Staianoplasticsurgery

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

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. We checked that patients were safe and protected from bullying, harassment, avoidable harm, neglect, abuse and discrimination.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant patients were safe and protected from avoidable harm.

We have not awarded this service a score for Safe.

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

The service had a positive and open safety culture, with staff encouraged to report incidents and raise concerns. Incidents were recorded and acted upon, with staff providing verbal examples of learning leading to improvements in practice. However, governance arrangements were not fully robust and shared learning across the team was not consistently documented.

Managers investigated incidents and complaints and provided resolution promptly where possible. Lessons were learned from incidents or complaints, resulting in changes that improved care for others. Incidents were reported and appropriate actions were taken. Incidents were recorded on a central spreadsheet, including details of actions and outcomes. For example, following identification of out‑of‑date sutures in September 2025, these were disposed of and a colour‑coded system was introduced to improve visibility of expiry dates. Incidents were discussed annually but minutes did not show in depth discussions. We spoke to the lead consultant who said there were no trends in 2025 to discuss.

The service had a positive culture of safety, based on openness and honesty. The team were open with each other about concerns that occurred in the clinic. They had weekly informal meetings where staff told us incidents were discussed however, minutes were not taken for these. Staff listened to concerns about safety and investigated and reported safety events. Staff described an incident of increased bleeding during a minor procedure when a nurse was not present. An alarm was installed afterwards to allow staff to be called.

Patients and staff were encouraged and supported to raise concerns. They felt confident they would be treated with compassion and understanding and would not be blamed or treated negatively if they did so. The staff acted immediately when patients raised concerns and proactively sought prompt feedback. For example, we were told about a patient who fell at the hospital, the nurse called them immediately and daily to offer support and sorted any issues they highlighted. This meant they had no formal complaints and very few verbal complaints. The service logged verbal complaints when they received them. They were proactive in seeking feedback from patients. A nurse telephoned all patients post-operatively, and where required, made daily calls to monitor recovery and comfort.

The service worked with patients and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. Staff made sure there was continuity of care, including when patients moved between different services.

Safety and continuity of care was a priority throughout a patient’s care journey. This happened through a collaborative, joined-up approach to safety that involved them along with staff and other partners in their care. Staff shared information about patients’ treatment appropriately with relevant healthcare professionals, such as their GP and the operating hospital. Patients saw their surgeon at every stage of their surgical journey which ensured continuity of care and high levels of patient satisfaction.

Policies and processes about safety, such as their admission criteria, were aligned with other key partners, such as the hospital where surgery took place, to enable shared learning and drive improvement. The service used a pre-operative medical questionnaire in line with the hospital requirements to ensure patients were safe to proceed with surgery. The information was provided to the hospital to review in advance of the surgery.

There was strong awareness of risks across the surgical pathway, with a proactive and effective approach to identifying and managing them. The service used comprehensive admission criteria aligned with hospital requirements to assess patient risk and determine appropriate clinical action.

The service actively sought and considered the views of patients and staff. All patients received a post-procedure follow-up call to check their satisfaction with care and aftercare. Staff described how they supported a patient following a fall at the hospital, including arranging regular consultant reviews and telephone calls to monitor recovery.

The service worked with patients and healthcare partners to understand what being safe meant to them and the best way to achieve that. Staff concentrated on improving patient’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately. However, the policy was out of date and contained incorrect referral details. This was escalated to the provider who told us they would update the policy.

There was a good understanding of safeguarding and how to take appropriate action. Patients were supported to understand safeguarding, and how to raise concerns when they did not feel safe, or they had concerns about the safety of other patients. Staff gave examples of concerns they would report, and the nurse had logged 1 safeguarding incident within the last 12 months. They had a process in place to allow patients to discuss issues privately if they were accompanied by someone. This helped in preventing a patient being coerced into having a procedure. There was a poster in the toilets with contact numbers for support if patients needed it such as domestic violence charities.

Staff received training specific for their role on how to recognise and report abuse. Staff received mandatory safeguarding children and adults training. All staff, including non-clinical staff, were trained to level 2 safeguarding adults and children and the registered manager and clinic manager were trained to level 3.

