Gosforth Private 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

Although managers and leaders had the skills and abilities to run the service, there were many deficiencies in the way the service was being managed.

Following assessment, the service provided a vision and values document for what it wanted to achieve which was limited in scope and relevance. We were not provided with any action plans to put this in to practice.

We were not assured the service operated effective governance processes. Staff were not clear about their roles and accountabilities and had not had regular opportunities to meet, discuss and learn from the performance of the service. Systems to manage performance were not appropriate nor effective. Some risks were identified but there was confusion amongst staff how these were meant to be escalated.

The service did not provide opportunities for career development. We did not see evidence the service supported staff to develop their skills.

However, managers and leaders were visible and approachable in the service for patients and staff and there was a positive culture within the service with individual staff focused on the needs of patients. The service did have an open culture where patients and staff could raise concerns.

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.

Staff and leaders told us they considered the vision as expanding the volumes of patients currently seen in the clinic, to be able to ‘run it better’ and necessary to improve their previous CQC rating.

Staff told us there was a ‘good’ working environment, relaxed with good support and positive patients.

Staff confirmed the external consultant was available for advice, in person or remotely.

Following assessment, the service provided a ‘Vision and Values’ document identifying a culture committed to treat everyone with respect and dignity, high quality care, clinically excellent staff and treating people with compassion and kindness.

Although some staff were aware the service had a vision and strategy, others were not and were unsure how this had been developed. They could not identify how their views had been captured and used in the development of the vision and strategy.

The owner confirmed an external consultant had been engaged to provide advisory management of the clinic. Although this arrangement had been in place for some time, an application to undertake this role as the registered manager had not been made to CQC.

The responsibilities of this role included providing safeguarding advice and oversight, incident recording and reporting when necessary, holding a management meeting each month, and acting as a point of contact for staff concerns. We were told the current role will increase to 50% commitment when a registered manager application is submitted, processed and confirmed.

Staff confirmed the owner was always available, and that they had created a positive working environment. They also confirmed the external consultant was accessible mainly remotely and occasionally on site.

A member of staff was acting as the operations manager sharing some responsibility with the owner for day-to-day management of the service. They had an oversight of management training, cleanliness and infection control, audit and risk, staff induction, and had contributed to the clinic’s vision and strategy. The owner confirmed their intention was for this member of staff to take on the role of nominated individual and they were confident they had the skills and experience to successfully apply for the role.

Staff said they were well supported and there was always a member of the management team available. However, we were told staff meetings were not held regularly due to individual working patterns. The last management meeting was held in June 2024.

We were told there were no processes in place to monitor and improve staff health and wellbeing, however morale was described as ‘fine’ by staff. Staff also confirmed they felt encouraged to escalate issues and concerns with the service owner and the external consultant employed.

Staff identified the top risks for the service as infection prevention and control, statutory and management training updates, and the maintenance of the building.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

Although leaders told us the service valued diversity in their workforce and worked towards an inclusive and fair culture, staff did not give examples of how the service had supported equal development opportunities.

The service had a small number of staff who told us they worked mainly by themselves, focused on their patients, and not necessarily being involved in the wider team.

Information provided did not demonstrate processes were in place to support equal opportunities for an inclusive and diverse workforce.

A registered manager was not in position at the time of our assessment, and records had not been updated from the provider for the registered manager or their nominated individual.

There was a lack of knowledge from staff who had responsibility for governance. Staff were not clear about roles or responsibilities in the management of the service and some staff were unable to confirm their job title.

Although staff told us there was a ‘policies and procedures file’ within the service, we were unable to locate any policies within date.

Following assessment, we were provided with a number of policies in date that had not been available on site; these did not all relate to practices in the service, contained processes not relevant to the service and referenced systems which staff were not aware of during interview.

We were told new staff were given the file as part of induction and required to ‘sign off’ that they had read, and updates to policies and procedures were emailed to staff and subject to the same ‘sign off’ procedure. This was not confirmed during interviews with staff.

Not all staff had a current job description and role specification but were clear on the management structure and lines of accountability directly to the owner. However, not all staff were able to identify the role of the external consultant, some describing them as the registered manager.

There was a lack of clarity from staff over the security of sonography scan results. We were told these were kept on the sonography machine, but there was uncertainty how secure the room was in which the machine was located.

Further, there was uncertainty whether data storage on the machine was password protected.

The service website was not up to date and gave the impression a wide range of services were provided which did not reflect those actually offered or those for which the service was registered.

We were provided with a daily, weekly, monthly and annual audit schedule and an 'Information Governance and Record Keeping Policy and Procedures following our on-site assessment. We were unable to identify how this schedule had been applied consistently within the service, outcomes from the schedule and action take as a result. During staff interviews it was unclear how this policy and related procedures had been implemented, for example how sonography results were accessed, stored, and held securely.

Staff asked patients to complete a feedback questionnaire focussed on arrival (accessibility, parking, initial welcome), waiting area (comfort, facilities) and clinic staff (friendly, care and attention, thoroughness of questions answered, arrangement of future appointments).

Patients self-referred to the service.

The outcomes from these questionnaires showed unanimously positive responses in all areas but represented a very small sample of patients.

We were not assured these had been discussed at staff and management meetings, and that improvements or changes to practice were identified as a result.

Staff told us patients appreciated the short waiting times for appointments, compared to the NHS.

Staff, managers and leaders did not give us examples of collaboration with the community and other organisations.

The provider had no formal processes in place to work collaboratively with staff to share learning or identify areas for improvement. Staff were however able to share feedback with the owner.

Staff told us there was an ambition to increase service capacity, and this was essential to introduce more services.

Some staff told us their engagement with colleagues was difficult because of their working patterns limiting contact.

A staff training matrix was in use to track completed and required training, and when this was due to expire.

The service relied on training received through the main employer of staff, for example the NHS, and kept records of completion.

The service did not provide training itself.