Laura Spence Aesthetics, a private nurse-led aesthetic clinic in Chester, was rated Good across all five KLOE key questions at its first CQC inspection since registration in July 2021. Four minor areas for improvement were identified relating to recruitment record completeness, complaints response timeframes, pending implementation of a formal incident recording system, and inconsistent policy dating.
Concerns (4)
minor
Record keeping
: “some staff personnel files did not contain full recruitment information such as full employment history or a medical fitness declaration”
minorComplaints handling: “there were no timeframes included in the response report in order to confirm they were working to their policy”
minorIncident learning: “The provider had recently developed a system for recording and acting on significant events, accidents and incidents. This was to be implemented at the forthcoming staff meeting.”
minorGovernance: “not all policies were dated with issue and review date and some contained inaccurate information in relation to named lead people”
Strengths
· Effective safeguarding systems and safety risk assessments in place, with DBS checks undertaken where required
· Staff appropriately qualified, professionally registered with NMC, and up to date with revalidation and training
· Effective infection prevention and control programme including annual audits with documented action plans
· Very positive patient feedback about care, treatment, and staff attitude evidenced through validated online reviews
· Consent processes fully compliant with legislation, including mental capacity assessment where appropriate
Quality-Statement breakdown (26)
safe: Safety systems and processesNot rated
safe: Risks to patientsNot rated
safe: Information to deliver safe care and treatmentNot rated
safe: Safe and appropriate use of medicinesNot rated
safe: Track record on safety and incidentsNot rated
safe: Lessons learned and improvements madeNot rated
effective: Effective needs assessment, care and treatmentNot rated
effective: Monitoring care and treatmentNot rated
effective: Effective staffingNot rated
effective: Coordinating patient care and information sharingNot rated
effective: Supporting patients to live healthier livesNot rated
effective: Consent to care and treatmentNot rated
caring: Kindness, respect and compassionNot rated
caring: Involvement in decisions about care and treatmentNot rated
caring: Privacy and dignityNot rated
responsive: Responding to and meeting people's needsNot rated
responsive: Timely access to the serviceNot rated
responsive: Listening and learning from concerns and complaintsNot rated
well-led: Leadership capacity and capabilityNot rated
well-led: Vision and strategyNot rated
well-led: CultureNot rated
well-led: Governance arrangementsNot rated
well-led: Managing risks, issues and performanceNot rated
well-led: Appropriate and accurate informationNot rated
well-led: Engagement with patients, the public, staff and external partnersNot rated
well-led: Continuous improvement and innovationNot rated