Practitioners and clinics will use a vast array of internal policies and procedures, but the most appropriate policies will always depend on the size and nature of the individual organisation. The policies are more effective if they are developed and reviewed on an ongoing basis with the involvement of staff, and are tailored to suit the specific needs of a clinic and its activities. However, some guidance and examples mean that you don’t have to start from scratch.
Save Face has developed a number of example generic policies which can be used as a basis for your own policies, where relevant these policies should be tailored to suit the needs and requirements of each individual practitioner and clinic.
Save Face accepts no responsibility for any third party loss or consequences arising from the use of these example policies.
Page BreakComplaints Policy
Everyone has the right to expect a positive experience and a good treatment outcome. In the event of concern or complaint, patients have a right to be listened to and to be treated with respect. Service providers should manage complaints properly so customers’ concerns are dealt with appropriately. Good complaint handling matters because it is an important way of ensuring customers receive the service they are entitled to expect. Complaints are a valuable source of feedback; they provide an audit trail and can be an early warning of failures in service delivery. When handled well, complaints provide an opportunity to improve service and reputation.
Aims & Objectives
We aim to provide a service that meets the needs of our patients and we strive for a
high standard of care;
We welcome suggestions from patients and from our clinicians and staff about the safety and quality of service, treatment and care we provide;
We are committed to an effective and fair complaints system; and
We support a culture of openness and willingness to learn from incidents, including complaints.
Patients are encouraged to provide suggestions, compliments, concerns and complaints and we offer a range of ways to do it.
Patients are encouraged to discuss any concerns about treatment and service with their treating clinician [or alternate], or they can complete our customer feedback form.
Clinicians and staff can also use the feedback form to record any concerns and complaints about the quality of service or care to customers.
All complainants are treated with respect, sensitivity and confidentiality.
All complaints are handled without prejudice or assumptions about how minor or serious they are. The emphasis is on resolving the problem.
Patients and staff can make complaints on a confidential basis or anonymously if they wish, and be assured that their identity will be protected.
Patients, clinicians and staff will not to be discriminated against or suffer any unjust adverse consequences as a result of making a complaint about standards of care and service.
All clinicians and staff are expected to encourage patients to provide feedback about the service, including complaints, concerns, suggestions and compliments.
Clinicians and staff are expected to attempt resolution of complaints and concerns at the point of service, wherever possible and within the scope of their role and responsibility.
The process of resolving the problem will include:
an expression of regret to the consumer for any harm or distress suffered;
an explanation or information about what is known, without speculating or blaming others; considering the problem and the outcome the consumer is seeking and proposing a solution; and confirming that the patient is satisfied with the proposed solution.
If the problem is resolved, clinicians and staff are expected to complete the Suggestion for
Improvement form to record feedback from patients.
Our clinicians and staff will consult with their manager if addressing the problem is beyond their responsibilities.
If the Complaint is Not Resolved
Complaints that are not resolved at the point of service, or that are received in writing and require follow up, are regarded as formal complaints.
Our clinicians and staff refer complaints to [complaints manager/clinical director] if:
After attempting to resolve the complaint, they do not feel confident in dealing with the complainant; or
The outcome the complainant is seeking is beyond the scope of their responsibilities Or;
They or the complainant believe the matter should be brought to the attention of someone with more authority.
If the complaint is not resolved at the point of service, clinicians and staff are expected to provide the complainant with the formal complaints policy.
Clinicians and staff then complete the first two sections of the Complaint Follow up form and forward it to Sian Robinson.
The complaints manager coordinates resolution of formal complaints in close liaison with the treating clinician and other staff who are directly involved.
Sian Robinson is responsible for coordinating investigation and resolution of formal complaints, conducting risk assessments (in consultation with clinicians), liaising with complainants, maintaining a register of complaints and other feedback, providing regular reports on informal and formal complaints, and monitoring the performance of the complaints policy and procedure.
Sian Robinson is responsible for a proactive approach to receiving feedback from patients and staff, risk management in consultation with Aesthetics by Sian.
Investigation and review of complaints and follow up action for serious complaints, or where complaints result in recommendations for change in policy of procedures.
Sian Robinson is responsible for;
Ensuring appropriate action is taken to resolve individual complaints;
Acting on recommendations for improvement arising from complaints;
Ensuring there is meaningful reporting on trends in complaints;
Ensuring compliance and review of the complaints management policy;
Notifications to insurers; and
Consultation with professional registration boards, and others where necessary.
Clinician and Staff Training
All clinicians and staff need to have been appropriately trained to manage complaints competently.
The service provides training in dispute management, customer service and our
complaints management procedures as part of induction and through regular updates.
Regular reviews are conducted by the Sian Robinson to check understanding of the
complaints process among clinicians and staff.
Information is provided about the complaints policy and external complaints bodies that
patients can go to with a complaint, such as [Save Face ltd] in a variety of ways, including;
On our website;
Through our patient feedback brochure;
Publicity about the service;
Posters in reception;
Discretely located suggestion boxes; and by clinicians and staff inviting feedback and comments.
After receiving a formal complaint, Sian Robinson reviews the issues in consultation with relevant clinicians to decide what action should be taken, consistent with the risk management procedure.
Assessing Resolution Options
Formal complaints are normally resolved by direct negotiation with the complainant, but
some complaints are better resolved with the assistance of an alternative disputes resolution provider.
Sian Robinson will sign post the complainant to an appropriate external body if;
There is a serious question about the adequacy and safety of a health practitioner;
The complaint is against a senior clinician or manager who will be responsible for investigating the complaint, resulting in a perception that there is a lack of independence; or
The complaint raises complex issues that require external expertise.
The complaint cannot be resolved internally to the patients satisfaction.
Aesthetics by Sian undertakes to signpost patients to approved (by the Chartered Trading Standards Institute (https://webgate.ec.europa.eu/odr/main/index.cfm?event=main.adr.show)
Formal complaints are acknowledged in writing or in person within 48 hours.
