The Hair Dr clinic at Dewsbury provides surgical hair transplant procedures and scalp micropigmentation. The service does not have any inpatient beds. We inspected this service using our focussed inspection methodology.
We carried out an unannounced, focussed inspection on 2 December 2020. During the inspection, we spoke with eight staff including the registered manager, hair technicians, and medical staff. We spoke with the patient who was using the service on the day of inspection. During our inspection, we observed patient care and interactions and reviewed patient and staff records. We also reviewed other information and data provided by the service to make our judgements.
During this inspection we focussed on elements of the safe and well-led key questions in response to some concerns that had been raised with us by an ex- employee.
We did not rate the Hair Dr clinic at this inspection as it was a focussed inspection and did not cover all domains.
We found the following areas of practice where the service needed to make improvements;
- The operating rooms did not have adequate ventilation and we were not assured that patients were aware of CCTV monitoring. When this was pointed out the provider took immediate actions to initiate improvements
- While restricted medicines were within a locked room they were not kept in a locked cupboard. Maximum safe amount of local anaesthetic and actual dose were calculated but not clearly recorded.
- The service did not use a safer surgery checklist and patient care records were not always complete. Not all relevant information was recorded. Pain/ comfort and nutrition and hydration were not recorded.
- The provider did not have an established governance structure and processes to manage risks and performance. They did monitor clinical outcomes, but this was not collated or recorded. There was no systematic approach to audit. A records audit had shown a need to improve recording practice but there was no evidence to demonstrate any improvements or monitoring had been put in place.
- We were not assured that the processes of safe recruitment and maintenance of staff records was thorough. There was little oversight of essential human resource information such as; references, training, appraisal and revalidation.
We found the following areas of good practice;
- The service had enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. All staff understood their responsibilities to safeguard patients from abuse and neglect and had appropriate training and support.
- The service, controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. The maintenance and use of facilities, premises and equipment was suitable for its purpose.
- Leaders had the integrity and abilities to run the service. Where they identified gaps in their own skills or abilities, they took appropriate action to compensate for this. They understood and managed the priorities and issues the service faced.