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Inspection Summary


Overall summary & rating

Good

Updated 12 August 2019

This service is rated as Good overall. (Previous inspection 14 February 2018. This inspection was unrated and was meeting the expected standards)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at Askinology on 6 June 2019 as part of our inspection programme.

We carried out this inspection under section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the service was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

Kiwi Skin Limited provides aesthetic medical and cosmetic services at Askinology in the City of London and treats adults over 18.

The service is registered with the CQC in respect of the provision of advice or treatments by a medical practitioner, including prescribing medicines for aesthetic purposes. At Askinology the cosmetic treatments that are provided by aesthetic therapists are exempt from CQC regulation.

The General Service Manager is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We received seven completed CQC comment cards. All were positive about the service commenting on the friendly and professional service received.

Our key findings were:

  • The service had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the service learned from them and improved.
  • The service reviewed the effectiveness and appropriateness of the care it provided. It ensured care and treatment was delivered according to evidence-based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Services were provided to meet the needs of patients.
  • Patient feedback for the services offered was consistently positive.
  • There were clear responsibilities, roles and systems of accountability to support good governance and management.

There were areas where the provider could make improvements and should:

  • Consider carrying out audits on the quality of prescribing.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 12 August 2019

Safety systems and processes

The service had a number of systems to keep patients safe and safeguarded from abuse.

  • The practice had systems to safeguard children and vulnerable adults from abuse which were reviewed in March 2019. Policies were available for safeguarding both children and adults and were accessible to all staff and these contained contact numbers for local safeguarding teams.
  • Staff were aware of safeguarding procedures for the service and they knew how to identify and report concerns. However due to the nature of the service and the client population, there had never been any safeguarding concerns raised by staff.
  • Staff had received up-to-date safeguarding children and adults training appropriate to their role.
  • The practice carried out staff checks, including checks of professional registration and indemnity where relevant, on recruitment and ongoing.
  • Disclosure and Barring Service (DBS) checks were undertaken for all members of staff. DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.
  • The service did not provide any intimate examinations that would warrant formal chaperone training, however the clinic had a chaperone policy in place in the event that clients requested to have a second staff member in the consultation room. Any staff member would act as the chaperone if this was required. Staff who acted as chaperones had received a DBS check.
  • The service had conducted a range of safety risk assessments for the premises including health and safety, legionella and control of substances hazardous to health (COSHH) and there was evidence that any concerns were identified and addressed.
  • There was evidence that a range of electrical equipment had been tested for safety, and portable equipment had been tested and calibrated appropriately. Most calibration was done internally, daily before use, for example the intense pulsed light (IPL) machine.
  • There was an effective system to manage infection prevention and control and a number of actions to improve infection control had been undertaken or were in progress, such as ordering additional cleaning equipment. There were systems for safely managing healthcare waste.
  • Staff received safety information for the practice as part of their induction and refresher training.

Risks to patients

There were systems to assess, monitor and manage risks to patient safety.

  • There were arrangements for planning and monitoring the number and mix of staff needed. The service did not employ locum or temporary staff; cover was arranged using existing staff members.
  • We found an effective and thorough induction system for new staff. This was tailored to their role and included a range of safety information and mandatory training.
  • The service had a lone working policy in place and a risk assessment had been completed, although there had been no instances of lone working since the service had been in operation.
  • The service had evidence of professional indemnity for the doctors undertaking aesthetic procedures and public liability insurance for the premises.
  • There were a number of actions in place for managing fire risk in the premises including regular fire drills, fire equipment checks and fire training updates during staff meetings from the service manager. A fire risk assessment had been completed in January 2019 and the service was undertaking actions to mitigate fire risk.
  • There was evidence of fire training for the all staff members including those who were designated fire marshals.
  • There was a procedure in place for managing urgent medical emergencies. It was practice policy to call 999 in the event of an emergency as emergency medical equipment was not kept at the service. There was a written risk assessment in place for emergency procedures which included all risks and mitigating actions recorded. The service had never had an instance where they had a medical emergency or an unwell client since they had been operating.
  • There was evidence of basic life support training for all staff that was completed within the last 12 months.
  • The service stocked one emergency medicine for treating anaphylaxis and appropriate checks were in place. The service had completed a risk assessment for emergency medicines they did not hold.
  • The practice did not have oxygen and defibrillator. A risk assessment for the need for a defibrillator had been carried out and it concluded there was no need for the service to purchase one as there was one accessible in the office building across the road. Since the inspection visit we were provided with evidence of the purchase of oxygen and that it had been added to the emergency equipment check list.
  • When there were changes to services or staff, the medical director and service manager assessed and monitored the impact on safety. The provider had a documented business continuity plan in place. We were told that risks to clients and staff were low as urgent services were not provided.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to clients.

