23MD

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

This is the first inspection for this service since its registration with CQC under this provider. This key question has been rated as Good. This is because we found no concerns with the effectiveness of the care delivered to the people.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Feedback from people using the service was positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual and cultural needs.

Clinical staff used consultation templates to ensure consistency and support the holistic review of individuals' health and wellbeing.

The service used a comprehensive assessment process including a full life history account and necessary examinations such as blood tests or scans to ensure greater accuracy in the diagnosis process. The assessments were tailored according to information on each patient and included their clinical needs and their mental and physical wellbeing.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards, such as the National Institute for Health and Care Excellence (NICE), the British Menopause Society (BMS).

The service had specialised in aesthetic procedures and individualised bioidentical hormone replacement therapy, which included offering weight loss support as part of menopause care. Patients were treated with unlicensed medicines in line with evidence-based guidelines, and systems were in place to ensure this was carried out safely. Clinical records we reviewed demonstrated that care was provided in accordance with current guidance.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The service worked with other services to ensure continuity of care.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Where appropriate, staff provided patients with advice to support self-care. Risk factors were identified and discussed with patients and, where necessary, shared with their usual care provider to support ongoing care. For example, staff gave advice on smoking cessation and weight management.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves.

The service carried out regular quality monitoring activities, including audits. For example, the service carried out records keeping audit, menopause consultations audits, hand hygiene audits and infection control audits.

We found the service was following up on pathology results and had an effective monitoring system in place to ensure that all abnormal results were managed in a timely manner and saved in the patient’s records.

From the clinical notes we reviewed, we found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded.

The lead clinician informed us that information regarding the use of medicines outside of their licence was provided to patients, with risks explained and documented during consultations. Patients signed consent forms prior to treatment acknowledging they were receiving an unlicensed medicine.