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Inspection Summary

Overall summary & rating


Updated 6 July 2021

This service is rated as

Good. This is the first time the provider has been inspected.

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 Hopwood Clinic as part of our inspection programme. The service is registered with Care Quality Commission (CQC) under the Health and Social Care Act 2008 for the regulated activities of surgical procedures and treatment of disease, disorder or injury. This is in relation to some, but not all, of the services it provides. There are some exemptions from regulation by CQC which relate to types of regulated activities and services and these are set out in Schedule 1 and Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Some of the services available at Hopwood Clinic, for example the aesthetic treatments, are exempt by law from CQC regulation. Therefore, we were only able to inspect the pre-operative and post-operative care for the following:

  • Consultation with a view to discuss possible surgical and non-surgical procedures
  • Referrals to other clinical professionals
  • Breast augmentation / uplift / reduction
  • Gynaecomastia (surgery to remove excessive breast tissue)
  • Liposuction
  • Tummy tuck
  • Fat grafting / fat transfer
  • Scar revision
  • Face lifts
  • Eyelid surgery
  • Rhinoplasty (nose reconstruction surgery)
  • Prominent ear correction

Hopwood Clinic provides pre-operative consultations and post-operative after care. The Beauty Gurus (the provider) transfers patients under their care into an independent hospital or private wing at an NHS Hospital for surgical procedures.

The nominated individual 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.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, considering the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A short site visit.

Our key findings were:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • Staff we spoke with felt proud to work at the clinic.
  • The service had a protocol to offer staff an annual appraisal, but these had been delayed due to the pandemic.
  • Whilst the service had meetings on a regular basis these were not documented.

The areas where the provider should make improvements are:

  • Improve the documentation of minutes for meetings taking place at the clinic.
  • Undertake staff appraisals annually.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas



Updated 6 July 2021

We rated safe as Good because:

Safety systems and processes

The service had clear systems to keep people safe and safeguarded from abuse.

  • The provider conducted safety risk assessments. It had appropriate safety policies, which were regularly reviewed and discussed. They outlined clearly who to go to for further guidance. Staff received safety information from the service as part of their induction and refresher training.
  • The service had systems to safeguard vulnerable adults from abuse. The clinic provided care and treatment to patients over the age of 18 and did not carry out any procedures for children.
  • The service worked with other agencies to support patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect. The staff we spoke with during the inspection shared that if family members were calling up on behalf of patients they would always speak with the patient before arranging any appointments. The procedures being done at the clinic were cosmetic in nature and there were checks in place to ensure patients were not committing to procedures that they did not want to happen. Individual patient choice was respected.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken where required. (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).

  • All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Staff who acted as chaperones were trained for the role and had received a DBS check.
  • There was an effective system to manage infection prevention and control. At the time of our inspection the process for legionella testing at the clinic was to run all the taps for five minutes before each clinic. This had been risk assessed for the clinic. Following our inspection, the provider has contacted an external company to carry out legionella testing on an annual basis.
  • The provider ensured that facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste.
  • The provider carried out appropriate environmental risk assessments, which considered the profile of people using the service and those who may be accompanying them. During the pandemic the waiting room in the clinic has not been used. The clinic had adopted a one-way system and patients waited in their car until it was their turn to be seen, in order to comply with social distancing.

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 clinic did not use agency staff. There was one clinic per week and therefore there was no requirement for extra staff. If the administration staff were not available, the healthcare assistant was able to act as a chaperone and vice versa.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage patients with severe infections, for example sepsis. The clinic provided care and treatment to patients who were fit and well. They had not had to deal with an emergency as yet but were aware of how to do so.
  • There were appropriate indemnity arrangements in place.
  • There were suitable medicines and equipment to deal with medical emergencies which were stored appropriately and checked regularly.

