The Care Quality Commission
  • Doctor
  • Independent doctor

Discover Laser

Overall: Good read more about inspection ratings

Crow Wood Leisure, Royle Lane, Burnley, Lancashire, BB12 0RT (01282) 420886

Provided and run by:
Discover Laser Ltd

Important: This service was previously registered at a different address - see old profile

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Discover Laser on 6 July 2023. 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 Discover Laser, you can give feedback on this service.

16 May 2023

During an inspection looking at part of the service

This service is rated as Good overall. (Previous inspection 10 August 2022 – Good)

The key questions are rated as:

Are services safe? – Good (Previous inspection 10 August 2022)

Are services effective? – Good (Previous inspection 10 August 2022)

Are services caring? – Good (Previous inspection 10 August 2022)

Are services responsive? – Good (Previous inspection 10 August 2022)

Are services well-led? – Good (This inspection 16 May 2023)

Following our previous inspection on 10 August 2022, the service was rated good overall with a rating of good for the key questions safe, effective, caring and responsive and a rating of requires improvement for the key question well led. We issued the service with a requirement notice for a breach of Regulation 17(1) Good governance. This inspection identified improvements in all areas noted at the inspection in August 2022, and the key question well led is now rated good.

The inspection in August 2022 was undertaken under the NHS and independent acute hospitals surgery framework. Since that inspection the taxonomy or classification of the service provided by Discover Laser Ltd has been adjusted as the services provided are more aligned with the Primary Medical Services (PMS) independent health inspection framework.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Discover Laser on our website at www.cqc.org.uk

Discover Laser is a registered location of Discover Laser Ltd. It is an independent health clinic providing a range of services to fee paying members of the public.

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. Discover Laser provides a range of non-surgical cosmetic interventions. For example anti-wrinkle treatments, dermal fillers, including lip fillers, skin and hair laser treatments. These types of treatments are not within CQC scope of registration. Therefore, we did not inspect or report on these services.

The Dr Jose Miguel Montero Garcia 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.

Our key findings were:

This inspection focused on the key question of Well led and the breaches of regulation identified at the previous inspection in August 2022.

  • The provider offered a range of different services, most of which were not within the scope of CQC registration.
  • Those services that were within CQC scope were offered on a private, fee-paying basis only and were accessible to patients who chose to use them.
  • Services offered at the time of this inspection that were within the scope of registration were Mohs Micrographic Surgery (MMS) used to treat some early stage skin cancers and undertaken by a Consultant Dermatologist. Patients attending for this type of surgery had received the appropriate clinical investigations prior to the surgical treatment being undertaken at Discover Laser.
  • Other services offered by Discover Laser included the removal of skin lesions such moles and cysts and other treatments including those for acne. The website for these offered comprehensive information about these services and included details of fees.

We found that the issues identified at inspection in August 2022 had been addressed. These included:

  • Since our previous inspection, the provider had invested in creating an MMS laboratory and treatment suite consisting of a secure laboratory, with a separate room for preparing, viewing and analysing slides of excised tissue. The suite of rooms also included two separate patient consultation/treatment rooms which had interconnecting doors with the laboratory promoting the safe flow of the excised tissue from patient to laboratory for preparation for examination and assessment.
  • The risk assessments for the MMS laboratory had been updated and were subject to regular review.
  • Systems for cleaning and equipment checking regimes for the MMS laboratory areas were established and were up to date.
  • The service had implemented a protocol to ensure pathological specimens were retained and stored in accordance with relevant guidance and standards.

We also found the areas identified at the previous inspection where the provider should make improvements had also been addressed, including:

  • Signage and security for MMS laboratory had been improved.
  • Systems to maintain oversight of the documentation in relation to the MMS service was now established.
  • Staff received regular appraisal.
  • The service accommodated patients with disabilities and could access additional support if required for those patients with sensory loss.
  • Feedback from staff indicated there was clear understanding of the vision and strategy for the service.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

10 August 2022

During a routine inspection

Our rating of this location improved. We rated it as good because:

  • The service provided mandatory training in key skills to all staff and made sure everyone completed it. Managers could demonstrate that all staff had up to date training on how to recognise and report abuse. The service had identified systems in place to monitor infection prevention and control measures. Staff completed and updated risk assessments for each patient and took action to remove or minimise risks. Staff had the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. The service had systems and processes in place to safely prescribe, administer, record and store medicines. Staff recognised and reported incidents and the service managed patient safety incidents.
  • Managers had introduced systems for monitoring the effectiveness of the service. Staff provided good care and treatment, gave patients enough to eat and drink, and gave them pain relief when they needed it. Staff worked well together for the benefit of patients and supported them to make decisions about their care. Key services were available six days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and helped them understand their conditions. They provided emotional support to patients, families and carers.
  • The service planned care to meet the needs of local people and made it easy for people to give feedback. People could mostly access the service when they needed it.
  • Leaders supported staff to develop their skills. Staff understood the service’s vision and values, and how to apply them in their work. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. Staff were committed to improving services continually.

However:

  • The service did not have an effective system to ensure Mohs Micrographic Surgery (MMS) equipment was kept secure and systems for Mohs Micrographic Surgery (MMS) laboratory equipment maintenance were not always clearly implemented. Environmental risk assessments for the Mohs Micrographic Surgery (MMS) laboratory were inconsistent and actions to mitigate risks were not fully identified.
  • Staff mostly kept detailed records of patients’ care and treatment, but records of multidisciplinary review were not always included in patient notes.
  • Managers did not always ensure all staff were up to date with appraisals.
  • The service mostly took account of patients’ individual needs but did not have robust systems for identifying and meeting the needs of patients with disabilities, including sensory loss.
  • Although leaders understood the priorities and issues the service faced, their overall ability to manage these was limited by the extent of the daily clinical demands. Relevant risks were not always identified, and actions taken to reduce their impact. Governance systems and processes had been strengthened but were not fully embedded.