The acknowledgment provides contact details for the person who is handling the complaint, how the complaint will be dealt with and how long it is expected to take.
If a complaint raises issues that require notification or consultation with an external body, the notification or consultation will occur within three days of those issues being identified.
Formal complaints are investigated and resolved within 10-31 days.
If the complaint is not resolved within 20 days, the complainant, clinicians and staff who are directly involved in the complaint will be provided with an update.
Records and Privacy
The complaints manager maintains a complaints and patient feedback register ( e.g. Save Face portfolio), with records of informal feedback (Suggestions for improvement and patient feedback forms) and formal complaints.
Personal information in individual complaints is kept confidential and is only made available to those who need it to deal with the complaint.
Complainants are given notice about how their personal information is likely to be used during the investigation of a complaint.
Individual complaints files are kept in a secure filing cabinet in the [complaints manager]’s office and in a restricted access section of the computer system’s file server.
Patients are provided with access to their medical records [in accordance with the confidentiality policy]. Others requesting access to a patients’ medical records as part of resolving a complaint are provided with access only if the patient has provided authorisation [in accordance with the confidentiality policy].
Open Disclosure and Fairness
Complainants are initially provided with an explanation of what happened, based on the known facts.
At the conclusion of an inquiry or investigation, the complainant and relevant clinicians and staff are provided with all established facts, the causal factors contributing to the incident and any recommendations to improve the service, and the reasons for these decisions.
Investigation and Resolution
Sian Robinson carries out investigations of complaints to identify what happened, the underlying causes of the complaint and preventative strategies.
Information is gathered from:
Talking to clinicians and staff directly involved;
Listening to the complainant’s views;
Reviewing medical records and other records; and
Reviewing relevant policies, standards or Guidelines.
Complaints about Individuals
Where an individual clinician or staff member has been nominated by a complainant, the
matter will be investigated by the relevant manager or supervisor, who will:
Inform the clinician or staff member of the complaint made against them;
Ensure no judgement is made against a clinician or staff member while an investigation is being carried out;
Ensure fairness and confidentiality is maintained during the investigation; and
Encourage the clinician or staff member to seek advice from their professional association/body, if desired.
The clinicians and staff members will be asked to provide a factual report of the incident, identify systems issues that may have contributed to the incident and suggest possible preventive measures.
Where the investigation of a complaint results in findings and recommendations about
individual clinicians and staff members, the issues are addressed through the service’s staff performance and review process.
Reporting and Recording Complaints
Sian Robinson prepares monthly reports on the number and type of complaints, the outcomes of complaints, recommendations for change and any subsequent action that has been taken. The reports are provided to staff, clinicians, senior management and if appropriate, uploaded into personal portfolio for audit and appraisal.
Sian Robinson periodically prepares case studies using anonymised individual complaints to demonstrate how complaints are resolved and followed up, for the information of staff, and for use in audit and appraisal.
Information about trends in complaints and how individual complaints are resolved is
routinely discussed at staff meetings and clinical review meetings as part of reflecting on
the performance of the service and opportunities for improvement.
Complaints reports are considered and discussed at monthly clinical review meetings and
An annual quality improvement report is published that includes information on:
The number and main types of complaints received, common outcomes and how complaints have resulted in changes;
How complaints were managed—how the complaints system was promoted, how long it took to resolve complaints (and whether this is consistent with the policy) and whether complainants and staff were satisfied with the process and outcomes; and
The results of the annual patient satisfaction survey.
The service promotes changes it has made as a result of patient complaints and suggestions in its general publicity.
Monitoring and Evaluation
Sian Robinson continuously monitors the amount of time taken to resolve complaints, whether recommended changes have been acted on and whether satisfactory outcomes have been achieved.
Sian Robinson annually reviews the complaints management system to evaluate if the complaints policy is being complied with and how it measures up against best practice guidelines. As part of the evaluation, consumers, clinicians and staff are asked to comment on their awareness of the policy and how well it works in practice.
References and Further Reading
Good Medical Practice (GMC,2013)
The Code; Standards of Conduct, Performance and Ethics (NMC,2012)
Standards for Dental Practitioners (2013)
Chartered Institute of Trading Standards http://www.tradingstandards.uk/advice/AlternativeDisputeResolution.cfm
Confidentiality; Guidance Notes and Background Information
A duty of confidentiality arises when one person discloses information to another in circumstances where it is reasonable to expect that the information will be held in confidence. This duty of confidence is derived from:
· Common law – the decisions of the Courts
· Statute law which is passed by Parliament
All staff must be aware of the following legislation and understand their responsibilities relating to confidentiality:
The General Data Protection Regulations 2018
This Act governs the processing of information that identifies living individuals. Processing includes holding, obtaining, recording, using and disclosing of information and the Act applies to all forms of media, including paper and electronic.
The Mental Capacity Act (2005)
This provides a legal framework to empower and protect people who may lack capacity to make some decisions for themselves. The assessor of an “individual’s capacity to make a decision will usually be the person who is directly concerned with the individual at the time the decision needs to be made” this means that different health care workers will be involved in different capacity decisions at different times.
The Freedom of Information Act 2000 and Freedom of Information (Scotland) Act 2002
These Acts grant people rights of access to information that is not covered by the Data Protection Act 1998, e.g. information which does not contain a person’s identifiable details.
The Computer Misuse Act 1990
This Act secures computer programs and data against unauthorized access or alteration. Authorized users have permission to use certain programs and data. If the users go beyond what is permitted, this is a criminal offence.
Disclosure means the giving of information. Disclosure is only lawful and ethical if the individual has given consent to the information being passed on. Such consent must be freely and fully given. Consent to disclosure of confidential information may be:
· Required by law or
· Capable of justification by reason of the public interest
Disclosure with Consent
Patients have a right to access their own medical records and receive copies of them, subject to certain safeguards. Administration fees cannot be charged.
