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Dr Victoria Cosmetic Dermatology and Anti-Ageing Medicine Clinic Good

Reports


Review carried out on 9 September 2021

During a monthly review of our data

We carried out a review of the data available to us about Dr Victoria Cosmetic Dermatology and Anti-Ageing Medicine Clinic on 9 September 2021. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Dr Victoria Cosmetic Dermatology and Anti-Ageing Medicine Clinic, you can give feedback on this service.

Inspection carried out on 2 June 2021

During an inspection looking at part of the service

This service is rated as

Good

overall. (Previous inspection July 2019 – rated Requires improvement)

The key questions are rated as follows, with the ratings of Good for caring and responsive carried over from the previous inspection:

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 focused inspection at Dr Victoria Cosmetic Dermatology and Anti-Ageing Medicine Clinic to follow up on a breach of regulations and areas identified for improvement from the previous inspection. When we previously inspected in July 2019, we rated the key questions Safe and Well led as Requires improvement. For this inspection in June 2021, we inspected Safe, Effective and Well led. The ratings of Good for caring and responsive were carried over from the previous inspection.

At the last inspection there was a breach of Regulation 17 of the Health and Social Care Act Regulations 2014, which relates to Good governance. The provider’s systems and processes were not in place or working effectively to enable the registered person to assess, monitor and improve the quality and safety of the services. The Care Quality Commission (CQC) inspected the service on 2 June 2021 and checked the areas identified in the last report and found the breach had been resolved.

One of the two directors of the company is the registered manager. A registered manager is a person who is registered with the CQC 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.

In advance of the inspection, the provider had collected feedback from patients using comment cards. All 18 comment cards provided highly positive feedback, with patients describing the team as welcoming, professional, caring and informative. People wrote that staff ensured patients were well informed about the procedures and options, and there was an emphasis on individual care and safety. People also said the additional infection control measures in place during COVID-19 were evident and reassuring.

Our key findings were:

  • The service provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • The practice was led and managed to promote high-quality, person-centred care.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection carried out on 18 July 2019

During a routine inspection

This service is rated as Requires improvement overall.

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

We carried out an announced comprehensive inspection at Dr Victoria Cosmetic Dermatology and anti-ageing Medicine Clinic on 18th July 2019 as part of our inspection programme. This is a newly registered service and thus their first inspection.

This service is registered with CQC under the Health and Social Care Act 2008 in respect of some, but not all, of the services it provides. There are some exemptions from regulation by CQC which relate to particular 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. Dr Victoria Cosmetic Dermatology and Anti-Ageing Medicine Clinic provides a range of non-surgical cosmetic interventions, which are not within CQC scope of registration. Therefore, we did not inspect or report on these services. The clinic provides a number of skin care and beauty treatments. The inspection was in relation to specific treatments which are in the scope of registration, such as facial thread lifts, treatment of excessive sweating and the removal of minor skin lesions.

One of the doctors (who is also joint business owner) 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.

There were no clients available to speak to on the day, but feedback was obtained through 36 completed comment cards.

Our key findings were:

  • Health and Safety risk assessments had been undertaken by the landlord or external agencies. The clinic had not kept copies of these risk assessments.
  • The clinic was not undertaking routine checks of water temperature to monitor the risk of Legionella nor was there a risk assessment in place.
  • Not all staff had undertaken safeguarding training. This had been rectified within two days of the inspection.
  • Checks of emergency medicine and infection control were undertaken but not documented.
  • Fire safety checks had been undertaken by an external company and the clinic was awaiting a copy of the report.
  • Not all recruitment checks had been documented in staff files but had been undertaken for example by obtaining verbal references.
  • Individual care records were written and managed in a way that kept patients safe.
  • Patients immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs as well as their mental and physical wellbeing.
  • Staff recognised the importance of peoples’ privacy, dignity and respect.
  • Patients had timely access to consultation and treatment.
  • The clinic was unable to offer services to wheelchair bound patients as there was no lift access to the first floor of the building.
  • Staff felt respected and supported. They were proud to work for the clinic.
  • Leaders had invested in training and development of staff, in relation to clinical competencies but not in relation to staff training.
  • There were multiple examples of the two doctors engaging in career professional development courses and conferences to continue learning and development as well as share best practice.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Improve consistency in implementing its recruitment policies and procedures.
  • Review the process for documenting vaccine storage cold chain temperature checks.
  • Obtain copies of the health and safety risk assessments undertaken by external organisations or landlord to assure themselves that actions had been taken to mitigate risks identified.
  • Review policies and procedures to ensure they contain clinic specific information.
  • Review processes for chaperoning to include training for all non-clinical staff undertaking these duties.

Dr Rosie Benneyworth BM BS BMedSci MRCGPChief Inspector of Primary Medical Services and Integrated Care