At the previous inspection in December 2021 we rated the practice as Good overall. At this inspection we have rated the service as
Requires improvement
overall.
The key questions are rated as:
Are services safe? – Requires improvement
Are services effective? – Good
Are services well-led? – Requires improvement
We carried out an unannounced focused inspection at Edgbaston Wellness and Medispa on 2 November 2022 due to information of concern.
Edgbaston Wellness and Medispa is a private cosmetic clinic for over 18s offering a range of treatments such as vitamin therapies, facial aesthetic and body treatments. The clinic also provides women’s health, men’s health and medical services such as travel vaccinations, private GP consultations and minor surgeries.
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. Edgbaston Wellness and Medispa 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.
Dr Kiranmayi Penumaka 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.
Our key findings were:
- Medical staff had the relevant skills, knowledge and experience to deliver the care and treatment offered by the service.
- The service did not always provide care in a way that kept patients safe and protected them from avoidable harm.
- Policies and procedures were in place to support the delivery of safe services however these needed embedding further.
- There were arrangements to ensure training for staff in key areas. However, there had been insufficient monitoring to ensure training was received in a timely manner.
- There were systems and processes to assess the risk of, and prevent, detect and control the spread of infections, however this needed strengthening.
- Patients received effective care and treatment that met their needs.
- There were systems in place for identifying, acting and learning from incidents and complaints to support service improvement.
- Staff treated patients with kindness, dignity and respect.
- The service encouraged and valued feedback from patients and staff. Feedback from patients was positive.
- Governance and monitoring processes required further embedding to provide assurance to leaders that systems were operating as intended.
- The practice organised and delivered services to meet patients’ needs.
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.
- 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:
- Update the providers statement of purpose to include the treatment of patients under the ages of 18 years.
(Please see the specific details on action required at the end of this report).
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services