Archived: The Nimmo Clinic

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• 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

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care.

The service was in breach of legal regulation in relation to their lack of governance and assurance processes. None of the significant concerns we found surrounding the management of medicines or infection prevention and control measures had been identified by the provider’s own quality assurance systems. Additionally, there was a lack of adherence to organisational policies which failed to clearly set out adopted processes. There was a failure to identify and act upon apparent risks.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

We did not look at Shared direction and culture during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.

We did not look at Capable, compassionate and inclusive leaders during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.

We did not look at Freedom to speak up during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.

We did not look at Workforce equality, diversity and inclusion during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.

The service had failed to establish clear responsibilities, roles, systems of accountability and good governance processes. They did not act on the best information about risk, performance and outcomes, or share this effectively with others where appropriate.

We found a lack of understanding by the registered manager, who was also the clinical director, of the requirements to ensure safe processes to support the ordering, prescribing and dispensing of medicines. Where we observed the issuing of an unlabelled weight loss medicine given directly to a patient during our site visit, the registered manager told us they were unaware of labelling requirements for prescription only medicines, such as the name of the person the medicine was prescribed for and dosage instructions.

We reviewed arrangements to ensure the safe storage of medicines requiring refrigeration. The provider’s medicines management policy stated a logbook would be held to record the current, minimum and maximum temperature of the fridge on a daily basis. The policy stated the record should include the date and time and the signature of the person making the record. However, we found the provider was not following their own policy and relied upon the fridge alarm sounding to alert them to an out-of-range temperature, and an integral temperature data logger which was not routinely checked.

We reviewed clinical records held within the service and found the provider had failed to ensure safe and complete prescribing processes. For example, prescriptions did not include the quantity of weight loss pens prescribed. Some prescriptions failed to include the dosage instructions. We found that some items prescribed were only recorded within the consultation notes, without a prescription document being created. In those instances, we found the prescribing was not supported by the prescriber’s signature which was required under the provider’s own prescribing policy.

The service requested details of a patient’s NHS GP at the point of registration with the service. However, our review of patient clinical records confirmed that even when GP details had been provided, there was a failure to share prescribing information with a patient’s GP to ensure the safe care and treatment of patients. For example, where patients were prescribed medicines for weight loss or weight management, or anti-inflammatory medicines following an aesthetic procedure. We identified one example where information about a patient’s weight loss treatment was provided to a specialist secondary care clinician. However, the details provided were inaccurate and did not reflect the patient’s clinical and prescribing records held by the service. We reviewed subsequent consultation records and found the patient continued to receive prescriptions from the service despite a lack of involvement or advice from the specialist. This meant the prescribing clinician had not ensured they had sufficient information about the patient’s health to enable safe care and treatment.

Where prescribing of weight loss medicines was outside of national guidance, we found there was a lack of recording of the rationale to support such a decision or to confirm that the patient had been made aware of and understood that rationale. For example, where patients had a body mass index (BMI) lower than the minimum recommended and guidance indicated prescribing should only proceed where the patient also had a specified associated medical condition, such as hypertension.

We found a lack of arrangements for any review or auditing of the service’s prescribing practices. However, the service’s prescribing policy stated that periodic review and auditing of prescribing practices would be conducted in order to monitor adherence to the prescribing policy and identify areas for improvement. The policy stated that prescribing audits would be performed on a biannual basis by the registered manager.

The service had undertaken some limited auditing of standards and completeness of clinical record keeping, for patients prescribed medicines for weight loss or weight management. However, this had failed to ensure a consistent approach to the standard and completeness of records held. We reviewed a sample of 15 patient clinical records and found there were no records of some consultations where patients had been prescribed a medicine for weight loss or weight management.

During our site visits to the service on 18 and 20 March 2025 we observed lone working by the sole male clinician, with a failure to consider or mitigate the associated risks. When we asked, the registered manager, who was the sole clinician, was unable to confirm the arrangements for chaperoning or seeking support in the event of a medical emergency, when no other staff members were present. We observed a failure to make patients aware of the absence of a female practitioner with whom their appointment was pre-booked, ahead of the appointment. We found there was no working lock on the door of the toilet used by patients, to protect patient privacy and ensure their safety.

We reviewed arrangements to ensure the safe storage and management of stock and consumable items within the service. We found the storage of consumable and other items in cupboards was haphazard and unsafe. We found some items past their expiry date which were available for use. The service’s medicines management policy stated the provider would undertake monthly audits of medicines stocks to ensure correct balances remained. The policy stated the audits would be recorded and retained. However, when we asked, the registered manager was unable to provide evidence of any records of medicines held and told us those checks had not been completed.

We did not look at Partnerships and communities during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.

We did not look at Learning, improvement and innovation during this assessment. There is no previous rating for the Well-led key question so we cannot yet publish a score for this area.