During this inspection we spoke with the register manager who was one of two doctors who provided treatments to people. We also spoke with a nurse and a clinic co-ordinator.

This inspection was carried out at the clinic where treatments were provided. We spoke with two people after the inspection to get their views of the service they had received.

People we spoke with told us they were given enough information about their treatment options. People felt involved in the choice of treatments they required. One person said: “I had a consultation and all options and outcomes were discussed. We went through all risk factors”. They also said: “I saw before and after photos of other people’s treatment so I knew what it may look like”.

People that used the service told us they were very happy with the quality of the information, care and treatment they received. One person we spoke with said they received was: “Top Class”. Another person we spoke with told us their experiences made them feel: “Happy because how I feel is reflected in how I look” and, “I can’t recommend them highly enough”.

We found that the provider had not made suitable arrangements to ensure that people who used the service were safeguarded against the potential risks of abuse.

Staff had not been recruited in an appropriate way. We found that thorough checks had not been undertaken before staff started work at the practice to ensure they were suitable to provide care for people.

We spoke with two people who were using the service on the day of our inspection. They both said that they were satisfied with the service that they received at the clinic. A person using the service told us “My overall experience has been fabulous from start to finish.”

People told us that they understood the care and treatment choices available to them. They told us that they had been fully involved in the decision to use the service and that they had been given enough information about the different treatments available to them. A person using the service told us “Following my consultation, I received a letter from the clinic. This outlined all of what we had discussed during the consultation and advised me to have a think about whether to proceed with the surgery or not.”

People told us that they were happy with the care and treatment they had received. They told us that they were confident that staff had a good knowledge of the treatments they provided and that staff supported them well during their appointments.

People told us that they were happy with the quality of service they received and that they felt confident that they could raise any concerns if needed. A person using the service told us “If I had any concerns I would not hesitate to talk to the clinic staff. I have not had any concerns though.”

CC Kat is operated by CC Kat Aesthetics Ltd. The service has no overnight or day beds. Facilities include one operating theatre and outpatient facilities.

The service provides surgery and outpatients services. We inspected both services.

We inspected this service using our comprehensive inspection methodology. We carried out the announced part of the inspection on 8 and 15 August 2017.

To get to the heart of patients’ experiences of care and treatment, we ask the same five questions of all services: are they safe, effective, caring, responsive to people's needs, and well-led? Where we have a legal duty to do so we rate services’ performance against each key question as outstanding, good, requires improvement or inadequate.

Throughout the inspection, we took account of what people told us and how the provider understood and complied with the Mental Capacity Act 2005.

We regulate cosmetic surgery services but we do not currently have a legal duty to rate them when they are provided as a single specialty service. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary.

The main service provided by this clinic was cosmetic surgery. Where our findings on surgery – for example, management arrangements – also apply to outpatients, we do not repeat the information but cross-refer to the surgery core service.

We found the following issues that the service provider needs to improve:

• There was no formalised safety procedure or instrument and swab count during surgical procedures. The provider did not follow national safety procedures such as the World Health Organisation checklist to ensure people were protected from avoidable harm in theatre.
• There was limited measurement and monitoring of safety performance. The provider did not use a clinical dashboard to review safety. Safety was only monitored through any complications of surgery.
• There was no evidence to show that staff were trained and qualified to an acceptable level to keep people safe, this included an absence of safeguarding training.
• There was no mandatory training programme in place and the provider did not keep mandatory training staff records.
• There were no systems or triggers in place to conform to Duty of Candour. People may not have always been told and may not have received an apology when things went wrong.
• When things went wrong, there was no evidence that suggested reviews and investigations were sufficiently thorough and there were no necessary improvements recorded.
• There were minimal systems in place for incident reporting and those that were in place were not always reliable or appropriate.
• Processes for ensuring good cleanliness, infection control and hygiene were not fit for purpose and were not in line with current guidance and best practice.
• Staff did not identify, assess, manage or monitor for risk, the potential hazards of space restriction within the clinic.
• The risks associated with anticipated events and emergency situations were not fully recognised, assessed or managed.
• The approach to assessing and managing day-to-day risks to patients was not fit for purpose.
• The provider did not provide care in line with 2014 Laser Radiation Guidance.
• Equipment and maintenance checks were not carried out regularly and COSHH records were not updated since 2006. Medicines were not stored appropriately and some were out of date.
• There was insufficient assurance systems in place to demonstrate that people received effective care.
• There was very limited monitoring of people’s outcomes of care and treatment.
• The provider was not developing a readiness to collect Patient Reported Outcomes Measures that the Royal College of Surgery (RCS) has deemed as particularly important in cosmetic surgery, despite the clinic undertaking procedures that would apply.
• There was no local audit programme, national benchmarking or participation in peer review or national audit programmes.
• There was a lack of assurance that people received care from staff who had the skills or experience that is needed to deliver effective care. There were gaps in management and supporting arrangements for staff such as regular appraisal, supervision and professional development.
• There were few policies in place to support staff and those that were contained irrelevant and out of date guidance and legislation.
• The waiting area did not always allow for patient privacy and confidentiality to be maintained.
• There was no evidence to show that waiting times, delays and cancellations were minimal and managed appropriately. There was no formal arrangement for managing patient flow and the provider did not assess or monitor cancellations. The provider however assured us these issues are practically irrelevant in private aesthetic practices as all patients had individual appointments.
• The service did not accommodate unplanned surgery. If patients were in need of unplanned surgery, they were directed to the local NHS service.
• The complaints procedure was out of date and did not make reference to relevant legislation such as the Duty of Candour.
• There was a reduction in the ability for the provider to learn from complaints due to stage three independent reviews not being part of the provider’s complaint process.
• Governance and assurance systems and processes were not robust, fallen into neglect or completely absent from the service.
• There was no effective system for identifying, capturing and managing issues and risks at team, directorate and organisation level.
• There were no formal processes in place to review key items or government arrangements. The only items the provider reviewed were complaints and complications of surgery.
• There did not appear to be a set of values or a strategy in place.
• Leaders were not always clear about their roles and their accountability.
• Systems in place to maintain and service equipment were not robust with much of the available documentation out of date.
• There were no arrangements in place to formally address the Fit and Proper Persons requirement for persons ‘directing’ the service.
• Leaders did not have the necessary knowledge of current relevant legislation and regulation requirements needed to provide a safe and effective service. This included conforming to the 2014 Laser Radiation Guidance and the Control of Artificial Optical Radiation at Work Regulations 2010.
• There were missed opportunities for analysing patient feedback. The system in place was not fit for purpose and had a low uptake. Patients did not know about the process for giving feedback and the provider did not conduct any patient surveys.

We found the following areas of good practice:

• All areas of the clinic and theatres were clean and regularly maintained. Staff adhered to infection, prevention and control policies and procedures.
• Consultants were undertaking pre-assessments and there was evidence of risk assessments and pre-operative risk assessments in patient records.
• The clinic was appropriately staffed by a qualified doctor and a qualified nurse. These were supported by support and administration staff.
• Staff managed people’s pain relief effectively.
• Staff could access information needed to assess, plan and deliver care to people in a timely way. People understand and had a copy of the information that was shared about them.
• Staff worked collaboratively to understand and meet the needs of people who used services.
• Detailed information about a patient’s procedure was shared with the patient and other relevant healthcare professionals with the patient’s consent.
• There was evidence that consent to care and treatment was in line with legislation and guidance. People were supported to make decisions.
• People were offered flexibility, choice and continuity of care and this was reflected in the services provided.
• The needs of people were taken into account when planning and delivering services.
• Care and treatment was coordinated with other providers.
• People could access care in a timely way at a pace that suited them.
• The provider took an ethical and moral approach to treatment; declining to carry out procedures where the cost to the patient would exceed the likely benefit or fail to meet their expectations.
• The provider responded to complaints in a timely way.
• Staff supported people who used services, treated them with dignity and respect, and involved them as partners in their care.
• People who used services were communicated with and received information in a way they understood.
• Staff gave sufficient information to people who used services to allow informed decision making and enabling people to become active partners in their care and treatment.
• Feedback from patients we spoke with was positive. They said staff treated them with compassion and respected their privacy and confidentiality.
• Staff encouraged patients to seek counselling for emotional support when they refused to treat for medical or ethical reasons.
• There was a clear vision that was person-centred.
• Staff felt well supported by leaders.

Following this inspection, we told the provider that it must take some actions to comply with the regulations and that it should make other improvements, even though a regulation had not been breached, to help the service improve. We also issued the provider with five requirement notice(s) that affected surgery and outpatients. Details are at the end of the report.

Heidi Smoult

Deputy Chief Inspector of Hospitals (Central Region)