  • Individual care records were written and managed in a way that kept patients safe. The care records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way.
  • The service had systems for sharing information with staff to enable them to deliver safe care and treatment.
  • Management of correspondence in the service was safe.
  • There were no formal processes for directly communicating with clients’ GPs. However, there were two examples where the doctors had had medical concerns, clients had been advised to see a GP, and feedback from the clients following the GP reviews were recorded.
  • There were processes for verifying a clients’ identity. Personal details were taken at registration and checked if there was a concern. The service only treated adults over 18 and they would seek to confirm age by checking proof of identity. There had been no instances where this had been required.

Safe and appropriate use of medicines

The practice had reliable systems for appropriate and safe handling of medicines.

  • There were effective systems for managing medicines, including medicines stocked in the refrigerator for additional aesthetic services offered by the clinic and emergency medicines. The service kept prescription stationery securely and monitored its use.
  • Doctors prescribed medicines to clients and gave advice on medicines in line with legal requirements and current national guidance, for example acne guidance from the British Association of Dermatology.
  • The clinic had formal arrangements with a third-party aesthetics distribution company for prescription medicines. The process for ordering, delivery and storage of the medicines were safe. Identification was sought from clients when prescription medicines were collected, and a log was kept. All repeat prescriptions were reviewed by the medical director.
  • There was minimal evidence that the service audited the quality of their prescribing.

Track record on safety

The service had a good safety record, risks had been fully assessed including fire risk, health and safety and infection control. All risk assessments were up to date.

Lessons learned and improvements made

The service learned and made improvements when things went wrong.

  • There was a system for recording and acting on adverse events and incidents. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • The provider focussed on learning and improving the service from adverse events and encouraged all staff to report these. There had been 10 adverse events recorded for the service as a whole in the last 12 months, the majority of which (6) related to unregulated aesthetic activities.
  • There were comprehensive systems for reviewing and investigating when things went wrong. The service learned and shared lessons with all staff, identified themes and took action to improve safety. For example, following a client suffering a skin reaction where they were advised to use a retail skincare product in addition to a prescribed skincare medicine, the medical director provided training for staff and improved the pathway so that staff consulted the doctor for all queries for clients with existing prescription skincare.
  • The provider was aware of and complied with the requirements of the Duty of Candour. The provider encouraged a culture of openness and honesty. The service had systems in place for knowing about notifiable safety incidents
  • When there were unexpected or unintended safety incidents:

    • The service gave affected people reasonable support, truthful information and a verbal and written apology.
    • They kept written records of verbal interactions as well as written correspondence.

  • There was an informal system for receiving and acting on safety alerts. The medical director and service manager received alerts, but the majority of these were not relevant to the services provided. All relevant alerts were discussed, and any necessary action taken.

Effective

Good

Updated 12 August 2019

Effective needs assessment, care and treatment

There was evidence in place to support that the service carried out assessments and treatment in line with relevant and current evidence-based guidance and standards such as the British Association of Dermatology and European Association of Dermatology acne guidance. The provider reported that they provided consultations for clients with mild skin conditions, namely acne and rosacea. If clients presented with more complex skin complaints, they advised them to see their GP and/or a dermatologist.