Explicit consent is obtained when the person in the care of a clinician agrees to disclosure having been informed of the reason for that disclosure and with whom the information may or will be shared. Explicit consent can be written or spoken. Implied consent is obtained when it is assumed that the person understands that their information may be shared within the clinical team. Clinicians should make the people in their care aware of this routine sharing of information, and clearly record any objections.
Disclosure without Consent
The term ‘public interest’ describes the exceptional circumstances that justify overruling the right of an individual to confidentiality in order to serve a broader social concern. Under common law, staff are permitted to disclose personal information in order to prevent and support detection, investigation and punishment of serious crime and/or to prevent abuse or serious harm to others. Each case must be judged on its merits. These decisions are complex and must take account of both the public interest in ensuring confidentiality against the public interest in disclosure. Disclosures should be proportionate and limited to relevant details.
Clinicians should be aware that it may be necessary to justify disclosures to the courts or to the appropriate statutory regulator and must keep a clear record of the decision making process and advice sought. Courts tend to require disclosure in the public interest where the information concerns misconduct, illegality and gross immorality.
Disclosure to Third Parties
This is where information is shared with other people and/or organizations not directly involved in a person’s care. Clinicians must ensure that the people in their care are aware that information about them may be disclosed to third parties involved in their care. Patients generally have a right to object to the use and disclosure of confidential information. They need to be made aware of this right and understand its implications. Information that can identify individual people in the care of a healthcare professional must not be used or disclosed for purposes other than healthcare without the individual's’ explicit consent, some other legal basis, or where there is a wider public interest.
Confidentiality after Death
The Police and Criminal Evidence Act (1984)
The duty of confidentiality does continue after death of an individual to whom that duty is owed.
Information Disclosure to the Police
In English law there is no obligation placed upon any citizen to answer questions put to them by the police. However, there are some exceptional situations in which disclosure is required by statute.
Police Access to Medical Records
The police have no automatic right to demand access to a person’s medical records. Usually, before the police may examine a person’s records they must obtain a warrant under the Police and Criminal Evidence Act 1984. Before a police constable can gain access to a hospital, for example, in order to search for information such as medical records or samples of human tissue, he or she must apply to a circuit judge for a warrant. The police have no duty to inform the person whose confidential information is sought, but must inform the person holding that information.
This Act allows healthcare professionals to pass on information to the police if they believe that someone may be seriously harmed or death may occur if the police are not informed. Before any disclosure is made healthcare professionals should always discuss the matter fully with other professional colleagues and, if appropriate consult their statutory regulator or professional body or trade union. It is important that healthcare professionals are aware of their organizational policies and how to implement them. Wherever possible the issue of disclosure should be discussed with the individual concerned and consent sought. If disclosure takes place without the person’s consent they should be told of the decision to disclose and a clear record of the discussion and decision should be made as stated above.
Special Considerations to be Taken into Account when Disclosure is Being Considered
In some circumstances it may not be appropriate to inform the person of the decision to disclose, for example, due to the threat of a violent response. The clinician may feel that, because of specific concerns, a supplementary record is required containing details of the disclosure. The GDPR 2018 does allow for healthcare professionals to restrict access to information they hold on a person in their care, if that information is likely to cause serious harm to the individual or another person. A supplementary record should only be made in exceptional circumstances as it limits the access of the person to information held about them. All members of the healthcare team should be aware that there is a supplementary record and this should not compromise the persons’ confidentiality.
Acting as a Witness in a Court Case
If summoned as a witness in a court case he/she must give evidence. There is no special rule to entitle healthcare professionals to refuse to testify. If the individual refuses to disclose any information in response to any question put to him/her, then a judge may find the individual in contempt of court and may ultimately send him/her to prison.
Risk or Breach of Confidentiality
If a member of staff identifies a risk or breach of confidentiality they must raise their concerns with someone in authority if they are unable to take affirmative action to correct the problem and record that they have done so. A risk or breach of confidentiality may be due to individual behavior or as a result of organizational systems or procedures.
Confidentiality is a fundamental part of professional practice that protects human rights. This is identified in Article 8 (Right to respect for private and family life) of the European Convention of Human Rights which states:
The common law of confidentiality reflects that people have a right to expect that information provided is only used for the purpose for which it was given and will not be disclosed without permission. This covers situations where information is disclosed directly and also to information obtained from others. One aspect of privacy is that individuals have the right to control access to their own personal health information.
· All staff will respect people's right to confidentiality.
· Staff must disclose information if they believe someone may be at risk of harm, in line with the law of the country in which you are practicing.
'The General Data Protection Regulation 2018 requires every organisation that processes personal information to register with the Information Commissioner’s Office (ICO), unless they are exempt. Failure to do so is a criminal offence.'
The fee for registration is £35 per annum. Further details and registration forms can be found on
References and Further Reading
· Patient Confidentiality (GDC)
· Standards for Dental Professionals (GDC,2013)
· Confidentiality (GMC)
· The Code: Standards of conduct, performance and ethics for nurses and midwives (NMC, 2018)
· The General Data Protection Regulations 2018 (GDPR)
· European Convention on Human Rights Act (2000)
· The Computer Misuse Act 1990
· The Freedom of Information Act 2000
· The Freedom of Information (Scotland) Act 2002
· The Mental Capacity Act (2005)
Template Confidentiality Policy
Aesthetics by Sian is committed to providing a confidential service to its users. No information given to Aesthetics by Sian will be shared with any other organisation or individual without the user’s explicit consent.
For the purpose of this policy, confidentiality relates to the sharing of personal, sensitive or identifiable information about individuals or organizations (confidential information), which comes into the possession of the organisation through its work.
Aesthetics by Sian holds personal data about its staff, users, members etc. which will only be used for the purposes for which it was gathered and will not be disclosed to anyone outside of the organisation without prior permission.
All personal data will be dealt with sensitively and in the strictest confidence internally and externally.
The purpose of the Confidentiality Policy is to ensure that all staff, members and users understand the organization’s requirements in relation to the disclosure of personal data and confidential information.
