Pharma Aesthetics

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• 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 people were protected from abuse and avoidable harm.

This is the first inspection for this service since its registration with CQC. This key question has been rated as Inadequate.

The service was in breach of legal regulation in relation to Regulation 12 (Safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This service scored 25 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We found systems for identifying, acting on, and learning from incidents were ineffective. Staff we spoke with were unable to describe how incidents were identified, reviewed or used to support learning and improvement. Staff were unable to produce a significant events register or explain the process for reviewing and monitoring incidents. They were unable to demonstrate how learning from incidents had been shared with staff and embedded into practice. Staff spoke about an example of a significant event that occurred, but there was no documentation to evidence this. Therefore, we could not be assured that opportunities to learn from incidents and reduce the risk of recurrence were being effectively identified and acted upon.

We were not assured there was a system in place for staff to raise concerns when things went wrong. There was no evidence of staff meetings taking place, and no evidence of appraisals through which concerns could be raised and discussed.

Processes to identify and manage risks to patients as they moved between care providers were not effective. There was no collaborative approach to safety as information about assessments, treatments and aftercare was not shared with patients’ other healthcare providers. We were unable to obtain assurances that appropriate information-sharing arrangements were in place with patients’ General Practitioners (GP) from our review of clinical records. We found no evidence that GPs had been informed where patients had been prescribed high-risk medicines. This was not in line with General Medical Council good practice in prescribing guidance. We saw no considerations or risk assessments to mitigate the risks about this guidance not being followed. This meant that peoples GPs may be unaware of controlled drugs prescribed by the service which can lead to issues identifying drug interactions, duplicating treatment or managing adverse effects.

The provider was unable to provide sufficient evidence to demonstrate that safeguarding arrangements were effectively managed or monitored. We were provided with evidence of adult and children safeguarding policies but they were unable to provide evidence of safeguarding incident logs, adequate safeguarding training records and were unable to explain clear processes for how safeguarding incidents were reviewed and escalated.

Following the assessment, the provider submitted evidence of a safeguarding log template, an escalation pathway and a training matrix designed to identify staff who had completed safeguarding training. However, the provider remained unable to provide examples of safeguarding concerns, records of investigations, or evidence demonstrating safeguarding incidents were routinely reviewed and monitored.

There were no records of meetings held where safeguarding matters were discussed across any of the services. Therefore, we were not assured that safeguarding risks were identified and managed appropriately, leaving vulnerable patients at potential risk of being unprotected from abuse and avoidable harm.

During our review of clinical records, we found patient identity verification processes were not consistently followed. For example, in one patient record there was no documented evidence of identity verification prior to prescriptions of controlled drugs being issued.Controlled drugs are subject to additional safeguards because of their potential for misuse and abuse. The absence of robust and consistently documented identity verification processes meant we could not be assured that medicines were being prescribed to the correct individuals. This increased the risk that failures in the identity verification process could result in inappropriate access to controlled drugs, potentially placing people at risk of harm.

The provider failed to demonstrate it worked effectively with patients to understand and manage risks associated with their care and treatment. Our review of clinical records did not provide assurances that patients were consistently informed of the specific risks associated with their treatment or prescribed medicines.

We found a defibrillator was not operational. Adult defibrillator pads had expired, and paediatric defibrillator pads were not available. There was no oxygen cylinder, and a risk assessment was not created for not having a working defibrillator or oxygen on site.

The provider did not provide evidence of systems to check and monitor emergency equipment available on the premises of Manchester Dermatology Clinic.

There were ineffective processes in place for the management of the environment and premises. The provider was unable to provide current risk assessments relating to health and safety, fire safety, or legionella management. After the assessment, the provider submitted evidence of internal fire safety and health and safety audits being conducted at Manchester Dermatology Clinic, but the audits were not comprehensive or carried out by external specialists. The provider was unable to demonstrate that environmental risks associated with the premises had been appropriately assessed or mitigated at either the Pharma Aesthetics or Manchester Dermatology Clinic locations.

There was no business continuity plan in place, so the provider could not demonstrate how essential services would be maintained in the event of significant disruption, emergency incidents or other unforeseen circumstances.

The service did not make sure there were enough qualified, skilled and experienced staff. There was insufficient evidence that leaders maintained effective oversight of staff training, competence, or compliance with mandatory training requirements. This increased the risk that staff may undertake clinical or non-clinical responsibilities without the necessary knowledge, skills, or training.

We were not assured that the provider had effective oversight of staff recruitment, training and competence. The provider submitted personnel files for eighteen members of staff. However, our review of these records found the provider was unable to demonstrate that staff working across Pharma Aesthetics, Manchester Dermatology Clinic and ADHDdiagnosis.co.uk had completed the training required to carry out their roles safely and effectively. For example, the records provided for four staff members contained no evidence of completed mandatory training, and nine members of staff had only completed mandatory training following our assessment.

