Archived: A Vita Limited Also known as A Vita Laser, Aesthetic and Beauty Specialists

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. At our last assessment, we rated this key question as requires improvement. At this assessment, the rating remains the same.

This service scored 41 (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 did not have a proactive and positive culture of safety.

There was a lack of processes in place to mitigate risks. Risks were overlooked. The service were not following their own polices. Lessons were not learnt to continually identify and embed good practice. Some of their policies were basic and did not follow legislation or best practice guidance. For example, the infection control and recruitment policies.

The service did not have a significant events policy.

We were unable to assess the processes for incidents and complaints as the service told us they had not received any complaints or generated any near misses or safety events in the last 12 months.

There was a system in place for patient safety alerts.

Staff told us there was an open culture

There was a complaints policy in place.

We were concerned that safety was not a priority in the care of clients who received treatment at the service. They did not always manage or monitor people’s safety. For example, there were no records of histology reports which were received back from the laboratory in any of the clinical records we reviewed. Nor did we see how the risk of the results not being received back from the laboratory were managed. Some records did say histology was negative, however, it was not recorded why, or any further information to support this conclusion. We were unable to see any clinical records regarding slimming injections which were prescribed by the service.

Clinical records were incomplete. For example, we were unable to establish in most records if the clients identity had been checked.

We found some of the questions on the questionnaires for surgery completed by clients in the clinical records were not completed.

The client’s records that we reviewed showed there were no plans for treatment or recovery.

We discussed safeguarding at our first site visit. The provider told us that they were the safeguarding lead for the service. They had received safeguarding level 3 training. Staff had received safeguarding training.

The service did not treat clients under the age of 18. They told us they had not had to raise any safeguarding referrals.

The provider told us that they were at the service one day per week. The nurses would deputise for safeguarding advice if the provider was not available.

We saw that appropriate disclosure and barring checks (DBS) had been carried out.

Nurses and non-clinical staff were available as chaperone. The provider told us the non-clinical staff had been trained to carry out this role, however there were no formal certificates to verify this. Following our assessment the provider sent us a chaperone training plan.

The service did not always work well with people to understand and manage risks.

Clinical records were of poor standard. It was difficult to establish if the service worked with clients to help them manage and understand the risks of surgery or treatment. There were no treatment or follow up plans in the records we reviewed.

Feedback from clients was limited. There was no direct feedback to the service from clients who used their services regulated by CQC.

Feedback we could access was from a website used for clients to feedback on beauty salons and hairdressers. Almost all reviews were regarding beauty treatments.

The safety of the environment at the service could be improved. The governance was ineffective.

We saw that facilities, equipment and technology were not always well-maintained. We were not assured that all risks associated with the premises had been identified and the provider was managing these risks.

At our site visit in March 2025, we were told that the service had an action log for items to be serviced. We asked to see calibration and servicing certificates. We were told that the patient bed in the surgical room was not serviced. The diathermy machine, which was subsequently decommissioned, had not been serviced. There were no calibration certificates. The boiler was overdue a service which had been booked. The health and safety policy said that portable appliance testing (PAT) would be carried out annually, this had last been carried out in 2023, testing had been booked. There was no legionella risk assessment.

We saw a fire risk assessment, fire procedure, fire extinguisher and emergency light servicing.

We saw paper medical records were stored in a cupboard, which was not locked. Tins of paint were stored on top of the cupboards, which presented a health and safety risk.

The surgical room was not well organised, there was no checklist or schedule of how this should be organised for surgery or how the room should be set up.

The service had a business continuity (contingency) plan, however this was basic and, for example did not hold a list of emergency contacts in case of emergency.

At our site visit in June 2025 we saw some improvements. There was still no calibration of equipment. However, PAT testing had been carried out. Paper records had been organised and the paint removed from the room where it was stored on top of clinical records.

We were concerned there was no signage on doors, for example fire exit signage which is a legal requirement for all non-domestic premises.

The information to ensure there were qualified, skilled and experienced staff, at the service was not always available. Policies did not contain sufficient information to ensure staff were vetted and trained for their roles.

We looked at recruitment records at our site visit of March 2025. We saw for example; the recruitment policy did not include the need for satisfactory evidence of conduct in previous employment for employees or the requirements for disclosure and barring service checks (DBS). Staff had received DBS checks, however satisfactory evidence of conduct in previous employment had not been requested at the recruitment stage for some staff.

