This service is rated as
Good
overall. (Previous inspection 10 August 2022 – Good)
The key questions are rated as:
Are services safe? – Good (Previous inspection 10 August 2022)
Are services effective? – Good (Previous inspection 10 August 2022)
Are services caring? – Good (Previous inspection 10 August 2022)
Are services responsive? – Good (Previous inspection 10 August 2022)
Are services well-led? – Good (This inspection 16 May 2023)
Following our previous inspection on 10 August 2022, the service was rated good overall with a rating of good for the key questions safe, effective, caring and responsive and a rating of requires improvement for the key question well led. We issued the service with a requirement notice for a breach of Regulation 17(1) Good governance. This inspection identified improvements in all areas noted at the inspection in August 2022, and the key question well led is now rated good.
The inspection in August 2022 was undertaken under the NHS and independent acute hospitals surgery framework. Since that inspection the taxonomy or classification of the service provided by Discover Laser Ltd has been adjusted as the services provided are more aligned with the Primary Medical Services (PMS) independent health inspection framework.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Discover Laser on our website at www.cqc.org.uk
Discover Laser is a registered location of Discover Laser Ltd. It is an independent health clinic providing a range of services to fee paying members of the public.
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 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. Discover Laser provides a range of non-surgical cosmetic interventions. For example anti-wrinkle treatments, dermal fillers, including lip fillers, skin and hair laser treatments. These types of treatments are not within CQC scope of registration. Therefore, we did not inspect or report on these services.
The Dr Jose Miguel Montero Garcia 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 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.
Our key findings were:
This inspection focused on the key question of Well led and the breaches of regulation identified at the previous inspection in August 2022.
- The provider offered a range of different services, most of which were not within the scope of CQC registration.
- Those services that were within CQC scope were offered on a private, fee-paying basis only and were accessible to patients who chose to use them.
- Services offered at the time of this inspection that were within the scope of registration were Mohs Micrographic Surgery (MMS) used to treat some early stage skin cancers and undertaken by a Consultant Dermatologist. Patients attending for this type of surgery had received the appropriate clinical investigations prior to the surgical treatment being undertaken at Discover Laser.
- Other services offered by Discover Laser included the removal of skin lesions such moles and cysts and other treatments including those for acne. The website for these offered comprehensive information about these services and included details of fees.
We found that the issues identified at inspection in August 2022 had been addressed. These included:
- Since our previous inspection, the provider had invested in creating an MMS laboratory and treatment suite consisting of a secure laboratory, with a separate room for preparing, viewing and analysing slides of excised tissue. The suite of rooms also included two separate patient consultation/treatment rooms which had interconnecting doors with the laboratory promoting the safe flow of the excised tissue from patient to laboratory for preparation for examination and assessment.
- The risk assessments for the MMS laboratory had been updated and were subject to regular review.
- Systems for cleaning and equipment checking regimes for the MMS laboratory areas were established and were up to date.
- The service had implemented a protocol to ensure pathological specimens were retained and stored in accordance with relevant guidance and standards.
We also found the areas identified at the previous inspection where the provider should make improvements had also been addressed, including:
- Signage and security for MMS laboratory had been improved.
- Systems to maintain oversight of the documentation in relation to the MMS service was now established.
- Staff received regular appraisal.
- The service accommodated patients with disabilities and could access additional support if required for those patients with sensory loss.
- Feedback from staff indicated there was clear understanding of the vision and strategy for the service.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services