Evamed UK Ltd

This service is rated as Good overall.

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at Evamed UK Ltd on 2 March 2023 as part of our inspection programme.

The service offers gynaecology, genital reconstruction and vaginal rejuvenation related treatments. In addition, the service offers individualised bioidentical hormone replacement therapy (BHRT).

This service is registered with CQC under the Health and Social Care Act 2008 in respect of some, but not all, of the services it provides. There are some exemptions from regulation by CQC which relate to particular types of regulated activities and services and these are set out in Schedule 1 and Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Evamed UK Ltd provides a range of non-surgical cosmetic interventions, for example, botox and fillers which are not within CQC scope of registration. Therefore, we did not inspect or report on these services.

The senior doctor is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

For reasons of safety and infection prevention and control related to the COVID-19 pandemic, we did not commission patient feedback with CQC comment cards. We spoke to four patients during this inspection and received positive feedback.

Our key findings were:

• Recruitment checks were not always carried out in accordance with regulations including Disclosure and Barring Service (DBS) checks.
• Some emergency medicines were not in stock.
• Consultations were mostly comprehensive. However, we noted that there was a lack of information in some care records.
• There were clear systems and processes to safeguard patients from abuse. All staff had received training appropriate to their role.
• There was evidence of quality improvement activity including clinical audits. However, a formal prescribing audit was not carried out.
• Consent procedures were in place and these were in line with legal requirements.
• There was an infection prevention and control policy and procedures were in place to reduce the risk and spread of infection.
• Staff members were knowledgeable and had the experience and skills required to carry out their roles.
• Clinical records were detailed and held securely.
• Patients were asked for feedback following each appointment. This feedback was logged, analysed and shared with staff.
• The service had systems to manage and learn from complaints. However, the policy and response did not include information regarding how to escalate the complaint if they were unhappy with the clinic’s response to their complaints.
• Patients were able to access care and treatment in a timely manner.

The areas where the provider must make improvements as they are in breach of regulations are:

• Ensure care and treatment is provided in a safe way to patients.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

The areas where the provider should make improvements are:

• Carry out formal regular prescribing audits and peer reviews.
• Review the complaints policy and include information regarding how to escalate the complaint if the patient was not satisfied with the response to their complaint.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services