inspection report - care quality commission · centre located in shirley solihull and provides a...

| Inspection Report | FUE Clinics | January 2013 www.cqc.org.uk 1

Inspection Report

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

FUE Clinics

Tanworth Lane Medical Centre, Tanworth Lane, Shirley, Solihull, B90 4DD

Tel: 01217334948

Date of Inspection: 05 December 2012 Date of Publication: January 2013

We inspected the following standards as part of a routine inspection. This is what we found:

Respecting and involving people who use services

Met this standard

Care and welfare of people who use services Met this standard

Safeguarding people who use services from abuse

Met this standard

Requirements relating to workers Action needed

Supporting workers Action needed

Assessing and monitoring the quality of service provision

Action needed


Details about this location

Registered Provider FUE Clinics

Registered Managers Mr. Jeremy Isherwood

Overview of the service

The FUE clinic is a private clinic based within a medical centre located in Shirley Solihull and provides a hair transplant service offering hair replacement by FUE (Follicular Unit Extraction) or FUT (Follicular Unit Transplantation). The service operates on a self-referral individually funded basis and is available to male or female clients with hair loss.

Type of service Acute services without overnight beds / listed acute services with or without overnight beds

Regulated activity Surgical procedures


Contents

When you read this report, you may find it useful to read the sections towards the back called 'About CQC inspections' and 'How we define our judgements'.

Page

Summary of this inspection:

Why we carried out this inspection 4

How we carried out this inspection 4

What people told us and what we found 4

What we have told the provider to do 4

More information about the provider 5

Our judgements for each standard inspected:

Respecting and involving people who use services 6

Care and welfare of people who use services 8

Safeguarding people who use services from abuse 9

Requirements relating to workers 10

Supporting workers 11

Assessing and monitoring the quality of service provision 12

Information primarily for the provider:

Action we have told the provider to take 14

About CQC Inspections 16

How we define our judgements 17

Glossary of terms we use in this report 19

Contact us 21


Summary of this inspection

Why we carried out this inspection

This was a routine inspection to check that essential standards of quality and safety referred to on the front page were being met. We sometimes describe this as a scheduled inspection.

This was an unannounced inspection.

How we carried out this inspection

We looked at the personal care or treatment records of people who use the service, reviewed information sent to us by other organisations, carried out a visit on 5 December 2012 and observed how people were being cared for. We checked how people were caredfor at each stage of their treatment and care, talked with people who use the service, talked with carers and / or family members and talked with staff. We talked with stakeholders.

What people told us and what we found

We reviewed policy documents, processes, records and comments from people who use the service and found the provider to be compliant in the areas as of involvement and information; personalised care and safeguarding and safety. We also found that people who use the service were very positive about the care they received.

However we found the provider non-compliant in requirements relating to workers and supporting staff because we could not evidence a robust process of recruitment and documentation of professional development linked to competence for all staff working at this service.

We also found the provider non-compliant in assessing and monitoring the quality of service provision because there was no evidence of the weekly audits the provider specified to regularly assess and monitor the quality of service that people receive. Additionally there was not enough evidence of risk assessments in place to assure that theprovider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others.

You can see our judgements on the front page of this report.

What we have told the provider to do

We have asked the provider to send us a report by 09 February 2013, setting out the action they will take to meet the standards. We will check to make sure that this action is taken.

Where providers are not meeting essential standards, we have a range of enforcement powers we can use to protect the health, safety and welfare of people who use this service


(and others, where appropriate). When we propose to take enforcement action, our decision is open to challenge by the provider through a variety of internal and external appeal processes. We will publish a further report on any action we take.

More information about the provider

Please see our website www.cqc.org.uk for more information, including our most recent judgements against the essential standards. You can contact us using the telephone number on the back of the report if you have additional questions.

There is a glossary at the back of this report which has definitions for words and phrases we use in the report.


Our judgements for each standard inspected

Respecting and involving people who use services Met this standard

People should be treated with respect, involved in discussions about their care and treatment and able to influence how the service is run

Our judgement

The provider was meeting this standard.

People's privacy, dignity and independence were respected because the service is adapted to the needs of the individual. Also people's views and experiences were taken into account in the way the service was provided and delivered in relation to their care.

