HEALTHCARE INSPECTORATE WALES Care Standards Act 2000 INSPECTION REPORT Independent Healthcare Swansea Laser Clinic 4 Castell Close, Phoenix Way, Llansamlet, Swansea DATE OF INSPECTION 16 January 2009 Regulation Team Healthcare Inspectorate Wales Bevan House Caerphilly Business Park Van Road, Caerphilly, CF83 3ED You may reproduce this Report in its entirety. You may not reproduce it in part or in any abridged form and may only quote from it with the consent in writing of Healthcare Inspectorate Wales.
INSPECTION REPORT Inspection Episode: April 2008 to March 2009 Healthcare Provision: Swansea Laser Clinics Limited Contact telephone number: 01792 797660 Opening Days/Hours Monday, Wednesday, Thursday and alternative Saturdays 9.30 am 3.30 pm Registered Provider: Swansea Laser Clinics Limited Responsible Individual Registered Manager: Number of places: Mr Maxwell S C Murison Mrs Gail Maimone N/A Category: Independent Hospital providing a Listed Service Date of first registration: 28 September 2001 Date of publication of this report: 5 th May 2009 Date of previous published report: 12 December 2007 Lead Inspector: Specialist Inspectors/Advisors/ Observer: Mr John Powell Inspections Manager Mr Mike Warsop Laser and Estates Adviser Final/JP/KR/Swansea Laser Clinics Limited 0809 2
GUIDELINES ON INSPECTION INTRODUCTION This report has been compiled following an inspection of the establishment undertaken by Healthcare Inspectorate for Wales (HIW) under the provisions of the Care Standards Act 2000 and associated Regulations. The report contains information on the process of inspection and records its outcomes. The report is divided into nine distinct parts reflecting the broad areas of the National Minimum Standards. An overall conclusion of the establishment s compliance with Private and Voluntary Healthcare (Wales) Regulations 2002 is recorded. The HIW s Inspectors are authorised to enter and inspect healthcare establishments at any time. At each inspection episode or period there are visit/s to the service in addition to a range of other activities such as, self- assessment and the use of questionnaires. HIW try to find the best way of capturing patients, their relative/representatives and staff employed within the service experiences. At any other time throughout the year visits may also be made to the service to investigate complaints and in response to changes in the establishment. Inspection enables the HIW to satisfy itself that continued registration is justified. It ensures compliance with: Care Standards Act 2000 and associated Regulations whilst taking into account the National Minimum Standards The setting s own Statement of Purpose Readers must be aware that the report is intended to reflect the findings of the particular inspection episode. Readers should not conclude that the circumstances of the service will be the same at all times; sometimes services improve and conversely sometimes they deteriorate. The National Minimum Standards are also very detailed and some are technical in nature and the HIW does not look in depth at all aspects of these standards on each visit. The report clearly indicates the requirements that have been made by HIW. This includes those made by HIW since the last inspection report which have now been met, requirements which remain outstanding and any new requirements from this recent inspection. The reader should note that requirements made in last year s report which are not listed as outstanding have been appropriately complied with. If you have concerns about anything arising from the Inspector's findings, you may wish to discuss these with the HIW or with the registered person. Healthcare Inspectorate Wales is required to make reports on registered facilities available to the public. The report is a public document and will be available on the Healthcare Inspectorate Wales web site: http://www.hiw.org.uk/ Final/JP/KR/Swansea Laser Clinics Limited 0809 3
OVERALL VIEW OF THE HEALTHCARE SETTING Swansea laser Clinics Limited was inspected during the morning of the 16 th January 2009 by an Inspection Manager and a laser and estates advisor. The responsible individual and the manager were present throughout the visit. Swansea Laser Clinics is a consultant led facility offering a range of medical cosmetic treatments conducted by nurse practitioners. Care is led by a consultant hand and plastic surgeon Mr M S C Murison MB, BCh, FRCSEd, FRCS (plast), who fulfils the statutory role and function of the Responsible Individual. Swansea Laser Clinic is situated in Swansea Enterprise Park and is easily accessed from the M4 Swansea East. The laser room is clean, tidy and appropriately maintained and all procedures, records and equipment were available and in order. Patient records are kept separately and securely. Documentation and information relating to IPL/Laser treatments are detailed and given to all patients, pre and post treatment. The Inspection Manager would like to thank Mr M S C Murison, Mrs G Maimone and Mrs Murison for their time and co-operation during the inspection visit. Final/JP/KR/Swansea Laser Clinics Limited 0809 4
