Chiltern Medical Clinic, Goring on Thames

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

We found a breach of the legal regulations related to governance, Regulation 17. There was a lack of documentation and follow up of actions, which meant expectations were not readily available, benchmarked or easily monitored. Therefore, there was the potential for harm to occur.

However, we found the service had made numerous improvements including monitoring of patient outcomes, staff recruiting processes and the development of formal risk assessments and a planned audit schedule. We found an open and honest culture where staff felt they were freely able to speak up, staff also felt supported by managers in their career.

This service scored 61 (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 formal set of values. However, their website displayed their ‘concept’, which was focused on patients receiving a safe service whilst being looked after by experienced medical professionals. All staff and the managerial team were focused on the services reputation within the industry and ensuring patient satisfaction rates were high. All staff stated the patient experience was at the heart of the service. We read 11 independent reviews and noted the service received an overall score of 4.8 out of 5.

The service collated staff wellbeing questionnaire results on a regular basis to ensure staff felt supported. We viewed the latest results and noted all staff gave the service and the management team a positive rating.

The services strategy included a recognition of the use of large amounts of paper. In response the service was reviewing methods for going paperless.

Staff gave us numerous examples of where they had been supported by managers in their career progression. For example, one member of staff moved from an administerial role to a therapist position. They advised us managers gave them protected time to complete their qualifications and signposted them to external support where appropriate. Staff advised us and we saw evidence that regular monthly staff meetings were now taking place. This ensured staff were kept informed of all notices and updates.

Managers were members of the British Laser Association, British Medical Association, and the Emergency Doctors Association. This ensured they kept up to date with guidelines and best practices.

All staff we spoke with described the culture as open and honest. Staff stated the managerial team were supportive and there was an ‘open door’ culture. Staff felt able to discuss issues and concerns with managers without reprisal.

Managers encouraged staff to speak up and when concerns were raised, managers completed thorough investigations and used findings to make improvements.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff advised us staff meetings were now being re-introduced on a regular basis. Staff understood their roles, responsibilities, and accountabilities regarding patient related risks, for example if a patient deteriorated. The day-to-day running of the service was discussed at the daily catch-up meetings. Managers now completed risk assessments of the service.

The services governance policy listed how the clinic supported the day-to-day management of the clinic. However, it did not include information on the overall governance structures. We viewed the services full policy catalogue and noted there was no risk policy. Therefore, there was no formal documented process for logging, escalating, monitoring or actioning risks. Whilst managers and staff were knowledgeable of the running of the service, the lack of documentation meant expectations were not readily available, benchmarked or easily monitored. Although monthly staff meetings were now taking place, a review of three consecutive meeting minutes showed there was no documented evidence that issues from previous meetings were followed up. For example, the January 2024 minutes stated staff were required to formally sign to state they had read and understood policies and a confidentiality agreement. We did not see evidence that this was followed up, and discussions around this topic were not included in the February 2024 meeting minutes. There were further examples in subsequent minutes that also did not have documented follow up. Governance meetings were held quarterly, we viewed minutes from the last three meetings. Although there was now a set agenda, again updates from previous minutes were not documented. For example, all minutes noted that the minutes from the previous meeting were discussed, however there was no context as to what has been completed and what tasks were still ongoing. We noted that under audits, all three minutes stated the audit plan was completed, with no documented discussion around findings, improvements, or re-audit. Therefore, there was a lack of documented oversight and follow up of actions and risk, so it was unclear how the provider effectively gained assurance matters were monitored and progressed.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Staff and managers advised us there had been improvements since the previous inspection.

Processes had been introduced to ensure staff completed the required training including basic life support training in accordance with Resuscitation Council (UK) guidelines. All staff received an appraisal in the last 12 months, and recruitment process had improved as all staff were required to have a disclosure and barring service (DBS) check. Steps had been taken to ensure only staff with the right training undertook tasks such as acting as a chaperone.

We saw evidence that the service was now collecting quality patient reported outcome measures (QPROMS) for patients undergoing blepharoplasty in accordance with The Royal College of Surgeons guidelines.