· All personal paper-based and electronic data must be stored in accordance with the GDPR 2018 and must be secured against unauthorized access, accidental disclosure, loss or destruction.
· All personal paper-based and electronic data must only be accessible to those individuals authorized to have access.
· Aesthetics by Sian is committed to effective audit of the use of and quality of its services in order to monitor performance. All audit records shared with third parties, such as to support staff appraisal or monitoring reports for regulators shall be produced in anonymous form, so individuals cannot be recognised.
Protecting Confidentiality in Discussions
It is not acceptable for staff to:
· Discuss matters related to the people in their care outside the clinical setting
· Discuss a case with colleagues in public where they may be overheard
· Discuss one patient with another without explicit and written consent.
· Consultations must not be undertaken where privacy and confidentiality cannot be assured.
Protecting Confidentiality Using the Telephone
· If telephone conversations to patients or potential patients are conducted in areas where they may be overheard, such as in reception or waiting areas, staff will not verbalize any identifiable confidential information, such as names, addresses or telephone numbers.
· Answer phone messages must not be played back aloud, where they can be overheard
· Messages, if confidentiality may be breached, must not be left on answer phones without the express permission of the patient.
Protecting confidentiality Using Computers/ internet
· Computer screens should not be visible to members of the public
· Access to data held on a computer must be password protected with access restricted to personnel with permissions
· Confidential patient information should not be shared by email without encryption
Protecting Confidentiality patient records (see policy- medical records)
Protecting confidentiality using social media or mobile devices
· Practitioners/employees will avoid using mobile devices to communicate with patients where confidential sensitive information might be disclosed.
· Respect all communication by text or messenger apps as part of the medical record.
· Practitioners will not store or retain patient information on mobile devices.
· Where mobile devices are used, devices must be password protected and stored securely.
· All confidential information must be stored securely on a cloud (not on the device itself) and encrypted.
· Explicit and written consent must be obtained for sharing any patient information, including photographs, on social media.
All hard copy records are kept in locked filing cabinets. All digital records are maintained securely in compliance with GDPR 2018. All hard copy information relating to service users will be kept securely. This includes notebooks, copies of correspondence and any other sources of information.
Breaches of Confidentiality
Aesthetics by Sian recognizes that occasions may arise where individual workers feel they need to breach confidentiality. Confidential or sensitive information relating to an individual may be divulged where there is risk of danger to the individual, a volunteer or employee, or the public at large, or where it is against the law to withhold it. In these circumstances, information may be divulged to external agencies e.g. police or social services on a need to know basis.
Aesthetics by Sian will monitor this policy to ensure it meets statutory and legal requirements including the GDPR 2018. Training on the policy will include these aspects.
Ensuring the Effectiveness of the Policy
All staff members will receive a copy of the confidentiality policy, and associated guidance notes. Existing and new workers will be introduced to the confidentiality policy via induction and training. The policy will be reviewed annually and amendments will be proposed and agreed by Sian Robinson. Staff members are required and supported to develop and maintain an understanding of information governance appropriate to their role.
Breaches of this policy will be dealt with under the Grievance and/or Disciplinary procedures as appropriate.
Consent to Treatment
For a patient to give ‘valid consent’ an exchange of information must take place. The simple signing of a consent form does not in itself constitute consent, likewise, the absence of a signature does not in itself mean that informed consent has not been given.
It is a legal and ethical principle that valid consent must be obtained before commencing physical examination or treatment. This principle reflects the right of patients to determine what happens to their bodies and is a fundamental part of good practice.
To give informed consent for cosmetic treatment a patient must;
· Have capacity to make a decision*
· Be over (18) unless parental consent is provided*
· Be fully informed about the procedure
· Understand the risks and benefits
· Know the alternatives
· Not be placed under any duress
* A patient will not be legally competent to give consent if they are unable to comprehend and retain information material to the decision and/or they are unable to weigh and use this information in coming to a decision. (Mental Capacity Act, 2005)
Informed Consent Requires;
· Explanation to the patient (verbal and written)
· Time to consider their decision
· Discussion of concerns
· Answering the patients questions
· Signing of the consent form by patient and clinician
The Consent Form
The consent form documents the information provided to the patient;
· An explanation of the product to be used
· An explanation of the indications for treatment
· The expected benefit to the patient
· The treatment process
· Possible side effects and risks
· Alternative treatments that may be considered, including the option to have no treatment
· How long the results are expected to last
· Material information
· After care that must be followed
· Follow up or treatment course
· Costs and terms of payment
· Consent should be confirmed and documented prior to each procedure and specific to the procedure.
The consent form and any supporting patient information should be regularly reviewed and updated (local policy)
The written information provided should not be seen as a substitute for face to face consultation and discussion with the patient.
Consent may only be obtained by a person who is competent to assess the patient, consent the patient and deliver the treatment.
The consent process may be waived in the event of an emergency which requires immediate lifesaving treatment.
References and Further Reading
· Reference guide to consent for examination or treatment (second edition) (DoH, 2009)
· Mental Capacity Act: code of practice (Department of Constitutional Affairs, 2005)
· Professional standards as per statutory bodies (GMC, NMC, GDC, GpHC).
FIRE SAFETY POLICY
Aesthetics by Sian Fire Safety Policy
STATEMENT OF GENERAL POLICY
This fire safety policy has been prepared by Sian Robinson as the responsible person for the premises known as Aesthetics by Sian to comply with The Regulatory Reform (Fire Safety) Order 2005 [FSO].
The purpose of this policy is to ensure the safety from fire of all relevant persons on, in or in the vicinity of the premises by effective planning, organisation, control, monitoring and review of the preventive and protective measures.
This policy will be used to ensure the provision of suitable and sufficient general fire precautions, assessment of risk and management of necessary fire safety arrangements.
As such the following will be provided;
· The position of Sian Robinson will be responsible for the provision of safety assistance to assist the responsible person in carrying out their duties under the FSO.
· A suitable and sufficient fire risk assessment will be prepared, regularly reviewed, and its significant findings acted upon.
