The Care Quality Commission
  • Hospital
  • Independent hospital

Archived: Epilium & Skin

Overall: Inadequate read more about inspection ratings

25-27 George Street, London, W1U 3QA (020) 7486 5134

Provided and run by:
Epilium & Skin Ltd

All Inspections

24 April 2023

During an inspection looking at part of the service

The service Epilium & Skin provides surgical procedures to adults only. We inspected the service using our focused inspection methodology.

This inspection was a focused follow up inspection to determine if all areas of concern raised at our previous inspections on 20 December 2022 and 28 February 2023, had been resolved and the risk of harm to service users had been removed. We did not rate the service at this inspection as we were following up on concerns raised at our previous inspections.

We found:

  • The service did not follow required legislation in relation to recruitment or registration of staff providing regulated activities.
  • There were no medicines management systems in place. There was no stock control system in place. There were no decontamination facilities or services in place.
  • The service did not monitor the effectiveness of care and there was no system to ensure the competence of staff.
  • Governance systems were not fit for purpose which meant the provider did not have a good understanding of the service or their responsibilities in relation to risk and leadership.

Following our comprehensive inspection on 20 December 2022, the service was rated inadequate. We suspended the registration of the provider and placed the service into special measures.

Following the focused follow up inspection on 28 February 2023, the suspension of the regulated activity was extended for a further eight weeks because the service had not made all the required improvements.

As a result of the focused follow up inspection undertaken on 24 April 2023, the suspension of the regulated activity was extended for a further sixteen weeks because the service had not made all the required improvements.

Services placed in special measures will continue to be monitored. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling the registration or to varying the terms of their registration within six months if they do not improve. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement, we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

28 February 2023

During an inspection looking at part of the service

The service Epilium & Skin provides surgical procedures to adults only. We inspected the service using our focused inspection methodology.

This inspection was a focused follow up inspection to review if all areas of concern raised at our previous inspection in December 2022, had been resolved and the risk of harm to patients had been removed. We did not rate the service at this inspection; we were following up on concerns raised at our previous inspections.

We found:

  • The service did not follow required legislation in relation to recruitment or registration of staff providing regulated activities.
  • There were no medicines management systems in place. There was no stock control system in place.
  • The service did not monitor the effectiveness of care and there was no system to ensure the competence of staff.
  • Governance systems were not functioning, and the provider did not have a good understanding of the service or their responsibilities in relation to risk and leadership.

Following our comprehensive inspection in December 2022, the service was rated inadequate, we suspended the registration of the provider and placed the service into special measures.

Following the focused follow up inspection, suspension of the regulated activities was extended for a further eight weeks because the service had not made all the required improvements.

Services placed in special measures will continue to be monitored. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling the registration or to varying the terms of their registration within six months if they do not improve. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement, we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

20 December 2022

During a routine inspection

We have not previously rated this service. We rated it as inadequate because:

  • Staff did not have up to date training in key skills that helped them to keep people safe. The service did not have measures in place to control infection risk. Staff did not assess risks to patients and care records were inconsistent.
  • The service did not follow required legislation in relation to recruitment or registration of staff providing regulated activities.
  • There were no medicines management systems in place. There was no system in place to manage safety incidents.
  • The service did not monitor the effectiveness of care and there was no system to ensure the competence of staff.
  • Governance systems were not functioning, and the provider did not have a good understanding of the service or their responsibilities in relation to risk and leadership.

Following the inspection, we took immediate action to suspend all regulatory activity at the provider for 3 months.

I am placing the service into special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement, we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

Dr Sean O'Kelly

Chief Inspector of Hospitals

11 June 2018

During a routine inspection

Epilium & Skin is operated by Epilium & Skin Ltd.

