Coltishall Cosmetic Clinic

Updated 21 February 2020

• The provider of this service is Coltishall Cosmetic Clinic.
• Coltishall Cosmetic Clinic is located at Bure House, Rectory Road, Horsted, Norfolk, NR12 7EP.
• The website address is: https://coltishallclinic.co.uk/
• Coltishall Cosmetic Clinic is an independent provider of cosmetic services. The clinic is located in the village of Horstead, a few minutes’ drive from the centre of Norwich. They offer treatments for aesthetic and medical purposes.
• Coltishall Cosmetic Clinic is registered with CQC to provide the regulated activities of treatment of disease, disorder and injury and surgical procedures. Therefore, we were only able to inspect regulatory compliance for treatments carried out for medical purposes, such as Botox injections for excessive sweating, ultrasound, surgical procedures including mole removal, liposuction, face lifts and weight loss services. The clinic offered other services that were out of regulatory scope; such as laser treatment for hair removal, tattoo removal and Botox injections for aesthetic reasons.
• The clinic had flexible opening times according to patient demand. They were open between Tuesday and Saturday.
• The staff consisted of a doctor (also the medical director), an administrator, two therapists and two receptionists. The clinic consisted of a reception area, a waiting room and two clinical rooms.

How we inspected this service

Before visiting, we reviewed a range of information we hold about the service and asked them to send us some pre-inspection information which we reviewed.

During our visit we:

• Spoke with a range of staff from the service including the lead clinician, aesthetic assistant, a receptionist and clinic manager.
• Reviewed a sample of treatment records.
• Reviewed comment cards where patients had shared their views and experiences of the service.
• 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 21 February 2020

This service is rated as Good overall. (Previous inspection July 2019 – Inadequate)

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 Coltishall Cosmetic Clinic on 29 January 2020. This inspection was to follow up on the breaches of regulation we found at the previous inspection, carried out in July 2019. At that inspection, we served the provider with warning notices for Regulation 12 (Safe Care and Treatment) and Regulation 17 (Good Governance). We also served two requirement notices for Regulation 18 (Staffing) and Regulation 19 (Fit and Proper Persons Employed). Details of the previous inspection and reports can be found by following the links for the provider at www.cqc.org.uk.

Coltishall Cosmetic Clinic is an independent provider of cosmetic services. The clinic is located in the village of Horstead, a few minutes’ drive from the centre of Norwich. They offer treatments for aesthetic and medical purposes.

This clinic is registered with Care Quality Commission (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 services and these are set out in Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Coltishall Cosmetic Clinic is registered in respect of the provision of treatment of disease, disorder or injury and surgical procedures. Therefore, we were only able to inspect treatments relating to medical conditions, such as Botox for excessive sweating, ultrasound, surgical procedures including mole removal, liposuction, face lifts and weight loss services. The clinic offered other services such as laser treatment for hair removal and tattoo removal and Botox for aesthetic reasons, these services are exempt from regulation.

The practice is registered with the CQC under the Health and Social Care Act 2008 to provide the following regulated activities:

• Surgical procedures

• Treatment of disease, disorder or injury.

The lead doctor is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the practice. 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 practice is run. The lead doctor is also the nominated individual. (A nominated individual is a person who is registered with the Care Quality Commission to supervise the management of the regulated activities and for ensuring the quality of the services provided).

As part of our inspection we asked for CQC comment cards to be offered to patients for completion, prior to our inspection visit. We received 25 comment cards, all of which were wholly positive about the service. The cards reflected the kind and caring nature of staff, how informative staff were, the pleasant environment and the positive effects of the treatment received. Eight cards told us that the service provided was “excellent”. Other forms of feedback, including patient surveys and social media feedback were also consistently positive.

Our key findings were:

• Significant improvements had been made to the service since the last inspection. The provider told us they were committed to providing a high-quality service and had addressed the issues identified at the previous inspection.
• Risk assessments had been completed to assure the provider of the safety of the premises.
• Staff were appropriately trained to carry out their roles. There was an appraisal system in place to support staff development.
• Some audit activity was used to support and drive changes within the clinic, although we saw the impact was currently limited.
• Patients were happy with the care they received in the clinic and feedback we reviewed was wholly positive.
• Governance systems and processes had been strengthened and implemented effectively.
• The clinic made referrals to other relevant services in a timely manner.
• Patients reported they were happy with the appointment system and the type of appointments on offer.
• The culture within the service was positive and staff were fully committed to implementing required improvements within the clinic.

The areas where the provider should make improvements are:

• Review and improve the system for completing clinical audits, including completing audits on prescribing of medicines.
• Embed the system for discussing significant events and complaints in meetings.
• Implement and embed a system to ensure changes to policies are signed by staff.
• Take action to ensure that correspondence sent with a client’s consent to their usual GP following treatment, contains information relating to prescribed medicines.
• Continue to review guidelines relating to prescribing.

This service was placed in special measures in July 2019. I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care