· A suitable and sufficient fire emergency plan will be prepared, regularly reviewed, and practised by the regular carrying out fire drills.
· All staff will be trained to satisfactorily carry out the fire emergency plan, regular fire drills and any other necessary actions to comply with the FSO.
· Employees will be provided with comprehensible and relevant information regarding the risks identified from the risk assessment and any other notification of risk by other employees, the preventative and protective measures, the fire emergency plan, and the identities of persons nominated to carry out the duties of the responsible person.
· The employer of any other employees, or any other person working on the premises, will be provided with the same information as the responsible person’s employees.
· All necessary systems required as part of the general fire precautions (or other general systems or appliances required to be satisfactorily maintained to prevent the likelihood of fire) will be tested and maintained in accordance with the relevant code of practice.
Full records of these measures will be kept and made available for audit by the Fire & Rescue Service as required.
Aesthetics Nurse / NMC Registered Nurse (Mental Health)
HEALTH AND SAFETY POLICY
Aesthetics by Sian Health and Safety Policy Statement
PART 1 - STATEMENT OF GENERAL POLICY
Aesthetics by Sian is committed to achieving high standards of health and safety. To achieve this aim we will ensure the health and safety of all people directly or indirectly involved with our activities by:
· Maintaining an effective health and safety management system
· Ensuring that adequate resources are provided for health and safety matters
· Managing risks to health and safety through the process of risk assessment and risk control
· Ensuring peoples’ responsibilities are clear
· Ensuring that safe systems of work are provided
· Ensuring that the correct work equipment is provided and maintained
· Ensuring that any accidents, incidents or dangerous occurrences are fully investigated and any necessary corrective actions are implemented
· Ensuring that the working environment is without risks to health and safety.
· Ensuring that staff have appropriate training
· Ensuring that there are effective health and safety communications
· Striving for continual improvement of our performance through inspection, audit and review.
Aesthetics Nurse / NMC Registered Nurse (Mental Health)
PART 2 – HEALTH AND SAFETY RESPONSIBILITIES
This section outlines the health and safety responsibilities for those employees who have additional specific health and safety responsibilities other than their day to day responsibilities.
All employees have a day to day health and safety responsibility which is outlined in their job descriptions. A hard copy of this information is provided for all new employees as part of their induction information.
The health and safety responsibilities of Aesthetics by Sian are devolved according to the following organisational responsibilities:
Aesthetics by Sian
Sian Robinson has:
· Overall responsibility for health and safety within Aesthetics by Sian.
· A responsibility to ensure that the actions stated in the Aesthetics by Sian General Policy Statement are implemented.
· Sets a personal example with regard to health and safety
All employees have the following general health and safety responsibilities:
· To adhere to the Company health and safety policy
· To carry out their duties in a safe manner in accordance with Company policy, procedures and safe working practices
· To be alert to hazards in the workplace and report all defects to their Line
Manager and to make suggestions for safer work procedures
· To commit themselves to training in order to ensure that they are competent to perform their role.
· To cooperate with managers and other employees in fulfilling the employees aims and statutory duties
· To ensure that accidents are reported to Sian Robinson.
· To ensure that work equipment including vehicles, DSE, PPE etc. are kept in good condition and safely stored.
PART 3– HEALTH AND SAFETY ARRANGEMENTS
The risk assessments and the accompanying Safe Systems of Work will be available to all employees. This information will disseminated through induction training documentation, work manuals, training manuals. This information will be regarded as controlled documentation. The responsibility for maintaining the latest versions of this information will be through Sian Robinson.
Whenever new risks are identified, these will be assessed and control measures put in to place through a Safe System of Work.
Assessments will be reviewed every 12 months or when the work activity changes, whichever is soonest.
All health and safety information, including risk assessments will be audited according to a pre-arranged, agreed audit programme.
Consultation with employees
Employees are consulted on health and safety matters through Aesthetics by Sian employees’ will be consulted on:
· Any change which may substantially affect their health and safety at work
· The planning of health and safety training
· The health and safety consequences of introducing new technology.
All work equipment (including electrical equipment) used at work, as part of the Company’s undertaking will comply with the Provision and Use of Work Equipment Regulations (P.U.W.E.R.).
Before new equipment is introduced into the working environment, an assessment will be made by the purchasing department in order to ascertain that the equipment is suitable for its intended use.
No employee will use work equipment for which they have not received specific training.
No employee will knowingly misuse work equipment or remove any guards that are in place to minimise a specified risk.
All work equipment will be maintained and inspected at suitable intervals either internally by a competent person or by specialist external companies. The frequency of work equipment maintenance or inspection will be based on manufacturer’s guidance and industry best practice. Any maintenance / inspections undertaken on company equipment will be formally recorded with a hard copy left on file.
If any faults or damage are found on any equipment, stop using the work equipment and then this is reported to the employee’s Line Manager.
Personal Protective Equipment (PPE)
Appropriate personal protective equipment will be issued to employees as and when necessary for work activities.
Training will be provided for employees on the safe use, storage and maintenance of the relevant equipment before issue and a written record detailing what PPE has been issued will be signed by the employees on receipt of the equipment and the hard copy kept on file.
Employees have a legal duty to wear PPE as specified in relevant site rules, risk assessments and method statements.
Any defects or malfunction of PPE must be reported to your supervisor.
Hazardous Substances (COSHH)
Before any hazardous substances are used during a work process, a material safety data sheet (MSDS) will be requested from the supplier and an appropriate assessment made of the risks from that substance will be undertaken by the Product Area Safety Representative. This should be in line with the Control of Substances Hazardous to Health Regulations (COSHH). Alternative less harmful substances will be used wherever possible.
Assessments will consider storage, handling, and aspects of use, exposure, PPE requirements, workers health, and emergency actions. Line Managers’ will brief staff on any hazard or substance precautions, with written records being kept.
COSHH assessments will be reviewed every 12 months or when the work activity changes, whichever is soonest.
Information, instruction and supervision
The HSE Health and Safety poster will be displayed in an appropriate location.