The service provides cosmetic surgery and other cosmetic treatments to adults over 18 years old. The service does not have inpatient beds and all patients are seen as day cases. Facilities include one operating theatre, one recovery room, consultation room and waiting area.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 11 June 2018.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

Services we do not rate

We regulate cosmetic surgery services but we do not currently have a legal duty to rate them when they are provided as a single specialty service. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary.

We found the following areas of good practice:

  • Systems and processes were in place to keep staff and patients safe. The service had systems in place for the reporting, monitoring and learning from incidents. Staff knew how to report incidents.

  • There were good infection prevention and control procedures in place, all areas were visibly clean and well equipped.

  • Staff used a ‘five steps to safer surgery’ World Health Organisation (WHO) checklist to minimise errors in treatment, by carrying out a number of safety checks before, during, and after each procedure. Patients received a thorough assessment prior to treatment and were given an emergency contact number following their discharge.

  • Policies, procedures and treatments were based on nationally recognised best practice guidance. Regular audits were carried out on a range of topics.

  • Care was delivered in a compassionate way and patients were treated with dignity and respect. Patients were kept informed throughout their care and encouraged to ask questions.

  • Managers were visible and respected by staff. Staff felt valued and supported.

  • Policies were in place for key governance topics such as information governance, incident management, risk assessment or management of complaints.

However, we also found the following issues that the service provider needs to improve:

  • There was no suction machine available.

  • Not all medical staff had completed mandatory training

  • There was no clinical escalation policy.

Amanda Stanford

Deputy Chief Inspector of Hospitals (London)

3 October 2013

During a routine inspection

People were complementary about the services they had received, telling us that the information provided enabled them to make decisions about treatment.

People told us they signed a consent form prior to treatment and we saw evidence that consent was fully considered.

People told us they were happy with their treatment and the approach of staff. We were told, "I feel that they really care about me." We saw that people were given detailed information about the treatment, including benefits and risks.

Care records were completed for each treatment and people were kept informed of their progress. We were told that, "They monitor you all the time."

We saw that medicines ware managed and administered appropriately. There was a recorded daily check of medicines and equipment, and a full and detailed record of all medications provided within personal treatment files.

We saw that effective recruitment procedures were in place, and that there was evidence that all staff were qualified to undertake the range of treatments provided.

We saw that arrangements were in place for assessing and monitoring the quality of services provided. People told us that they felt able to discuss their expectations and if these were not being met and that these would be addressed by staff.

31 October 2012

During a routine inspection

People who use the service were provided with sufficient information. People had a comprehensive consultation with the doctor two weeks before a procedure was carried out. We looked at consultation notes and saw that the procedure, the risks, benefits and side effects had been discussed. We saw that there were information leaflets available about the different procedures offered by Skin Oasis.

A detailed medical history was taken for each person to ensure that the treatment was appropriate. All staff had received basic life support training and there was emergency equipment available should an emergency arise.

It was not possible to speak with people who use the service as no one had booked an appointment on the day of the inspection. However, we looked at recently completed feedback questionnaires. These indicated that people were happy with the service. People rated the overall service as "good" or "excellent". No complaints had been received in relation to the surgical procedures offered at the clinic. However, the complaints policy was on display and any concerns raised were discussed at clinic meetings.

There were effective systems in place to reduce the risk and spread of infection. The clinic appeared to be clean and well maintained. There were policies in place in relation to infection control and the decontamination of instruments. The provider might find it useful to note that we found one laser lipo-suction catheter was out of date.

4, 14 April 2011

During a routine inspection

The clinic provides non-invasive cosmetic services that do not require registration. They also provide surgical cosmetic services for which they are registered. At the time of the visit, there weren't any people using the surgical services. The majority of the people (4 - 5 in total) who have used this service are from overseas and therefore receiving feedback has been difficult.

We did speak to one person using the non-invasive cosmetic services, as the clinic share the same facilities. This person told us that they had always found staff to be friendly and approachable. Staff introduced themselves and explained all procedures. They were given information about the procedures they were having and had used the clinic on at least four occasions.