• Hospital
  • Independent hospital

Archived: Bearwood Cosmetic Clinic

Bearwood Dental Clinic, 4 St Marys Road, Smethwick, West Midlands, B67 5DG 07886 288349

Provided and run by:
Bearwood Cosmetic Clinic Ltd

All Inspections

29 November 2018

During an inspection looking at part of the service

Bearwood Cosmetic Clinic is operated by Bearwood Cosmetic Clinic Ltd.

The service provided cosmetic surgery for adults over 18 years either as out patients or on a day case basis. The service has no overnight beds.

We inspected this service using our focussed inspection methodology. We carried out an unannounced inspection on 29 November 2018 due to concerns we identified through routine intelligence monitoring processes.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

The main service provided by this service was surgery.

Services we rate

We did not rate this service in line with our focussed inspection methodology. This inspection focussed on the safe domain and specifically the assessment and response to risk, medicines management and staffing. Where we identified and gained information in other areas and domains we have also included this throughout the report.

Due to the very serious nature of our concerns, we made an urgent cancellation of the providers registration. This means they can no longer undertake the regulated activities they were previously registered to provide.

Throughout this report the person undertaking the surgery will be referred to as the ‘provider’. This is because the doctor undertaking the surgery was the registered provider, registered manager and doctor for this service.

We found areas of significant concern during this inspection including:

  • The provider was undertaking surgery that he was not competent or trained sufficiently for.

  • The provider was administering large doses of sedation without sufficient safety arrangements. This placed patients at risk of severe harm or death.

  • The provider was operating in unhygienic conditions which posed a serious risk of infections to patients.

  • Cleaning arrangements were insufficient.

  • The equipment used for surgery was visibly dirty and soiled with malodourous bodily fluids and rust.

  • The machine used to sterilise surgical instruments was visibly dirty inside with obvious signs of rust.

  • The theatre environment was unsafe and not fit for purpose. This included holes in the theatre walls with live wires exposed and plaster falling out.

  • There were insufficient safety arrangements in the event of an emergency. For example, there was a lack of available resuscitation equipment and airway support in the event of medical emergencies.

  • Medications were managed unsafely. The provider providerwas prescribing medicines in larger doses than recommended and for uses for which it was unintended.

  • Patients were sedated without appropriate safety measures in place. This posed a risk of serious harm or death.

  • Records were poorly completed and the inspection team observed the provider retrospectively adding entries into records at the time of the inspection.

  • There was insufficient monitoring of patients during and post-surgery.

  • The provider did not ensure there were suitably qualified staff to undertake surgery.

  • Staff did not undergo any expected checks such as qualifications and criminal records checks.

  • There was an absence of any safety and escalation measures should a patient deteriorate and become unwell.

  • There was inconsistent follow up arrangements for patients and a lack of clarity around how patients could seek help for complications or concerns post procedure.

  • There were poor arrangements in place for governance and risk management.

As a result of these concerns the providers registration was urgently cancelled.

Heidi Smoult

Deputy Chief Inspector of Hospitals