Signature Clinic - Manchester Also known as Rochdale 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

Our rating of well-led stayed the same. We rated well-led as requires improvement.

There were clear governance, management and accountability arrangements. Staff understood their roles and accountabilities. They understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. Leaders promoted a positive work culture based on equality, diversity and inclusion. Staff were supported to speak up or raise concerns. Leaders understood the key risks to the service and had plans to make improvements.

However, we identified a regulatory breach in relation to governance and assurance processes in the key question for well-led, where we have told the service it needs to make improvements.

We found the service did not have an effective process for carrying out checks on company directors, in line with regulatory requirements for fit and proper persons; directors.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Staff told us there was a friendly and open culture focussed on teamwork and providing quality care. They spoke positively about the support they had received from managers.

Staff told us the provider’s mission, values and objectives had been shared with them and they had a good understanding of these.

Managers told us progress against the business objectives was reviewed as part of routine governance meetings.

The provider’s mission statement was ‘We want to be seen as the friendliest cosmetic surgery clinic group that offers treatments in a fuss-free manner that provides excellent value for money’.

This was underpinned by a set of 3 core values; great results that are life changing, friendly positive experience and minimally intrusive.

The service had a number of core objectives relating to improving pre-operative consultation and aftercare processes and around improving people’s outcomes and experiences.

Staff spoke positively about the support they had received from managers. They told us leaders were visible, approachable and provided them with good support and guidance.

The overall lead for the service was the medical director, who oversaw the surgeons and was also the registered manager for the service. The clinic manager oversaw the day to day running of the service and managed the clinic staff.

The service had recently appointed a clinical supervision and education manager to support staff. The governance and aftercare manager oversaw the aftercare team.

Staff at the clinic were supported by the consulting doctors, director of clinical governance, the associate director of clinical governance, the group pharmacist and the infection prevention and control nurse manager, who were all based at the provider’s other locations.

Leaders had the relevant skills and abilities to manage the services. They understood the risks to the services and had clear oversight on safety, governance and performance issues through daily involvement and quality monitoring.

Staff told us they felt confident they could raise any issues with their managers and that managers listened to them.

Staff were aware of the whistleblowing policy and understood how to contact the freedom to speak up guardian if needed.

Managers reported there had been 1 freedom to speak up concern raised during the past 12 months and this had been resolved.

The service had whistle blower and freedom to speak up policies that provided guidance for staff around how to raise concerns. The freedom to speak up guardian was based at another of the provider’s locations and was independent to the service.

There not been any whistle blower or freedom to speak up concerns received by the Care Quality Commission relating to this service during the past 12 months.

Staff told us the service had an inclusive working culture and they were treated with respect and equity.

Staff told us managers engaged with them regularly and they felt confident their concerns were listed to. All the staff we spoke told us they had not experienced any instances of unfair treatment, discrimination or harassment.

Managers told us equality, diversity and inclusion was embedded in the culture of the service. They told us staff recruitment processes enabled equal opportunities and they engaged with staff routinely to maintain an inclusive work environment.

The service had an equality, diversity and inclusion policy and this was also incorporated in the recruitment policies and processes. There were support mechanisms for staff with protected characteristics, including flexibility around working arrangements and shift patterns.

Managers engaged with staff on a daily basis to monitor work culture and identify any bias or discrimination. The service planned to undertake a formal staff survey during January 2025 to seek feedback from staff anonymously.

Staff told us information on performance, risks and governance was discussed during daily huddles and routine team meetings.

Staff participated in quality monitoring and audit processes. They told us their performance was routinely monitored and they received feedback following audits to aid learning and improvement.

Managers understood the key risks to the service and maintained a risk register. Staff were aware of how to record and escalate key risks on the risk register.

Managers were aware of their responsibility to report notifiable incidents. They told us there was a system to ensure safety alerts were actioned and cascaded to all staff.

The service did not have a formal policy or process detailing how fit and proper persons checks were undertaken for directors.

The service had 2 company directors, the medical director and a finance director. The fit and proper persons files for the 2 company directors (medical director and finance director) included some information relating their qualifications and identification checks. However, none of the records included any evidence to show that additional checks had been carried out to confirm they were of good character or to confirm there were no concerns around past criminal or financial irregularities, in line with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 5 requirements for fit and proper persons; directors.

The service had governance structures that provided assurance of oversight and performance against safety measures. Staff took part in twice daily huddle meetings, routine clinic staff meetings, infection control committee meetings and and clinical governance and performance meetings to review information.

Meeting minutes showed key discussions took place around performance, risk, governance, audit findings and incidents. Action logs were in place for key performance indicators and these were followed up at subsequent meetings.

We identified concerns around the management of risk registers during our previous inspection. During this inspection we found improvements had been made.

An electronic system was implemented in June 2024 to manage the organisational risk register. The risk register showed key risks were identified and these were reviewed during monthly governance meetings. A risk scoring system was used to identify and escalate key risks and each risk had an accountable person assigned.

Routine audit and monitoring of key processes took place to monitor performance against safety standards and organisational objectives.

People told us care and treatment was well co-ordinated before, during and after their surgery.

Managers told us the service only provided privately-funded day case cosmetic surgery procedures for adults. They told us the service did not have any NHS commissioning arrangements or contractual arrangements with other healthcare providers in relation to undertaking surgical procedures.

Service partners based at the provider’s other locations told us they worked closely with clinic staff to deliver safe care and treatment. They told us they were involved in daily team calls and attended routine governance and performance meetings.

Staff at the clinic had daily collaborative team working with service partners, such as consulting doctors and governance leads, that were based at the provider’s other locations.

The service did not routinely engage with local communities due to the nature of the cosmetic surgery services provided, but there was routine public engagement through social media and marketing to promote the services offered.

Staff told us there was a culture of learning and improvement across the service. They told us routine audits took place to monitor compliance and learning was shared through daily huddles and routine meetings.

We saw evidence of learning and improvement resulting from findings from audit results and incidents and shared learning was cascaded to staff to aid learning.

The service had made improvements in areas identified as shortfalls at our previous inspection in January 2024, such as incident reporting processes and maintaining risk registers.

The service had implemented an electronic quality management system in June 2024 for managing incidents, policies and risk registers. The leadership and staff support mechanisms had been strengthened over the last 12 months through the appointment of senior nursing and governance leads. This had led to improvements in clinical pathways, staff training and competencies as well as governance, risk management and quality monitoring processes.

Leaders understood the key risks to the service and had plans in place to improve in areas such as people’s experience, outcomes and around reducing surgical site infection rates. However, these improvements had not yet been implemented.