12 and 13 January 2022

During a routine inspection

Discover Laser Ltd. is an independent health clinic. They are registered to provide diagnostic and screening procedures, services in slimming clinics, surgical procedures and treatment of disease, disorder or Injury. The treatments provided by the clinic which fall into the scope of regulation includes the treatment of excessive sweating, slimming clinics, acne treatment and Mohs micrographic surgery. The clinic also provides a range of other aesthetic services which are not regulated.

We carried out this unannounced comprehensive inspection of Discover Laser Ltd. on the 12 and 13 January 2022 as part of our continual checks on the safety and quality of healthcare services. We issued two section 29 warning notices as we found that the service was required to make significant improvements within Regulation’s 12 and 17 of the Health and Social Care Act 2008.

Details for the surgery service inspected can be found later within the report, a summary of the safe, effective, caring, responsive and well led is below.

We rated it as inadequate because:

  • The service did not always provide mandatory training in key skills to all staff and did not always make sure everyone completed it. Managers could not demonstrate that all staff had up to date training on how to recognise and report abuse. The service did not always have effective systems in place to monitor infection prevention and control measures effectively. The service did not have an effective system to ensure equipment was kept secure and were suitable for the purpose for which they were being used. Staff did not complete and update risk assessments for each patient and did not evidence that they removed or minimised risks. The service did not have enough staff to keep up with the demand of the service to provide the right care and treatment. The service could not always demonstrate that staff had the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Staff did not always keep detailed records of patients’ care and treatment. The service did not demonstrate they had systems and processes in place to safely prescribe, administer, record and store medicines. This exposed patients to a potential risk of harm. The service did not manage patient safety incidents well. Staff did not recognise and report incidents and near misses. Managers did not investigate incidents and did not provide evidence that they shared lessons learned with the whole team. Managers did not ensure that actions from patient safety alerts were implemented and monitored.
  • The service did not always provide up to date care and treatment guidance and policies based on national guidance and evidence-based practice. Managers did not check to make sure staff followed guidance. We were concerned that the service did not have effective systems and processes in place to monitor the effectiveness of care and treatment. They did not always use the findings to make improvements. They did not always achieve good outcomes for patients. The service did not always make sure staff were competent for their roles. Managers did not always appraise staff’s work performance and did not always hold supervision meetings with them to provide support and development. Doctors and staff worked together as a team but did not always demonstrate that they worked to benefit patients.
  • The service could not demonstrate that they were always inclusive and took account of patients’ individual needs and preferences. The service could not always demonstrate that they made reasonable adjustments to help patients access services. The service did not monitor and report on patients receiving care and treatment in a timely manner. It was not always easy for people to give feedback and raise concerns about care received. The service did not always treat concerns and complaints seriously, they did not evidence that they investigated them and shared lessons learned with all staff. The service did not always include patients in the investigation of their complaint. The service did not have a system for referring unresolved complaints for independent review.
  • Leaders did not always have the capacity, skills and abilities to run the service. They did not always understand and manage the priorities and issues the service faced. Leaders did not operate effective governance processes, throughout the service. Team meetings were not always recorded effectively and did not demonstrate that discussions had been undertaken for staff to learn from the performance of the service. Leaders did not use systems to manage performance effectively. They did not always identify and escalate relevant risks and issues and did not identify actions to reduce their impact. The service did not always collect reliable data and analyse it. Staff could not always find the data they needed, in easily accessible formats, to understand performance, make decisions and improvements. The service could not demonstrate that data or notifications were not always consistently submitted to external organisations as required. Leaders could not demonstrate that the service was continuously improving.

However:

  • The service kept equipment and the premises visibly clean. Staff used equipment to protect patients, themselves and others from infection. Staff managed clinical waste well. The service made sure patients knew who to contact to discuss complications or concerns. Records were clear, up to date, stored securely and easily available to all staff providing care.
  • Staff ensured that patients were not without food or drinks for long periods. Staff assessed and monitored patients regularly during their treatment to see if they were in pain and gave pain relief in a timely way. Patients could contact the service seven days a week for advice and support after their surgery. Staff supported patients to make informed decisions about their care and treatment. They understood how to support patients.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, and took account of their individual needs. Staff provided emotional support to patients to minimise their distress. They understood patients' personal, cultural and religious needs. Staff supported patients to understand and make decisions about their care and treatment.
  • People could access the service when they needed it and received the right care. They were focused on the needs of patients receiving care.
  • Leaders were visible and approachable in the service for patients and staff. The service had a vision for what it wanted to achieve and a strategy to turn it into action. Staff felt respected, supported and valued. Staff at all levels were clear about their roles and accountabilities.

27 August 2013

During a routine inspection

We looked at the latest patient satisfaction survey for 2013. This told us that people who used the service were satisfied with their treatment. Comments included 'The staff were lovely, pleasant and highly professional'. All five of the randomly selected patient satisfaction surveys told us that the people accessing the clinic would recommend the service to their family and friends.

We found Discover Laser had suitable arrangements in place for obtaining consent from patients using the service.

We looked at four consultation and treatment records; these told us that patients accessing the service had treatment that met their individual treatment needs. Preventative measures were in place to ensure the welfare and safety of their patients.

We found systems and processes were in place to maintain the cleanliness of the service and to prevent the control of any spread of infections. Comments included in the patient satisfaction surveys we reviewed included, 'A fantastic environment, lovely tidy spaces always smelt lovely and clean'.

We found there was an appropriate complaints process in place to ensure that any comments and or complaints were listened to and acted upon.