CLNQ Deansgate Square

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

This was the first inspection for this service since its registration with CQC in 2023.

We looked for evidence that people were protected from abuse and avoidable harm.

This key question has been rated as Good.

At CLNQ Deansgate Square we found clear processes ensured staff acted to keep people safe.

Managers investigated all reported incidents to reduce the likelihood of them happening again. Learning was shared with staff and systems and processes were reviewed and developed to improve the safety of services.

Consent to procedures was well managed because, people engaged in discussions about their choice of treatment and were given opportunities to reconsider their choices.

There were sufficient suitably trained and qualified staff to promote safety and ensure people’s needs were met.

The environment and equipment were correctly maintained to promote safety.

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.

Feedback and discussions with the managers and staff indicated that all events and changes were shared with all staff.

The CLNQ Deansgate Square team discussed the care and treatment of clients at regular meetings. This included highlighting, reviewing and documenting where improvements were needed. We observed an open culture at the clinic.

Staff stated openness was an essential element for keeping people safe and spearheading continual improvements in outcomes.

The provider had processes for staff to report incidents, near misses and safety events.

There was a system to record and investigate complaints, and processes in place for ensuring that if things went wrong, staff apologised, and people given the support needed.

These processes meant learning from incidents and complaints resulted in changes and improved care for others.

Safety through learning and changes was also informed by information received through medical safety alerts. All information and learning was shared with staff who described changes made as a result of learning from various sources.

Records confirmed action was taken to ensure staff received regular supervision and training. Audits were completed to ensure staff followed all processes as required. Training was updated to align with any changes to processes.

The service collaborated with people to establish and maintain safe systems of care. There were robust processes in place to register and monitor what treatments people had received. There was a clear pathway for sending samples for histology and other analysis; for tracking and receiving results; for updating the patient with this information and liaising with the patients GP if appropriate.

Each procedure completed by CLNQ Deansgate Square had been risk assessed, and a standard operating procedure or protocol put in place. We saw that checks were made to ensure these protocols were followed and appropriate action taken if not.

CLNQ Deansgate Square had clear processes in place which were understood and followed by staff to safeguard people from abuse. The safeguarding policy aligned with the local authority policy. Staff described the questions asked to ensure that signs and symptoms of concern were identified and investigated if apparent.

All staff had completed the required level of safeguarding training required for their role.

CLNQ Deansgate Square could improve safeguarding if steps were taken to confirm proof of identity of clients accessing the service.

CLNQ Deansgate Square could improve safeguarding if steps were taken to confirm the relationship of people who support clients accessing the service.

The service collaborated with people to understand and manage risks by acting holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Processes were in place to detect and control potential risks in the care environment at CLNQ Deansgate Square. Policies and action plans identified equipment that needed to be calibrated and maintained. Records confirmed that all maintenance was up to date.

Safety checks such as fire alarm tests and evacuations were managed by the building management company and records confirmed that CLNQ Deansgate Square staff were fully informed and knew what actions to take if the clinic needed to be evacuated. Fire safety information was on display in the clinic.

The leader ensured staff completed the appropriate aesthetic and clinical training for the procedures carried out at CLNQ Deansgate Square. Feedback from people who used the service confirmed they were impressed with the level of skill shown by staff in completing these procedures. Staff were employed using formal processes including completion of disclosure and barring service (DBS) checks. References from previous employers were also obtained. Staff were appropriately appraised and supervised to ensure they applied new learning and were competent in their roles. Regular meetings ensured the team worked closely together to provide a safe and effective service.

The service assessed and managed the risk of infection.

The leaders took robust steps to assess and manage the risk of infection. Consulting rooms were cleaned after each consultation.

There was a cleaning schedule and checklist, which was audited and monitored for compliance. Staff were observed during audit to ensure they completed tasks to minimise the risk of infection.

The leaders ensured sufficient personal protective equipment (PPE) was available and records indicated a regular supply was fully available to staff.

Clinical waste was stored and collected by an established clinical waste company. The reports confirmed boxes for used sharp instruments such as hypodermic needles and other waste was safely secured and packaged for collection.

The provider had effective systems to manage and respond to safety alerts and updates about the use of aesthetic medicines.

Staff followed established processes to ensure people with specific risks were identified and provided with recommended advice. Staff said they received regular training on managing the medicines used at CLNQ Deansgate Square.

Staff knew where emergency medicines were stored and how to access these when required. Leaders confirmed that all medicines were purchased from a reputable specialist pharmacy. Not all medicines were ordered specifically for each patient and we saw that these medicines remained individually packaged and included the original patient information leaflets. A record of what was administered was provided to the patient.

CLNQ Deansgate Square offered bioidentical hormone replacement therapy which included personalised prescriptions of unlicensed medicines. (Unlicensed medicine prescribing is when medicines are used to treat illnesses and conditions they are not officially licensed for). The prescriptions provided at CLNQ were made up specifically for each patient and the prescription sent to a UK based specialist compounding pharmacy which was registered with the General Pharmaceutical Council in the UK. Patients received their medicines direct from the pharmacy.

We saw that staff managed medicines safely and regularly checked the stock levels and expiry dates for all medicines, including emergency medicines. Medicines monitoring records confirmed medicines were consistently stored at the required temperature.