Queens Clinic

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• 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 that the service was not providing well led care, because: The service had not improved or developed leadership and governance procedures to address breaches of CQC regulations identified in previous inspections. The service continued to have a lack of effective audits, and risk assessments for undertaking procedure under local anaesthetic without a second regulated clinician. There continued to be a lack of clear clinical governance procedures at the service to show that the service was providing safe and effective care.

This service scored 25 (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 had not addressed the process breaches detailed in the last inspection report. The provider did not have a service manager at the time of the inspection, and as such it was unclear who had responsibility for the operational management of the clinic. The provider had not implemented clear clinical governance systems and processes to ensure safe and effective care.

The provider was not able to demonstrate that they had implemented any demonstrable changes to address breaches in regulation found at the inspection of January 16 and 24 2024.

The provider was not able to demonstrate that there were effective clinical or operational governance procedures at the service. We asked the provider how in the absence of a service manager for the past three months the registered provider would have oversight of policies and operational governance. The provider told us that they were trying to recruit someone who could undertake this, and shared an interview template that had been completed in the past week. However, they gave no further information on how changes and updates had been reviewed in the past three months. The provider did not demonstrate an understanding of their role in oversight of governance updates, as they reported that this would be the responsibility of a newly appointed manager, rather than their role as provider. There are currently no other staff at the service that could provide this oversight of policies and operational governance, and no temporary cover arrangements are in place until a service manager is appointed. The lack of oversight of governance at the service meant that the registered provider could not demonstrate that any new guidance was being integrated into the service’s systems.

The service had very limited quality assessment and improvement systems in place for its clinical care, and clinical records reviews showed that best practice was not being followed. Policies at the service had not been updated since the previous inspection. At that time we found that although some adaptions had been made, the safeguarding and incident policies did not include contact details, or details of processes that should be followed. The complaints policy also made repeated reference to NHS processes, which were not relevant to this service. At the time of our inspection the provider was not registered for the CQC regulated activity of surgical procedures, which is required given the services provided. Clinical processes and procedures at the services had not been sufficiently risk assessed to assure that safe and effective processes were being provided.

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.

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