08 December 2022
During a routine inspection
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 this announced comprehensive inspection of Light Touch Clinic on 8 December 2022, under Section 60 of the Health and Social Care Act 2008. This inspection was planned to check whether the service was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008. This was the provider’s first inspection of the service since it registered with the Care Quality Commission (CQC).
How we carried out the inspection:
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.
This included:
- Speaking with staff in person, on the telephone and using video conferencing.
- Requesting documentary evidence from the provider.
- A site visit.
We carried out an announced site visit to the service on 8 December 2022. Prior to our visit we requested documentary evidence electronically from the provider. We spoke to staff on the telephone and using video conferencing prior to our site visit.
Light Touch Clinic is an independent provider of consultations and treatment for dermatological conditions, including acne, and Botox (Botulinum toxin) injections for the treatment of excessive sweating and teeth grinding.
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. Light Touch Clinic also provides a wide range of non-surgical aesthetic interventions. These include cosmetic Botox injections, dermal fillers, body contouring and skin tightening treatments, which are not within CQC scope of registration. Therefore, we did not inspect or report on those services.
Light Touch Clinic is registered with the Care Quality Commission to provide the following regulated activities: Treatment of disease, disorder or injury; Diagnostic and screening procedures.
There was no registered manager for the service at the time of our inspection. 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. The provider’s practice manager, who was about to leave their employment, had previously held the role of registered manager. The medical director was in the process of submitting their application to CQC to become the registered manager.
Our key findings were:
- There were safeguarding systems and processes to keep people safe.
- There were records to demonstrate that recruitment checks had been carried out in accordance with regulations.
- There were processes in place for the training, performance review and monitoring of staff. There were some current gaps in required training for the one clinician involved in regulated activities which were addressed immediately following our inspection.
- There were effective systems and processes to assess the risk of, and prevent, detect and control the spread of infection. There were processes to maintain and monitor the immunisation status of staff.
- Cold chain monitoring processes were ineffective in ensuring the safe storage of medicines.
- There were some arrangements to manage medical emergencies but no oxygen supply on site and no supporting risk assessment in place to assess the level of risk to patients in the event of a medical emergency, such as anaphylaxis.
- Fire safety processes were in place. Staff had participated in fire drills and had received fire safety training.
- There were comprehensive health and safety and premises risk assessments in place.
- There was evidence of regular auditing of clinical record keeping processes.
- Clinical record keeping sampled was clear and complete.
- There were governance and monitoring processes, including assessment by external advisors, to provide assurance to leaders that systems were operating as intended.
- Policies and procedures were monitored, reviewed and kept up to date with sufficient information, to provide effective guidance to staff.
- There was regular and open communication amongst the staff team and staff felt well supported.
- Patients were routinely asked to provide feedback on the service they had received.
- Complaints were managed appropriately.
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.
(Please see the specific details on action required at the end of this report).
The areas where the provider should make improvements are:
- Continue to monitor staff training completion to ensure timely training updates.
- Complete development of risk assessments to support the control of substances hazardous to health (COSHH).
- Review the service’s infection control manual to ensure it provides clear and relevant guidance for staff.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services