The doctors advised clients what to do if their condition got worse and where to seek further help and support. Leaflets containing comprehensive information about prescription skincare were provided where indicated.

We looked at nine client records. All were completed appropriately.

We saw no evidence of discrimination when making care and treatment decisions.

Monitoring care and treatment

The provider carried out monthly records audits for injectable treatments and these are fed back to doctors during their monthly supervision meetings.

The service also continuously monitored quality of care and treatment through a comprehensive review of adverse incidents and events and complaints on a weekly basis and put actions place to improve quality. They used photographs and patient feedback to monitor patient outcomes and quality.

Effective staffing

Evidence reviewed showed that staff had the skills and knowledge to deliver effective care and treatment although some improvements were required.

  • The service had an induction programme for newly appointed staff. This covered topics such as fire safety, hand washing, health and safety and data protection. The service manager provided training as part of the induction programme.

  • The provider kept records to demonstrate that staff had appropriate training to cover the scope of their work including training for basic life support, safeguarding, infection control, health and safety, fire safety and data protection.
  • The service could demonstrate how they ensured role-specific training and updating for relevant staff. For example, for the doctors had attended courses in aesthetics and dermatology. The medical director was an expert in their field and also provided training externally in the industry and spoke at conferences nationally.
  • The learning needs of staff were identified through a system of appraisals, meetings and reviews of service development needs. Doctors’ appraisals were up to date and both had been revalidated by the General Medical Council (GMC). There was evidence of a comprehensive mentoring programme for one of the doctors.

Coordinating patient care and information sharing

We found that the service had effective systems in place for coordinating patient care and sharing information as and when required.

  • The doctors met regularly and worked together for a number of consultations and treatment as part of a mentoring programme.
  • There was no formal process for communicating with a client’s GP and the GP contact details were not taken on registration. Due to the nature of the population who received treatment from the service and the types of minor aesthetic treatments provided, it was practice policy that where doctors had any medical concerns, they advised the client to follow up this concern with their GP. For example:

    • The doctors advised clients to see GPs where they were concerned about the presentation of moles and skin tags. There was evidence that this had occurred and feedback from clients had been obtained following their GP reviews.

Supporting patients to live healthier lives

The service gave lifestyle advice where this was relevant to skin health during acne and pigmentation consultations.

Consent to care and treatment

The service obtained consent to care and treatment in line with legislation and guidance.

  • Doctors understood the requirements of legislation and guidance when considering consent and decision making. There had been no instances where there had been concerns about a clients’ capacity to consent.
  • Written consent was obtained for all doctor interventions and treatment and we saw this was in line with General Medical Council (GMC) guidance.
  • We reviewed records audits undertaken which monitored the process for seeking consent.

Caring

Good

Updated 12 August 2019

Kindness, respect and compassion

Staff treated clients with kindness, respect, dignity and professionalism.

  • Staff understood the personal, cultural, social and religious needs of clients.
  • The service gave clients timely support and information.
  • The service manager and receptionist described instances when clients wanted to discuss sensitive issues they were offered a private room to speak with a member of staff.
  • We observed treatment rooms to be spacious, clean and private.
  • We received feedback from eight clients including Care Quality Commission comment cards. All comments were highly positive about the service experienced. Clients described the service as professional, accommodating and thorough. They felt they were treated with respect and listened to.
  • The service reviewed online feedback from Google and Treatwell. The majority of comments were very positive, with the service scoring 4.9 and 4.7 stars out of 5 respectively.

Involvement in decisions about care and treatment

Staff helped clients be involved in decisions about their treatment.

