Dr Tanja Phillips Medical Aesthetic Clinic Ltd

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 is the first inspection for this service since its registration with CQC. This key question has been rated as Good.

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.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

Leaders encouraged staff to raise concerns when things went wrong, and there were clear procedures for reporting incidents, near misses and safety events. For example, a recent data breach was managed efficiently and documented in line with the service’s policy. The incident involved an invoice being mistakenly sent to the wrong person; however, no address details were shared. The situation was promptly resolved, and a new process was introduced using the digital records system to ensure invoices go only to registered email and phone contacts. An incident report and risk assessment were completed to prevent recurrence.

All staff had successfully completed online training on accident and incident reporting and could demonstrate what they would do if an accident or incident occurred. Staff received support from leaders when completing the incident forms, and shared examples of how incidents were investigated and resolved.

During staff meetings, clinical issues and significant events were discussed, and learning outcomes were shared with staff. Learning from incidents and complaints resulted in changes that improved care for others. Staff described an open, blame-free culture with a strong focus on safety. There were policies and procedures to guide the recording, investigation, and response to incidents and complaints. Guidance was also available to ensure outcomes were shared in line with the duty of candour, this included open discussions and sharing the changes that had been implemented.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were systems to process information relating to new service users and the service collected necessary safety information. For example, a medical questionnaire was provided to people at their initial visit, requesting information regarding overall health status, allergies, and next of kin details.

The service delivered shared care with specialist services at the Candover Clinic, such as dermatology. Referrals, where applicable, were managed in a timely way. The service only shared information with a person’s GP when there was a clear clinical need to do so and with the person's consent. If the service determined after assessment, it could not provide direct support, it would offer advice to the individual and direct them to more suitable services, or signpost back to their GP. In instances where skin lesions were potentially suspicious for cancer, people were promptly signposted or referred to their GP for further evaluation. The service also offered referral options, enabling people to be directed to private GPs or specialists at the Candover Clinic, as appropriate. This approach ensured timely and appropriate escalation of care, in line with safe systems and pathways.

The service worked with people to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

There was a designated safeguarding lead at the service. There was a safeguarding policy in place and known to staff, who were appropriately trained in safeguarding procedures. Safeguarding posters were on display for staff to refer to, and safeguarding information was provided within the service’s visitors book to inform people who used the service.

The service’s clinicians reviewed people’s treatment requests and held discussions to ensure they were appropriate for treatment and using judgement to identify any concerns, such as neglect, abuse and psychological assessments. To enhance current procedures, the service was in the process of introducing an additional questionnaire, incorporating this process, to determine whether treatment was appropriate for people.

There was a chaperoning policy in place, and posters advertising chaperones were clearly displayed throughout the service. A mixture of clinical and non-clinical staff members had chaperone responsibilities as part of their role. All staff members had completed Disclosure and Barring Service (DBS) checks and relevant training to ensure they would be appropriate to undertake this role.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them. Clinicians consulted with people about their requests and proceeded with treatment only when it was in the person’s best interest, carefully documenting and explaining their reasoning to them.

All emergency equipment was present, properly stocked, well-maintained, and within its expiration date. Staff had relevant training for dealing with medical emergencies, including basic life support and anaphylaxis. Staff could recognise a deteriorating person and knew of action to take should the need arise during or post-appointment.

People who used the service were advised on risks related to their treatment and actions to take if their condition deteriorated. After treatment, the service offered relevant treatment plans and after-care leaflets, making sure people were informed about whom to contact with any concerns.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care. Contracts were in place to ensure the premises were maintained. Electrical, gas and water testing had been undertaken regularly. There was a business continuity plan to support any major service disruptions, such as IT failures, which was monitored and reviewed.

Portable appliance testing and equipment calibration had been completed routinely. Risks such as fire, hot water systems, and legionella were assessed and managed appropriately. The service had a clear fire evacuation plan and policy, and fire warden training had been completed by the appropriate members of staff. The service maintained a ‘grab bag’ containing essential documents, including the business continuity plan, to ensure the service was prepared for emergency situations. Scheduled safety checks were conducted on the fire alarm system, such as, emergency lighting and equipment as per service policy. There were suitable arrangements for the storage of oxygen with correct safety signage in place.

Health and safety risk assessments and audits were completed, with identified risks being properly managed. However, during the inspection, it was found that the service did not conduct annual display screen equipment (DSE) assessments for staff who used DSE daily for continuous periods of an hour or more, as per Health and Safety (DSE) Regulations 1992. The provider confirmed staff were instead given the opportunity to discuss reasonable adjustments during their 3-month probation review and at subsequent appraisals, as evidenced by signed comments in staff files. After informing leaders about the lack of staff DSE assessments, they promptly provided evidence showing these assessments had since been introduced, complete with yearly review dates.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

Training was up to date, and learning needs and development of staff was managed appropriately. Staff worked within their agreed areas of competence, and these areas were assessed and documented through annual appraisals and regular one-to-one meetings with leaders. Staff received a structured induction tailored to their specific roles and responsibilities, which also included time for shadowing colleagues. Ongoing support was provided through regular supervisions and annual appraisals.

Safe recruitment processes were followed in line with national legislation. The provider’s recruitment and Human Resource (HR) records met the requirements of their policy and Schedule 3 of the Health and Social Care Act 2008. Our review of 3 staff files showed appropriate recruitment checks had been completed, and records were maintained accurately. However, no health questionnaire records for staff were available, although staff confirmed that these topics were discussed and documented during their one-to-one sessions. Following our onsite visit, health questionnaires were promptly introduced, along with procedures to ensure these records are reviewed each year.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The service had a designated infection prevention and control (IPC) lead. Cleaning schedules were being followed, and we saw evidence of daily cleaning being undertaken in line with the schedules. Risk assessments and audits were completed, and actions taken to mitigate risks.

All staff had completed relevant IPC training as part of their mandatory training programme and had a good understanding of IPC principles. Staff vaccinations were kept up to date in line with the latest national guidance. Personal protective equipment (PPE) was appropriately stocked and accessible to all staff. The service had clear processes for managing clinical waste. Waste was segregated correctly and disposed of safely in line with current waste management standards.

The facilities and premises were clean during our onsite visit, and the service had systems to prevent the spread of infection. All cleaning items used in the service had appropriate processes and risk assessments in place to control substances hazardous to people’s health, and staff had received specific training in control of substances hazardous to health (COSHH).

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.People knew what to do and who to contact if they experienced any unexpected symptoms. Staff received regular training, were competency assessed on medicines optimisation, and felt confident managing the storage, administration and recording of medicines. Medicines were stored securely and at appropriate temperatures.

Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines and medicines stored in the medicine fridges. Fridge temperature recordings were taken in line with the provider’s cold chain protocol, and no concerns had been identified. The provider had effective systems to manage and respond to safety alerts and medicine recalls, and systems to ensure effective oversight of medicine prescribing.