The Care Quality Commission
  • Hospital
  • Independent hospital

Signature Clinic - Manchester Also known as Rochdale Clinic

Overall: Requires improvement read more about inspection ratings

93A Manchester Road, Rochdale, OL11 4JG (01706) 452550

Provided and run by:
Signature Medical Limited

All Inspections

During an assessment of Surgery

The main service provided at the Signature Clinic - Manchester was surgery. We commenced a responsive assessment on 29 October 2024 because of concerns we received from people who used the service. We carried out an unannounced inspection on 19 and 20 November 2024. During the inspection, we spoke with staff, leaders, people who use the service and service partners. We looked at care records, policies and other documents relating to the service.

Our overall rating for surgery stayed the same. We rated surgery as requires improvement.

We identified regulatory breaches relating to infection, prevention and control, listening to and involving others and governance processes, where we have told the service it needs to make improvements.

We found the service did not have effective systems to identify or prevent surgical site infections. The service also used benchtop sterilisers for surgical instruments on site, which was not in line with national guidelines.

The service did not have effective systems for managing people’s complaints or around gathering feedback about people’s experiences. The service did not have an effective process for carrying out checks on company directors, in line with regulatory requirements for fit and proper persons; directors.

However, we also found areas of good practice.

The service had enough suitably trained staff. Staff protected people from abuse and managed incidents and medicines well. Staff assessed people’s risks and health needs, gained their consent and worked well together as a team. Most people experienced positive outcomes following surgery.

Staff treated people with compassion, kindness and respect. People could access the service when they needed it, in a way that promoted equality and protected their rights. Leaders understood the key risks to the service and had plans to make improvements. Leaders promoted a positive work culture based on equality, diversity and inclusion.

During an assessment of the hospital overall

Signature Clinic - Manchester is operated by Signature Medical Limited. The clinic offers cosmetic surgery treatments for private fee-paying adults over 18 years old. The main cosmetic procedures offered are blepharoplasty and gynaecomastia. We commenced a responsive assessment on 29 October 2024 because of concerns we received from people who used the service. We carried out an unannounced inspection on 19 and 20 November 2024. During the inspection, we spoke with staff, leaders, people who use the service and service partners. We looked at care records, policies and other documents relating to the service. Our rating for Signature Clinic - Manchester stayed the same. We rated it as requires improvement. We identified regulatory breaches relating to infection, prevention and control, listening to and involving others and governance processes, where we have told the service it needs to make improvements. We found the service did not have effective systems to identify or prevent surgical site infections. The service also used benchtop sterilisers for surgical instruments on site, which was not in line with national guidelines. The service did not have effective systems for managing people’s complaints or around gathering feedback about people’s experiences. The service did not have an effective process for carrying out checks on company directors, in line with regulatory requirements for fit and proper persons; directors. However, we also found areas of good practice. The service had enough suitably trained staff. Staff protected people from abuse and managed incidents and medicines well. Staff assessed people’s health needs, gained their consent and worked well together as a team. Most people experienced positive outcomes following surgery. Staff treated people with compassion, kindness and respect. People could access the service when they needed it. Leaders understood the key risks to the service and promoted a positive work culture.

3 January 2024

During an inspection looking at part of the service

Our rating of this location improved. We rated it as requires improvement because:

  • Whilst the service recorded incidents, there was not a robust system for reporting and monitoring incidents. However, leaders told us they were implementing a new system imminently which would enable them to have better oversight of incidents.
  • At the time of this inspection, the service still did not have robust systems for gathering patient feedback to help shape services.
  • The service conducted staff surveys but there was no evidence of collating and analysing feedback in order to make improvements.

However:

  • The service had enough staff to care for patients and keep them safe. Staff had training in key skills, understood how to protect patients from abuse, and managed safety well. During the previous inspection the safeguarding lead did not have the appropriate level of safeguarding, however there were now 2 safeguarding leads with Level 3 training.
  • The service controlled infection risk well. Staff assessed risks to patients, acted on them and kept good care records. They managed medicines well. The service had made improvements since the last inspection including introducing an infection prevention and control lead and regular audits. They were no longer undertaking any procedures requiring general anaesthetic which reduced risks including that posed by the location of the theatres on the first floor.
  • At the time of the previous inspection, we found that leaders did not fully monitor the effectiveness of the service and there were insufficient governance processes in place. There was now a new leadership team, and a clear governance process was in the process of being embedded in the service.

18 July 2023

During a routine inspection

Our rating of this service went down. We rated it as inadequate because:

  • Staff had a basic understanding of how to protect patients from abuse and the safeguarding lead in the service did not have the required level of safeguarding training for their role. The service did not have sufficiently trained staff to care for patients. The service did not manage safety incidents well and there was limited learning from incidents. The service did not always control infection risk well. Staff did not assess risks to patients or act on them and staff did not keep good care records. They did not manage medicines well.
  • Staff did not always have access to good information about patient outcomes. The service did not always follow national guidance to gain patients’ consent. They did not always support patients to make decisions about their care.
  • The service did not always take account of service users’ individual needs, and it was not always easy for people to raise their concerns.
  • Managers did not fully monitor the effectiveness of the service or make sure staff were competent. Leaders did not use reliable information systems to run services well. Leaders did not always support staff to develop their skills. Staff had limited understanding of the service’s vision and values, or how to apply them in their work. Staff were not always clear about their roles and accountabilities. The service did not always engage well with patients to plan and manage services and there was a lack of focus on quality improvement in the service.

However:

  • Staff had training in key skills.
  • Staff provided good care, gave patients enough to eat and drink, and gave them pain relief when they needed it. Staff worked together for the benefit of patients. Key services were available 7 days a week.
  • Staff treated patients with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to service users.
  • The service planned care to meet the needs of local people. People could access the service when they needed it and did not have to wait too long for treatment.
  • Staff felt supported by their managers. They were focused on the needs of patients receiving care.

15 March 2022

During an inspection looking at part of the service

93A Manchester Road is operated by Signature Medical Limited. The service is based close to Rochdale town centre and the service offers cosmetic surgery for private fee-paying adults.

The service is delivered within a two-storey building on Manchester road. 93A Manchester Road is situated on the first floor of the building which can only be accessed by stairs. At the time of our inspection the service was having building renovations on the ground floor with a view to expanding its services. The clinic facilities are spread over ten rooms, which include a service user waiting area and reception and two theatres, two service user recovery rooms, a kitchen, a bathroom, a utility room and a storeroom.

We rated it as good because:

  • The service had enough staff to care for service users and keep them safe. Staff had training in key skills, understood how to protect service users from abuse, and managed safety well. The service controlled infection risk well. The service kept good care records. The service managed safety incidents well and learned lessons from them.
  • Staff provided good care and treatment and gave service users enough to drink. Managers monitored the effectiveness of the service and made sure staff were competent. Staff worked well together for the benefit of service users, supported them to make decisions about their care, and had access to good information.
  • Staff treated service users with compassion and kindness, respected their privacy and dignity, took account of their individual needs, and helped them understand their conditions. They provided emotional support to service users, families and carers.
  • The service planned care to meet the needs of local people, took account of service users individual needs. People could access the service when they needed it and did not have to wait too long for treatment.
  • Leaders ran services well using reliable information systems and supported staff to develop their skills. Staff felt respected, supported and valued. They were focused on the needs of service users receiving care. Staff were clear about their roles and accountabilities. The service engaged well with service users.

However:

  • There was no lift access to the service.
  • There was no clinical audit activity to measure service user clinical outcomes or monitor infection rates.