Archived: The Pemberdeen Laser Cosmetic Surgery Clinic Limited

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

Our overall rating of safe at The Pemberdeen Laser Cosmetic Surgery Limited has gone down to inadequate. We looked for evidence that people were protected from abuse and avoidable harm. We found that the service lacked the infrastructure to protect patients from harm. Systems and processes were not always in place to ensure that the environment was safe to treat patients. This included but not limited to; infection prevention and control, fire risk assessments, planned preventative maintenance and ensuring medications were available and in date.

This service scored 31 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We looked for evidence that there was an inclusive and positive culture of continuous learning and improvement that was based on meeting the needs of people who used services and wider communities. However, we could not find evidence of this. We checked that leaders proactively supported staff and collaborated with partners to deliver care that was safe, integrated, person-centred and sustainable, and to reduce inequalities. However, we found significant shortfalls in the service provision.

The key question was previously rated as requires improvement. This key question has been rated inadequate. This meant there were widespread and significant shortfalls in service leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

The service was in breach of regulations for people’s safe care and treatment the premises and equipment used within the building, staffing , the ways people’s medicines were managed safely and the governance at the service. We requested further information from the provider to address these concerns.

CQC has taken regulatory action in relation to the concerns that we found. We may publish this information on our website after any representations and/or appeals have been concluded, if the action has been taken forward.

The evidence showed some shortfalls. Whilst the service worked well with people it did not always work well healthcare partners to establish and maintain safe systems of care. The service ensured that the individual expectations were managed through the assessment process. A pre-operative assessment was undertaken by both the medical and nursing staff. The information about surgery and post operative arrangements was discussed at the team briefing the morning of the operation. They did not always make sure there was continuity of care, including when people moved between different services. There was a policy on the transfer out of a deteriorating patient, but this was not available to the ward staff or available out of hours. There were no contracts in place to support this policy. The service was in negotiation for the supply of blood products should a patient require this, but staff could not direct inspectors to a storage facility for blood products. Although the procedures undertaken rarely incurred significant blood loss, we were concerned that there were no processes in place and that this would place patients at risk. They did not always manage or monitor people’s safety. Clinical staff risk assessed patients prior to and on admission. They recorded observations and reported to the medical team any concerns. Post discharge patients could contact the service for advice through a telephone number which linked to either the director or a nurse. They could in turn seek medical advice from the surgeon and agree a plan of action. However, this process was not documented or reviewed for efficacy.

The evidence showed significant shortfalls. There was no evidence that the service worked with people and healthcare partners to understand what being safe meant to them and how to achieve that. We reviewed medical records available on site and there were no assessments of the vulnerability or not of a patient. There was a safeguarding policy, but it lacked any information for staff on how they should concentrate on improving people’s lives or protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The policy discussed the need for reporting of concerns but there were no details of to whom the staff should report this to. Similarly, the policy stated that there was a safeguarding lead but not who this person was. There was no evidence if they had shared concerns quickly and appropriately. The service did not have comprehensive records of the level and date when training in respect of safeguarding was undertaken by each member of staff. The clinic manager was not currently trained to level three in safeguarding practices although this was planned there was no date for this to occur.

The evidence showed some shortfalls. The service did not always work well with people to understand and manage risks. Whilst the pre-assessment process was focused on managing some risks it did not encompass any discussion with the patients general practitioner to evaluate any medical risks for the patient. Staff did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Nursing and medical staff discussed care with the patient and patients were provided with a feedback mechanism although they rarely used this questionnaire. Instead a web based platform was used to review the service. For patients who required a translation service we were told and this was confirmed by the safeguarding policy that “We can provide translation by using the services of Microsoft Translation Services.” However, the policy also stated “Where possible an independent interpreter should be used.” Therefore, there was no clear direction given to staff in respect of translation services.

The evidence showed significant shortfalls. The service did not always detect and control potential risks in the care environment. They did not make sure that equipment, facilities and technology supported the delivery of safe care. We requested the planned preventative maintenance plan for the equipment at the hospital. However, there was not one. Instead, we were shown reports on some equipment that showed that it had been tested. When reviewing the same piece of equipment, the defibrillator near the theatre suite, we found that the sticker on the equipment noted the date of the next test to be September 2022. Therefore, staff could not be assured that the equipment had been tested since 2021. When reviewing the ward area inspectors noted that the defibrillator upstairs was plugged into the wall next to a handwashing basin. This increased the possibility of water droplets being splashed onto this plug socket causing an electrical event.

