Sk:n - Leicester Gallowtree Gate

This service is rated as Requires improvement overall.

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

We carried out an announced inspection at SK:N Leicester Gallowtree Gate on 9 August 2022 as part of our inspection programme.

SK:N Leicester Gallowtree Gate is registered under the Health and Social Care Act 2008 to provide the following regulated activities:

• Diagnostic and screening procedures.

• Surgical procedures.

• Treatment of disease, disorder or injury

This service is registered with CQC in respect of some, but not all, of the services it provides. The service provides private dermatology services, offering some skin treatments and minor surgery which fall under the scope of CQC registration, as well as other non-regulated aesthetic treatments. There are some exemptions from regulation by CQC which relate to particular types of regulated activities and services and these are set out in Schedules 1 and 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We only inspected and reported on the services which are within the scope of registration with the CQC.

There was no registered manager on site on the day of the inspection. However, the provider’s nominated individual was present throughout the day. 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 Director of Clinical Services was the nominated individual at the time of the inspection and was responsible for supervising the management of the regulated activity provided. The only staff who were associated with the delivery of regulated activities were the two clinicians, a nurse and the management team. There were other staff on the premises who provided the non-regulated activities. The provider holds a contract to provide some NHS treatments at this location.

Due to the current pandemic we were unable to obtain comments from patients via our normal process of asking the provider to place comment cards within the service location. However, we saw from reviews on social media that patients had given mixed reviews about the service.

Patients also commented on the clinic being well-maintained and clean. We did not speak with patients on the day, as there were none attending for regulated activities.

Our key findings were:

• We found that the service was caring and compassionate towards patients and we observed many positive comments received from those who had used the service.
• On the day of the inspection we found at this location that clinical records reviewed did not always contain the required relevant information to ensure patient safety. No audits were available in regard to this location. However, we were assured after the inspection that they were aware of this issue across the whole organisation and had sent in June 2022 an email to all clinicians but audits to monitor this issue had only recently commenced.
• There had been insufficient action taken to address some legionella, fire safety and health and safety risks.
• There were some processes to assess the risk of, and prevent, detect and control the spread of infection. However, staff immunisations were not monitored in line with current guidance. We saw evidence at the inspection that this process had recently commenced.
• Most policies were in place and provided relevant and sufficient information, to provide effective guidance to staff. Some policies, for example, fire safety needed further information and there was no policy in place for legionella and patient safety alerts.
• There was a lack of evidence of clinical audit and regular auditing of clinical record keeping processes.
• The service involved patients in decisions about the care and treatment.
• Appointments were pre-bookable by phone or in person.

The areas where the provide must make improvements are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

• Demonstrate that actions from risk assessments and infection control audits are documented when completed.
• The infection control lead should undertake additional training to support this role.
• Seek feedback on the quality of clinical care received as well as customer satisfaction.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

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