Signature Clinic - Central London Also known as Signature Medical Ltd

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

At our previous inspection in August 2023, it was concluded that this service was not well-led. At this inspection, we were unable to rate well-led, as this inspection looked only at addressing each specific area of the enforcement action that we took against the provider following the previous inspection. We assessed one quality statement relating to governance, management and sustainability. Leaders had the skills and knowledge, experience and credibility to lead the service. They demonstrated their integrity and honesty which was recognised by their staff. There was a clear system of governance and risk management based around delivering safe and good quality care and treatment. The service was prepared for emergencies and major incidents and worked with others as part of a multiagency response.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

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

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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.

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 had time and resources to undertake effective governance and manage risk. They had access to a range of accurate and timely data and information to understand performance and quality and improvements were made as needed. Governance systems facilitated learning, improvements and innovation in the service. Patient information was stored securely and appropriate measures were in place to protect confidential patient data and images. Computers were password-protected and they were locked when not in use. Staff demonstrated to us that each individual member of staff had their own password log-in identity. Staff stored patient’s electronic photographs and cameras securely, these were only accessible to authorised members of staff.

The service took action to identify, escalate and mitigate relevant risks and issues to reduce their impact. The service had a risk register which identified risks and actions taken, including infection prevention and control, patient safety and medicines management. The service identified and escalated risks through its programmes of audits, weekly and monthly governance meetings, team meetings, daily safety huddle and daily debrief meetings. The service’s audit plan for 2024, introduced by the senior nurse overseeing service development at the location, included: daily, weekly and monthly cleaning logs, health and safety audits, Control of Substances Hazardous to Health Regulations audits, hand hygiene audits, infection prevention control audits, General Data Protection Regulation audits, medicines management audits, venous thromboembolism audits and WHO audits. We found illegible doctors’ handwriting in patient records at our previous inspection. As a result, the senior nurse overseeing service development had written to the surgeons where illegible handwriting had previously been identified. This was followed up by audits of medical records at the service. The details of the audits included dates, entries on record, black ink, legibility, medical history and chaperone details recorded. The service ensured that internal security measures were in place within the building for staff and patients. We observed that all doors that led off the corridor were locked and accessed by combination codes. This included access to restricted areas such as the theatres, the kitchen and the decontamination room. We were sent an updated fire risk assessment action plan that had made a number of recommendations for improvement. We saw evidence that the provider had taken appropriate action to address the majority of the concerns raised. The service held monthly all-staff meetings. The senior nurse overseeing service development and the clinic manager sent out a monthly newsletter

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.