· Health and Safety induction training will be provided for all new employees by Sian Robinson.
· A training matrix for each employee will be set up, recorded and monitored by Sian Robinson.
As a minimum the following requirements will be adhered to:
· Toilet/washing facilities
· Eating/rest facilities
Accidents, first aid and work-related ill health
First aid boxes will be kept at the Aesthetics by Sian clinic and a notice will be placed to indicate:
i. Where the first aid boxes are located.
ii. Who the trained first aiders are.
All work-related accidents are reported to Sian Robinson for review and action will be taken where necessary.
Accidents that require reporting to the enforcing authority under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 are automatically reported by NAME
Responsibilities towards visitors and third parties
Sian Robinson has a responsibility towards visitors and any other third parties who may be affected by its work activities.
Risk Assessments under the following titles:
· Work by Contractors
· Visitor Safety
Fire and evacuation
A fire risk assessment is undertaken and implemented for all Aesthetics by Sian areas. Escape routes are checked daily by the Responsible Person at each office.
Fire extinguishers are maintained and checked by the approved contractors every 12 months.
Alarms are tested at the following frequencies:
· Emergency evacuation will be tested every six months by Sian Robinson.
Health and Safety Management System
The Aesthetics by Sian Health and safety management programme has been set up and is monitored according the recommendations of the HSE publication ‘Successful Health and Safety Management (HS(G)65)’. Its successful implementation will minimise the health and safety risks of all Aesthetics by Sian employees and those that might be indirectly affected by their activities.
The following can lead to infection/cross infection;
· Contaminated equipment or instruments
· Infection sources in the clinical environment
· Dirty hands
· Failure to adequately cleanse and disinfect skin prior to injection/invasive procedure
· Failure to safely dispose of used swabs, protective clothing or instruments
· Accidental needle stick/sharps injury
· Hair must be tied back to prevent it requiring frequent touching (e.g. to remove it from eyes) or touching the patient or equipment during treatment.
· Fingernails must be short and clean- without varnish or extensions.
· Wristwatches, bracelets and rings should not be worn whilst performing clinical procedures.
· Long sleeves must be rolled up
· Disposable examination gloves must be worn when performing procedures
· Disposable aprons should be worn to protect clothing if there is a risk of blood splashing
· Protective eyewear should be worn when performing Laser/IPL treatments
· Face masks should be worn when filling or disposing of soiled microdermabrasion crystals
· Clinical staff should have Hep B immunity
Using Soap and Water;
· Wet hands with warm water before applying soap
· Apply liquid soap to all surfaces of the hands
· Rub hands vigorously for at least 15 seconds
· Rinse thoroughly using warm water
· Dry thoroughly using a disposable paper towel
Using Alcohol Hand Gel;
· Ensure hands are free from visible soiling
· Apply alcohol gel to all surfaces of the hands
· rub continuously until all the alcohol has dried
Alcohol hand gel may only be used as an alternative to washing when hands are visibly clean.
Hand Washing Should Take Place;
· On arrival at work
· On leaving work
· Before and after each patient contact
· Before handling food or drink
· After removing gloves
· After handling potentially contaminated products or laundry
All cuts and grazes on hands and forearms must be covered with waterproof dressings
· The work surfaces are cleaned daily, including treatment couches and chairs, with antiseptic products such as alcohol wipes or sanitising spray.
· Workplace furniture including telephones and fittings are kept clean
· The floor is washed daily
· Storage drawers and cupboards should be cleaned (local policy)
· Medicines fridge should be cleaned (local policy)
· Reusable medical devices should be wiped using alcohol wipes at the end of each treatment
· Non disposable linen when soiled (local policy)
· Soiled soft waste such as swabs and couch roll should be disposed of in the designated clinical waste bags.
· All waste is removed from the treatment room daily and disposed of (local policy)
· Soap and paper towel dispensers are kept topped up
· Toilets are cleaned and disinfected daily
Safe Treatment Protocols
· Use only legitimate products and supply
· Use within expiry date
· Do not administer products from a syringe to multiple patients, even if the needle or cannula on the syringe is changed. Needles, cannulae, and syringes are sterile, single-use items; they should not be reused for another patient nor to access a product that might be used for a subsequent patient.
· Do not administer products from single-dose syringes or ampules to multiple patients or combine leftover contents for later use.
· Reconstitute using aseptic technique as per manufacturer guidelines and discard any unused product.
· If multidose vials must be used, both the needle or cannula and syringe used to access the multidose vial must be sterile
· Multi dose vials should be discarded within 28 days unless manufacturer advises otherwise.
· All makeup should be removed with facial wash and followed with antiseptic skin preparation of the treatment area such as 2%chlorhexidine and isopropyl alcohol 70%, if no history of sensitivity. Skin disinfection should be undertaken after makeup removal and after any application of ice
· Skin disinfectant solution should be applied using gentle friction – repeated up and down, back and forth strokes for 30 seconds – to reduce the number of resident bacteria present at the insertion site which could serve as a source of infection
· the solution should be allowed to fully air dry
· use of an aseptic technique, including hand hygiene
· Sterile field and gloves to be used for deep tissue augmentation with dermal fillers.
Patients should be advised to avoid touching the area for 4 hours and to refrain from applying makeup for 12 hours. For patients who are observed to unconsciously and habitually touch their face it may be appropriate to apply alcohol gel to their hands on completion of the treatment session.
Safe Management of Sharps
‘Sharps’ describes any item which may cause penetrative injury or may puncture waste bags, typically; needles, blades, razors, glass ampoules.
· Disposable gloves must be worn when using sharps
· All sharps must be disposed of immediately, in a designated puncture proof sharps bin
· It is the responsibility of the staff members using the item to dispose of it correctly, immediately after use.
· Sharps must never be re-sheathed. Needles and syringes must be disposed of as one unit whenever possible.
Sharps boxes must be;
· Assembled correctly, including completion of label on the box
· Placed in a safe and accessible place in the treatment room
· Closed when ¾ full as indicated by black line or after 3 months of use.