Systems and processes to protect patients from abuse and neglect were not effective. The safeguarding policy was out of date and included incorrect local safeguarding contact details, which could result in delays if staff used the policy to make a referral.

Children were permitted to attend the clinic when supervised by a parent or adult. A risk assessment was in place; however, this was brief and did not clearly outline specific risk controls to protect children from clinical and environmental risks.

The service had a defined recruitment pathway and procedure to help ensure that the relevant recruitment checks had been completed for all staff. We looked at 2 staff records and found these were completed correctly.

There was a good understanding of the requirements of the Mental Capacity Act (MCA). All staff had undergone mental capacity act training.

The service worked with patients to understand and manage risks. Staff provided care to meet patient’s needs that was safe, supportive and enabled patients to do the things that mattered to them.

Staff were able to describe the actions they would take if a patient’s condition deteriorated; there was a policy that supported this. Staff told us that patients would be transferred to hospital using the 999-emergency service if required. There had been no emergency transfers in the last 12 months. Records showed that 100% of staff had completed basic life support training.

Patients were provided with information about potential risks and how to keep themselves safe. Staff assessed risks in partnership with patients. Risk assessments were completed during consultations, minor surgical procedures, and post-operative reviews, with appropriate questions asked to identify any concerns.

All patients were required to complete documentation detailing their medical history, current medicines, allergies and GP details. For those undergoing major surgery, a nurse completed a pre-operative assessment, including a comprehensive questionnaire in line with the operating hospital’s admission requirements.

Risks were clearly assessed, with established admission criteria for day surgery to ensure patients were suitable to proceed. Patients were assessed against these criteria, for example requiring a body mass index (BMI) below 30 for cosmetic surgery.

The service had processes in place to ensure age verification was completed on all patients 25 years and under.

There was a balanced and proportionate approach to risk that supported patients and respected the choices they made about their care. All patients who underwent day surgery attended a minimum of 2 consultations which clearly described the risks and benefits of the surgery prior to it being undertaken.

Patients were given comprehensive information prior to their procedure. This was sent in different formats including video and email to ensure patients understood the risks. All patients were given the out of hours phone number and staff were contactable 24 hours a day 7 days a week before and after surgery to support them in their journey.

All procedures carried out at the clinic were performed under local anaesthetic. Staff did not use general anaesthesia or sedation. Any procedures requiring general anaesthesia were undertaken at an affiliated hospital.

The service operated a ‘see and treat’ model, which included procedures such as mole removal, lipoma removal, cyst removal and areola reduction. Patients accessed this service by making enquiries online and submitting a photograph of their concern to the clinical team before booking a procedure. Prior to attending the clinic, patients were provided with comprehensive information about the procedure they wished to have. On the day of their appointment, patients attended the clinic, were seen by the surgeon, and underwent treatment during the same visit.

The service used the World Health Organisation (WHO) surgical safety checklist; however, this was not always completed in line with its intended process. We observed safety checks being carried out before and during procedures, but these were not consistently read aloud to ensure full team participation and effective communication. Following the inspection, the provider amended the checklist to include prompts for verbal confirmation of key details, such as patient identity and procedure. This was also communicated to the team. We reviewed 4 completed checklists, which were fully completed. However, completion of the WHO checklist was not included within the service’s documentation audit process.

The service had policies in place for anaphylaxis and sepsis, and relevant algorithms were displayed. However, the nurse had not received training in the management of anaphylaxis, and the basic life support algorithm in use was outdated, with guidance last updated in 2021 and not aligned with current 2025 standards.

The service did not always detect and control potential risks in the care environment. Staff did not make sure facilities supported the delivery of safe care.

The arrangements to monitor the safety and upkeep of the premises were not effective. The service did not complete a comprehensive health and safety audit. A monthly building check was carried out; however, this consisted of 6 basic health and safety questions and was not sufficient to identify or mitigate key risks. Although the checklist stated that an annual health and safety audit had been completed, there was no evidence to support this.

As a result, significant risks had not been identified or addressed. For example, staff were not aware that a fire risk assessment had not been completed for the clinic. There was no evidence to confirm that this had ever been completed, despite the service policy stating this should be undertaken annually.

