The Care Quality Commission
  • Doctor
  • Independent doctor

10 Harley Street

Overall: Requires improvement read more about inspection ratings

10 Harley Street, London, W1G 9PF 07720 463080

Provided and run by:
Botonics Limited

Important: We are carrying out a review of quality at 10 Harley Street. We will publish a report when our review is complete. Find out more about our inspection reports.

All Inspections

5 July 2023 and 13 July 2023

During an inspection looking at part of the service

This service is rated as Requires improvement overall. (Previous inspection in July 2022 – Inadequate).

The key questions are rated as:

Are services safe? – Good

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

We carried out an announced comprehensive inspection at 10 Harley Street to follow up breaches of regulations from the July 2022 inspection. When we inspected the service in July 2022, we asked the provider to make improvements following breaches of regulations and we issued a Warning Notice under Section 29 of the Health and Social Care Act 2008 for Regulation 17, good governance. Requirement Notices were also issued for Regulation 12, safe care and treatment and Regulation 18, staffing. We checked these areas as part of this comprehensive inspection and found most of the breaches identified had been resolved and significant improvement had been made in providing safe care to patients; however, we continued to find gaps in the effective care of patients and in relation to governance.

There is a registered manager in place. A registered manager is a person who is registered with the Care Quality Commission (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.

Botonics Limited, 10 Harley Street is an independent provider and is registered with the CQC to provide diagnostic and screening procedures, surgical procedures and treatment of disease, disorder or injury in relation to cosmetic treatments where there are some exemptions from regulation by CQC. These 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.

The provider also provides a separate aesthetics service delivered by a clinician working in the service. This included full facial rejuvenation and anti-ageing treatments. These types of arrangements are not within CQC scope of registration; therefore, we did not inspect or report on these services.

There were no comment cards distributed to patients as part of this inspection and no patient interviews were carried out during the inspection. Patient feedback was found on Trustpilot online and google reviews.

Our key findings were:

  • The provider had taken steps to ensure Isotretinoin prescribing doctors at the service were now part of a consultant led team.
  • The provider checked and verified the identity patients using their services in accordance with GMC guidelines.
  • There was now a named safeguarding lead and a safeguarding policy in the service.
  • Indemnity arrangements were in place for the service.
  • There was now a process in place to log, discuss, share and action safety alerts.
  • The provider obtained consent prior to providing care and treatment.
  • Online patient feedback showed significantly high numbers of positive patient satisfaction with the service.
  • Staff felt respected and valued.
  • The provider did not always assess needs and deliver care and treatment in line with current legislation, standards and guidance.
  • There were gaps in governance arrangements.
  • Processes for managing risks, issues and performance were not always clear or effective

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.
  • Ensure staff receive training relevant to their role.

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

The areas where the provider should make improvements are:

  • Continue with quality improvement activity.
  • Review and act on the recent national recommendations in relation to notifying the GP when a patient commences treatment with Isotretinoin.
  • Review national guidance in relation to first consultations being carried out face to face wherever possible.
  • Take action to provide a google translate option on the provider website.
  • Share business contingency plan with all staff.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Healthcare

6 July 2022

During a routine inspection

This service is rated as Inadequate overall.

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Inadequate

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Inadequate

We carried out an announced comprehensive inspection at 10 Harley Street on 6 July 2022 as part of our inspection programme and in response to medicines management related concerns. This service had not previously been inspected.

Mr William Green is the registered manager. A registered manager is a person who is registered with the Care Quality Commission (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.

Botonics Limited, 10 Harley Street is an independent provider and is registered with the CQC to provide diagnostic and screening procedures, surgical procedures and treatment of disease, disorder or injury in relation to cosmetic treatments
where there are some exemptions from regulation by CQC. These 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. The provider also provided a separate aesthetics service delivered by a clinician working in the service. This included full facial rejuvenation and anti-ageing treatments. These types of arrangements are not within CQC scope of registration; therefore, we did not inspect or report on these services.

The provider was issued with a Section 64 Information Request letter on 21 May 2021 due to concerns received by CQC in relation to their prescribing of Isotretinoin (for severe acne), which is a medicine that should only be prescribed by a specialist dermatologist or within a specialist team. This means prescribed only by a consultant dermatologist led team, prescriptions issued under the consultant’s name and from a community pharmacy. The Section 64 letter contained a number of assurances the provider was asked to provide the Commission with.

There were no comment cards distributed to patients as part of this inspection and no patient interviews were carried out during the inspection. Patient feedback was found on Trustpilot online.

Our key findings were:

  • Staff did not have the right specialist skills to carry out their roles.
  • The service did not have clear systems to keep people safe and safeguarded from abuse.
  • Staff did not always have the information they needed to deliver safe care and treatment to patients.
  • The prescribing systems in place were not safely managed.
  • The arrangements in place for making improvements when things went wrong and learning required improvement.
  • We were not assured the provider always assessed needs and delivered care and treatment in line with current legislation, standards and guidance.
  • The service was not actively involved in quality improvement activity.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Staff worked together and worked well with other organisations.
  • Staff were consistent and proactive in empowering patients and supporting them to manage their own health and maximise their independence.
  • The service obtained consent to care and treatment in line with legislation and guidance.
  • Governance processes were not operating effectively.
  • The service did not always act on appropriate and accurate information.

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

  • Ensure care and treatment is provided in a safe way for patients.
  • 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:

  • Consider provisions for those whose first language is not English.
  • Take action to monitor the process of seeking consent appropriately prior to treatment.
  • Record full complaint details to demonstrate learning from complaints.
  • Implement a formal system to share meetings and implement guidance.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

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