INFORMATION PROVISION (C1) Statement of Purpose A Statement of Purpose was available and this contained details of the staff and their qualifications. In addition the available treatments were listed and included: Tattoo removal, hair removal, vascular lesions, thread veins, wrinkles treatment, Photo rejuvenation and skin resurfacing. Patient s Guide A range of patient guides and information booklets were available and consisted of the following: Patient information booklet that identified the range of treatments available at the clinic. In addition, the booklet also contained details in relation to Mr Murison in terms of his experience and training. Patient information booklet in relation to the Lumenis One Intense Pulsed Light (IPL) system and Nd:YAG Laser. This booklet also identified the areas that were suitable for treatment. A patient information booklet was also available on the specific acne treatments. A patient booklet was also available in relation to NLite laser wrinkle treatment. A further guide to laser wrinkle removal and laser acne treatment was also available. A further information booklet was available in relation to skin resurfacing and wrinkles and acne treatment. A comprehensive list of treatments and prices was also available at the clinic. Patient Satisfaction Questionnaires An audit of patient satisfaction had been undertaken and the results were displayed within the clinic. When Completed New requirements from this inspection: Final/JP/KR/Swansea Laser Clinics Limited 0809 5
Good Practice Recommendations: QUALITY OF TREAMENT AND CARE (C2 C7) Patient Centred Care There was a range of documents available to ensure that patients care needs are met. The Inspection manager was informed that a pre-treatment checklist was completed for all potential patients. Pre and post treatment information was available and given to patients. Quality of Care and Management of Patient Conditions The manager was a registered nurse and the responsible individual was a consultant. In addition, the additional members of the staff team were registered nurses. A range of courses and training had been undertaken by the staff team. Clinical outcomes and an adverse incident analysis process was in place. Policies and Procedures There were comprehensive policy and procedure manuals available. All staff sign to state that they have read and understood the policies and procedures. Available policies and procedures included: Quality system policy Whistle blowing policy Appraisal policy Staff supervision policy Training policy Infection control policy Protection of Vulnerable Adults (PoVA) policy Policies and procedures were reviewed on a 3 yearly basis unless there were any changes that needed to be reflected. Quality Audit and Clinical Governance The responsible individual and manager demonstrated a clear awareness of the importance of a clinical governance system. A clinical governance strategy policy had been developed and implemented and this gave the clinic a mechanism to demonstrate a positive approach to quality and governance issues. Reviews undertaken included: analysis of patient satisfaction questionnaires, equipment and facilities checks and analysis of any adverse incidents. When Completed Final/JP/KR/Swansea Laser Clinics Limited 0809 6
New requirements from this inspection: Good Practice Recommendations: Final/JP/KR/Swansea Laser Clinics Limited 0809 7
MANAGEMENT AND PERSONNEL (C8 C15) Manager The Manager is a registered nurse who is appropriately qualified and experienced to work as a laser practitioner and clinic manager. An application to become the registered manager has recently been submitted. Policies and Procedures Human Resources A range of policies and procedures were in place including a policy on the selection and recruitment of staff. The registration of nurses was routinely checked and Criminal Record Bureau checks had been undertaken for all employees. There was documentary evidence that staff had been recently supervised and an appraisal had been undertaken. Within this documentation developmental initiatives, to improve patient care, had been identified. Protection of Vulnerable Adults The Comprehensive policy in relation to the Protection of Vulnerable Adults was available and Inspection Manager was informed that all staff had attended PoVA training. Within the documentation reviewed it was clearly stated that no one under the age of 18 years would be treated. When Completed New requirements from this inspection: Good Practice Recommendations: Final/JP/KR/Swansea Laser Clinics Limited 0809 8
COMPLAINTS MANAGEMENT (C16 C18) Complaints Process A clear complaints policy and procedure was available and this was displayed within the clinic. A complaints book and form were also available. Whistle-blowing A whistle-blowing policy and procedure was in place and the Inspection Manager was informed that any issues identified would be dealt with by the responsible individual and/or manager. When Completed New requirements from this inspection: Good Practice Recommendations: Final/JP/KR/Swansea Laser Clinics Limited 0809 9
PREMISES, FACILITES AND EQUIPMENT (C19 C21) Premises The accommodation is located in a newly refurbished area on the ground floor, and forms part of a commercially occupied building. The accommodation comprises of an administrative/reception area, an internal consulting room, through which access is gained to the main treatment room. All areas of the clinic were clean and well lit, and were maintained to a high standard. Waste material was appropriately stored and disposed of through a contract set up with Howard and Palmer. There was no written maintenance plan, and repairs were carried out as and when they were required. The premises were equipped with an automatic fire alarm system an emergency lighting, and these were inspected on an annual basis. The Fire Log was available on the day of inspection and indicated that the emergency lighting was checked on a monthly basis. However, the routine checking of the fire alarm system indicated that it was checked on a 3 to 4 monthly basis. This is not satisfactory and internal fire alarm tests need to be undertaken on a weekly basis and documented accordingly. A fire risk assessment had not been undertaken for the clinic and this was discussed with the manager who confirmed that a risk assessment would be completed. In addition there was no evidence that a recent fire drill had been undertaken. The testing records of portable electrical appliances was not sighted during the inspection. When Completed Final/JP/KR/Swansea Laser Clinics Limited 0809 10