Inspectors inspected the basement. The door to the vestibule of the basement was open, which meant that patients or visitors could access this area. This is a potential safety risk. Inside the vestibule we saw three out of date fire extinguishers. The fire door to the basement was propped open with a wooden chock. The clinic manager removed this as fire doors should not be propped open. However, after descending the stairs the inspector and the clinic manager noted that there were significant amounts of out of date stock held in the basement in cardboard boxes and paper packaging above which there were a number of open electric circuit board cupboards. Further into the basement we noted old metal equipment, supplies locked behind a gate, also in cardboard boxes and paper packaging. Behind a door there were filing cabinets of what appeared to be patient records. Some of these were stored in cardboard boxes on top of the filing cabinets. We were unable to access this room due to the clutter in the initial room. The inspector was concerned that this environment posed a fire risk and we shared our concerns with the Fire Brigade. The provider arranged for this clutter to be removed in the following days, and we were sent photographs of the first room to demonstrate that the clutter had been moved.

The evidence showed significant shortfalls. The service made sure there were enough staff in the hospital before an operation commenced. The staffing numbers were in line with the operating department’s guidance on staffing. Most patients were day cases but if patients stayed overnight there were arrangements for a doctor and two nursing staff to be available on site overnight. These staff were described as bank staff, yet the service held limited information on the qualifications, skills and experience of these staff. The contract that we were sent when we tried to ascertain who employed these staff related to a third-party organisation, which is not registered and we did not inspect. However, The Pemberdeen Laser Cosmetic Surgery Clinic had no governance process in place to make sure staff received effective support, supervision and development. There was no evidence that an induction or updates had ever been given to these staff despite them having worked with the hospital for a significant period of time. We reviewed seven staff records held on the clinic manager’s computer. This contained a variety of information about the staff who regularly worked at the hospital. None of these files were complete in line with the relevant legislation. Therefore, the service could not ensure that all staff had the relevant up to date training required for their role. Staff worked well together to provide safe care that met people’s individual needs. The ward staff attended the pre operating team brief with the operating staff before surgery commenced. This ensured that everyone was aware of the individual patient’s procedure.

The evidence showed significant shortfalls. The service did not assess or manage the risk of infection. We saw that the environment did not promote good infection control processes in that; paint on the walls were damaged by the removal of posters, the floor into the theatre area was damaged, the room used as a waste path and to store substances hazardous to health was cluttered with cleaning products and mops stored on the floor. The provider was informed about the area called the Control of Substances Hazardous to Health (COSHH) and they arranged over the following few days to remove detritus and store cleaning products safely. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly. There was no infection prevention and control policy available to ward staff. There were no cleaning schedules nor signed contract for the cleaning service at the hospital. Inspectors were informed that a “deep clean” had been undertaken but no evidence of what had been cleaned. We were concerned that this was effective given that there was clutter in each room of the theatre suite. For instance, the changing rooms held what we were informed was an obsolete operating table and an anaesthetic machine, an old office chair which was in disrepair as well as the clutter noted in the COSHH room. However, clinical staff cleaned equipment and used “I am clean” stickers to identify that this had been completed.

There were no robust records of the training staff had received in respect of infection prevention and control. We noted that female staff wore jewellery, and some had nail polish on. One member of staff who had not planned on working on the day of inspection but was called in to the operating theatre had nail polish on and so refused to undertake the role of the operating assistant. However, they were still within the theatre department working. Any chips or cracks in nail polish and the wearing of jewellery decrease the effectiveness of hand washing. All staff were bare below the elbow to assist with and washing practices. We noted that the supply of toilet paper, handwashing fluid, towels and gloves were not maintained. The consultation room contained an almost empty container of domestic hand washing soap but no towels, handwash or gloves in the dispenser above the sink.

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. We inspected the medicines cupboards in the anesthetic and recovery room. These were appropriate for the use and were locked. However, when we inspected the medicines contained within the medicine cupboards we found multiple boxes of four medicines that were out of date. We also noted that the emergency box for patients suffering malignant hypothermia did not contain the medicine which is the primary treatment for this condition. The cupboard which stored controlled or schedule 3 drugs was appropriate for its use and stock levels were stored well and appropriately checked prior to a theatre list commencing. The fridge in the anesthetic room was checked that it remained within a safe temperature and contained those medicines requiring fridge storage. Staff followed good practice guidance in recording medicines. However, we did not see a medicines management policy.