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Inspection Summary

Overall summary & rating

Updated 22 November 2018

We carried out an announced comprehensive inspection at the above provider on 11 October 2018 to ask the service the following key questions; are services safe, effective, caring, responsive and well-led?

Our findings were:

Are services safe?

We found that this service was providing safe care in accordance with the relevant regulations.

Are services effective?

We found that this service was providing effective care in accordance with the relevant regulations.

Are services caring?

We found that this service was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found that this service was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found that this service was providing well-led care in accordance with the relevant regulations.

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.

The Sheffield Clinic is a small independent sector healthcare provider that provides minor skin surgery and procedures such as laser hair removal, skin tightening and Laserlipolysis (with or without aspiration). The clinic is located within Sloan Medical Centre and shares their facilities. The service consists of two general practitioners and one laser therapist who offer an initial patient consultation, minor cosmetic procedures or laser treatment and post-operative care and support to self funding patients. The provider is registered with the Care Quality Comission to provide diagnostic and screening, surgical services and the treatment of disease, disorder or injury.

Feedback obtained speaking with patients during the inspection was excellent. We did not receive any comment cards however we spoke to five patients on the day of inspection.

Our key findings were:

  • There was a framework in place which supported the delivery of quality care.
  • There was good clinical leadership within the service which was supported by an administrative team.
  • Clinicians were committed to delivering quality care.
  • The provider encouraged patient feedback which was positive about the staff and the service they received.
  • Before patients received any care or treatment they were asked for their consent and the doctors acted in accordance with their wishes. Patients said they were informed of the treatments and associated risks and they were given time to consider these.
Inspection areas


Updated 22 November 2018

We found that safe services were provided in accordance with the relevant regulations.

Safety systems and processes

  • The provider managed health and safety effectively and had systems in place to keep people safe and safeguarded from abuse.
  • Risk assessments and safety checks were carried out at a local level. For example, clinical equipment and premises were regularly checked and records kept by staff at Sloan Medical Centre.
  • There was a range of infection prevention and control (IPC) processes in place. These included an annual IPC audit. Where actions had been identified there was evidence to show they had been addressed. We saw that cleaning schedules were thorough and completed to a high standard.
  • There were policies in place regarding safeguarding. All staff had been trained in safeguarding adults and children staff that we spoke with could demonstrate they had a good understanding of adult and children's safeguarding although children do not access this service.

  • Staff recruitment procedures were in place to ensure staff were suitable for their role. Appropriate recruitment checks had been undertaken, which included proof of qualifications and registration with the appropriate professional bodies. Disclosure and Barring Services (DBS) checks were also undertaken. (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).

Risks to patients

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

  • Risk assessments had been carried out to identify any areas of risk to patients and there were appropriate control measures and quality assurances in place. For example, legionella testing.

  • Arrangements were in place to deal with emergencies and incidents. All clinical staff had received annual basic life support training. There was emergency equipment, such as oxygen and a defibrillator, and medicines appropriate to the service, which were easily accessible to staff in clinical areas. These were checked on a daily basis by clinical staff.
  • Clinicians had the appropriate indemnity cover to carry out their role.

Information to deliver safe care and treatment

  • The information needed to plan and deliver care and treatment was available through the service’s patient record system and provider intranet. This included information relating to initial health assessment and advice and treatment plans for surgical and laser interventions.
  • The procedures offered by The Sheffield Clinic included the pre-operative, peri-operative and and follow up for these patients.

Safe and appropriate use of medicines

  • A range of medicines were kept on the premises including those which could be used in emergency situations. These medications were stored safely and checked in accordance with regulations.

Track record on safety

There was a system in place for reporting, recording and investigation of incidents.

  • Staff told us they reported and recorded issues and where any changes to practice were required. these were logged.

  • There were arrangements in place to deal with foreseeable emergencies. These were in line with Sloan Medical Centre's personal emergency evacuation plans.

Lessons learned and improvements made

  • The provider was aware of and complied with the requirements of the Duty of Candour. (The duty of candour is a set of specific legal requirements that providers of services must follow when things go wrong with care and treatment).
  • The provider encouraged a culture of openness and honesty. When there were unexpected incidents the service gave affected people reasonable support, truthful information and either a verbal or written apology as appropriate.
  • Staff held informal weekly governance and review meetings.


