Archived: The Pemberdeen Laser Cosmetic Surgery Clinic Limited

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Our overall rating for Safe at Pemberdeen Laser Cosmetic Surgery Limited remains inadequate. We looked for evidence that people were protected from abuse and avoidable harm. We found that the service lacked the infrastructure to protect patients from harm. Systems and processes were still not in place to ensure that the environment was safe to treat patients. This included but not limited to; infection prevention and control, fire risk assessments, planned preventative maintenance and process were in place to ensure medications were available and in date.

This service scored 41 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

At our previous inspection in August 2025, we found significant shortfalls in the standard of care. We found no improvement when we inspected on 20 November 2025, and the service did not report any action taken to improve the service. We have taken further regulatory action in relation to these ongoing issues.

These findings had not changed when we inspected on 20 November 2025, and the service did not report any action taken to improve service provision in this area. The CQC has taken further regulatory action in relation to these ongoing issues.

At our previous inspection in August 2025, we found significant shortfalls in the standard of care. Since our last inspection the hospital had not undertaken any surgery, so we did not inspect the pre assessment and discharge processes. We found no improvement when we inspected on 20 November 2025. During the suspension the providers management company had sent us a suite of policies pertaining to ensuring safe systems, pathways and transitions for patients. However, these policies were generic to the NHS and did not reflect the services or activity at the hospital. The provider informed inspectors that there had been no further work undertaken on ensuring that they had safe systems in place to ensure the safe care of patients. The provider clarified that the service was not responsible for the management or supply of blood products, which explained why staff could not identify a storage facility during the August 2025 inspection. However, there was no documentation available to support this. We have taken further regulatory action in relation to these ongoing issues.

At our previous visit in August 2025, we found evidence of shortfalls in safe systems and pathways. Since our last inspection the hospital had not undertaken any surgery, so we did not inspect medical records or training records. The provider informed us that there were currently no plans for training in this area. While the service had worked well with people, it had not consistently worked with healthcare partners to establish and maintain safe systems of care. In October 2025 the providers management company provided CQC with a policy regarding safeguarding. However, this policy did not reflect the location of the hospital as it mentioned sending the alert form to Thurrock local authority, despite the hospital sitting in the borough of Greenwich. The policy also referred to the fourth stage of the safeguarding process and that Norfolk safeguarding children’s partnership would investigate the matter. It is unclear why Norfolk safeguarding services would be involved in a safeguarding matter from London. The provider was informed of these shortfalls in the policy on 4 November 2025. However, at our inspection on 20 November 2025 they remained unaware of these issues and had not sought to resolve them.

At our previous inspection in August 2025, we found significant shortfalls in the standard of care. Since our last inspection the hospital had not undertaken any surgery, so we did not inspect the pre assessment and discharge policies. We found no improvement when we inspected on 20 November 2025, and the service did not report any action taken to improve the service. We have taken further regulatory action in relation to these ongoing issues.

In October 2025 the providers management company provided CQC with a policy regarding managing risks to patients. When we reviewed these policies, we found that they referred to NHS principles and facilities. These policies were not relevant to the provider’s own arrangements. This included policies on providing professional translation and interpretation services to support patients from the NHS provision. However, the service would not have access to the NHS contracted services.

At our previous inspection in August 2025, we found significant shortfalls in the standard of care. Since our last inspection the hospital had not undertaken any surgery, so we did not inspect PPM, equipment testing. We found some improvement when we inspected on 20 November 2025, and the service did report some improve the service.

At this inspection, the improvements we observed included that the COSHH cupboard was better organised, although some equipment was stored on the floor. Toilets and the anaesthetic room were clean and clutter-free, and old equipment had reportedly been moved to a storage facility. Shelving and plastic storage boxes had been added.

The provider, told us they were compliant with London Fire Brigade requirements, including having a zoning plan. However, we did not see this plan on site, and fire safety arrangements remained unclear. They verbally described evacuation routes, stating patients would exit via the main entrance, even though this could involve passing through the building during a fire when an alternative exit was available at the rear of the building. There was no documented fire escape plan or evidence that staff had been trained in evacuation procedures. The provider confirmed that there were currently no plans to train staff in fire evacuation. Fire extinguishers were wall-mounted and last checked in July 2025, and electrical equipment had been safety tested in August 2025.

At this inspection, we found that while clutter had been reduced, significant risks remained. The London Fire Brigade’s requirements had not been fully met. There was no evidence of fire drills or staff training, and no zone plan was provided. The health and safety policy, sent in October 2025 contained only general fire safety guidance and did not include instructions for evacuation. The provider showed us a ski pad which would be used in the event of a fire to move patients who were either drowsy or unable to manage the staircase. However, there were no instructions for its use or training arranged for staff to ensure patient safety in the event of a fire.

We remain concerned that inadequate fire safety measures and lack of staff training place patients at significant risk in the event of a fire. We have taken further regulatory action in relation to the ongoing issues that do not meet an acceptable regulatory standard.

We did not look at Safe and effective staffing during this assessment. The score for this quality statement is based on the previous rating for Safe.

At our previous inspection in August 2025, we found significant shortfalls in the standard of care. Since our last inspection the hospital had not undertaken any surgery, so we did not inspect training of staff. We found some improvement when we inspected on 20 November 2025, and the service reported some action taken to improve the service.

When we re-inspected the service on 20 November 2025, the location appeared decluttered and generally clean. Glove and paper towel dispensers were stocked, and hand hygiene products were available. Disposable curtains in patient rooms were last changed on 19 August 2025. Clinical waste bins were correctly labelled and fitted with yellow liners, and sharps bins were wall mounted. These findings and evidence supplied by the provider on 11 September 2025 supported the provider’s statement that a further deep clean was undertaken in September 2025. However, the inspection team noted that the cracked flooring and damaged walls reported previously remained. The provider told us there was no cleaning contract in place, as they considered this unnecessary during suspension. There was also no evidence of arrangements for regular cleaning or decontamination of reusable surgical equipment if the service resumed operations. Although the provider reported a contract with an NHS provider for sterilisation, no supporting documents were provided.

The lack of infection control policies and procedures meant patients and staff were not protected from the risk of harm. We have taken further regulatory action in relation to these ongoing issues.

At our previous inspection in August 2025, we found significant shortfalls in the standard of care. We found some improvement when we inspected on 20 November 2025, and the service reported some action taken to improve the service.

At this inspection, medicine cabinets were less cluttered, and expiry dates were clearly marked on packets. Out-of-date medicines had reportedly been removed by a third-party management company. However, we found controlled drugs, including fentanyl, that were out of date and stored separately. We checked the nurses’ station cupboard and found recently expired medicines, including Tramadol and an opened bottle of Oramorph past its expiry date. Oxygen cylinders were in date with an expiry date of June 2026.

We also found limited stocks of emergency medicines for post-operative complications and no clear plan for ensuring timely access to these medicines in an emergency. For example, we observed that two vials of Dantrolene (20mg each) were available in the controlled drugs cupboard. The PEM Management of malignant Hypothermia SOP sent to us in October 2025 states that the service should have available 36 vials of Dantrolene as per appendix 3 based on guidance from the Association of Anaesthetists (2003). We remain concerned that 2 vials would be insufficient to treat malignant hyperthermia.

While some improvements were noted, the lack of robust medicines management policies and insufficient emergency medication continued to place patients at risk. We have taken further regulatory action in relation to these ongoing issues.