· Stored for collection safely, away from public areas
· Disposed of by a licensed contractor
Event of a Sharps Injury
In the event of sharps injury, when contaminated with patients’ blood, First Aid must be administered as below:
• The wound should be encouraged to bleed by squeezing The wound should be washed thoroughly with soap and warm water
• Splashes to the eyes, mouth or nose should be washed promptly and thoroughly with tap water or preferably eye wash solution
• The wound should be covered with a dressing
• Ascertain the HIV/HepB status of the donor and or assess risk of infection. Social history may indicate risk if status unknown.
Send recipient of injury immediately to the nearest NHS centre (as above).
• Contact the nearest NHS centre to inform them of the incident and that the recipient is on the way.
• Ensure that the following information is available to the NHS:
• HIV/Hep B /Hep C status of recipient
• HIV/ Hep B/Hep C status of the donor (patient)
• Risk Assessment details and Incident record form should be completed.
References and Further Reading
• Control of substances hazardous to health (COSH, 1999)
• Guidance on The Control of Substances Hazardous to Health Regulations (Health and Safety Executive, 2002)
• Guidance for Clinical Healthcare Workers: Protection against blood borne viruses (DH,1998)
• Safe Management of Healthcare Waste (RCN, 2007)
• Prevention and control of healthcare-associated infections in primary and community care (NICE, 2012) • Safe Injection Practices Coalition, 2009 One and Only Campaign, last accessed April, 2014
Medicines Management Policy
Medicines management and prescribing in the UK are governed by a complex framework, comprised of legislation, policy and professional standards.
Many government and other agencies are involved in medicines management from manufacture, licensing, prescribing and dispensing, to administration. This policy reflects the process from prescribing through to dispensing, storage, administration and disposal. There exists an extensive range of guidance on medicines management from a range of relevant bodies.
Sian Robinson shall be responsible for ensuring safe and secure handling of medications at Aesthetics by Sian, Unit 14 The Hopmarket, Worcester WR1 1DL.
All medications are administered on the aforementioned premises(s) are administered on the personal authority of the treating medical practitioner or prescribing nurse.
Sian Robinson – NMC Pin 16L0406E.
Purchasing, use, recording and disposal of medicines is the responsibility of Sian Robinson.
· All medicinal products must be stored in accordance with the patient information leaflet, summary of product characteristics document found in dispensed UK-licensed medication, and in accordance with any instruction on the label.
· Medicines will only be stored in locked cupboards or a locked pharmacy fridge in a secure location, without public access.
· Keys to medicines stores will be kept in a locked key cupboard when not in use.
· Only members of the nursing and medical team will have access to medicines.
· A daily record of fridge temperature is made in a logbook kept next to the fridge.
· Date and time
· Current temperature at time of recording
· Maximum temperature
· Minimum temperature
· Signature of the person making the record
· The fridge recording device will then be reset
· No medicines shall at any time be stored in a domestic refrigerator used for the storage of food
· The fridge temperature, unless otherwise stated, should be maintained between 2 and 8 degrees centigrade.
· Should the fridge temperature fall outside the stated range without obvious reason, the products from the fridge may be used until the fault is investigated
Storage and Supply of Medical Gasses
Sian Robinson shall be responsible for the control of medical gas cylinders where used, including:
· Ordering of supplies
· Ensuring contract is in place for maintenance and refilling with named supplier.
· Safe storage, including chaining and appropriate warning signs where necessary.
· Use of medical gases shall be restricted for use by or on the order of a treating clinician with prescribing qualifications, or a registered nurse, under the emergency oxygen protocol.
· A prescriber is legally permitted and qualified to prescribe and takes the responsibility for the clinical assessment of the patient or client, establishing a diagnosis and the clinical management required, as well as the responsibility for prescribing, and the appropriateness of any prescribing.
· Prescribers will have access to The British National Formulary to provide information about medicines and possible interactions.
· Where appropriate medicines will be used as specified within the published manufacturers data sheets.
· Where products are used outside licensed indications, patients will be informed this is the case.
· Unlicensed medicines are not used for cosmetic indications (MHRA)
· Patient group Directions are not used for cosmetic indications (MHRA).
Clinics that do not hold stock (nurse led- without a Clinical Director registered with the GMC or GDC).
· The patient will be seen, assessed and consented by a qualified prescriber
· The prescriber will write a prescription
· The prescription must include the following information;
· Name and address of the patient (date of birth is under 18)
· Name, dose, form, strength, frequency and route of administration of the medicine
· Details of any known allergies
· Any special requirements
· The prescription will be faxed or scanned to the dispensing pharmacy. The original shall be posted to the dispensing pharmacy. A copy shall be retained for the patient record. or prescribed electronically if this service is available.
· On receipt of the patient specific medicine (appropriately labelled)
· The medicine will be stored according to the policy, on behalf of the patient, until it can be administered
· The medicine will be administered according to a patient specific direction recorded in the patient record.
· The medicine will only be administered to whom it has been dispensed.
Clinics that hold stock- Have a Clinical Director registered with The GMC or GDC
· Medicines may only be administered against a patient specific direction recorded in the patient record.
· Patient specific direction definition: Written instructions from a doctor, dentist or nurse prescriber for a medicine to be supplied or administered to a named person. This could be demonstrated by a simple request in the patient or client’s notes
· A patient specific direction may only be written by a qualified prescriber following a face to face consultation.
Administration of Medicines
Medicines shall only be administered by the prescriber or delegated to an appropriately qualified, trained nurse who is judged competent in the administration of that medicine.
Medicines shall only be administered against a properly completed, legible, patient specific direction, signed by the qualified prescriber.
