The Rostra 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

Well-led – 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 Requires Improvement. At this assessment the rating has remained Requires Improvement.

This service scored 46 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider 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.

However, staff understood the challenges and the needs of people and their communities.

Managers had no formal vision or mission statement for the service. When we asked about values, staff told us these were available on their website.

The providers values were effective, efficient, caring and accountable.

Staff had plans to relocate and build a new purpose-built clinic facility in their current car park. However, they had not yet written any formal business plan or strategy, as they were waiting to identify capital funding.

Leaders were not always accountable or ‘fit and proper’ to lead effectively. They did not always do so with integrity, openness and honesty. They did not always embody the values of their workforce and organisation.

However, leaders understood the context in which the provider delivered care, treatment and support. They had the skills, knowledge and experience required for their role and service.

The RM admitted their strengths lay in the clinical side of the business rather than the bureaucratic side. They had the clinical expertise and experience for the regulated procedures.

However, they did not possess all the right ‘fit and proper’ characteristics as the ‘responsible person’ with daily oversight of the service to address or amend outstanding breaches and longstanding issues. The RM did not meet the provider value of ‘accountable’ as they had taken very little action to address our previous breach or improve governance processes. We could not evidence their service met the provider value of ‘effective’ as staff still completed no audits and could not evidence how they monitored or improved outcomes. This meant on this assessment we identified further regulatory breaches.

The consultant nurse led the clinical team which consisted of themself and an HCA. They were the organisation’s RM and reported into the executive board of directors through the operations director.

On-site the RM had not updated their location’s statement of purpose since April 2020. After our assessment, we saw evidence this was updated to reflect their patient referral pathways and the loss of an NHS contract.

The provider fostered a positive culture where people felt they could speak up, and their voice would be heard.

Patients told us they felt comfortable and supported by staff to raise any questions. They added staff were considerate, explained everything clearly and did not hurry or pressure them into having treatment.

The provider had appointed a freedom to speak up guardian (FTSUG) known to staff. The service only had two staff members; both stated they were happy raising any concerns or issues informally.

We observed staff supporting patients to raise any queries or concerns during their appointments and procedures.

The provider did not always value diversity in their workforce. They did not always work towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The RM completed training in equality, diversity and human rights as part of their mandatory and statutory training.

After our on-site assessment, we were sent the provider’s in-date equal opportunities policy. This outlined manager and employees’ responsibilities for ensuring equality at work. However, the service had not recruited any other staff in 15 years. This meant we could not evidence how staff adhered to this policy.

The service had no Equality Diversity and Inclusion policies or initiatives to help further staff’s understanding.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

Managers had still not addressed or taken actions to improve governance processes since their last inspection. For example, no audit processes were recorded or reviewed. We found limited evidence of quality, safety or assurance checks in line with national requirements of equipment or systems such as a suitable electrical fire alarm.

The service’s top risks on their risk assessment register (RAR) did not correspond to risks managers mentioned on-site. This meant we could not ensure staff had control measures or actions in place to mitigate all risks discussed. However, they annually identified, monitored and reviewed hazards to the service.

We asked the RM about the service’s top risks. They said they were aware of all potential risks, including those we found around equipment. They confirmed the service did not maintain a formal risk register.

On-site the RM outlined major risks not captured on their RAR. These included the overall economic landscape, the aged infrastructure and maintenance, and staff not keeping up to date with current sector best practice. We asked what actions managers had put in place to mitigate these risks. They replied they kept educated about latest treatments available in anticipation of patient queries.

After our on-site assessment, we were sent the service’s latest RAR from May 2025. This identified seven ‘hazards’ all related to environment, equipment and furnishings, and outlined their existing controls. Laser usage’s potential to cause eye damage and skin burns was the hazard with the most existing controls in place. No actions were required for any. Hazards were reviewed yearly.

However, the register lacked any hazard scores, categorisation or dates of when they were first identified or added. This meant we could not ensure staff promptly acted to control or mitigate all hazards.

The service held bi-annual formal executive board meetings (EBMs). After our on-site assessment, we were sent minutes from the last three EBMs. The RM chaired, and the HCA attended in order to be quorate. The MD and Operations Director were also listed as attendees. However, they were absent in all three sets of minutes we reviewed.

The RM had informed us on-site these meetings covered all clinical governance and other key issues. However, no clinical performance data or numbers of procedures and scans undertaken were shared in the minutes. This meant we could not evidence the service monitored or improved its clinical performance. We could also not ensure staff were capturing, reviewing and mitigating all the service’s key clinical issues. This lack of formal governance processes meant staff were unaware of many issues and oversights we found on assessment.

The RM told us they did not need any other meetings or team briefs, as both staff discussed business informally to stay aware of any developing issues.

After our on-site assessment, we were sent the provider’s in-date clinical governance strategy. This summarised their core strategy and its elements which included ‘a system for establishing quality appraisal’ and ‘a programme for monitoring the effectiveness of the strategy’s implementation’. However, on-site we found both staff appraisal forms were mostly blank. Also, the service still undertook no audits of their strategy or otherwise. Managers lacked a clear vision for the service. This meant staff did not meet the strategy’s aims.

After our on-site assessment, we reviewed the provider’s in-date business continuity policy. However, the policy’s scope mentioned the NHS and trust several times, as well as ‘partner trust’, which the service no longer had after ending the contract. The policy outlined the basic principles of the Civil Contingencies Act (CCA) 2004 as being emergency planning and exercising and evaluating plans regularly. On-site we found staff carried out no planning or scenarios to help them respond in the event of a major incident or service interruption. This meant they did not comply with policy.

We also reviewed the provider’s in-date risk management policy and procedure. This policy acknowledged incident reporting, risk assessment and monitoring as key tools in risk management and identification. However, on-site we found staff had no examples of learning from incidents or risks. This meant we could not ensure they were always proactive in identifying, assessing, analysing, monitoring and controlling all risks to the service.

The provider did not understand their duty to collaborate and work in partnership, so services work seamlessly for people. They did not share information and learning with partners or collaborate for improvement.

Leaders we spoke with could provide no examples of partnership working or engaging with any community groups to expand the remit of their service. We did not receive any data to support partner working after leaving site.

The provider did not focus on continuous learning, innovation and improvement across the organisation and local system. Managers did not encourage creative ways of delivering equality of experience, outcome and quality of life for people.

We found and the service provided no examples of staff being committed to continuous learning, improvement or innovation.

After our on-site assessment, we were sent the provider’s environmental policy and statement. These were both last reviewed in May 2023. They outlined how the service sought to reduce its activities’ environmental impact. The policy considered life cycle management, energy consumption, materials, waste and sub-contractors.

However, on-site we saw no examples of these initiatives. We were unclear how often they were reviewed by the provider’s executive board.