We were not assured that the provider had effective oversight of staff recruitment procedures. We were provided with personnel files for 18 members which demonstrated that appropriate recruitment checks had not been carried out. For instance, there were no DBS records for eight members of staff, no evidence of previous employment history for 14 staff members, no evidence of proof of identity for 13 staff members and no evidence of employment contracts for 9 members of staff.

The absence of complete recruitment records meant the provider could not demonstrate that appropriate pre-employment checks had been undertaken for their staff. As a result, the provider was unable to provide assurance that staff were suitably qualified, experienced, and fit to carry out their roles.

The service did not assess or manage the risk of infection. They did not detect and control the risk of it spreading or share concerns with appropriate agencies promptly.

Significant concerns were identified regarding infection prevention and control (IPC) arrangements across the physical premises of Pharma Aesthetics. We found the premises were poorly maintained and visibly unclean. Flooring within the clinical room was visibly dirty, and carpeting throughout the premises was worn and soiled in several areas. Storage areas used for equipment, medicines, and clinical supplies were cluttered and unclean. Personal protective equipment (PPE) was found to be out of date in two storage areas. Sterile medical equipment, including syringes and blood collection kits, had expired. Handwashing facilities located within the main corridor were visibly dirty.

Infection prevention and control (IPC) arrangements were ineffective, with no evidence of routine IPC audits, no clearly identified IPC lead, and insufficient records demonstrating IPC training across all three services. We found a sharps container containing used sharps was not appropriately labelled. There was no designated lead for cleaning and decontamination across either physical location. Cleaning equipment consisted of a single mop and bucket which were visibly dirty and not colour-coded, and cleaning products were stored inappropriately on the floor within the toilet area and a storage room. A Control of Substances Hazardous to Health cupboard was present, but it was inaccessible during the assessment.

We found there was no documented cleaning schedule or cleaning rotas covering clinical rooms and non-clinical areas for all physical premises. After the site visit, the provider sent evidence of cleaning schedules for reception, waiting rooms and corridors between April to June 2026 conducted in the premises of Manchester Dermatology Clinic.

During the site visit, staff could not locate evidence of Infection Prevention and Control arrangements, such as audits being conducted at all premises (including the premises of Manchester Dermatology Clinic). After the site visit, the provider submitted evidence of an infection prevention and control audit from May 2026 being conducted at the premises of Manchester Dermatology Clinic and a ‘walk-in, health and safety and infection control 20-point check’ dated 5 July 2026.

Although service users were not, at the time of the inspection, being seen for regulated activities at the premises at 16 Broadway, Rainham, RM13 9YW, poor infection prevention and control arrangements presented a potential risk of harm when patient-facing activities resumed. The absence of robust IPC systems and processes meant the provider could not demonstrate that risks associated with infectious diseases had been appropriately assessed and managed.

The service did not make sure that medicines and treatments were safe and met people’s needs, capacities and preferences.

The provider did not have effective clinical oversight of patient care and treatment. There were no clinical leadership arrangements or processes that would ensure prescribing decisions were safe, appropriate, and in line with relevant guidance, or that consultations were subject to appropriate clinical governance and quality assurance arrangements.

During the assessment, we reviewed the clinical records of people who had received online consultations through ADHDdiagnosis.co.uk. A random sample of six patient records was examined, and significant concerns were identified regarding the quality and completeness of the clinical documentation as consultation notes for all six patients remained saved as drafts within the clinical record system.

The service did not securely maintain an accurate, complete and contemporaneous record of treatment and care for people using their service. Prescribing records were incomplete and did not consistently contain sufficient information to support safe prescribing and effective clinical oversight, with the quantity of medication prescribed omitted or no record of medication being prescribed within the records. In one instance, we saw that that records were updated retrospectively after a patient reported side effects of a new dose of medicine as the change in dose had not been recorded in records initially.

We found physical health monitoring and baseline observations were not consistently recorded in clinical records in line with national guidance and product licenses. In one patient record, there was a significant discrepancy between recorded pulse rate measurements, with no evidence that clinicians had considered or investigated the difference despite the potential for an underlying cardiovascular concern.

In other patient records, there was no documented evidence that pulse rate and blood pressure had been monitored in accordance with national guidance and medication licensing requirements. Required assessments before starting treatment, following medication changes, and during ongoing treatment were either not recorded or not completed. There was also a lack of documented review of medication effectiveness and associated discussions when treatment was changed.

During the assessment, we reviewed the records of a random sample of five patients who had received treatment through Manchester Dermatology Clinic. Our review identified an absence of documented clinical records for all five patients. The documentation provided contained no clinical information regarding the care and treatment delivered to patients and therefore we were unable to assess the appropriateness, safety, or effectiveness of the care provided.

The provider did not have an effective system to ensure receipt, review, dissemination, implementation and monitoring of medicines and drug safety alerts. Whilst staff described a process for managing safety alerts, the provider was unable to provide any supporting documentation to evidence that this process was operating in practice. The provider could not assure us that relevant safety information was consistently acted upon to protect patients from avoidable harm.