Birkinshaw Aesthetics and Wellbeing Ltd

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

This is the first assessment for this service since its registration with CQC. This key question has been rated as Requires Improvement. We found breaches of regulation in relation to good governance.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider demonstrated a positive, compassionate, listening culture that promoted trust and understanding between them and people using the service. The provider had developed a vision and set of values which expressed their drive to provide high-quality, ethical, and person-centred care and treatment. A brief business plan had recently been developed which included target market analysis, an overview of risk management, and business development plans.

The provider was aware of challenges to the service, which included limited public awareness of the service. The provider had planned measures to tackle this, including development of the provider website.

The provider did not have fully developed systems and processes to support effective leadership. There were gaps in governance, including incomplete information sharing with GPs and limited oversight of prescriptions, policies and premises maintenance. This meant that leaders were not always able to ensure risks were well managed or that expected standards were consistently upheld.

The provider demonstrated openness and honesty throughout the assessment. and was willing to learn and improve. Since the assessment, the provider has taken steps to strengthen their skills, including signing up to relevant training, and has developed plans to improve processes.

The service was operated solely by the registered manager, with no staff employed. A freedom to speak up policy was in place should the provider choose to employ staff in the future. The policy contained a link to an external organisation for advice and support.

The provider demonstrated an understanding of the duty of candour and operated in an open and transparent manner.

This quality statement is not relevant for this service and has not been assessed.

The provider was unable to demonstrate that clear and effective governance, management, and accountability arrangements were in place.

The provider used a large number of pharmacies to order medications and did not have an effective method for tracking prescriptions once issued, which meant that there was no clear audit trail for prescriptions and a lack of oversight regarding the dispensing and issuing of prescriptions. Some prescriptions could not be accounted for during the assessment.

Letters sent by the provider to people’s GPs after consultations were not always reliable or well‑managed. Letters were not dated and sometimes contained incomplete or inconsistent clinical information.

Record‑keeping arrangements were not robust. Clinical records for regulated activities were paper‑based and the filing system lacked structure.

Some premises documentation was unavailable when requested and it was not clear whether required actions highlighted in risk assessments had been completed. The provider explained their reliance on building management due to renting the premises but acknowledged that greater oversight of premises safety and maintenance was required.

Policies and procedures were not consistently maintained or reviewed. Some documents, including a safeguarding children policy and medical emergencies policy, were drafted or updated during the assessment. In addition, the complaints policy did not reflect how complaints would be managed in practice.

The service’s website contained inaccurate information about opening times and services offered, indicating that information was not subject to regular review.

The provider acknowledged the concerns identified. They told us they were committed to strengthening governance arrangements and had taken initial steps, including signing up to a safe prescribing course and a clinical governance in private practice course. They had plans to improve processes and had begun updating key documents to reflect this, however further work and time was needed to strengthen this and to allow for these processes to be fully implemented and embedded into practice.

The provider told us they met regularly with professionals from similar services to share insights, learning, and to support service development.

Letters were routinely sent to the service user’s GP following an appointment, however information in these was sometimes limited.

The provider focused on continuous learning and improvement. They sought to deliver on service user expectations and improve the quality of life for those who accessed the service.

The provider had implemented procedures for clinical audit, and to gain feedback which they used to assess service user satisfaction.

We saw that required training had been undertaken and there was regular attendance at training courses and conferences, to support continuous learning.