Tajmeel 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

At our last assessment we rated this key question requires improvement. At this assessment the rating has improved to good.

Good: This meant people were safe and protected from avoidable harm.

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.

Description: We have a positive culture of safety based on openness and honesty, in which concerns about safety are listened to, safety events are investigated and reported thoroughly, and lessons are learned to continually identify and embed good practices.

Quality Statement Score:

We scored the service as 3. The evidence showed a good standard. The service had a positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events.

The surgeon was aware of what incidents to report and how to report them. There had not been any serious incidents, including never events, in the 12 months before our inspection or since the service opened. There was an incident reporting process and form. The form provided reminders to staff of what to assess if incidents were required to be reported under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations. Incidents would be discussed within staff meetings which were held monthly.

We could not review any incidents investigations records as there had been no incidents that required an investigation.

The surgeon understood the duty of candour. They knew to be open and transparent and gave patients a full explanation if and when things went wrong. The surgeon explained there had been no incident’s where duty of candour applied since the service opened.

Description: We work with people to establish and maintain safe systems of care, in which safety is managed, monitored and assured.

Quality Statement Score:

We scored the service as 3. The evidence showed a good standard. The service worked with people to establish and maintain safe systems of care, in which safety was managed or monitored.

The service planned and organised services, so they met the needs of patients. Consultations were by appointment only and meant patients could see the surgeon at a time to suit them.

The surgeon followed a standardised consultation process to determine if patients were suitable for treatment. This included a review of medical history, allergies and medications. The service also reviewed patients’ capacity and understanding of the proposed treatment.

The surgeon would refer patients for help and support if required, either through their GP or privately, with the consent of the patient. For example, if following an assessment the surgeon had concerns regarding the patient’s mental health or appropriateness for the procedure. However, there were no documented referral processes for onward referral to mental health liaison and specialist mental health support.

Description: We work with people to understand what being safe means to them as well as with our partners on the best way to achieve this. We make sure we share concerns quickly and appropriately.

Quality Statement Score:

We scored the service as 3. The evidence showed a good standard. The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The service described how they would share concerns quickly and appropriately.

Staff received and completed online training specific for their role on how to recognise and report abuse. The registered manager knew how to identify adults and children at risk of, or suffering, significant harm including individuals who may be subject to human trafficking. There was a safeguarding policy that reflected current standards, although it was not dated. The policy included information about escalation of concerns to the police, community health services or children’s services.

Staff were not required to undertake training in safeguarding children training. This was because the service did not treat children and advised patients that children could not be accommodated during appointments and were not allowed to attend.

The registered manager told us what steps they would take in the event of a safeguarding concern. The service had raised no safeguarding concerns in the year preceding the inspection.

Description: We work with people to understand and manage risks by thinking holistically so that care meets their needs in a way that is safe and supportive and enables them to do the things that matter to them.

Quality Statement Score:

We scored the service as 3. The evidence showed a good standard. The service worked with people to understand and manage risks by thinking holistically. Staff provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Access to the service was predominately via self-referral. The service said patients would tell them they had been recommended by former patients or they had read reviews of the service online. Staff used the consultation and consent process with patients to inform them of their options care and treatment. This was clearly recorded in patients’ notes.

The service’s website offered an opportunity to provide feedback or send a message to the clinic manager.

Description: We detect and control potential risks in the care environment and make sure that the equipment, facilities and technology support the delivery of safe care.

Quality Statement Score:

We scored the service as 3. The evidence showed a good standard. The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

The design of the environment followed national guidance. There were two clinical procedure rooms in the clinic but only the larger clinic room was used for cosmetic surgery procedures (hair transplant and PDO lifts). This room was large enough to fit the patient chair and to enable two members of staff to work safely at the same time. There was a reception, patient waiting area, a staff toilet and an accessible patient toilet. The accessible patient toilet had an emergency pull-cord and grab rails.

The service had carried out a fire risk assessment for the Tajmeel Clinic. Fire escape routes were clearly signposted, a fire extinguisher was available and fire alarms were tested monthly. The service had installed emergency lighting throughout the clinic should there be a power cut or fire.

The service had enough suitable equipment to help them to safely care for patients. Staff used single use equipment and consumables where possible. Those we checked were of good quality and within their expiry date.

The service had an autoclave which was used to sterilise equipment used during treatments. The autoclave had been serviced and maintained. We saw evidence of annual servicing on the autoclave and portable appliance testing (PAT), which ensures that electrical equipment is safe to use.

The service had an ultrasonic machine which staff used to clean some reusable equipment such as the handles used to hold punch needles used in hair transplant procedures. The ultrasonic machine was maintained and serviced.

There were mirrors for patients in line with national guidance so they could assess the immediate impact of treatment.

