaviours. However, not all staff we spoke with said that senior leaders were visible enough. One staff member told us they hadn’t seen one of the registered managers in over three years.

Staff we spoke with felt comfortable raising their concerns and would approach their line manager rather than someone more senior.

Staff vacancy levels were low at the time of our inspection.

We observed staff were not always bare below the elbows in clinical areas. The provider told us that staff acted in line with their local hand hygiene policy.

We fed back our concerns to service leaders on day one of the assessment but found similar issues the following day. We escalated our concerns at the end of our visit and asked the provider to take immediate action. The provider submitted evidence following our inspection showing action had been taken to improve.

Policies such as the escalation of concerns and whistleblowing policy provided guidance for staff on how to raise concerns regardless of their role in the department. Posters clearly displayed the process and included details of how to use a range of methods to raise concerns. The service had two freedom to speak up guardians.

Staff felt comfortable to raise concerns in a variety of ways and gave examples of raising concerns with managers, and how they would contact the freedom to speak up guardian. The service was in the process of reviewing a policy to support staff in identifying managing anxiety and depression.

Service leaders told us they had a diverse workforce and ensured all staff members completed equality diversity training. Compliance levels for equality diversity training were 96%.

The service had an up-to-date equality and diversity policy. The service also had a flexible working and home working policy that were up to date. Staff had access to the services' policies and systems. Staff felt supported by their line managers.

Governance systems did not operate effectively within the service to identify and address risks and areas of improvement.

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The service had quarterly Medical Advisory Committee MAC and clinical governance meetings. The MAC committee and clinical governance meetings were supposed to include designated members of those committees such as the clinical director, clinical advisor, directors, hospital manager, registered managers, ward and theatre managers. The meetings reviewed performance, risk, audit, culture and workforce. Service leaders told us the meetings enabled feedback, insights, actions and accountability and ownership across the organisation. The past 3 MAC meetings showed a poor attendance, with just the Hospital Manager and one of the Registered Managers in attendance. We did not see any replication of regular governance or safety meetings for clinical staff to attend. The service did not have any regular or official meeting whereby lessons learnt, or quality improvements standards could be shared with ward or clinical staff. Staff told us when incidents occurred, they would receive an email or 1:1 meeting with a manager.

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The service had a specific infection prevention and control committee, whereby risks could be identified and escalated to governance meetings for senior review. However, infection prevention and control processes were not embedded in the service.

The service organisational chart and policies we reviewed were clear and identified responsibilities for directors and staff across the service. Most of the policies we reviewed were up to date or in the process of being reviewed, however we found older copies of policies kept in clinical and staff areas that did not always reflect the most recent guidance.

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A variety of audits were undertaken by the service, leaders told us any themes or trends would be shared with the staff via email. The service had an audit schedule matrix which covered a range of areas. Audit tools were in line with national guidance for example, the World Health Organisation's 5 steps to safer surgery. However, we saw a significant number of times when the scheduled audits had not been completed. We found concerns in areas such as infection control, cleaning, theatre checklists, consulting rooms, fire safety and legionella.

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Service leaders told us the top 3 risks for the organisation were weather, equipment and staffing. All these concerns were documented on the service risk register.

We did not look at Partnerships and communities during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.

Learning and improvement were not consistent within the service. We found examples where audits and areas of improvement had not been addressed.

The service held workshops for managers focusing on leadership skills, effective communication, and team management. Pall Mall engaged a third party, to provide tailored one-to-one coaching for managers and up-and-coming leaders.

Staff told us they could apply for funding for relevant courses and qualifications. One staff member was currently undertaking their immediate life support training. Service leaders told us they sponsored staff to undergo a variety of training and development modules such as Surgical First Assistant, Theatre Practitioner and Management Accountant qualifications.

We were told that surgeons would regularly present research cases and findings at international conferences. The service had partnerships with oversea programmes where international surgeons could come and observe techniques practiced at Pall Mall.

The service had been approved by a local university to support nursing students and offer them a practical learning environment as part of their training.

The provider shared an example of attendance at a national event to improve safety standards in surgery.