Reasons for our judgement

This is a self-referral service. People who use the service understood the care and treatment available. Individual consultations are arranged at a place near to their home where possible to discuss the options, risks, benefits and costs of treatment. An information pack containing a health questionnaire is provided.

Peoples diversity and human rights were respected because an interpreter is available if required and on the day of the procedure people using the service can attend with family. Catering is provided for all and can be adapted for individual needs based on diet or culture. Photographs are usually documented pre and post procedure but can be declined.

Peoples dignity is respected as a disposable top and trousers and a dressing gown is provided to wear during the procedure. The policy folder contains a clinic philosophy whichrequires staff to act respectfully and professionally and to adapt the service around the needs of the individual. The need for confidentiality is stated as a core part of clinics code of practice. The procedure is available to men and women, although predominantly has male clientele. We were advised that treatment can be provided by a female consultant if requested.

On the day of the visit there were no procedures listed so we were unable to speak to staffor people who use the service. The nominated individual was available and provided us with the visitors book, the policy folder and patient notes. We also had access to the treatment room where procedures are carried out and the conference room where people who use the service wait and are catered for. We also spoke to the registered manager and utilised all these methods on which to base judgement.

People who use the service are encouraged to write in the visitors book at each visit and the complaints procedure is also explained and detailed in the policy folder. We reviewed the visitor book from October 2010 when this service was registered to the present day. There were no negative comments. Generally comments stated that people were very


pleased with the service, the facilities and catering, the procedure and that the staff were very professional and attentive. One person commented that there was less pain than expected, being nervous but put at ease and being happy with the results. Some people wrote "excellent service, very professional, made you feel welcome and at ease, great teamwork". "Perfect service, sound advice, amazing attention to detail" and "all staff very friendly, approachable and supportive at all times". "Fantastic team who advised me throughout the whole process, informed me about every decision, double-checked everything was ok and had a professional manner".


Care and welfare of people who use services Met this standard

People should get safe and appropriate care that meets their needs and supports their rights

Our judgement


People experienced care, treatment and support that met their needs and protected their rights because there are systems in place to identify individual needs and risk factors and manage accordingly. Additionally, there are policies and procedures to deal with possible clinical or environmental emergencies.


People's needs were assessed and care and treatment was planned and delivered in line with their individual care plan because the procedure involves an individual consultation and a health questionnaire which enables individual choices of treatment and identifies specific health needs.

We reviewed two sets of notes which contained a confirmation letter following initial consultation and relevant pre and post treatment information. Both sets of notes linked to the visitors book. Patient 1 commented "I am indeed very happy to write a comment in this book because the care I received was excellent in every way". Patient 2 wrote "excellent treatment, quick, wonderful nurses who put me at ease and did a wonderful job".

Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare because there are processes in place to identify and manage risk factors including pre and post operative factors. All food provided is pre-packed, bought daily and prepared strictly to instructions.

There were arrangements in place to deal with foreseeable emergencies. This included guidance in the event of cardiac arrest which is also part of staff induction and there is resuscitation equipment in the clinic. There is also a protocol for failure of a medical devicewith instructions for action to be taken. The clinic is located within a Medical Centre and there is a reciprocal agreement in place in case of clinical emergency or business continuity issue. Procedures are carried out under local anaesthetic so patients could be moved in the event of an emergency. In terms of the environment there is a fire, waste management and sharps policy.

Relevant research and guidance is available as this is a highly specialised treatment centre, surgical procedures are delivered by a consultant dermatologist who also delivers care in NHS environments.


Safeguarding people who use services from abuse Met this standard

People should be protected from abuse and staff should respect their human rights

Our judgement


People who use the service were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.


We were advised that there are arrangements in place to provide a chaperone if required at the consultation appointment. On the day of the procedure there is a male consultant and female technician and there are provisionsin place for a female consultant to deliver care if requested. Due to the sensitive nature of this procedure confidentiality is considered a priority. Any person undergoing the procedure can be accompanied by a friend or family member. Treatment involves a signed consent form and consent can be withdrawn at any time. The procedure usually involves pre and post photographic documentation but this can be refused.

We were advised that safeguarding is part of induction and mandatory training, there is a whistle blowing policy in place and part 3 of the policy folder provides advice concerning gifts and gratuities which must be declared to registered manager to evaluate appropriateness.


