Dr Victoria Cosmetic Dermatology and Anti-Ageing Medicine Clinic

This service is rated as Requires improvement 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? – Requires improvement

We carried out an announced comprehensive inspection at Dr Victoria Cosmetic Dermatology and anti-ageing Medicine Clinic on 18th July 2019 as part of our inspection programme. This is a newly registered service and thus their first inspection.

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. Dr Victoria Cosmetic Dermatology and Anti-Ageing Medicine Clinic provides a range of non-surgical cosmetic interventions, which are not within CQC scope of registration. Therefore, we did not inspect or report on these services. The clinic provides a number of skin care and beauty treatments. The inspection was in relation to specific treatments which are in the scope of registration, such as facial thread lifts, treatment of excessive sweating and the removal of minor skin lesions.

One of the doctors (who is also joint business owner) 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.

There were no clients available to speak to on the day, but feedback was obtained through 36 completed comment cards.

Our key findings were:

• Health and Safety risk assessments had been undertaken by the landlord or external agencies. The clinic had not kept copies of these risk assessments.
• The clinic was not undertaking routine checks of water temperature to monitor the risk of Legionella nor was there a risk assessment in place.
• Not all staff had undertaken safeguarding training. This had been rectified within two days of the inspection.
• Checks of emergency medicine and infection control were undertaken but not documented.
• Fire safety checks had been undertaken by an external company and the clinic was awaiting a copy of the report.
• Not all recruitment checks had been documented in staff files but had been undertaken for example by obtaining verbal references.
• Individual care records were written and managed in a way that kept patients safe.
• Patients immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs as well as their mental and physical wellbeing.
• Staff recognised the importance of peoples’ privacy, dignity and respect.
• Patients had timely access to consultation and treatment.
• The clinic was unable to offer services to wheelchair bound patients as there was no lift access to the first floor of the building.
• Staff felt respected and supported. They were proud to work for the clinic.
• Leaders had invested in training and development of staff, in relation to clinical competencies but not in relation to staff training.
• There were multiple examples of the two doctors engaging in career professional development courses and conferences to continue learning and development as well as share best practice.

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

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

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

• Improve consistency in implementing its recruitment policies and procedures.
• Review the process for documenting vaccine storage cold chain temperature checks.
• Obtain copies of the health and safety risk assessments undertaken by external organisations or landlord to assure themselves that actions had been taken to mitigate risks identified.
• Review policies and procedures to ensure they contain clinic specific information.
• Review processes for chaperoning to include training for all non-clinical staff undertaking these duties.

Dr Rosie Benneyworth BM BS BMedSci MRCGPChief Inspector of Primary Medical Services and Integrated Care