Updated 22 November 2018

We found that effective services were provided in accordance with the relevant regulations.

Effective needs assessment, care and treatment

  • Clinicians assessed patients’ needs and delivered care in line with relevant and current evidence based guidance and standards, such as National Institute for Health and Care Excellence (NICE).
  • The service provided an initial appointment to each patient in order to offer and discuss a range of services to meet their needs in relation to elective minor skin procedures or laser treatments. Most patients were seen and treated within 4 weeks.

Monitoring care and treatment

  • Decisions about care and treatment were made by the appropriate staff at the appropriate level. Patients were seen by specialist doctors who maintained their registration and were also employed in the NHS environment.
  • The provider had systems and key performance indicators in place to monitor and assess the quality of the service.
  • The quality of consultations with patients was monitored through patient feedback. This feedback was used to inform and develop the service.

  • Clinical staff participated in regular audits and quality improvement activity. We reviewed a number of audits carried out during 2017 relating to coding, consent and record keeping. Clinical audits had also been carried out to monitor surgical procedures.

Effective staffing

There were systems in place to support effective staffing.

  • There were three staff groups involved in the treatment and care of patients: two general practitioners, a laser therapist and an administrative team. When patients arrived for their appointment at the clinic they were checked in by reception staff working at Sloan Medical Centre.
  • Clinical staff working for The Sheffield Clinic were appropriately qualified and registered with a professional body.
  • Staff had received training, which consisted of topics such as basic life support, fire safety, IPC, safeguarding, health and safety, whistleblowing, information governance, equality and diversity.

  • Staff were required to ensure their training was updated as necessary.
  • The learning needs of staff were identified through one to one support and appraisals.
  • Staff told us that they enjoyed working at The Sheffield Clinic.

Coordinating patient care and information sharing

  • Patients self referred to the service through an on-line enquiry form on the Sheffield Clinic website. We discussed the various consents which were sought from the patients such as consent to obtain information from their GP, getting agreement for treatment and sharing information with other professionals in the best interest of the patient to ensure they received appropriate diagnosis and treatment.

  • Before patients received any care or treatment they were asked for their consent and the doctors acted in accordance with their wishes. Patients said they were informed of the treatments and associated risks and they were given time to consider these.

Supporting patients to live healthier lives

  • The aims and objectives of the service were to provide patients with elective minor skin procedures or laser therapy through a process of initial assessment and post treatment care. Patient information leaflets were supplied and additional information was available on the provider website.

Consent to care and treatment

  • Patients received consultation and treatment options from the general practitioners or laser therapist at the Sheffield Clinic who carried out the treatment and consulted with the patient following treatment.
  • Staff understood and sought patients’ consent to care and treatment in line with legislation and guidance.
  • The organisation was aware of the new General Data Protection Regulation (GDPR) and were handling patients’ personal data in line with the regulation.


Updated 22 November 2018

We found that caring services were provided in accordance with the relevant regulations.

Kindness, respect and compassion

  • We observed that members of staff were courteous and treated people with dignity and respect. All the staff we spoke with demonstrated a patient centred and caring approach to their work.
  • Comments we received from patients were positive, citing staff as being polite and professional. They also said they received an excellent and professional service and were pleased with the surgical interventions that they received.
  • Patients views of the service were obtained through questionnaires and surveys. Patient satisfaction about staff and the service they received was very positive.

Involvement in decisions about care and treatment

  • Staff helped patients to be involved in decisions about care and treatment. They were aware of the Accessible Information Standard (a requirement to make sure that patients can access and understand the information they are given).

  • At the initial consultation with The Sheffield Clinic, patients told us that they were encouraged to be involved in decisions about their care and treatment. Patients we spoke with told us that the doctors provided a telephone number to them as a point of contact throughout the process.
  • Clinics were held on Thursdays at times suitable for patients in order to allow equitable access for example, during the evening.
  • People received a patient pack on their first consultation which included: patient pre and post procedure guidelines, consent to surgery form and leaflet containing information about the clinic including costs of treatment. People spoken with confirmed they had received these.
  • We spoke with the laser therapist who explained the treatment process. She explained that people attended for a consultation and had a patch test depending on the nature of the treatment. During the consultation a medical history was undertaken.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Staff recognised the importance of patients’ dignity and respect.
  • Consultation room doors in clinical areas were closed to avoid conversations with patients being overheard.
  • Curtains were provided in consulting rooms to maintain patients’ privacy and dignity during examination, investigation or treatment.
  • Chaperones, interpreters and translators were provided if patients needed assistance during their consultation.