The service carried out regular checks of fire extinguishers, emergency lighting and fire alarms. They had new emergency lighting installed in December 2025 and fire extinguisher checks had been completed in May 2026 by an external company. Staff also completed bi-annual fire evacuation drills in line with policy, and these were documented. However, the absence of a fire risk assessment meant that fire safety risks had not been formally assessed or mitigated. We raised this with the provider who immediately booked a fire risk assessment for the 12 May 2026.

The service had a health and safety policy that referenced relevant legislation and set out key responsibilities and safety arrangements. However, the policy was largely high‑level and lacked sufficient detail about how systems were implemented, monitored and reviewed in practice.

We found some environmental risk assessments had been completed, including those for display screen equipment and manual handling. However, several risk assessments were either insufficiently detailed or absent, including assessments relating to environmental risks such as carpeted flooring in consulting rooms. Staff told us they mitigated this risk by creating a small area of lino around where the patient couch was and ensuring they undertook all clinical activity including reviewing post-operative patients in the minor operations room. However, there was no documented risk assessment to support this approach or to outline cleaning arrangements for the carpeted areas. Following the inspection, the clinic had arranged for quotes to replace some areas of carpet within the clinic.

The building was not originally equipped for clinical care, but the service had worked to ensure that it met patient’s needs. The clinic followed national guidance in relation to clinical environment design, but the infection control of the environment needed improving. The waiting areas were furnished to provide a luxurious and relaxing environment and there were ornaments, faux flowers and candles throughout the clinic that gathered dust.

The treatment room was located on the first floor and could only be accessed by stairs. As a result, the service was unable to provide surgical treatment to patients with limited mobility at this location. There was a policy for disability and access for relevant patients, it stated alternative arrangements could be made at a local hospital and the surgeon told us they would facilitate a referral.

The minor operations room had some ventilation measures in place, including a portable air‑cooling fan with a filter and a window air ventilator to support airflow. The service tested the water in line with legionella guidelines.

Equipment and technology were well-maintained and consistently supported staff to deliver safe and effective care. Equipment used to deliver care and treatment was suitable for the intended purpose, stored securely and used properly.

Staff carried out daily safety checks of specialist equipment. Equipment was maintained in accordance with relevant guidelines or manufacturer instructions.

The service made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care that met patient’s individual needs.

The service was delivered by a small team of 4 staff and was led by the owner of the clinic, who was a consultant. The service employed 2 additional consultants with practising privileges, each of whom managed their own caseload. Practising privileges are arrangements that allow independent clinicians to provide care in a service, within an agreed scope based on their skills and experience. Consultants were supported by a nurse and non-clinical staff to help ensure patients received safe and good‑quality care. There was an up-to-date practising privileges policy.

There were effective recruitment practices to make sure staff were suitably experienced, competent and able to carry out their role. Staff had been employed within the service for several years. We reviewed 2 staff files and found recruitment processes were fair and safe.

Staff received training appropriate and relevant to their role. All staff had an induction, and staff were provided with supervision as needed. Training compliance data showed 100% of staff had completed their mandatory training.

Staff were supported to deliver safe care through supervision, appraisal and development opportunities. Staff at all levels had access to learning, and any performance concerns were managed appropriately. We reviewed the nurse’s appraisal, which clearly identified development needs and training opportunities, including a requested wound management course that had been approved.

The clinic manager and administrator were self‑employed and did not have formal appraisals; however, they told us the manager was supportive and offered opportunities for development when required.

There was a full-time nurse who supported the procedures completed in clinic and provided pre- and post-operative care, such as wound management.

Appraisals were obtained from the hospitals where the consultants worked as substantive surgeons. We reviewed appraisals and practicing privileges and found them to be completed appropriately and up to date.

