Vysana Clinic

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm. This was the first inspection for this service since its registration with CQC. This key question has been rated as good. This meant people were safe and protected from harm.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Feedback from people who used the service was very positive. People reported that the provider was knowledgeable in all aspects of the services they provided. The service had a clear, accessible complaints policy and process. Since registering with the CQC in April 2021, the service had not received any formal complaints. Patient feedback was encouraged. For example, there were comment cards in the waiting area for people to complete and return. The service had a proactive and positive culture of safety, based on openness and honesty. Policies and procedures were in place for identifying and reporting incidents and safety events. No patient incidents had occurred since registering with CQC. As the provider was a lone clinician, they had linked with other clinicians external to the service to share lessons learned and embed good practice.

The provider owned the service and ensured service users were provided with safe, continuous care. The provider liaised with the service users’ registered GP. In circumstances where a patient could not be accepted for treatment due to clinical, safety, or ethical concerns, the provider referred the patient to the appropriate service to ensure safe and appropriate onward care. This was often discussed as part of the consultation process. All patients underwent a clinical consultation and assessment prior to treatment. There was an effective process to ensure lab results including blood test results were managed appropriately.

The service had appropriate safeguarding policies in place for reporting safeguarding concerns to keep people safe from harm. Local contacts were established if further guidance was needed to make a referral. The provider and clinic manager had completed appropriate training for safeguarding adults and children. In addition to safeguarding training, the provider understood mental health conditions including body dysmorphia, where people worry about flaws in their appearance that others cannot see. The provider was passionate about educating patients and told us they would refuse treatment to ensure service users received care in line with their best interests. The service treated adults only. Chaperones were not always available during opening hours. However, the provider assured us that chaperones were always offered and if a patient wanted a chaperone, an appointment would be made on a day that a chaperone was available. For example, if a patient wanted a chaperone, the clinic asked to be notified 48 hours in advance to their treatment to ensure this could be arranged.

The service worked well with people to understand and manage risks. They provided care to meet needs that were safe, supportive and enabled people to do the things that mattered to them. People said they were given information and guidance about their options for their care and the risks and benefits were also explained.

Health and safety risk assessments were completed to identify and control potential risks in the environment. The service had procedures to ensure equipment, facilities and technology supported the delivery of safe care. There was a business continuity plan in place. Portable appliance testing and calibrations were completed. A fire risk assessment was completed. Systems were in place to check safety equipment including fire alarms and emergency lighting. Fire evacuation drills had been completed. During the onsite visit, the premises were visibly clean and tidy with a professional and welcoming layout for people using the service. Cleaning schedules were in place to maintain a clean and safe environment.

The provider was qualified, skilled and experienced to ensure they provided safe care that met people’s individual needs. The provider and clinic manager were the only people working at Vysana Clinic, however, they had developed appropriate policies for staff training and staff recruitment if additional staff were recruited in the future. We received positive feedback from patients about the care and treatment they received from the provider. We saw evidence that appropriate training had been completed by the provider and clinic manager. The provider had their qualification certificates on display in the consultation room showcasing that treatments were delivered by a qualified and experienced clinician working within their professional scope of practice. It was evident from discussion with the provider that they were diligent about keeping up to date with continued professional development.

The service assessed and managed the risk of infection. The provider had completed infection prevention and control (IPC) training. The IPC policy was in line with national guidance. The consultation and treatment room had adequate provision of personal protective equipment (PPE) and handwashing facilities. IPC audits were completed, and actions were taken when necessary to mitigate any risks. Cleaning schedules were in place. Processes were in place for the removal and collection of clinical waste and cleaning schedules were established and followed. We observed the clinic to be very clean and tidy. Patient feedback also reflected this as they described the environment as very clean and hygienic every time they visited.

People were fully informed about the treatment they were receiving. People were given clear detailed instructions regarding the medicines prescribed. Medicines were stored safely and stock levels and expiry dates for all medicines were regularly checked. Fridge temperatures were monitored daily, and the provider knew what action to take if the temperature was out of range. The provider had effective systems to manage and respond to safety alerts and medicine recalls.