Edgbaston Wellness and MediSpa

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

This key question has been rated as Requires improvement. We assessed all quality statements in the well led key question.

The leadership, management and governance assured person-centred care. However, there were gaps in some governance systems, which prevented leaders from having oversight of information about risks and performance. This limited opportunities to identify improvement. however, the provider took immediate action to address the concerns found during our first assessment on 12 November 2025. Improvements were observed during our assessments on 17 November 2025 and 10 December 2025.

The service was in breach of legal regulation in relation to governance.

This service scored 57 (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 and engagement.

Leaders had not identified the serious concerns with the service found during this assessment. However, the provider took immediate action to address these concerns and provided an urgent action plan on 14 November 2025. We observed the immediate improvement actions taken throughout our assessments on 17 November 2025 and 10 December 2025.

Although there was a policy in place for Freedom to Speak Up principles and a Freedom to Speak Up guardian, some staff told us they did not always feel they could speak up. However, the provider ensured quarterly staff surveys were carried out to ensure staff were able to contribute their views, we were provided with evidence of these surveys following our assessment.

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

The service had governance systems in place. However, these were not operating effectively to provide sufficient assurance. For example, there were gaps in the records of staff recruitment processes and checks, and staff training. There were also safety issues with the clinical environment, equipment checks, infection prevention and control and medicines management.

These issues were identified during our assessment but had not been recognised through the provider’s own governance and oversight processes. Following the assessment, the provider took immediate action to mitigate risks and strengthen systems to protect patient safety. However, it was too early to determine whether these changes had been fully embedded or could be sustained.

The leaders worked well in the community and wider network of health services.

During our assessment we identified that leaders did not always have effective quality assurance systems and failed to identify areas needing improvement, such as missing and out of date equipment, issues with infection prevention and control and the management of medicines. However, during our assessment, the provider took immediate action to address the concerns found during our first assessment on 12 November 2025, we observed the improvement actions taken during our visits on 17 November and 10 December 2025.