19 September 2019
During a routine inspection
We carried out an announced comprehensive inspection at Bijoux Medi Spa as part of our inspection programme. We had previously inspected this service as part of our unrated programme of independent health inspections. At our last inspection undertaken on 18 July 2018 we found that the service was in breach of regulation 12 (safe care and treatment) and regulation 17 (good governance) and regulation 18 (staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At that inspection we found that the provider had not adequately mitigated risks associated with infection control, checking medical equipment, not all staff had completed the requisite training, and there was a lack of quality improvement activity. There was a lack of oversight in key areas of risk and safety and there was no system to oversee governance and risk management. There were no ongoing quality assurance activities in place to allow the practice to assure themselves that the standards of care and treatment for regulated activities delivered, were being consistently met in line with current legislation and guidance. The provider sent us their action plan in November 2018 telling us about their plans to address the concerns identified at our inspection in July 2018. At this inspection we found that all of these concerns had been addressed and resolved.
The service manager for the service 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.
Twenty-two patients provided wholly positive feedback to CQC about the service. Patients said that the treatment provided was excellent and met their needs.
Our key findings were:
- The provider had systems in place in relation to safeguarding.
- We found evidence of improvement in monitoring and mitigating risks relating to the safety of service users.
- The service reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence based guidelines.
- Appropriate emergency equipment was available on site. Staff we spoke with knew what they would do if a patient presented with the symptoms of sepsis.
- There were systems in place to report and discuss significant events.
- Medicines were appropriately managed and there were systems in place to respond to safety alerts.
- Care and treatment provided was effective and met patient needs.
- Feedback from patients was positive about access to treatment and the care provided and there was a system for managing complaints.
- Staff felt involved and supported and worked well as a team.
- Governance arrangements had improved. The provider had effective systems in place to oversee risk.
The areas where the provider should make improvements are:
- Consider ways to better accommodate patients with accessibility needs.
Dr Rosie Benneyworth BM BS BMedSci MRCGPChief Inspector of Primary Medical Services and Integrated Care