The service did not always effectively assess or manage the risk of infection. Infection prevention and control arrangements were not robust, with no comprehensive cleaning schedules or records in place and some areas of the clinic visibly dusty, including the consultation room. While the minor operations room was clean, responsibilities for cleaning the clinic were not clearly defined, resulting in limited accountability. A weekly cleaning schedule was in place but lacked sufficient detail and did not cover all areas, such as surfaces and flooring. In addition, there was no routine infection prevention and control audit to monitor standards or identify improvements; only infrequent hand hygiene audits had been completed. Deep cleaning was not routinely undertaken. Following the inspection, the service employed a weekly cleaner, who commenced on 14 May 2026 and this had been added to their risk register to keep oversight of it until the risk was reduced.

Consulting rooms were carpeted, with only a small wipeable lino area beneath the patient couch. There was no risk assessment to identify the risks associated with carpeted flooring or to demonstrate how these risks were mitigated. Staff told us they mitigated this risk by undertaking all clinical activity and reviewing post-operative patients in the minor operations room.

We observed a chair in the nursing consultation room had damaged protective covering, exposing the foam interior, which meant it could not be effectively cleaned.

Although colour-coded mops were used for different areas, these were only replaced when staff felt it was necessary, approximately every 3 months. We observed mop heads that were visibly dirty.

The service carried out MRSA screening for patients prior to surgery where identified risk factors were present, such as recent hospital admission or employment in a healthcare setting.

The service had an infection prevention and control (IPC) policy in place, which included relevant guidance. However, governance arrangements were not followed. The policy stated that an annual IPC statement would be produced, outlining significant events, audit findings, staff training and an action plan; this had not been completed. Following the inspection the service completed an annual statement on the 12 May 2026 with objectives to achieve within the year.

Data showed 100% of staff had completed their infection prevention and control mandatory training.

Staff followed infection control principles including the use of personal protective equipment. Hand-washing and sanitising facilities were available for staff and visitors throughout. We observed the staff within using effective handwashing and personal protective equipment during the minor operation.

All equipment used within the minor operations room were single use.

Staff followed protocols to minimise the risk of surgical site infections. Reported infection rates were low, with a rate of 2.3% recorded for 2025.

The service did not always effectively assess or manage the risk of infection. Infection prevention and control arrangements were not robust, with no comprehensive cleaning schedules or records in place and some areas of the clinic visibly dusty, including the consultation room. While the minor operations room was clean, responsibilities for cleaning the clinic were not clearly defined, resulting in limited accountability. A weekly cleaning schedule was in place but lacked sufficient detail and did not cover all areas, such as surfaces and flooring. In addition, there was no routine infection prevention and control audit to monitor standards or identify improvements; only infrequent hand hygiene audits had been completed. Deep cleaning was not routinely undertaken. Following the inspection, the service employed a weekly cleaner, who commenced on 14 May 2026 and this had been added to their risk register to keep oversight of it until the risk was reduced.

Consulting rooms were carpeted, with only a small wipeable lino area beneath the patient couch. There was no risk assessment to identify the risks associated with carpeted flooring or to demonstrate how these risks were mitigated. Staff told us they mitigated this risk by undertaking all clinical activity and reviewing post-operative patients in the minor operations room.

We observed a chair in the nursing consultation room had damaged protective covering, exposing the foam interior, which meant it could not be effectively cleaned.

Although colour-coded mops were used for different areas, these were only replaced when staff felt it was necessary, approximately every 3 months. We observed mop heads that were visibly dirty.

The service carried out MRSA screening for patients prior to surgery where identified risk factors were present, such as recent hospital admission or employment in a healthcare setting.

The service had an infection prevention and control (IPC) policy in place, which included relevant guidance. However, governance arrangements were not followed. The policy stated that an annual IPC statement would be produced, outlining significant events, audit findings, staff training and an action plan; this had not been completed. Following the inspection the service completed an annual statement on the 12 May 2026 with objectives to achieve within the year.

Data showed 100% of staff had completed their infection prevention and control mandatory training.

Staff followed infection control principles including the use of personal protective equipment. Hand-washing and sanitising facilities were available for staff and visitors throughout. We observed the staff within using effective handwashing and personal protective equipment during the minor operation.

All equipment used within the minor operations room were single use.

Staff followed protocols to minimise the risk of surgical site infections. Reported infection rates were low, with a rate of 2.3% recorded for 2025.