Archived: The Pemberdeen Laser Cosmetic Surgery Clinic Limited

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Our overall rating for Well-led at the Pemberdeen Laser Cosmetic Surgery Clinic Limited remains inadequate. We looked for evidence of an inclusive and positive culture of continuous learning and improvement, based on meeting the needs of people who use services and the wider community. However, we did not find evidence of this.

We checked whether leaders now had policies and procedures in place to support staff and collaborate with partners to deliver care that was safe, integrated, person-centred, sustainable, and aimed at reducing inequalities. We found significant shortfalls in service provision.

This key question was previously rated inadequate, meaning there were widespread and significant shortfalls in leadership. Leaders and the culture they created did not assure the delivery of high-quality care.

We have taken regulatory action in relation to these findings. We may publish this information on our website after any representations and/or appeals have been concluded, if the action is taken forward.

This service scored 32 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We did not look at Shared direction and culture during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Capable, compassionate and inclusive leaders during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Freedom to speak up during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Workforce equality, diversity and inclusion during this assessment. The score for this quality statement is based on the previous rating for Well-led.

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 despite the service had sent us some action plans to improve the service.

The evidence showed continued significant shortfalls. The service still did not have clear responsibilities, roles, systems of accountability and good governance. Since our inspection in August 2025 there had been no surgery at the hospital. Therefore, the provider had no further information about risk, performance and outcomes. There had been no further meetings of the Quality, Governance, Patient Safety and Risk committee. There had been no patient record audits despite having operated throughout May, June and July 2025.

The provider had been asked to send us an action plan for improvements. We received several of these with future compliance dates. However, we were sent no evidence of improvements to the issues we had raised. In October 2025 we were sent a suite of policies which were to be ratified by the management at the Hospital. However, on reviewing these policies we found they were not appropriate to the function and provision of services at the Hospital. The Good Governance policy informs the reader that several audits will be undertaken and that “Effective Auditing is a comprehensive subject matter in itself. Please refer to separate Quality Assurance and Audit Policy for more detailed information.” However, the Quality Assurance Policy refers the reader back to the Good Governance Policy and neither outline what will be audited. We were not sent an Audit Policy.

The provider sought advice from a management team who were to provide registered persons for the hospital. However, subsequently they retracted from this position. Therefore, the provider continues to have no registered manager or nominated individual in place. Following our inspection the provider sent assurances that a management team were available to the provider to assist them to achieve compliance with the regulations. Our inspection identified several concerns and breaches of regulation that put people at risk. The provider’s governance processes had not identified these issues or improved them.

We did not look at Partnerships and communities during this assessment. The score for this quality statement is based on the previous rating for Well-led.

We did not look at Learning, improvement and innovation during this assessment. The score for this quality statement is based on the previous rating for Well-led.