Archived: Queens 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

We found that the service was not providing well led care because: There were no systems or processes to support governance and leadership, despite CQC telling the provider to do so at numerous previous inspections. There were no systems or processes in place to assure the service it was providing safe and effective care. The provider showed a lack of understanding of governance and its importance to patient safety. The provider had not responded to continued breaches of regulation found at previous inspections in order to mitigate risks to patient safety and eliminate identified breaches. The provider showed a lack of understanding of Health and Social Care Act (2008) regulations that underpin care provision and provided treatments that they were not regulated by CQC to carry out.

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.

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.

The provider was not able to demonstrate they had implemented any significant changes to address breaches in regulation found at the previous inspections.

The provider had not appointed a service manager at the time of the inspection. The provider had not implemented clinical governance systems and processes to ensure safe and effective care. There were no systems and processes to maintain leadership competency and demonstrate leadership support and development.

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.

We asked the provider to detail clinical governance at the service. They were unable to do so nor were they able to demonstrate a clear understanding of governance and its importance to patient safety. During the assessment, we were told a process for the review of policies was planned to be in place soon, but no evidence or date was provided. Feedback from staff demonstrated that there was a lack of governance infrastructure to assure the service of its safety.

The service had not developed or implemented leadership and governance processes to address breaches of CQC regulations identified in previous inspections. The lack of two-cycle audits had been noted in previous CQC inspection reports between 2020 and 2024, but the service had not taken any steps to address this. There were no clear clinical governance processes at the service to show that the service was providing safe and effective care. No audits had taken place since the previous practice manager left in December 2023. Audits prior to December 2023 were of poor quality and did not provide meaningful information with which to improve services. There was no process in place for the review of policies or to assure the service staff had read and understood them. The provider was carrying out surgical procedures which they were not registered by the CQC to do; this is a regulatory requirement. Clinical processes and procedures at the services had not been sufficiently risk assessed to ensure safe care was 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.