Requirements relating to workers Action needed

People should be cared for by staff who are properly qualified and able to do theirjob

Our judgement

The provider was not meeting this standard.

The provider has not met this standard because there is no process and documentation of appropriate checks for all staff to ensure that people were cared for, or supported by, suitably qualified, skilled and experienced staff.

We have judged that this has a minor impact on people who use the service, and have toldthe provider to take action. Please see the 'Action' section within this report.


We were advised that the service has a recruitment process in place and that all staff havechecks for CRB, references and professional certification on appointment. Additionally they have an occupational health assessment including Hep B status and induction process. The policy and procedure file shows evidence of a recruitment and induction programme that includes a declaration on previous convictions and contract of employment templates for each specified role. There was no evidence available to supportcompliance on the day of inspection that appropriate checks were undertaken before staff commenced work. Nor was there evidence that there were effective recruitment and selection processes in place and that staff fitness to work was assessed. Therefore the registered manager was contacted by telephone to request the following information: recruitment information, evidence of CRB, references and induction.

On 11th December 2012 we received a copy of the personnel file for the permanent member of staff detailing CRB status and declaration of no convictions and induction. There was no additional documentation on recruitment. Additionally there was no process in place to record recruitment information, CRB status and declaration regarding convictions in place for the other two members of staff. Although the registered manager informed us that he has recorded the consultant dermatologist GMC registration number.


Supporting workers Action needed

Staff should be properly trained and supervised, and have the chance to develop and improve their skills

Our judgement


The provider was not meeting this standard as there is not sufficient documented evidencethat the staff are receiving appropriate training, professional development, supervision andappraisal.



We were advised that there is one employed member of staff working as a hair technician who attends every session and acts as the decontamination lead. The remaining consultant dermatologist and second hair technician working at this location are highly specialised and engaged on a self-employed sessional basis.

We were advised that following the recruitment process and occupational health check, including hepatitis B status, that all staff attend induction and further mandatory training linked to their areas of competence. We reviewed the policy and procedure file which details an induction programme, mandatory training, contracts of employment templates for each specified role, annual appraisal and whistle blowing policy. There is also a checklist for staff signatures acknowledging sight of policy folder and contents. However, there was no available documentary evidence on the day of inspection to support compliance; therefore we contacted the registered manager to request evidence of attendance at induction and mandatory training to support individual areas of competence and signatures linked to viewing the policy file for all staff working at this location.

On 11th December 2012 we received a copy of the personnel file for the permanent member of staff detailing attendance at mandatory training in May 2012 to include: basic life support, fire safety, manual handling, health & safety, complaints handling, conflict resolution, infection control, lone working, information governance and safeguarding and evidence of seeing the policy file.

There was no additional documentation on mandatory training linked to individual areas of competence. Additionally there was no documentation on induction or the process in placefor the other two members of staff.



Action needed

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care

Our judgement


The provider does not have an effective system to regularly assess and monitor the qualityof service that people receive.

The provider does not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who use the service and others.



As there were no procedures on the day of inspection there were no staff or people who use the service available. Therefore, we observed the clinic rooms, reviewed the visitors book comments from October 2010 to last entry on 2 December 2012; read the policy and procedure file; tracked two sets of patient notes and spoke with the registered manager and nominated individual to gain information.

From the available evidence we found that people who use the service were asked for their views about their care and treatment and their views were acted on because of the number of positive comments within the visitors book. Additionally, the number and content of comments indicated helpful and efficient staff and the fact that people using the service are actively encouraged to comment. We were informed that patient satisfaction information is also requested from patients returning for further treatment but we did not see documented evidence of this.

We found that the provider took account of complaints and comments to improve the service because the policy folder contained a complaints procedure called "Listening to You" and we were advised that people who use the service are made aware of the complaints policy alongside the visitors book. The clinic has been registered since October 2010 and has received one complaint in that time.

There is an incident policy and CAS alerts process in place, the Central Alerting System (CAS) is a web-based cascading system for issuing patient safety alerts, important public health messages and other safety critical information and guidance to the NHS and others,including independent providers of health and social care. Although we were advised that because clinic is specialised and relatively low risk there have been no notifiable incidents to report and to date CAS alerts have not required action.