Updated 22 November 2018

We found that responsive services were provided in accordance with the relevant regulations.

Responding to and meeting people’s needs

  • The provider made it clear to patients what services were being offered and further information was available through patient information sheets and on the Sheffield Clinic website.
  • Patients were able to self refer to the service through an enquiry form on the provider website and consultations were offered to anyone who was referred.

  • The waiting areas for patients at Sloan Medical Centre were spacious with on-site toilet facilities. The consulting rooms were clean, tidy and well equipped. A lift was available for patients to use as the clinic was on the first floor . The responsibility for the repair and renovation

    maintenance of clinical areas was undertaken by Sloan Medical Centre.

  • Staff informed us that the service was person centred and flexible to accommodate patients’ needs.

Timely access to the service

  • Patient consultations were booked initially through a central appointments system administrator. Feedback we received was that the service was timely and prompt.

Listening and learning from concerns and complaints

  • The provider had a complaints procedure and there was patient information leaflets about how to make a complaint. This informed patients how they could refer their complaint to the Independent Health Care Advisory Service if they were not happy with the outcome or how their complaint had been managed by the provider.

  • The Registered Manager was the lead for managing complaints.
  • We saw there had been one complaint in the preceding 12 months, relating to dissatisfaction with the service. We found this complaint had been responded to satisfactorily.


Updated 22 November 2018

We found that well-led services were provided in accordance with the relevant regulations.

Leadership capacity and capability

  • On the day of inspection the staff that we spoke to at The Sheffield Clinic demonstrated they had the experience, capacity and capability to run the service. They told us they prioritised safe, high quality, individualised care.
  • The relationship between the laser therapist and the general practitioners within The Sheffield Clinic was evident and supportive.

  • Staff were aware of their roles and responsibilities. The Sheffield Clinic consistes

    d of a small team although we saw that they were supportive of one another and there was a cohesive approach.

  • The laser therapist had an annual appraisal which was undertaken by the registered manager, we saw evidence of this. The laser therapist also confirmed that she had a personal development plan in place and that she had received sufficient training to undertake her role. 

  • Both general practitioners had undertaken clinical supervision as part of their role.

Vision and strategy

  • The provider had a clear vision to provide a high quality service. All staff shared this view and spoke enthusiastically about the work they undertook to achieve the vision. They told us that they always ‘put patients needs first.’


  • The provider was aware of, and had systems in place, to ensure compliance with the requirements of the duty of candour.
  • There was an open and transparent culture and this was apparent when speaking with staff. They told us they felt confident to report any concerns or incidents.

  • Regular multi-disciplinary team and governance meetings were held where staff could suggest improvements to service delivery.

Governance arrangements

  • The Sheffield Clinic, as the provider, had an overarching governance framework which supported objectives, performance management and the delivery of quality care.
  • Staff were aware of their roles and responsibilities.
  • Systems were in place for monitoring the quality of the service and making improvements.

Managing risks, issues and performance

  • We saw there were effective arrangements in place for identifying and managing risks. Risk assessments we reviewed were comprehensive. There were a number of daily, weekly, monthly, quarterly and annual checks in place to monitor the performance and safety of the service. We saw there was clear communication and collaboration between staff at The Sheffield Clinic and Sloan Medical Centre.

Appropriate and accurate information

The provider acted on appropriate and accurate information.

  • Quality and operational information was used to monitor and improve service performance.
  • All staff had signed confidentiality agreements as part of their contractual arrangements.

Engagement with patients, the public, staff and external partners

  • Patients were actively encouraged to provide feedback on the service they received. This was monitored and action was taken if feedback indicated that the quality of the service could be improved.
  • The provider’s system of analysing feedback could provide a breakdown of patient experiences.

Continuous improvement and innovation

  • There was a focus on learning and improvement within the organisation whereby staff were encouraged to develop their skills through courses and continuing professional development.