Birkinshaw Aesthetics and Wellbeing 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

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

This service scored 66 (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 culture of safety, based on openness, honesty, and self-improvement. The provider had established processes to improve services based on learning; this included learning from incidents, audit findings, and service user feedback. The provider had procedures for identifying, investigating and taking corrective actions to improve. The provider told us that since they started operating in 2023, they had not received any complaints and had recorded 2 incidents. We saw that these had been investigated, and appropriate action taken.

There was a programme of audits in place which included infection prevention and control, clinical and record keeping audits.

There were systems in place for processing information relating to new service users. However, the provider was reliant on service users giving current and up to date information on what medicines and treatments they were receiving from their GP. The provider had no way of accessing GP records, which could pose a risk of interactions or duplicated prescriptions taking place.

There was evidence of letters being sent to the service user’s GP following an appointment, however these did not always include correct or in-depth information.

If the provider felt they could not support the service user directly after assessing their needs, they sought to support them by giving advice and signposting to more appropriate services.

There were procedures and measures in place to safeguard service users, and protect them from harassment, abuse, discrimination, avoidable harm and neglect. Disclosure and Barring Service checks and safeguarding training had been completed.

There was an adult safeguarding policy which contained relevant contact details and escalation processes. Services were not provided to people under 18 years of age. However, there were other services in the building which permitted children to enter the building. Despite this, the provider did not have a child safeguarding policy in place at the time of the assessment. After the assessment we saw that the provider had drafted a child safeguarding policy.

The provider worked with service users to understand and manage risks. The provider undertook consultations during which they discussed with service users their medical history, symptoms and any contraindications. Service users were advised on risks related to their condition.

If required, service users were able to bring friends, family or others to support them with their language needs, however the provider could also access an interpretation service to enable more effective communication.

Due to the nature of the service, limited medicines to deal with emergencies were held. Decisions made regarding equipment and medicines held had been subject to a risk assessment. Basic life support training had been undertaken.

The service was delivered from a premises shared with other businesses. The provider told us that the building management team were responsible for health and safety maintenance of the premises. We saw there were some processes in place for health and safety risk management. For example, gas and electrical equipment had been safety tested, and fire alarm maintenance had been completed. However, there was no evidence of regular fire alarm evacuation drills. In addition, the fire risk assessment and legionella risk assessment had been carried out after the assessment was announced, and it was not clear when these had been carried out previously. Furthermore, these risk assessments had highlighted several actions that were needed, some of which were high or medium risk. Despite this, we did not see evidence of action plans in place to address these risks. After the assessment the provider told us that going forward, they would ensure they had better oversight of premises health and safety maintenance.

The service is operated by a single practitioner who, alongside this service, also worked within the mainstream NHS, as a registered nurse. We saw that required training had been undertaken and that appropriate documentation, such as Disclosure and Barring Service checks and immunisation history were in place.

The provider was subject to external appraisal and revalidation and there was regular attendance at training courses and conferences.

The provider assessed and managed the risk of infection. There were appropriate infection prevention and control (IPC) processes in place. IPC training and audits were regularly undertaken.

We found the premises and equipment to be clean, tidy and well maintained when we visited. Sharps bins were dated and signed, and clinical waste was appropriately managed by an external company. Personal protective equipment was available.

Minimal medicines were kept onsite due to the nature of the service. Some emergency medicines were kept onsite, and the provider had assessed and documented the rationale for selecting these specific medicines.

As medicines had been delivered to a different address to the location of the service the provider could not demonstrate that the cold chain of medicines requiring refrigeration had been upheld. However, refrigerator temperature monitoring was taking place regularly at the clinic, and the provider told us that the alternative delivery location was used so they could always accept the deliveries to help maintain the cold chain.

People that used the service for regulated activities had paper records which were filed by treatment given. The provider was reliant on service users giving current and up to date information on what medicines and treatments they were receiving from their GP. The provider had no way of accessing GP records, which could pose a risk of interactions or duplicated prescriptions taking place.

When a consultation had taken place, there was evidence of letters being sent to the service user’s GPs, but these did not always include in-depth information. There were no dates on letters sent to GPs, so the provider could not demonstrate that these were sent in a timely manner. After the assessment the provider advised that, as letters were sent via e-mail, this would record the date at the time of sending. The provider also advised that going forward they would ensure that dates were included on letters held within patient records. Some letters also included differing information on doses of medicines being prescribed, and dates of administration of injections.

When asked to provide evidence of completed prescriptions, the provider was not always able to demonstrate where these had been sent as numerous pharmacies were being used. This meant there was no clear audit trail for prescriptions and a lack of oversight regarding the dispensing and issuing of prescriptions.

The provider acknowledged that the governance of record keeping needed improvement. After the assessment we received further documentation to evidence the provider had taken this into account.