There was a sharps policy in the policy folder and a process for counting blades and sharps before and after procedures documented in the patient records. This was completed in one set of records but not in the second we viewed. We also found evidence in the sluice attached to the treatment room of a small amount of out of date stock which isbeing investigated by the registered manager.

There are recommended audits in place for patient consent (weekly); patient notes (weekly); treatment room cleaning sheets (weekly); CQC audit (annually). However, as there was no evidence of completed audit available on the day of inspection or a policy available for the cleaning of the treatment room a telephone request was made to the registered manager to provide evidence of this.

On 11th December the annual clinic audit was supplied dated November 2012 detailing 84procedures throughout the year. The audit states that there were no incidents reported and no issues concerning errors in documentation. However we found missing information regarding the count of blades post-procedure in one of the sets of notes we tracked.

The cleaning audit is identified as being recorded in the notes and in the notes we viewed there were signed entries for cleaning the treatment room before and after procedures. However we did not find evidence of a documented cleaning standard and no risk assessment has been supplied. We were supplied with the infection control audit dated February 2011 for the GP medical centre in which the clinic is located, but there is no evidence that the FUE service and its staff were included in this audit.

The audit supplied also states that although patients are given a post treatment questionnaire to complete at home and return to the clinic, there have been no returns for this period. However, there are very positive comments in the visitors book.

This section is primarily information for the provider


Action we have told the provider to take

Compliance actions

The table below shows the essential standards of quality and safety that were not being met. The provider must send CQC a report that says what action they are going to take to meet these essential standards.

Regulated activity Regulation

Surgical procedures Regulation 21 HSCA 2008 (Regulated Activities) Regulations2010

Requirements relating to workers

How the regulation was not being met:

No process to record information on recruitment for all staff working for the service. No evidence to show that they have character, qualifications, skills health and experience to provide care Reg 21(a)(b) Registered person must operate effective recruitment procedures to ensure that all staff are of good character with qualifications, skills health and experience necessary for regulated activity



Supporting workers


Insufficient evidence of process to record staff attendance at induction, training and development linked to areas of competence. No evidence of staff viewing the policy file. Reg 23(1) Registered person to ensure that staff are supported to deliver safe appropriate care (2) System of clinical governance to ensure staff can provide evidence that they continue to meet their professional standards.


This section is primarily information for the provider





No risk assessments were supplied for the treatment room to assure that the provider had a system in place to identify, assessand manage risks to the health, safety and welfare of people who use the service. Reg 10(1a-b) Registered person must protect service users, against the risks of inappropriate or unsafecare and monitor the quality of service that people receive

This report is requested under regulation 10(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

The provider's report should be sent to us by 09 February 2013.

CQC should be informed when compliance actions are complete.

We will check to make sure that action has been taken to meet the standards and will report on our judgements.


About CQC inspections

We are the regulator of health and social care in England.

All providers of regulated health and social care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care.

The essential standards are described in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. We regulate against these standards, which we sometimes describe as "governmentstandards".

We carry out unannounced inspections of all care homes, acute hospitals and domiciliary care services in England at least once a year to judge whether or not the essential standards are being met. We carry out inspections of dentists and other services at least once every two years. All of our inspections are unannounced unless there is a good reason to let the provider know we are coming.

There are 16 essential standards that relate most directly to the quality and safety of care and these are grouped into five key areas. When we inspect we could check all or part of any of the 16 standards at any time depending on the individual circumstances of the service. Because of this we often check different standards at different times but we always inspect at least one standard from each of the five key areas every year. We may check fewer key areas in the case of dentists and some other services.

When we inspect, we always visit and we do things like observe how people are cared for, and we talk to people who use the service, to their carers and to staff. We also review information we have gathered about the provider, check the service's records and check whether the right systems and processes are in place.

We focus on whether or not the provider is meeting the standards and we are guided by whether people are experiencing the outcomes they should be able to expect when the standards are being met. By outcomes we mean the impact care has on the health, safety and welfare of people who use the service, and the experience they have whilst receiving it.

Our inspectors judge if any action is required by the provider of the service to improve the standard of care being provided. Where providers are non-compliant with the regulations, we take enforcement action against them. If we require a service to take action, or if we take enforcement action, we re-inspect it before its next routine inspection was due. This could mean we re-inspect a service several times in one year. We also might decide to re-inspect a service if new concerns emerge about it before the next routine inspection.