Information to deliver safe care and treatment

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

  • 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. Paper records were stored in a secure locked cabinet. There was also a system called Private Practice Manager (PPN) to record financial aspects and invoices within the system. This computer system recorded patients details such as their addresses, date of birth and payment records.
  • The clinic used a fully encrypted email system.
  • The service had a system in place to retain medical records in line with Department of Health and Social Care (DHSC) guidance if they cease trading. The clinic had enough storage for 10 years. If this situation changed, they would rent a suitable space to store notes within the DHSC guidelines.

Safe and appropriate use of medicines

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

  • The systems and arrangements for managing medicines, including vaccines, emergency medicines and equipment minimised risks. The service kept prescription stationery securely in line with national guidance and monitored its use.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. Processes were in place for checking medicines and staff kept accurate records of medicines.
  • There were effective protocols for verifying the identity of patients.

Track record on safety and incidents

The service had a good safety record.

  • There were comprehensive risk assessments in relation to safety issues.
  • The service monitored and reviewed activity. This helped identify risks and gave a clear, accurate and current picture that led to safety improvements.

Lessons learned and improvements made

The service learned and made improvements when things went wrong.

  • There was a system for recording and acting on significant events. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The service learned and shared lessons, identified themes and took action to improve safety in the service. We reviewed an example of when no glucagon was available in the emergency medicines for two months. (Glucagon is a hormone that helps to control blood sugar levels). The decision was made to not allow diabetic patients to book for procedures in the clinic for these two months until supplies were restored. This was explained to patients on their website. At the time of our inspection glucagon supplies had been restored.
  • 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. There was a duty of candour policy stored on the shared drive at the clinic which all members of staff had access to.
  • The clinic shared another example where clinics had been overrunning. In order to improve this the practice had increased the length of the clinic depending on the needs of individual patients.



Updated 6 July 2021

We rated effective as Good because:

Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence-based practice. We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance (relevant to their service)

  • Patients’ immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their mental and physical wellbeing.
  • The consultant surgeon kept up to date with current evidence-based practice and maintained a senior role in the NHS. The consultant surgeon was actively involved in peer review with two consultant colleagues from the Queen Elizabeth Hospital. This was part of keeping up to date and having discussions with clinical colleagues.
  • Clinicians had enough information to make or confirm a diagnosis
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Arrangements were in place to deal with repeat patients. Some patients came back to the clinic for different procedures.
  • Staff assessed and managed patients’ pain where appropriate.

Monitoring care and treatment

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • All staff were appropriately qualified. The provider had an induction programme for all newly appointed staff.
  • The consultant surgeon was registered with the General Medical Council (GMC) and was up to date with revalidation
  • The provider understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop. In the last year the lead consultant surgeon had provided some bespoke training to the non-clinical staff to explain about the procedures that the service provided to give staff an enhanced understanding to better support prospective patients. The staff we spoke with explained how helpful this had been for them.

Coordinating patient care and information sharing

Staff worked together, and worked well with other organisations, to deliver effective care and treatment.

  • Patients received coordinated and person-centred care. Staff referred to, and communicated effectively with other services when appropriate. For example, when surgical procedures were taking place with the independent hospital and the private wing of the local NHS hospital.
  • Before providing treatment, clinical staff at the service ensured they had adequate knowledge of the patient’s health, any relevant test results and medical history. As the service provided elective procedures, these were only suitable for people who were in good health.
  • All patients were asked for consent to share details of their consultation and any medicines prescribed with their registered GP on each occasion they used the service. The clinic wrote directly to GPs following procedures at the clinic. There was a systematic approach where the consultant surgeon explained to the GP what to expect post operatively. We reviewed a template letter used by the service during the inspection which outlined all concerns, the consent process and expectations.
  • Patient information was shared appropriately, and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way. There were clear and effective arrangements for following up on people who had been referred to other services.
  • If follow up was required, then the clinic would refer patients to their own GP or to the QE Hospital, depending on circumstances. All suspected cancers are referred immediately in line with national guidelines.
  • The service monitored the process for seeking consent appropriately.

Supporting patients to live healthier lives

Staff were consistent and proactive in empowering patients and supporting them to manage their own health and maximise their independence.

