CJA Medical

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 - We looked for evidence that service leadership and management 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 Requires Improvement.

The service was in breach of legal regulation in relation to good 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 did not have a clear shared vision, strategy and culture which was based on equity, equality and human rights, diversity and inclusion, and engagement. They did not always understand the challenges and the needs of people and their communities. The service had not developed and implemented a vision, strategy, mission statement or improvement plan to provide clear direction, ensure high-quality patient care were achieved through measurable objectives, and align staff toward common goals.

However, there were processes for leaders to share their vision, experience and support with colleagues, through service meetings. Although staff told us there was a positive team culture and they felt supported by senior leaders, there was limited opportunity for staff to contribute to discussions about service improvements through a formal staff survey. Staff we spoke with during our on-site visit told us they were proud to work for the service and had received appraisals to support them with personal development and help to deliver high-quality care.

Not all leaders understood the context in which the service delivered care, treatment and support. They did not always embody the culture and values of their workforce and organisation. Leaders did not always have the skills, knowledge, experience and credibility to lead effectively. The CQC registered manager of the service was absent during the assessment. In their absence, the nominated individual, was at times unclear regarding the legal responsibilities, especially in relation to CCTV cameras situated within the service’s treatment rooms. However, staff told us leaders at the service were approachable and responded to any concerns raised.

The service fostered a positive culture where people felt they could speak up and their voice would be heard. The service had established Freedom to Speak up arrangements in place as well as a whistleblowing policy.

We reviewed the service’s incident management systems and processes, which demonstrated when something went wrong, people received an honest and timely apology and were told about any actions being taken to prevent the same happening again.

Staff had access to an employee assistance program (EAP) through occupational health services where required.

There was a zero-tolerance policy in relation to the abuse of staff with systems in place to protect people and minimise the likelihood of reoccurrence.

The service valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality for people who work for them. Policies and procedures to promote diversity and equality were in place. Systems were in place to address concerns relating to discrimination. Adjustments had been made to ensure all staff were valued. For example, we noted there were reasonable adjustments in place to support the risks posed to the health and safety of staff at the service such as display screen equipment, ergonomics and moving and handling.

The service did not have clear responsibilities, roles, systems of accountability and good governance. Risks had not been effectively identified, assessed, or mitigated in areas relating to health and safety, fire safety, infection prevention and control and chaperoning. In addition, the service failed to ensure the use of CCTV surveillance cameras within the service was lawful, safe, and compliant with relevant data‑protection requirements. Internal quality monitoring systems had also not identified shortfalls in these areas, and they did not always act on information about risk. Therefore, there were unactioned risks relating to the health, safety and welfare of people. The service did not have effective governance arrangements to support the delivery of safe, high‑quality and sustainable care. Responsibilities, roles and systems of accountability were not clearly defined or embedded. As a result, leaders did not have effective oversight of key operational risks or assurance processes. In addition, there was a lack of systems for the monitoring and acting upon people’s feedback to assess and improve the service.

However, the service had a business continuity plan in place which gave guidance to staff for the preparation of major incidents. Staff were able to demonstrate how to access service policies and procedures and gave examples of how working arrangements had been adjusted due to previous incidents.

The service is a private aesthetic and cosmetic clinic. Whilst this quality statement is not relevant for this service, staff made adjustments to improve coordination of their service including sharing and obtaining information where appropriate with other stakeholders.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research. For example, the service did not have a programme of quality improvement audit activity to routinely review the effectiveness and appropriateness of the care provided. There was an unclear plan for conducting clinical and non-clinical audits. Therefore, outcomes and learning were unable to be shared with staff to ensure future recommendations were implemented. In addition, the service did not seek feedback for the purposes of continuous improvement.

However, the service was SaveFace accredited which involved independent auditing of the clinical procedures provided by the service and review of professional qualifications, reducing the risk of complications and improving people’s outcomes. Staff sought training opportunities to maintain knowledge of emerging aesthetic techniques and research trends. People benefited from a service that looked ahead and adapted to support safe, high‑quality cosmetic care.