In between inspections we continually monitor information we have about providers. The information comes from the public, the provider, other organisations, and from care workers.

You can tell us about your experience of this provider on our website.


How we define our judgements

The following pages show our findings and regulatory judgement for each essential standard or part of the standard that we inspected. Our judgements are based on the ongoing review and analysis of the information gathered by CQC about this provider and the evidence collected during this inspection.

We reach one of the following judgements for each essential standard inspected.

Met this standard This means that the standard was being met in that the provider was compliant with the regulation. If we find that standards were met, we take no regulatory action but we may make comments that may be useful to the provider and to the public about minor improvements that could be made.

Action needed This means that the standard was not being met in that the provider was non-compliant with the regulation. We may have set a compliance action requiring the provider to produce a report setting out how and by when changes will be made to make sure they comply with the standard. We monitor the implementation of action plans in these reports and, if necessary, take further action.We may have identified a breach of a regulation which is more serious, and we will make sure action is taken. We will report on this when it is complete.

Enforcement action taken

If the breach of the regulation was more serious, or there have been several or continual breaches, we have a range ofactions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers include issuing a warning notice; restricting or suspending the services a provider can offer, or the number of people it can care for; issuing fines and formal cautions; in extreme cases, cancelling a provider or managers registration or prosecutinga manager or provider. These enforcement powers are set out in law and mean that we can take swift, targeted action where services are failing people.


How we define our judgements (continued)

Where we find non-compliance with a regulation (or part of a regulation), we state which part of the regulation has been breached. We make a judgement about the level of impact on people who use the service (and others, if appropriate to the regulation) from the breach. This could be a minor, moderate or major impact.

Minor impact – people who use the service experienced poor care that had an impact ontheir health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly.

Moderate impact – people who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly.

Major impact – people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly

We decide the most appropriate action to take to ensure that the necessary changes are made. We always follow up to check whether action has been taken to meet the standards.


Glossary of terms we use in this report

Essential standard

The essential standards of quality and safety are described in our Guidance about compliance: Essential standards of quality and safety. They consist of a significant numberof the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009. These regulations describe theessential standards of quality and safety that people who use health and adult social care services have a right to expect. A full list of the standards can be found within the Guidance about compliance. The 16 essential standards are:

Respecting and involving people who use services - Outcome 1 (Regulation 17)

Consent to care and treatment - Outcome 2 (Regulation 18)

Care and welfare of people who use services - Outcome 4 (Regulation 9)

Meeting Nutritional Needs - Outcome 5 (Regulation 14)

Cooperating with other providers - Outcome 6 (Regulation 24)

Safeguarding people who use services from abuse - Outcome 7 (Regulation 11)

Cleanliness and infection control - Outcome 8 (Regulation 12)

Management of medicines - Outcome 9 (Regulation 13)

Safety and suitability of premises - Outcome 10 (Regulation 15)

Safety, availability and suitability of equipment - Outcome 11 (Regulation 16)

Requirements relating to workers - Outcome 12 (Regulation 21)

Staffing - Outcome 13 (Regulation 22)

Supporting Staff - Outcome 14 (Regulation 23)

Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10)

Complaints - Outcome 17 (Regulation 19)

Records - Outcome 21 (Regulation 20)

Regulated activity

These are prescribed activities related to care and treatment that require registration with CQC. These are set out in legislation, and reflect the services provided.


Glossary of terms we use in this report (continued)

(Registered) Provider

There are several legal terms relating to the providers of services. These include registered person, service provider and registered manager. The term 'provider' means anyone with a legal responsibility for ensuring that the requirements of the law are carried out. On our website we often refer to providers as a 'service'.

Regulations

We regulate against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009.

Responsive inspection

This is carried out at any time in relation to identified concerns.

Routine inspection

This is planned and could occur at any time. We sometimes describe this as a scheduled inspection.

Themed inspection

This is targeted to look at specific standards, sectors or types of care.


Contact us

Phone: 03000 616161

Email: [email protected]

Write to us at:

Care Quality CommissionCitygateGallowgateNewcastle upon TyneNE1 4PA

Website: www.cqc.org.uk

Copyright Copyright © (2011) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with thetitle and date of publication of the document specified.

inspection report - care quality commission · centre located in shirley solihull and provides a...

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