22 November 2022
During a routine inspection
We rated the service as inadequate because:
- Managers did not make sure staff were competent. The service did not have processes to monitor the professional registration of the bank nurse working in the service. They did not have assurance of checks in place for agency nurses used to support the delivery of services as they did not keep records of agency usage. They did not have processes in place to provide assurance that staff had up to date training in key skills, understood how to protect patients from abuse, and managed safety well.
- The service did not control infection risk well. Processes for checking medicines and emergency equipment were not regularly carried out. A significant amount of medicines stored in the treatment room had expired and medicines requiring refrigeration were stored at room temperature. The controlled drugs accountable officer had not received training for this role. Controlled drug entries in the register were not always recorded in line with required standards of the controlled drug regulations.
- Risks to patients were apparent in relation to poor maintenance and availability of clinical equipment, the presence of expired single use clinical equipment and environmental risks that had not been sufficiently assessed or mitigated. There was limited evidence the service managed safety incidents well and learned lessons from them due to limited reporting of events and learning opportunities.
- Consent processes did not include evidence of a cooling off period when patients were making decisions about cosmetic surgery. There was little evidence of recognised national guidance informing clinical protocols within the service. The provider had no processes to collect performance measures and supply these to the Private Healthcare Information Network (PHIN).
- Leaders did not have the necessary knowledge, skills or abilities to run the service. Leaders did not operate effective governance processes throughout the service. Staff did not use systems to manage performance effectively. They did not identify, review or manage risks and issues effectively.
However:
- People could access the service when they needed it and did not have to wait too long for treatment. The service planned and took account of patients’ individual needs. Staff were focused on the needs of patients receiving care.
- The service engaged well with patients and made it easy for them to give feedback.