Implant and Aesthetic Center Limited

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

We found this practice was not providing well-led care in accordance with the relevant regulations. We will be following up on our concerns to ensure the provider had made the required improvements.

During our inspection of this key question, we found a lack of systems or processes that enabled the registered person to assess, monitor and improve the quality and safety of the services being provided. There was also a lack of systems or processes to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk.

In addition, the registered person did nothave effective systems in place to maintain records as are required in relation to persons employed. This included information relating to the requirements under Regulations 4 to 7 and/or Regulation 19 of this part (part 3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This resulted in a breach of Regulation 17, Good governance.

You can find more details of our concerns in the detailed findings below.

Find out what we look at when we assess this area in our information about our new Single assessment framework.

The judgement for Shared direction and culture is based on the latest evidence we assessed for the Well-led key question.

The judgement for Capable, compassionate and inclusive leaders is based on the latest evidence we assessed for the Well-led key question.

The judgement for Freedom to speak up is based on the latest evidence we assessed for the Well-led key question.

The judgement for Workforce equality, diversity and inclusion is based on the latest evidence we assessed for the Well-led key question.

The practice did not have effective governance systems. Systems and processes were not embedded. While policies and procedures were available, these were not sufficient to ensure patient safety and regulatory compliance.

The practice's risk management systems for monitoring and mitigating the various risks arising from the carrying on of the regulated activities required improvement. In particular, the risks associated with infection prevention and control, the management of medical emergency equipment and medicines, fire safety, radiation safety, COSHH, and sharps safety. In addition, improvements were required to recruitment processes to ensure they complied with legislation.

Where the assessment highlighted significant issues, the practice took some action to address these concerns immediately. Staff demonstrated an open culture in relation to people’s safety and wanted to demonstrate improvement.

The practice had ineffective systems in place for learning, quality assurance and continuous improvement. The practice completed audits in infection prevention and control, radiography, antimicrobial prescribing and clinical record keeping. However, these audits did not reflect our findings on the day of our inspection and did not identify any areas requiring improvement.

Relevant policies and protocols were in place for the use of closed-circuit television (CCTV), but it was not clear to the inspection team if patients were fully informed that CCTV was used within private treatment rooms. The inspection team only saw 1 sign which informed patients of the presence of CCTV in the treatment rooms, and it was not clear if the use of CCTV within the treatment rooms was necessary or proportionate for the proposed purpose.

Staff were aware of the importance of protecting patients’ personal information. Staff password protected patients’ electronic care records, and paper records were stored securely and complied with General Data Protection Regulations.

There were processes for investigating incidents and accidents, but there were no systems in place to keep up to date with changes in guidance or being able to receive and act on safety alerts such as safety information provided by the Medicines and Healthcare products Regulatory Agency (MHRA).

Staff had clear responsibilities. However, the registered manager who was the principal specialist oral surgeon, attended the clinic in London approximately once a month and was often out of the country. No other staff had been delegated deputising managerial responsibilities; there was insufficient oversight to support effective governance.

Concerns and complaints were responded to appropriately, and outcomes were discussed to share learning and for improvement.

We noted innovative approaches to providing person centred care. For example, patients could opt to have treatment completed at the partner clinic in Hungary while still having access to post-operative care at the practice in London.

Staff feedback was obtained through meetings and informal discussions. They were encouraged to offer suggestions for improvements to the service, and they said these were listened to and acted upon, where appropriate.

The practice gathered feedback from patients, and responded accordingly.

The practice had taken steps to improve environmental sustainability. For example, by turning off equipment when not in use, to save on electricity.

The judgement for Partnerships and communities is based on the latest evidence we assessed for the Well-led key question.

The judgement for Learning, improvement and innovation is based on the latest evidence we assessed for the Well-led key question.