New requirements from this inspection: The registered person shall ensure, by means of fire drills and practices at suitable intervals, that the persons employed in the establishment and, so far as practicable, patients and medical practitioners to whom practising privileges have been granted, are aware of the procedure to be followed in case of fire. Internal weekly fire alarm checks to be undertaken. A fire risk assessment to be undertaken. A copy of the most recent portable appliance testing documentation to be submitted to HIW Good Practice Recommendations: Immediately Immediately Regulation 24(4)(d) Regulation 24 (4) (a) 31 March 2009 Regulation 24 (4) (a) 31 March 2009 Regulation 24 (2) (d) Final/JP/KR/Swansea Laser Clinics Limited 0809 11
RISK MANAGEMENT (C22 C30) Risk Management The following policies and procedures were available: Health and safety policy. Risk assessment strategy. Risk management policy. There was a strong commitment from the staff, at the clinic, in terms of the management of risk and the policies and procedures should give the staff a robust framework to manage the risks identified. The Inspection manager was informed that an audit of any accidents is taken as part of the risk management approach. Infection Control A policy and procedure was available in relation to infection control and universal precautions. Resuscitation A policy and procedure was in place in relation to first aid and basic life support measures. The medical practitioner was suitably trained and experienced to provide life support pending the arrival of any emergency services. When Completed New requirements from this inspection: Good Practice Recommendations: Final/JP/KR/Swansea Laser Clinics Limited 0809 12
RECORDS AND INFORMATION MANAGEMENT (C31 C33) Information Management/Patient Records All records were stored in a lockable cabinet within the clinic and only authorised members of staff had access to the records. A range of polices and procedures were in place and these included: a record keeping policy, control of records keeping policy and an access to patient health records policy. Patient records were not viewed as part of this inspection process. Confidentiality A policy on confidentiality had been formulated and the Inspection Manager was informed that all staff sign to state that they have read and understood the policy. When Completed New requirements from this inspection: Good Practice Recommendations: Final/JP/KR/Swansea Laser Clinics Limited 0809 13
RESEARCH (C34) No research was carried out at this establishment When Completed New requirements from this inspection: Good Practice Recommendations: Final/JP/KR/Swansea Laser Clinics Limited 0809 14
Prescribed Techniques and Technologies (Standards P1 to P3) CLASS 3B AND 4 LASERS AND/OR INTENSE PULSED LIGHT SOURCES STANDARD P1 : Procedures for Use of Lasers and Intense Pulsed Lights The clinic offered a range of treatments including: Pigmented lesions Vascular lesions Wrinkle treatment Acne treatment The treatment protocols came under the expert medical practitioner, Mr B Davies who was assisting Mr Simon Evans. During the inspection the Inspection Manager was shown a range of documentation that was utilised with all patients, this documentation included: A comprehensive pre-treatment checklist Patient contract record. A consent for treatment record. Documentation in relation to post care treatment The Laser Protection Supervisor for the site was Mr. Max S C Murison, who is an experienced medical practitioner. When Completed Final/JP/KR/Swansea Laser Clinics Limited 0809 15
New requirements from this inspection: Good Practice Recommendations: STANDARD P2 : Training for Staff using Lasers and Intense Pulsed Lights Inspection manager was informed that all operators of the lasers had received appropriate training and all members of staff received clinical supervision and appraisals. The clinic had a comprehensive training policy to ensure that staff had a robust framework to meet their educational and developmental needs. When Completed New requirements from this inspection: Good Practice Recommendations: Final/JP/KR/Swansea Laser Clinics Limited 0809 16
STANDARD P3 : Safe Operation of Lasers and Intense Pulsed Lights The area in which the lasers were operated was suitably controlled and the Inspection Manager was informed that the room was locked during procedures, and warning notices displayed at the entrance to the Laser Controlled Area. An attack alarm system is in place. Whilst there were three lasers present in the Laser Controlled Area, however, procedures were in place to ensure that only one machine at a time was operated. Suitable information was displayed adjacent to each of the lasers in respect of wavelengths and output power. As Class 4 lasers are operated, suitable signage was displayed on the entrance door that conformed to EN 60825-1. Appropriate goggles were placed at each machine position, in sufficient numbers for the patient and operator. Patient safety in respect of medications and skin types were adequately documented in the written policies and procedures. Formal procedures were in place for machine key safety, and these were adequately documented. Daily safety checks were documented, together with monthly cleaning/checks of lasers, and refrigerator temperatures were monitored daily. When Completed New requirements from this inspection: Final/JP/KR/Swansea Laser Clinics Limited 0809 17
Good Practice Recommendations: Inspector s Name: John Powell Date: 15 th March 2009 Inspector s Signature: Final/JP/KR/Swansea Laser Clinics Limited 0809 18
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