Epilium & Skin

Independent Healthcare Org · London

Overall Rating
Inadequate Last inspected 24 April 2023
Domain Ratings
Safe
Inadequate
Effective
Inadequate
Caring
Not Yet Rated
Responsive
Requires Improvement
Well-led
Inadequate

View Full CQC Report

6 must-do actions

Must-Do Actions (6)

Legal requirements based on regulation breaches identified during inspection.

Must Do
Safe
The service must ensure decontamination facilities or decontamination services are available to ensure the safe use of surgical equipment.
Regulation 12
There were still no decontamination facilities for surgical equipment and staff were unable to explain how reusable equipment was cleaned ready for use. There were still no audit records to provide assurance of such processes were in place.
Must Do
Safe
The service must implement and maintain consistent, safe medicines management. This must include safe procedures in line with national requirements that include storage, stock management, prescribing, administration, and destruction.
Regulation 12
There was still no medicines management system in place. Medicines were stored in various drawers, cupboards, and trolleys. There was no stock control or tracking system. The service was not undertaking or documenting the checking of the ambient temperature in the theatre where medication was being stored. The Controlled Drugs …
Must Do
Safe
The service must ensure medical emergency equipment is suitable, available, and maintained.
Regulation 12
Emergency medical equipment remained unfit for purpose. The resuscitation trolley was used to store non-emergency medicines and equipment, delaying access. There was not enough equipment to provide emergency care, for example, only one laryngeal airway mask suitable for a limited weight range.
Must Do
Safe
The service must implement clinical monitoring and outcome processes.
Regulation 12
Staff did not complete risk assessments for each service user. There was no policy for staff to identify and act upon service users at risk of deterioration. There was still no risk assessment or inclusion/exclusion criteria in place to identify if a service user was unsuitable for cosmetic surgery. The …
Must Do
Safe
The service must ensure it fully complies with Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 in relation to the safe recruitment of staff.
Regulation 12
The service could not evidence it had enough staff with the right qualifications, skills, training, and experience. There was no process to keep records of theatre support staff. Employee files lacked evidence of in-date Disclosure and Barring Service (DBS) checks, right to work in the UK, application forms, CVs, interview …
Must Do
Well-led
The service must ensure clinical governance processes are fit for purpose, contribute to the safer running of the service, and enable the registered manager to gain assurance that risk and performance is managed effectively.
Regulation 17
The governance system remained not fit for purpose. The provider and registered manager were not compliant with their regulatory responsibilities and didn’t have processes in place to ensure safe standards of working. The service still didn’t have a deteriorating service user policy or an admissions and exclusion criteria policy in …

Previous Inspection (18 April 2023)

Rating: Inspected but not rated Type: Focused followup inspection Actions: 6 must-do
6 repeated
Location Details
CQC ID: 1-112011971
Local Authority: Westminster
Region: London
Inspection Report
Type: Focused inspection
Date: 24 April 2023
Rating: Inspected but not rated
Actions: 6 must-do
AI-extracted 17 Feb 2026