  • Feedback from clients included comments that communication was excellent.
  • Clients felt the doctors were thorough and took time to talk through treatments, never overselling un-necessarily.
  • We saw that detailed information was provided about prescription skincare.
  • The service had procedures in place to ensure clients could be involved in decision about their care and treatment:

    • Where clients did not have English as a first language they were advised ahead of their appointments to arrange an interpreter.
    • Those that acted as interpreters and the clients signed a written agreement that the information provided was accurate.
    • There had not been instances where they had treated clients with visual or hearing difficulties, but we were told they could print large print information leaflets if needed.

Privacy and Dignity

The staff respected and promoted patients’ privacy and dignity.

  • Staff recognised the importance of patients’ privacy and dignity when taking telephone calls or speaking with clients.
  • Staff could offer clients a private room to discuss their needs in the reception area.
  • We observed treatment rooms to be spacious, clean and private.

  • From our observations during the inspection, there was evidence that the service stored and used patient data in a way that maintained its security, complying with the Data Protection Act 1998.

Responsive

Good

Updated 12 August 2019

Responding to and meeting people’s needs

The clinic organised and delivered services to meet clients’ needs and expectations.

  • The facilities and premises were appropriate for the services delivered.
  • The clinic was housed over four floors; regulated activities and treatment were provided on the lower ground or basement level accessed via stairs. Currently the clinic were not able to treat those with mobility restrictions who were unable to use stairs. Clients were informed the premises were not accessible if they used a wheelchair or mobility aid.
  • Where clients had language barriers, they were advised ahead of their appointment to bring someone to act as an interpreter.
  • The website contained enough information regarding the services offered and pricing structures.
  • Opening hours accounted for the needs of clients who were of working-age and wanted to attend before or after work, or during lunch periods. The provider recognised that the majority of clients were ‘time poor’ and there were expectations that the service needed to run to time.
  • Clients had a choice of booking with a male or female doctor.
  • Unanswered telephone calls to the service’s main number were diverted to an aesthetics response call handling centre who in turn contacted the service.

Timely access to the service

The clinic provided a range of services, and appointments allowed clients to access treatment within an acceptable timescale:

  • Doctors were available Monday to Friday. Opening hours were 10am-8pm on Monday and 8am to 8pm Tuesday to Friday. The service was also open between 10an and 4pm on a Saturday.
  • We saw that appointments could be booked within two days for a skin consultation with a doctor.
  • The service did not provide emergency appointments as the services provided were routine aesthetic procedures. However, if clients had concerns we saw that these were quickly responded to with a telephone call and followed up by an appointment if indicated.
  • Out of hours, the medical director oversaw the service’s email account for urgent queries and responded to these as required.
  • Clients felt they were easily able to contact the service and reported that communication was excellent.
  • Feedback from clients including CQC comment cards showed that appointments generally ran on time with delays minimised.

Listening and learning from concerns and complaints

The service had a clear procedure for managing complaints. They took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available and it was easy to do. Staff treated clients who made complaints compassionately.
  • The complaints information detailed that complainants could refer their complaint to the Independent Health Care Advisory Service.
  • The service manager reported that 23 complaints had been recorded in the last 12 months for the service as a whole which included services not regulated by CQC. Eleven complaints were received for services regulated by the CQC.
  • It was the service’s policy to capture and record all verbal as well as written complaints and these were recorded on a log and reviewed weekly along with adverse events in order to identify any themes or trends.
  • We reviewed two complaints and found that these were satisfactorily handled in a timely way, in line with the provider’s complaints policy.
  • There was evidence that there were learned lessons from individual concerns and complaints and from analysis of trends which were acted on to improve the quality of the service. For example, the service identified from complaints that the procedure for dealing with deposits for treatments was not communicated effectively to clients. They amended the procedure to ensure clear information was given to clients at registration. This resulted in a reduction in the number of complaints of this nature.

  • There was evidence that complaints and learning points were shared with all staff during monthly team meetings.

Well-led

Good

Updated 12 August 2019

Leadership capacity and capability

Leaders had the skills and capacity to deliver the service and provide high quality care.