The provider sent us their mandatory training policy. This set out mandatory training as basic life support (BLS), safeguarding, infection prevention and control, fire safety and equality and diversity training. We were not assured that this was sufficient training, for example, there was no health and safety, mental capacity act or information governance training mentioned as being mandatory for staff.

We were told about, and shown records of the training staff had received, however these ware not comprehensive or up to date. Some of the training set as mandatory in the policy had not been completed by all staff. Equality and diversity had only been carried out by the nurses. Some health and safety training had been done. We were told staff had carried out chaperone training, however, no certificates were available.

The nurses had not received training in learning disability or autism, which is a requirement for healthcare staff in CQC registered services.

The provider told us that clinical supervision of clinical staff was every week.

The service did not assess or manage the risk of infection. They did not have high standards of the prevention of infection or good management and processes of cleanliness.

At our previous inspection in 2023 we found the provider lacked an effective infection control system.

At our first site visit of this assessment in March 2025 we found that arrangements for infection prevention and control were ineffective. The premises were seen to be visibly unclean. The surgical room was dirty and dusty.

Equipment had not been cleaned, such as the medicine refrigerator, the trolleys and drawers for medical equipment for surgery.

We sent a letter of concern to the provider detailing the seriousness of concerns and that we required an urgent action plan setting out how these issues were to be addressed and when.

We received a response with a letter and information of how the service had addressed these concerns.

For re-assurance on infection control issues, we arranged a second site visit in June 2025. We saw some improvements had been made to the infection control arrangments at the service however, we were not re-assured about the governance of this.

The provider had told us a contractor was to be engaged to carry out the cleaning; this had not yet happened at the time of our 2nd site visit in June 2025. The service manager who was carrying out the cleaning had not completed the required training to do this effectively and in line with best practice guidance. For example, they did not have the knowledge regarding the use of colour coded mops to prevent cross contamination when cleaning the floors.

There was a cleaning schedule which set out what needed to be cleaned. This was a daily schedule, however, cleaning was not carried out every day, only before the room was to be used. There were no agreed standards of cleaning, deep cleaning, products or equipment. Wheels of trolleys were still found to be unclean.

We found the bags of clinical waste in the outside bin awaiting contractor collection, were not signed or dated and sharps bins were not properly prepared for disposal. The outside bins were not attached to the wall.

We said in our letter of concern on 20 March 2025 that the infection control audit was ineffective. We received on 2 July, following our second site visit, a one-page statement stating the premises was compliant with CQC guidelines. It was not an infection control audit. It did not contain close examination of the premises or evidence of issues identified by the audit and how they were to be addressed.

Arrangements for medicines were not always safe or met people’s needs.

At our previous inspection in 2023 we found no checks were made on emergency medicines, and some stock had expired.

At our site visit in March 2025, we saw that emergency medicines were not always checked according to the provider’s policy, which stated they would be checked weekly. The log on front of the box of medicines showed the checks were sporadic. For example, there was a gap from 3/10/24 to 15/11/2024 and then 18/2/2025 to 12/03/2025. Some of the expiry dates were difficult to read on the medicines, for example, emergency eye wash.

We checked the defibrillator. There were adhesive defibrillator pads, however there was no spare set as recommended by the resuscitation council guidelines.

One of the refrigerators used to store medicines was not designed for pharmaceutical products and we found this to be unclean. This was decommissioned after our first visit.

We found some medicines were not stored in a locked cupboard, this included adrenaline and intra veinous fluids.

At our second site visit in June 2025, we saw that some arrangements for medicines had been improved. The emergency medicines were adequate; however, the eye wash was not kept separate. (This would ensure a sterile and readily available solution for immediate use in case of eye contamination).

There was a new medicines refrigerator. However, this had a build-up of ice inside of it, the staff told us it had recently been cleaned and defrosted. There were large amounts of slimming injections inside which were close to the ice in the fridge. The staff said they did not have responsibility for looking after these; they were the responsibility of the doctor who came to the practice to administer these (every Thursday). There had been an issue over one of these injections which had gone missing, it had then been found. There was no accountability or management of these medicines.