  • Where appropriate, staff gave people advice so they could self-care. We saw an example where the patient had been advised to lose weight before a surgical procedure could be carried out due to the risks associated. This had been handled delicately by the service.
  • Risk factors were identified, highlighted to patients and where appropriate highlighted to their normal care provider for additional support.
  • Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.

Consent to care and treatment

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

  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions.



Updated 6 July 2021

We rated caring as Good because:

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • The service sought feedback on the quality of clinical care patients received. We saw that the clinic regularly received thank you cards and letters from patients. During the inspection we saw that the clinic had an electronic system to record feedback. Patients could either log on to the system at home to provide comments or provide the feedback via electronic devices which were available at the clinic.
  • We reviewed 16 pieces of feedback and found them all to be positive. Patients had commented on how friendly and helpful the secretary has been to them. They stated that the consultant surgeon is extremely skilled and approachable. Some patients referenced their whole journey explaining that they felt involved in their care and comfortable to make informed decisions about their elective treatment. Patients also commented about how discreet they found the clinic to be.
  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The service gave patients timely support and information.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment.

  • Interpretation services were available for patients who did not have English as a first language.
  • Staff communicated with people in a way that they could understand.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect.
  • Staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.



Updated 6 July 2021

We rated responsive as Good because:

Responding to and meeting people’s needs

The service organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.

  • The provider understood the needs of their patients and improved services in response to those needs. For example, clinic times were adjusted as they were overrunning.
  • The facilities and premises were appropriate for the services delivered.

Timely access to the service

Patients were able to access care and treatment from the service within an appropriate timescale for their needs.

  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients have fed back to the clinic how easy it is to make an appointment with the clinic either on the phone or by email.

Listening and learning from concerns and complaints

The service 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. Staff treated patients who made complaints compassionately.
  • The service informed patients of any further action that may be available to them should they not be satisfied with the response to their complaint.
  • The service had a complaint policy and procedure in place. The service learned lessons from individual concerns, complaints and from analysis of trends. It acted as a result to improve the quality of care. During the inspection we reviewed a complaint where a patient had been unhappy with the position of their scar following surgery. The consultant surgeon met with the patient and sent an empathetic response letter. The situation has now been resolved between the patient and the service.



Updated 6 July 2021

We rated well-led as Good because:

Leadership capacity and capability;

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them. The consultant surgeon regularly met with peer colleagues to review case studies and share experiences of complex cases to further enhance and develop their own professional development.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service.

Vision and strategy

The service had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.

  • There was a clear vision and set of values. The service had a realistic strategy and supporting business plans to achieve priorities.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them
  • The service monitored progress against delivery of the strategy.


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

  • Staff felt respected, supported and valued. They were proud to work for the service.
  • The service focused on the needs of patients.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints.
  • Staff told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included appraisals. The appraisals had been delayed during the pandemic, but we saw that these were booked in for July 2021. This is because the lead consultant had been working more hours in the NHS during the pandemic.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between the manager and the team.

Governance arrangements

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

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care.
  • As the service was a small clinic with four members of staff, meetings were not always formalised. Whilst all staff we spoke with during the inspection were able to give us examples of discussions, this was not formalised. The clinic was going to address this following the inspection and keep a record of minutes from meetings.
  • Staff were clear on their roles and accountabilities
  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended. During the inspection we saw a catalogue of policies, which included, but was not limited to, a communication policy, a recruitment policy, an information governance policy, an equality and diversity policy and a lone worker policy.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The service had processes to manage current and future performance. Leaders had oversight of safety alerts, incidents, and complaints.
  • The provider had plans in place and had trained staff for major incidents.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • The information used to monitor performance and the delivery of quality care was accurate and useful.
  • The service submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The service involved patients to support high-quality sustainable services.

  • The service encouraged and heard views and concerns from patients and staff.
  • Staff could describe to us the systems in place to give feedback.
  • The service was transparent and open.

Continuous improvement and innovation

There was evidence of systems and processes for learning, continuous improvement and innovation.

  • The service made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • The consultant surgeon had run teaching courses on plastic surgery for recently qualified surgeons.