The Whiteley Clinic London

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. Leaders had systems for identifying and responding to deteriorating patients in the service, in the operating theatre and recovery. People received treatment and care to reduce the risk of avoidable harm, such as pressure damage, blood clots or falls. There were safety processes arranged before surgical procedures and operations started, with staff working together to ensure the right patient had the correct operation. Medicines were managed safely. Patients were safe from neglect, abuse and discrimination. Patients gave informed consent prior to procedures and where they were unable to consent, those close to them were involved in decisions made in their best interests.

At our last assessment we rated this key question good. At this assessment the rating has remained good. 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 culture of safety, based on openness and honesty. Staff and leaders listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Learning was shared with staff.

The service managed patient safety incidents well. Staff who we spoke with knew what incidents to report and how to report them. Managers investigated incidents and shared lessons learned with the whole team and the wider service. When things went wrong, staff apologised and gave patients honest information and suitable support.

The service had not had any never events or serious injuries within the past 12 months. Never events are serious, preventable patient safety incidents that should not happen if available preventative measures are followed. They include things like wrong site surgery or foreign objects left in a person’s body after an operation.

Staff had raised concerns and reported incidents and near misses in line with provider policy. The service reported 25 clinical and non-clinical incidents, 3 near misses (an event or situation where an accident or harm almost occurred but was narrowly avoided) and 1 hazard in the last 12 months. Incidents were looked at to identify trends or themes and if any individual member of staff needed additional training. All these incidents resulted in no harm or low harm. We saw evidence that each incident was thoroughly investigated and the right action was taken to reduce the risk of recurrence. The incidents were discussed at management meetings and learning was shared across the whole team and the wider service where required.

The service had a current incident reporting and reviewing policy, which reflected the provider and national guidance. Findings and lessons learned were shared through clinical governance and management meetings to promote a culture of openness, accountability, and continuous improvement. The policy also supported effective communication with patients where required and included what should be done to report notifiable incidents to the right external bodies. There was a dedicated IT platform for staff to leave positive feedback received from patients, as well as having this forum to praise colleagues and celebrate any achievements.

Staff understood the duty of candour regulation. They were open and transparent and gave patients and families a full explanation if, and when things went wrong. All staff received training in the duty of candour, which was required to be completed annually, regardless of role or level of responsibility.

The service provided mandatory training in key skills to all staff. Mandatory training modules included topics such as health and safety awareness, infection prevention and control, information governance, fire safety awareness and equality and diversity. There were also specific mandatory training modules that all staff needed to complete, including legionella awareness and sharps in care awareness training. Managers monitored mandatory training and alerted staff when they needed to complete updates.

Clinical staff, including nurses, healthcare assistants (HCAs), sonographers and radiographers, usually received and kept up-to-date with their mandatory training. The data showed a completion rate of 89%. However, this was slightly below the service’s target for mandatory training compliance among staff, where the service told us the target was always above 90%.

Non-clinical staff received and kept up-to-date with their mandatory training. The data showed a completion rate of 100%.

Consultants also kept up-to-date with their mandatory training. The data showed a completion rate of nearly 98%.

Staff also received training and awareness on recognising and responding to autistic people and people with a learning disability.

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 responsibility for patient care moved between different areas of a service and between providers.

Safety and continuity of care was a priority throughout people’s care pathway. Patients were assessed prior to surgery and findings taken into account when planning care and treatment.

All patients treated at the service were self-paying or had healthcare insurance. The NHS did not refer any patients to the service. There was an admission criterion for patients, which included an initial assessment and a pre-operative assessment on the first visit to the clinic. Patients requiring tests and investigations were given enough information to enable them to understand the procedure. Patients were involved in their care planning, and their families and those close to them were able to attend consultations and treatments with them. We reviewed 4 care records, which confirmed that patients were involved in their care planning.

The service performed all procedures under local anaesthetic. There were systems and processes to ensure the correct patients were treated throughout the patient journey. We observed handover of patient information, including all related identification checking processes. Staff completed the World Health Organisation (WHO) 5 steps to safer surgery checklists for all theatre cases.

The transfer of patients from the operating theatre to the recovery area was managed safely. Suitably skilled and qualified staff accompanied patients in all areas.

Patient records were a mixture of electronic and paper based and were kept securely. The IT system was available across the service to meet the needs of staff completing the records.

Care and support was planned and organised with patients, together with partners and communities in ways which ensured continuity. If the patient wished, the service would write a letter to their GP summarising the procedure undertaken at the clinic and any medicines the patient needed as part of discharge planning. We saw evidence of the service planning care and support with patients’ GPs after reviewing patients’ records.

The service had protocols for staff to follow in the event of a medical emergency. All staff at the service were trained in basic life support and could provide immediate first aid to any person on the premises who became unwell. In the event of an emergency, initial care would be provided within the clinic, and where appropriate, emergency services would be contacted via 999 to ensure ongoing monitoring and further assessment within the NHS. The service had a first aid policy which contained guidelines that staff needed to follow by the Resuscitation Council UK when managing emergencies. A structured clinical handover was required to be completed for the receiving service, and the consultants ensured that patient records were updated and a clinical summary or letter was produced where required. Staff also followed the Resuscitation Council UK guidance for all patients who had an anaphylactic reaction. Anaphylaxis is a severe, life-threatening allergic reaction after exposure to allergens such as certain foods or medication. The service checked the anaphylaxis kit monthly for the nursing staff and this was recorded in teams.

Following the incident, a follow-up with the patient would be undertaken, and any adverse events would be recorded using the clinic’s incident reporting system. This was confirmed in the service’s incident management policy. We reviewed clinical governance meeting minutes which showed that incidents were discussed, and learning was shared to support improvement in patient safety.

The service worked with patients and healthcare partners where required, to understand how best to keep people safe, what it meant for individuals and the best way to achieve that. Staff concentrated on protecting the patient’s right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect.

Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff received adult and children's safeguarding training. All staff members were required to complete Level 3 Safeguarding training. All staff also received training in the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS), and Female Genital Mutilation (FGM). All registered managers completed Level 4 Safeguarding training. There were current safeguarding policies and procedures, and these reflected the national guidance for adults and children, including visitors. There were clear processes for staff on how to report abuse, for example to contact the police and the patient’s GP immediately if staff felt the person was at risk of suicide or self-harm.

Staff knew how to identify adults and children at risk of, or suffering, significant harm and worked with other agencies to protect them. Staff knew how to make a safeguarding referral and who to inform if they had concerns. The service gave staff members safeguarding referral guides. There was information on display in different areas of the service advising patients, visitors and staff who they needed to contact if they or somebody they knew was in danger of abuse, neglect, exploitation etc. These were the contact details of the local authority safeguarding team, which also included an out of hours telephone number.

The registered manager had oversight of safeguarding within the service and was the dedicated safeguarding lead. The service confirmed there had been no safeguarding referrals in the last 12 months. Discharge and follow up arrangements were organised safely. Patients knew what to expect and when they would be next seen by a nurse or doctor.

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

The service worked with patients to understand and manage any possible risks to them. Treatment and care met patients’ needs in a way which was safe and supportive and enabled them to do the things that mattered to them.

We saw evidence that consultants carried out all necessary risk assessments for patients pre-procedure. This included deep venous thrombosis (DVT) risk assessments, risks related to allergies, whether the patient was a smoker, had a medical history of heart attacks, strokes, diabetes etc, and an assessment of family history of venous conditions. The service carried out clinical and medicines audits every 6 months, where risk assessments for patients were carried out. The compliance rates of these audits were seen to be above 90%. All safety checks were reviewed and confirmed verbally by the clinical team during the pre-procedure safety briefing, as part of the phlebology safety checklist the service used. These were signed and dated by the clinical staff. Phlebology is a branch of medicine for the diagnosis, treatment, and prevention of vein diseases, such as varicose veins, spider veins, and chronic venous insufficiency. Safety checks included written confirmation the patient’s scans were reviewed, their allergy history was reviewed, their medication information was updated, and the type of surgical procedure was confirmed.

We saw that staff completed the World Health Organisation (WHO) 5 steps to safer surgery checklists for all theatre cases. The service also carried out audits for the WHO safer surgery checklists, of which 100% compliance rates were achieved.

The service had a policy where patients undergoing treatment at the clinic must be in good health and fully mobile for surgery, so they were unlikely to have a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) form in place. Staff discussed this information with patients during their initial consultation. However, in the rare event that someone presented with a DNACPR form completed by their GP or expressed their choice not to be resuscitated in the event of a cardiovascular emergency, patients needed to provide a copy or complete a DNACPR form with their consultant, which was signed and dated by their consultant.

The service gave all patients information leaflets advising them what to do in the event of post-procedure complications. This included informing patients of relevant contact details of the clinic and an out of hours telephone service for patients who required urgent advice and support. Patients were encouraged to follow these processes during courtesy follow-up calls from nurses and healthcare assistants (HCAs), which were conducted after every procedure, and during pre-operative telephone calls from nurses and HCAs which took place a week in advance of their procedures.

We spoke to 5 patients during our assessment who told us they felt listened to, risks had been explained, and they were involved in decisions about their care and treatment.

The service detected and controlled potential risks in the care environment. Leaders and staff took steps to make sure equipment, facilities and technology supported the delivery of safe care. Where they were unable to do so, they managed the risks.

The design, maintenance and use of facilities, premises and equipment kept people safe. Staff were trained to use equipment and to manage different types of waste safely.

The design of the environment followed national guidance around the built environment. Areas were secure and protected patients, and where required rooms and other areas were locked to control access.

The environment of the treatment rooms and other areas used for patient care reduced the risk of patient harm, and included, for example, safe flooring, handrails and window restrictors.

Fire safety equipment was available and had been serviced. Fire exits were clear and free from obstruction.

There was suitable equipment provided and used correctly, such as for patients who were at increased risk of pressure damage or a blood clot developing. Staff carried out daily safety checks of specialist equipment. There was ready access to resuscitation equipment in theatres. All equipment was PAT tested.

Leaders maintained oversight of equipment to ensure it was safe and ready to use. Equipment audits were completed and outcomes shared with staff. Staff told us they had enough equipment to carry out their work safely and to support the treatment and care needs of patients. There were effective means of ensuring repair of replacement of broken or missing equipment.

Specialist equipment used in the operating theatres was used in accordance with national guidance and regulatory requirements.

The service had suitable facilities to meet the needs of patients’ families when necessary.

Staff disposed of clinical waste safely. Waste was segregated and labelled in accordance with the clinic’s policy. Clinical waste was securely stored in a locked yellow bin in a room that required keypad access. There was a service level agreement in place with a registered clinical waste disposal company, who collected the waste several times a week.

Hazardous substances were stored safely and information about products was available to staff.

The service made sure there were adequate numbers of qualified, skilled and experienced staff, who received effective support, supervision and development. Staff worked together well to provide safe care, which met patients’ individual needs.

The service had enough clinical staff including surgeons, consultants, nurses and sonographers with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment. Staff were made aware of their shifts in advance and could make requests.

The service carried out Disclosure and Barring Service (DBS) checks for clinical staff every 3 years and carried out DBS checks for non-clinical staff every 5 years. New staff received a full induction tailored to their role before they started work.

Managers reviewed the number and grade of clinical staff, healthcare assistants (HCAs) and other key roles, needed for each shift in accordance with national guidance. However, the service required 1 HCA and had a vacant post for this role. Managers told us that staff would work between different clinics to fill any vacant posts and provide care to patients. Managers could therefore adjust staffing levels daily according to the needs of patients. The service had low turnover rates of staff. The service had a stable workforce, as many staff members had worked at the service for over 5 years. The service regularly used bank staff. The service did not use locum or agency staff. The service had low sickness rates.

Staff we spoke to said they felt the service was safe. They were able to take breaks during their shifts.

Patients spoken with felt their needs were met in a timely way. We saw patients were attended to in a kind and supportive way. Patients appeared comfortable and were engaged in conversations because there were sufficient staff.

The service supported the learning and development needs of staff and made sure staff received any specialist training for their role. Managers identified any training needs their staff had and gave them the time and opportunity to develop their skills and knowledge. For example, legionella awareness and sharps in care awareness training.

Managers made sure staff attended team meetings or had access to the information shared, when they could not attend. We saw notes from team meetings and other general information was shared on notice boards.

Consultant surgeons were registered with the General Medical Council (GMC). They were subjected to a full assessment through the practicing privilege process. The service had 3 doctors who worked solely at the clinic, whilst all other doctors also worked for the NHS. They were required to provide evidence of appraisal and re-validation.

Surgical procedures and clinical decisions were carried out by doctors with appropriate seniority and speciality training. Patients were clear who the doctors involved in their treatment were.

The service assessed and managed the risk of infection. Staff detected and controlled the risk of it spreading by following policies. Infection and prevention and control data was collected and reviewed. Where required, actions were taken to improve shortcomings.

The service generally managed infection risks well. The service used systems to identify and prevent surgical site infections. Staff used equipment and control measures to protect patients, themselves, and others from infection. They kept equipment and the premises visibly clean.

All clinical and non-clinical areas were visibly clean, free from clutter and had suitable furnishings which were clean and well-maintained. This included all consultation and treatment rooms, which had cleaning charts situated on the back of doors, and which were signed by staff and fully up-to-date.

Staff supported infection prevention and control measures by following the uniform policy. Nail varnish and jewellery was not worn, and staff in clinical areas were bare below their elbows to allow for full hand decontamination.

The theatre environment followed national guidance, with separate areas to enable flow from clean storage, preparation through to an area for dirty equipment and waste management. There was storage for equipment including sterile packs, uniforms and linen.

All surgical items were purchased sterile and were disposable for single use only.

There was a separate cupboard for the control of substances hazardous to health (COSHH), which was kept locked. No medical gases were used at the service.

The service had an infection prevention and control (IPC) policy and supporting guidance that was accessible to staff, which was detailed and in date. The provider’s guidelines reflected national IPC guidance from Public Health England (PHE). Staff had access to expertise in infection control as needed. Staff understood the process for managing spillage of body fluids, and the process for managing this was outlined in the IPC policy.

There was a programme of IPC audits at the service, and the service monitored IPC through 4 key audit processes. This included IPC audits conducted every 6 months, where compliance above the target of 90% was achieved. Any clinical or non-clinical areas that required improvement were noted and prompt action was taken to address such areas, for example cleaning dusty floors and replacing clinical waste bins. The service also carried out monthly IPC spot-check audits, where 100% compliance was mainly achieved during the 12-month reporting period. Environmental cleaning audits were undertaken together with a representative from the cleaning provider the service used. Hand hygiene audits were completed every 3 months for each staff member to monitor compliance and support continuous improvement in infection prevention and control standards. The service achieved 100% compliance with this audit, and they performed well in local IPC audits.

We saw staff were following infection control principles including compliant handwashing and the use of personal protective equipment (PPE) as outlined in the service’s PPE standard operating procedure. Theatre practice minimised the risk of cross infection and we saw staff following best practise regarding the treatment and care of their patients.

However, although visibly clean, we saw the disposable curtains used in the consultation, scan and treatment rooms did not always comply with best practice. The curtains in all of these rooms were last changed in July 2025. CQC infection prevention and control guidelines recommended curtains should be changed at least once every 6 months. We immediately brought this concern to the attention of the registered manager, who addressed this area. The provider’s IPC policy has been reviewed and amended, specifically the section relating to disposable curtains, to align with CQC guidance requiring replacement every 6 months. Clinical staff were immediately notified and instructed to replace all curtains in line with the updated 6-month schedule.

The service made sure that medicines and treatments were safe and met patients’ needs, capacities and preferences. Staff involved patients in planning, including when changes happened.

The service used systems and processes to safely prescribe, administer, record and store medicines.

Staff followed systems and processes to prescribe and administer medicines safely.

Doctors reviewed each patient’s medicines on admission and liaised with the patient’s GP if any withholding of blood thinners was required prior to surgical procedures, to ensure it was safe to proceed.

The service stored medicines securely in locked cupboards. We reviewed medicines in theatres which were in date. There was a service level agreement with a local pharmacy to provide medicines. Staff carried out daily temperature checks of the medicine fridge. The clinic did not routinely use or store any controlled drugs.

The service had a medicines management policy which contained guidance on who was authorised to prescribe medicines. The consultants were responsible for prescribing and issuing prescriptions. Administrative staff were trained to manage all prescription-related communications, including recording any paper prescriptions on the tracker for auditing purposes. Prescriptions were issued via an advanced electronic private prescription service. The policy also contained guidelines to maintain use and supply of oxygen cylinders, emergency medicines, and equipment on-site for use in medical emergencies and to support resuscitation.

The medicines records of patients were assessed through 6-monthly audits conducted by the registered manager, which aimed to achieve more than 90% compliance. The last medicines audit in March 2026 achieved 95% compliance. In addition, the safety management and handling of medicines were reviewed through monthly audits carried out by the lead nurse supervisor, with overall oversight provided by the registered manager.

However, in 1 of the treatment rooms, we found 12 expired transwabs which had expired in January 2026. We immediately brought this concern to the attention of the registered manager, who addressed this area. We saw these were removed immediately after informing the service of this.