Background to this inspection
Updated
27 July 2021
- we spoke with staff
- reviewed key documents which support the governance and delivery of the service
- made observations about the areas the service was delivered from
- reviewed a sample of treatment records.
- looked at information the service used to deliver care and treatment plans.
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
27 July 2021
This service is rated as Good overall. The previous inspection was undertaken in January 2014 and was unrated.
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
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 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. Holderness Laser Clinic Limited 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. One of the clinicians 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 people’. 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.
Holderness Laser Clinic is registered in respect of the provision of treatment of disease, disorder or injury and is in the process of registering for surgical procedures. Therefore, we were only able to inspect treatments relating to medical conditions, these were Botox for excessive sweating and sclerotherapy. The clinic offered other services such as laser treatments and Botox for aesthetic reasons, these services are exempt from regulation.
We carried out an announced comprehensive inspection at Holderness Laser Clinic Limited
as part of our inspection programme.
At the time of the inspection there were no patients attending or receiving regulated services due to COVID -19 and we were unable to ask them about the service.
Our key findings were:
- The service provided care in a way that kept patients safe and protected them from avoidable harm. However, we identified some areas requiring attention.
- Patients received effective care and treatment that met their needs.
- Risk assessments had been completed to assure the provider of the safety of the premises. We identified some risk areas that needed to be addressed.
- Staff were appropriately trained to carry out their roles.
- There was an open and transparent approach to safety and an effective system in place for reporting and recording incidents.
- Staff maintained the necessary skills and competence to support the needs of patients.
- Staff were up to date with current guidelines.
- The provider was aware of, and complied with, the requirements of the Duty of Candour.
- The clinic made referrals to other relevant services in a timely manner.
The areas where the provider should make improvements are:
- Complete a risk assessment to assess the risk of not stocking the full range of emergency medicines.
- Review and improve infection control monitoring.
- Review and develop the process for staff appraisals.
- Review and develop the system for completing clinical audit.
- Review and monitor the process for recording fridge temperatures
- Improve the storage of supplies
- Review and keep up to date and available staff records
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care