  • The medical director was the leader and owner of the service. The service had been in operation for less than four years at the time of the inspection after opening in June 2015.
  • The general service manager was the registered manager of the service with the Care Quality Commission.
  • Both the medical director and service manager provided effective leadership which prioritised high quality care. They worked cohesively to address the business challenges in relation to performance of the service and oversight of risks.
  • Both the medical director and service manager were visible and approachable. They worked closely with staff and they were supportive and inclusive.

Vision and strategy

The service had a clear vision to deliver high quality care, excellent customer care and an overall positive client experience.

  • There was a mission statement and staff were aware of this.
  • There was a comprehensive business plan in place.

  • The service manager and medical director had clear priorities set out for the service including staffing, use of technology and gathering client feedback.

Culture

The service had a culture of high-quality sustainable care.

  • Staff stated they felt respected, supported and valued. They were proud to work in the service.
  • Leaders and managers had process to act on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • Staff we spoke with told us they were able to raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • Staff felt they were treated equally.
  • There were processes for providing staff with the development they needed. This included mentoring, one to one meetings and appraisals. Staff were supported to meet the requirements of professional revalidation where necessary.
  • All staff were invited to weekly communications meetings and monthly team meetings. This provided an inclusive culture for all staff and provided a forum to discuss incidents, complaints, training and service performance. Comprehensive records of these meetings were kept. If staff were not able to attend they were provided with a copy of the meeting minutes.

Governance arrangements

There were responsibilities, roles and systems of accountability to support good governance and management.

  • There was an organisational structure and staff were aware of their roles and responsibilities.
  • There was a range of service specific policies that were available to all staff; for example, dealing with an unwell client and carrying out identification checks for clients to confirm age.
  • Governance of the organisation was monitored and addressed during weekly meetings with the service manager and medical director.

Managing risks, issues and performance

There was evidence of processes for managing risks, issues and performance.

  • There were systems to identify, understand, monitor and address health and safety risks and most risks related to the premises.
  • The service had a business continuity plan in the event of an emergency affecting the running of the clinic. The service did not provide urgent care to clients; however, the provider had a plan in place for dealing with any potential issues.
  • The practice leaders were fully aware of all adverse incidents and complaints; systems for identifying trends and acting on concerns was well-managed.
  • The provider had an oversight of training completed by staff and a record of training certificates where training had been undertaken, especially where this related to training courses carried out under a previous employer.
  • The service carried out records audits of injectable treatments on a monthly basis. The provider told us there was very limited evidence base within their field in order to conduct an effective clinical audit, however we saw that they monitored quality by ongoing review of complaints, concerns and adverse incidents.
  • The service manager and medical director had a clear oversight of performance of the service and targets. These were shared with staff.

Appropriate and accurate information

The service had process in place to act on appropriate and accurate information.

  • The service had systems in place which ensured clients’ data remained confidential and secured at all times.
  • Data protection training occurred internally for most staff and the medical director had undertaken online training in management of information.

  • The practice used information from a range of sources including targets, financial information, incidents, complaints and online reviews of the service to ensure and improve performance.
  • The provider submitted data or notifications to external organisations as required.

Engagement with patients, the public, staff and external partners

The provider had systems to involve patients, the public, staff and external partners to improve the service delivered.

  • The service encouraged feedback from clients. Staff told us they encouraged clients to leave an online review on Google and Treatwell.
  • The service manager and medical director regularly monitored online comments and reviews and responded to these and they were shared in staff meetings.
  • The service had 334 reviews on Google with an average of 4.8 stars out of 5 and 152 reviews on Treatwell. This included feedback from clients receiving a range of services offered by the clinic.

Continuous improvement and innovation

There were systems and processes for learning, continuous improvement and innovation.

  • Adverse incidents and complaints were shared with all staff during staff meetings and these were used to make improvements
  • The service had comprehensive processes for ongoing support for staff development. There was a strong focus on high quality, through role specific training and mentoring in aesthetics processes.
  • The medical director provided training in their field externally and spoke at national conferences.