Pharma Aesthetics

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

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

This is the first assessment for this service since its registration with CQC. This key question has been rated as Inadequate. We have identified a breach of Regulation 17 (good governance) 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.

The provider failed to demonstrate they had a shared vision, strategy and culture that was implemented into their day-to-day activities. Staff we spoke with were unable to explain the current direction and culture of the provider.

Concerns identified during the assessment indicated that staff and leaders did not ensure risks to delivering the strategy were understood and addressed. There was no evidence of leaders monitoring and reviewing progress of, for example, clinical consultations, staff recruitment and training, risk assessments and safeguarding.

We did not see a business plan that highlighted the services direction and culture, and the providers statement of purpose was not relevant to current activities.

The concerns identified during the assessment meant that leaders could not demonstrate they had the capability to ensure regulated activities were delivered to patients appropriately, safely, and to the expected standards. The service could not demonstrate they had inclusive leadership or any understanding of the context in which they delivered care, treatment and support.

Leaders in the practice were not visible. During the assessment, we could not speak to those responsible for leading the service.

We found a lack of clear leadership arrangements and staff we spoke to were unable to clearly describe the management structure, identify who held key leadership and governance responsibilities, or explain who they should escalate concerns to. There was also a lack of understanding among staff regarding each other’s rolesand scope of practice. For example, we saw no evidence of communication or meetings to discuss arrangements or responsibilities for care provided online at ADHDdiagnosis.co.uk or care provided for people using services at Manchester Dermatology Clinic. This meant there was no clear line of accountability for overseeing the delivery of care, clinical decision-making or staff performance.

We were not assured that there were clear leadership arrangements in place for the oversight of the regulated activities being delivered by the service. There was a lack of clarity regarding who was undertaking, or responsible for, the duties typically associated with the role of the CQC Registered Manager. We were informed a recently appointed manager, who had worked in the premises of Manchester Dermatology Clinic since June 2025, would assume responsibilities of the CQC Registered Manager. However, staff were unable to provide or locate relevant documentation and information to evidence this.

The provider had a Freedom to Speak Up policy, however, there was no established Freedom to Speak Up Guardian. Staff we spoke with were not aware on who to approach to raise concerns and did not feel confident to do so. There was no evidence of incidents being reported, documented and investigated appropriately.

The provider was unable to identify systems and processes in place to support the safety, equitable treatment, and well-being of staff. A policy was in place in relation to diversity and equality were in place, but we did not see training completed in equality and diversity for all members of staff.

The service did not have clear responsibilities, roles, systems of accountability to enable good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate. Under the registration of Pharma Aesthetics, the provider was unable to demonstrate oversight of services carried out at ADHDdiagnosis.co.uk and Manchester Dermatology Clinic. They could not assure us there were leaders in place who had oversight of the services, if meetings were held and if any leaders were present at the services.

The assessment identified significant failures in governance arrangements. The provider did not have effective systems or processes in place to assess, monitor and improve the quality and safety of the services provided. We found leaders were unable to demonstrate effective oversight of key operational and regulatory requirements, and records were either unavailable, incomplete or created after the assessment. As a result, the provider could not assure us that risks to patients were being appropriately identified, monitored and mitigated, in relation to, for example, safeguarding concerns, medicine management, staff training and competency and risk assessments.

Staff members we spoke to were unable to demonstrate effective governance and oversight of services delivered from Manchester Dermatology Clinic under its satellite arrangements. They told us that governance or oversight visits had not been undertaken to see the premises at Manchester Dermatology Clinic. In addition, we did not see evidence of audits, monitoring activities, meeting minutes, or other documentation demonstrating oversight of the quality, safety, and regulatory compliance of the services delivered from the premises.

After the assessment, the provider submitted evidence of internal audits (fire safety, health and safety and infection prevention control) being conducted at Manchester Dermatology Clinic. However, there was no evidence to show the audits were shared with leaders, along with evidence of meetings and monitoring activities. As a result, we were not assured that leaders had sufficient oversight of the activities being undertaken at this location or that risks to patients would be identified and escalated appropriately.

The absence of effective governance arrangements increased the risk that concerns relating to patient safety and regulatory compliance would not be identified or addressed in a timely manner, potentially exposing patients to harm.

The provider did not collaborate or share information with relevant external stakeholders, to support care provision, service development and joined-up care. Information was not shared with GPs, and from our review of clinical records, we did not see discussions took place regarding information sharing and consent.

The service did not focus on continuous learning, innovation and improvement across the organisation and local system. They did not encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not actively contribute to safe, effective practice and research.

There were no processes in place to ensure that learning and improvement was captured when things went wrong, as there were no formal arrangements for doing so and incidents were not appropriately identified, recorded and investigated.

There were no systems in place to gather and review patient feedback.