Staff disposed of clinical waste safely. Clinical waste was discarded into dedicated clinical waste bags. Clinical waste bags are used for infectious or potentially infectious clinical waste contaminated with blood or bodily fluids.

The service had a service level agreement for the collection of clinical waste which was stored securely in locked waste disposal bins outside the clinic. There was secure access only to prevent unauthorised people to enter the area. Arrangements with a third-party provider for waste collection, including clinical waste, was managed effectively in accordance with the service level agreement.

An external company had been contracted to survey the risks due to Legionella bacteria and pseudomonas. Legionella bacteria are commonly found in water and can cause Legionnaire’s disease. The most recent survey report indicated no areas of concern.

Description: We make sure there are enough qualified, skilled and experienced people, who receive effective support and supervision and work together effectively to provide safe care that meets people’s individual needs.

Quality Statement Score:

We scored the service as 3. The evidence showed a good standard. The service made sure there were enough qualified, skilled and experienced staff, who received effective support and supervision. They worked together well to provide safe care that met people’s individual needs.

The service had enough staff to keep patients safe. The service was small and employed 1 surgeon and 2 hair transplant technicians. The hair transplant technicians assisted the surgeon during hair transplant surgery, platelet rich plasma (PRP) therapy or consultations. All hair technicians worked closely and under the supervision of the surgeon.

The surgeon received an annual appraisal through third party arrangements, including the completion of continuous professional development activity. Records showed compliance with annual appraisals and revalidation requirements as set out by the General Medical Council.

A formal process had been introduced that recorded support given to staff to develop through yearly, constructive appraisals of their work. Training needs were identified and discussed; staff were given the time and opportunity to develop their skills and knowledge.

Staff were experienced and qualified and had the right skills and knowledge to meet the needs of the patient group. The provider ensured staff received the necessary specialist training for their roles. All staff working at the service had had an appraisal in the last 12 months.

In addition, staff completed mandatory training modules in a range of subject including, but not limited to health and safety, infection control, fire safety, data security. Records provided by the service showed all staff were up to date with their training requirements.

The surgeon, who was also the registered manager, oversaw the governance and running of the service.

Description: We assess and manage the risk of infection, detect and control the risk of it spreading and share any concerns with appropriate agencies promptly.

Quality Statement Score:

3. We scored the service as 3. The evidence showed a good standard. 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 clinic was visibly clean and had suitable furnishings which were clean and well-maintained. The clinic had been designed and fitted to relevant best practice guidelines relating to infection control in a healthcare setting. For example, the flooring complied with Health Building Note 00-10 Part A- Flooring. This stated flooring should be seamless and smooth, slip-resistant, easily cleaned and appropriately wear-resistant.

All surfaces within the clinical environment were wiped down with disinfectant following each procedure. Staff kept comprehensive cleaning records documenting each time the clinic had been cleaned, including between patients and when it was deep cleaned. We did not find any dust in hard to reach places.

Staff followed infection control principles including the use of personal protective equipment (PPE). Staff demonstrated good handwashing techniques and were bare below the elbow, in line with national guidance. Effective handwashing posters were displayed above sinks, these demonstrated best practice handwashing techniques with a step by step guide.

Staff cleaned equipment after patient contact. Staff used single use disposable surgical instruments wherever possible. They followed processes for sterilisation of equipment when this was needed. All cleaning and sterilisation products were stored securely in a locked cupboard.

Staff worked effectively to prevent, identify and treat surgical site infections. The service had not reported any surgical site infections in the 12 months before our inspection. All patients who received a hair transplant or PDO lift (procedure that uses dissolvable sutures to tighten and reposition sagging skin) were prescribed a three-day course of antibiotics to proactively prevent surgical site infections.

Description: We make sure that medicines and treatments are safe and meet people’s needs.

Quality Statement Score:

We scored the service as 3. The evidence showed a good standard. The service made sure that medicines and treatments were safe and met people’s needs.

The surgeon recorded the total amount of local anaesthesia by using a specific template to show the different preparations used. This was recorded in the patient record.

Staff stored and managed all medicines and prescribing documents safely. There were effective processes to purchase medicines and to account for all medicines purchased and supplied to patients. All medicines we checked were within their expiry date and stored in a locked medicines cupboard.

Antibiotics were prescribed prophylactically to reduce the incidence of infection in all follicular unit extraction (FUE) hair transplant cases. There is no professional guidance specific to antibiotic prophylaxis and FUE hair transplants, and there is a mix of views as to whether they are required. According to NICE guidelines on surgical site infection: prevention and treatment, antibiotic prophylaxis is required for clean surgery involving the placement of a prosthesis or implant.

Staff learned from medicine safety alerts and incidents to improve practice.