Archived: The Park Club Medi Spa

We carried out an announced comprehensive inspection on 14 and 16 September 2016 to ask the following key questions; Are services safe, effective, caring, responsive and well-led? We do not currently have a legal duty to rate this type of service but we highlight good practice and any issues that service providers need to improve.

Our findings were:

Are services safe?

We found that this service was providing safe care in accordance with the relevant regulations.

Are services effective?

We found that this service was providing effective care in accordance with the relevant regulations.

Are services caring?

We found that this service was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found that this service was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found that this service was providing well-led care in accordance with the relevant regulations.

Background

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the service was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

The Park Club Medi Spa was located in the basement level of a family club, gym and spa facility. The service offered a range of facial aesthetic treatments, as well as dermatology consultations, mole checks, mole mapping and excision of moles and blemishes. The service comprised of a waiting area with reception desk and consultation room.

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 service and these are set out in Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At The Park Club Medi Spa, we reviewed the dermatology, mole checks, mole mapping and excision aspects of the services provided.

The service was run and provided by a single clinician, who was a qualified doctor and also 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.

Five patients provided feedback about the service, and all were extremely positive about their experiences.

Our key findings were:

• There was no evidence of incident recording, investigation or learning, and the registered manager did not fully identify the types of situations which should be recorded as incidents. There was no mechanism for monitoring or learning from incidents in place at the time of our inspection. This meant the registered manager was not able to have full oversight of incident trends.
• At the time of our inspection, we noted that medicines were not managed in a proper way, although the registered manager assured us this issue was rectified immediately when this was raised as a concern following the inspection.
• Some elements of record keeping were poor, such as patients’ past medical histories and details of procedures completed.
• The registered manager had completed level 2 safeguarding vulnerable adults and children training, which was not sufficient to meet NHS England recommendations.
• There were no formal governance arrangements in place and, although environmental risk assessments had been completed, there was no risk register which demonstrated risk mitigation, particularly relating to patient procedures.

However:

• The registered manager offered a range of consultation options, such as a dermatology consultation, a mole check with mole mapping and a mole check without mole mapping, which provided patients with choice.
• Patients could frequently access appointments on the same or next day as they booked their consultation, and did not have to wait beyond their appointment time to be seen by the registered manager .
• The clinic premises and equipment were well maintained and fit for purpose.
• Infection prevention and control practices were appropriate and compliance with NICE CG74 (surgical site infections; prevention and treatment) recommendations were noted.
• We observed that the registered manager's practice demonstrated adherence to British Association of Dermatologists recommendations and an awareness of NICE PH32 (skin cancer prevention).

There were areas where the provider could make improvements and should:

• Review medicines management processes to ensure medicines are ordered correctly.
• Review patient documentation to ensure accurate and complete records are maintained.
• Review the level of safeguarding training completed to ensure it meets the level recommended by NHS England.
• Review governance processes and documentation to ensure risk identification and mitigation is demonstrated.