The Care Quality Commission
  • Hospital
  • Independent hospital

Archived: Skin and Follicle Birmingham

Overall: Good read more about inspection ratings

214D Hagley Road, Birmingham, West Midlands, B16 9PH 0800 772 3501

Provided and run by:
Surgen Ltd

Important: The provider of this service changed. See new profile

All Inspections

12 April 2021

During a routine inspection

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

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. The service managed safety incidents well and learned lessons from them. Staff collected safety information and used it to improve the service.
  • Staff provided good care and treatment and gave patients pain relief when they needed it. Managers monitored the effectiveness of the service and mostly made sure staff were competent. Staff worked well together for the benefit of patients, advised them on how to lead healthier lives, supported them to make decisions about their care, and had access to good information. Key services were available Monday to Saturday from 10am till 6pm.
  • Staff treated patients with compassion and kindness, took account of their individual needs, and helped them understand their choices. They provided emotional support to patients.
  • The service planned care to meet the needs of local people, took account of patients’ individual needs, and made it easy for people to give feedback. People could access the service when they needed it and did not have to wait too long for procedures.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff felt respected, supported and valued. They were focused on the needs of patients receiving care. Staff were clear about their roles and accountabilities. The service engaged well with patients to plan and manage services and all staff were committed to improving services continually.

However:

  • Leaders and teams did not always identify and escalate relevant risks and issues and identify actions to reduce their impact. Flammable substances were not stored appropriately, and the risk assessments were not reflective of the storage need.
  • The storage and management of medicines was not in line with national guidelines.
  • Staff did not total up early warning scores when monitoring patients during procedures. This meant that there was a risk of not detecting a deteriorating patient.

Outpatient services is a small proportion of clinic activity. The main service was surgery. Where arrangements were the same, we have reported findings in the surgery core service report below.

11 September 2019

During a routine inspection

Skin and Follicle Birmingham is operated by Surgen Ltd.

The service provides cosmetic surgery for adults over 18 years either as on a day case basis. The service has no overnight beds.

We inspected this service using our comprehensive inspection methodology. We carried out an unannounced inspection on 11 September 2019.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

The main service provided by this service was cosmetic surgery.

Services we rate

This was the first inspection of the service. We rated it as Inadequate

We found areas of practice that were inadequate:

  • Leaders did not have the necessary capacity or capability to lead effectively.

  • The service did not operate effective governance processes. Roles and accountability were unclear. There were limited opportunities for staff to meet, discuss and learn from the performance of the service.

  • There was no established effective incident reporting system to demonstrate how incidents were reported, investigated and when appropriate learnt from.

  • A lack of incident reporting and incomplete complaint records did not give full assurance of an open culture. Staff did not recognise concerns, incidents or near misses.

  • There was a lack of systems and processes to ensure the safe management and storage of medicines and consumables.

  • The monitoring of the effectiveness of care and treatment was not effective to demonstrate improvements and identify good outcomes for patients.

We found areas of practice that require improvement:

  • Assurance was not available to confirm staff had the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.

  • There was a lack of systems to assess and respond to potential patient risks or abuse. Systems to identify and record surgical site infections were not in place

  • The service did not always provide care and treatment based on national guidance and evidence-based practice.

  • The service was not inclusive and did not take account of patients’ individual needs and preferences. Reasonable adjustments were not in place to help patients access services.

  • Arrangements for the management of complaints and concerns was inconsistent and did not give assurance they were treated seriously. There was insufficient information available to provide assurance all complaints were investigated, and shared lessons learned shared with all staff.

  • The service had a vision for what it wanted to achieve although there was no strategy to turn it into action.

We found areas that were good:

  • Staff treated patients with compassion and kindness and respected their privacy and dignity.

  • The service controlled infection risk well. Staff used equipment and control measures to protect patients, themselves and others from infection. They kept equipment and the premises visibly clean.

  • Patient records were stored securely.

  • Staff gave patients practical support and advice about contacting other agencies to support them to lead healthier lives.

  • People could access the service when they needed it and received the right care promptly. Waiting times from referral to treatment were in line with national standards.

  • Staff supported patients to make informed decisions about their care and treatment. They followed national guidance to gain patients’ consent.

  • Medical staff encouraged innovation and participation in research and service improvement.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with five requirement and one warning notice, the details are at the end of the report.

We are placing the service into special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate overall or for any key question or core service, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

Bernadette Hanney

Head of Hospitals