The clinician administering must;
· Check the identity of the patient to whom the medicine is to be administered
· Check that the patient is not allergic to the medicine before administering it
· Know the therapeutic uses of the medicine to be administered, its normal dosage, side effects, precautions and contraindications
· Check that the prescription or the label on medicine dispensed is clearly written and unambiguous
· Check the expiry date (where it exists) of the medicine to be administered
· Have considered the dosage, volume where appropriate, method of administration, route and timing
· Must administer or withhold in the context of the patient’s condition e.g. if the patient is unwell on the day, or their medicines or medical history has changed.
· Contact the prescriber or another authorised prescriber without delay where contraindications to the prescribed medicine are discovered, where the patient develops a reaction to the medicine, or where assessment of the patient indicates that the medicine is no longer suitable
· Where medication is not given, the reason for not doing so must be recorded
Record Keeping - The patient record
A record of the patient specific direction must include;
· Drug name
· Route of administration
· Reconstitution drug if relevant and volume.
· Site or indication for administration
· Signature and name printed, of prescriber
· Any special instructions
A record of administration
· Lot number and expiry date
· Detail of administration
· Signature of administering clinician
Procedure Log Book - A Tool for Audit
· Patient name
· Drug/device used
· Site of or indication for administration
· Administrator's signature
· Prescribers signature
Disposal of Pharmaceutical Waste
· Pharmaceutical waste is disposed of in accordance with legislation.
· Pharmaceutical waste is disposed of in designated sharps bins.
· A contract is in place with Business Waste Ltd a provider approved by The Environment Agency for the disposal of group D- pharmaceutical waste. All duty of care transfer notes will be retained for a period of 8 years from the date of issue.
In the event of any suspected adverse drug reaction related to any medicines or medical devices administered to a patient or used to treat a patient, it shall be the responsibility of the treating clinician to submit a report to The MHRA under the yellow card scheme where appropriate.
Reports can be made online at
· A record of any adverse events
· A record of any errors in drug administration
Drug Safety Updates
· Aesthetics by Sian is registered with the MHRA at online services, for email receipt of drug safety updates.
· Updates will be reviewed by Sian Robinson who will take action to ensure patient safety is maintained in response to relevant updates.
· Where appropriate all clinicians will be made aware of relevant updates.
Errors of Administration
Errors of administration could include;
· Medicine given to the wrong patient
· The wrong medicine given
· An incorrect dose being given
· The wrong route of administration
· Failure to record an omission of administration
In the event of an error of administration, the following actions will be taken;
· Any necessary first aid or medical treatment will be given in accordance with instructions from the treating clinician.
· The registered manager will be informed
· A record of the incident will be recorded in the patient record
· In all cases an incident report will be completed.
· An investigation will be conducted and an action plan formulated to introduce necessary measures to prevent recurrence.
· On a (monthly) basis an audit of the medicines stored in the clinic will be recorded and retained to ensure correct balances remain.
· If any losses or discrepancies are identified an investigation will be undertaken and a report written. If necessary procedure protocols will be reviewed and amended.
Review Date: 15/06/2022
References and Further Reading
· Medicines Matters, (DoH,July 2006)
· Standards for Dental Practitioners (GDC,2013)
· Responsible Prescribing, (GDC, 2008)
· Good Medical Practice (GMC,2013)
· A Single Competency Framework for all Prescribers (NICE, 2012)
· Standards of Proficiency for Nurse and Midwife Prescribers (NMC, 2006)
· Standards for Medicines Management (NMC, 2007)
· Medicines Act 1968
· The Yellow Card Scheme (MHRA, 2012)
Non-Surgical Terms and Conditions
· All patients are required to provide contact details; including address, telephone and email in order to secure an appointment.
· All clients will complete a Medical history form at their first appointment, this is necessary to inform the consultation and treatment planning process.
· All information will be treated as confidential and protected in accordance with Data Protection legislation
· Patient information will not be shared with third parties without written permissions and you will not receive unsolicited information from us.
· You may choose to remove yourself from our mailing list at any time, by unsubscribing.
New Patient – Telephone Consultation
Whilst telephone consultations are discouraged, we acknowledge some circumstances when this service may be helpful; particularly for our patients who will be travelling long distance. New patients, seeking advice from a practitioner in a telephone discussion, require a diary appointment of 30 minutes. Patients must call the clinic at the time agreed. A charge of (£50) is made, payable in advance.
· You will be sent appointment reminders 48 hours before your appointment, either by text or email.
· Please provide as much notice as possible, if you need to cancel or reschedule your appointment, so that we may make best use of our appointment diary.
· We take a deposit of £20 upon appointment booking to secure your appointment – this is reduced from your total bill.
· Please do NOT attend the clinic for an appointment if you are unwell. If you are unsure, please call and discuss with the practitioner. Many treatments are contraindicated if you are unwell; this includes colds, cold sores or local skin infections.
· Routine review appointments are offered after treatment with Botulinum Toxin as a courtesy. No additional treatment or ‘top up’ is provided free of charge, once the review period of 2-3 weeks has passed.
· (laser/IPL/hyaluronidaise) treatment cannot be performed without a prior assessment and test patch.
We do not treat children or young adults under the age of 18.
Please do not bring children to the clinic unless they are old enough to be left unsupervised.
Children will not be allowed to accompany you into the treatment rooms.
· Patients will receive free of charge consultations.
· You will be advised of the full costs of any treatment plan proposed and agreed, including that of any maintenance treatment, before any treatment is undertaken.
· Payment is taken, in full at the time of treatment – minus the deposit payment.
· The clinic accepts cash, or major debit and credit cards.
· A discretionary deposit will be taken for some treatments and in some circumstances
· Discounts/vouchers cannot be applied to treatments on special offer.
Fees charged for treatment are for the delivery of a treatment and the accompanying service, which is inclusive of;
· Consultation and assessment
· Provision of information and advice
· Safe treatment with evidence based products
· Follow up appointments and aftercare advice and support as appropriate
Whilst we undertake to provide excellent service; factual, honest and ethical advice, safe, expert treatment in experienced hands and only the best products, we cannot guarantee your results and cannot offer refunds if the results achieved fail to meet your expectations.
Skin care products are non-returnable/refundable.