Henley Medical Aesthetics

Updated 9 January 2023

The address of the registered provider and the service is Henley Medical Aesthetics Limited, The Hart Surgery, York Road, Henley-on-Thames, Oxfordshire, RG9 2DR. The registered provider only has this service under registration with the Care Quality Commission (CQC).

Henley Medical Aesthetics was first registered with CQC in July 2019 and is registered to treat adults and children. The service provides several regulated activities such as minor surgical procedures including the excision of non-cancerous moles and other skin lesions. Other services include private immunisations, ear microsuction, treatment of hyperhidrosis (excess sweating) and prescribing for dermatological conditions. Activities outside the CQC scope of regulation include anti-ageing injections and skin care advice.

The service is in the centre of Henley-on-Thames and can be accessed via public transport, car or on foot. The service operates from the premises of a NHS GP practice where it rents a consultation room and waiting area. However, the service has its own, separate entrance and waiting area which is accessed from the rear of the NHS GP practice via a pathway from the premise’s private car park. This includes disabled parking spaces near to the building. Both the car park and premises are located on the ground floor.

The clinic is open on Thursday mornings from 9am to 1pm and certain treatments are available outside of those hours by arrangement with the service.

The staff team is comprised of a part-time practice manager, a part-time administrator, and 2 doctors and 1 nurse who provide treatments on 1 morning per week, unless alternative arrangements are agreed with the service. All staff who work for the service are either employed by or are the partners of the NHS GP practice which Henley Medical Aesthetics rents facilities from. The governance arrangements between the two services are such that staff from the NHS GP practice also provide relevant roles in support of this service. For example, a GP partner is also the safeguarding lead and the lead nurse manages infection prevention and control for both services.

How we inspected this service

Throughout the COVID-19 pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

The 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:

• Speaking with staff in person on the telephone and using video conferencing facilities.
• Requesting documentary evidence from the provider.
• A site visit.

We carried out an announced site visit to the service on 24 November 2022. Before the site visit we requested documentary evidence electronically from the provider and interviewed staff via video teleconferencing.

Due to the current pandemic, we were unable to obtain comments from patients via our normal process where we ask the provider to place comment cards in the service location. However, we were shown examples of patient feedback and asked the provider to provide patients with a link to our give feedback on care page on our website. We did not speak to patients on the day of the site visit.

To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions:

• Is it safe?
• Is it effective?
• Is it caring?
• Is it responsive to people’s needs?
• Is it well-led?

These questions therefore formed the framework for the areas we looked at during the inspection.

Updated 9 January 2023

This service is rated as Good overall.

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 Henley Medical Aesthetics. The reason for the inspection was because our current inspection priorities include services that have been registered with the Care Quality Commission (CQC) for over 12 months without being inspected. Henley Medical Aesthetics met these priorities because it registered with on 26 July 2019 and the provider had not been inspected.

Henley Medical Aesthetics provides a range of medical aesthetic treatments which include minor surgical procedures and treatment of hyperhidrosis (excess sweating). The service also provides private immunisations and treatments which are not available to patients on the NHS, for example ear microsuction. These services are offered via doctor and nurse led clinics. The service also offers other non-regulated aesthetic treatments.

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. Henley Medical Aesthetics provides a range of non-surgical cosmetic interventions, for example dermatological skin care treatments and anti-ageing injectables, which are not within CQC scope of registration. Therefore, we did not inspect or report on these services.

Henley Medical Aesthetics is registered with CQC to provide the following regulated activities:

• Treatment of disease, disorder or injury.
• Diagnostic and screening procedures.
• Surgical procedures.

One of the clinical leads 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.

Our key findings were:

• There were clear processes and systems to keep patients safe and safeguarded from abuse.
• Systems and processes existed to monitor, detect and reduce the risk of infection.
• Staff were clear about their roles and responsibilities and explained what they would do if a patient’s condition was not suitable for treatment by the service.
• Clinical records were written clearly, stored securely and contained accurate information which enabled clinicians to deliver high quality care.
• Clinicians had access to peer support from other healthcare settings which helped ensure they remained up to date with current best practice.
• Evidence-based best practice guidance was followed when providing treatment to patients.
• There was a chaperone policy and all staff had completed training and received a disclosure and barring service check before carrying out the role.
• Staff understood the legislation around gaining consent to treatment from patients and we found this was documented in all the clinical records we reviewed.
• The provider shared premises and staff with a co-located service (a NHS GP practice) and had adopted the governance arrangements of that service. Systems, policies and procedures therefore existed but were not specific to the provider.

The areas where the provider should make improvements are:

• Formalise the process for confirming parental authority for adults accompanying children at the service.
• Review the process for notifying patients’ NHS GP practices about treatment.
• Revise the governance systems, processes and policies to make sure any issues, risks or actions directly related to the service are fully considered, risk assessed and documented.
• Revise the complaints process & associated information so patients have access to the necessary information they may need should they wish to make or escalate a complaint.
• Increase audit activity and use the findings to drive improvements in the quality of services for patients.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

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