Background to this inspection
Updated
5 November 2018
This service is provided by The Hadleigh Clinic Limited. The Aesthetic MediSpa is a private medical clinic located in Buckhurst Hill in a multipurpose building housing several different organisations. There is level access into the building and either lift or stair access to the basement floor where the clinic is situated.
This service is provided to patients who are 18-year olds and over only. At the time of our inspection the service had less than 100 patients a year requesting regulated activities.
The regulated aspects of this service are provided by a GMC registered clinician. Support is provided by a clinic manager and administrative staff known as the front of house team.
The aspects of the service regulated by CQC includes: Botox injections for Hyperhidrosis (excessive sweating); as well as wart, skin tag, cyst and mole removal.
The service provides the regulated activities of: Treatment of disease, disorder or injury; surgical procedures; diagnostic and screening procedures.
Our inspection team was led by a CQC Lead Inspector and included a GP Specialist Advisor. An inspection manager also attended in an observation role.
Before visiting, we reviewed a range of information we hold about the service.
During our visit we:
- Looked at the systems in place for the running of the service.
- Explored how clinical decisions were made.
- Viewed a sample of key policies and protocols which related to regulated activities.
- Spoke with a range of staff involved in the regulated activities.
- Checked the environment and infection control measures.
- Reviewed CQC comment cards which included feedback from patients about their experiences of the service.
To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:
- Is it safe?
- Is it effective?
- Is it caring?
- Is it responsive to people’s needs?
- Is it well-led?
These questions therefore formed the framework for the areas we looked at during the inspection.
Updated
5 November 2018
We carried out an announced comprehensive inspection on 02 October 2018 to ask the service the following key questions; Are services safe, effective, caring, responsive and well-led?
Our findings were:
Are services safe?
We found that this service was providing safe care in accordance with the relevant regulations.
Are services effective?
We found that this service was providing effective care in accordance with the relevant regulations.
Are services caring?
We found that this service was providing caring services in accordance with the relevant regulations.
Are services responsive?
We found that this service was providing responsive care in accordance with the relevant regulations.
Are services well-led?
We found that this service was providing well-led care in accordance with the relevant regulations.
We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. 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 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. The Aesthetic Clinic provides a range of non-surgical cosmetic interventions, for example, dermal fillers and Botox for the face, which are not within CQC scope of registration. Therefore, we did not inspect or report on these services. We were only able to inspect the service with regard to: Botox for hyperhidrosis; skin tag, mole and lesion removal (where there was no sign or suspicion of malignancy).
The lead clinician 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.
Three people provided feedback about the service via Care Quality Commission comments cards. Feedback was positive about the service provided and staff, although some of this feedback may have related to services not regulated by CQC.
Our key findings were:
- There were systems in place to safeguard people and their information.
- Information relating to patients was accurate and enabled staff to make appropriate treatment choices.
- There were systems in place to identify, assess and manage risk.
- The process for ensuring that patients were not under the age of 18 required strengthening.
- Patient feedback from the service’s satisfaction surveys and from our comment cards were positive.
- Recruitment processes included immunisation checks for Hepatitis B only for clinical staff.
- There were appropriate emergency medicines and equipment kept on site in case of anaphylactic shock.
- There were monitoring processes in place to ensure that medicines stored in fridges were kept at an acceptable temperature, however there was only one thermometer in-situ and it was not regularly calibrated.
- There were systems in place to respond to incidents and complaints. Although no significant events or complaints had occurred in the preceding 12 months, there was a clear structure in place to ensure that learning from incidents and complaints would be shared.
- Staff had access to appropriate training.
- Staff were aware of their roles and responsibilities.
- Governance arrangements ensured policies and procedures relevant to the management of the service were in place and kept under review.
- There was a clear commitment to regulation and using this as a framework to ensure a high and safe standard of treatment.
There were areas where the provider could make improvements and should:
- Review the need for a second fridge thermometer or regular calibration of the primary thermometer.
- Review the process for verifying the age of patients who may be under 18.
Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice