Archived: AIG Aesthetic Care

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

The service had improved systems to report and manage patient safety incidents through a new governance structure. However, staff could not identify any incidents or near misses in the previous 6 months and we were not assured their knowledge was good enough to recognise when an incident occurred. The service was not open and honest when things went wrong and senior staff were defensive in their communications with patients. Staff had the required levels of training to safeguard vulnerable adults. Systems to maintain safe systems of care were not functioning effectively. There was limited continuity of care when people needed follow-up support. The service did not have processes to ensure staff assessed the risks to patients and treatment presented a high risk of infection or other harm. The design, maintenance and use of facilities, premises, and equipment did not promote safety. The service did not have enough staff with the right skills, training and experience, and supervision was limited. The service did not maintain a clean and hygienic environment. Systems to administer, record, and store medicines did not meet basic safety standards.

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 had implemented a new governance system since our last inspection, part of which focused on the service’s learning culture. The system enabled staff to record incidents and near misses in a single location so they could investigate causes and implement solutions more quickly. However, only doctors understood this system and technicians, who spent the most time with patients, did not demonstrate good knowledge. Staff had not reported any incidents since the system was implemented and could not discuss how they would identify or categorise a near miss or reportable risk.

There was not a learning culture or ethos amongst staff. Doctors exercised a ‘territorial’ approach to patients and follow-up communication was accessible only by the treating doctor in most cases. This meant there was no assurance that post-operative issues, such as infections, were recorded or shared. None of the staff we spoke with could explain how the service identified, implemented, or shared learning. While staff said the managing director had recently started staff meetings, they could not identify any learning discussed in them.

There were significant shortfalls in safe systems of working and in care pathways. While the provider had implemented improvements since previous inspections and regulatory action, these were only partly functioning and did not contribute to safe standards of practice. For example, a new electronic system enabled staff to document patient care and treatment, including pre- and post-operative photographs of the surgical site. The system included sections to record each patient’s medical history, medicines administered, and details of follow-up care. While this reflected a degree of improvement, staff did not use the system consistently. We found discrepancies in the care recorded on the system compared with the care patients said they received, wide variations in how doctors documented follow-up care, and a lack of detail about pre-operative safety checks for patients.

Doctors and patients told us it was common practice for them to communicate with each other using a digital messaging app. While this provided rapid access to advice for patients and enabled doctors to check on post-operative needs, the provider did not have safe standards of practice in place to ensure communication was effective and led to good outcomes. For example, doctors used their personal phones to communicate with patients and did not always copy information from the app into the patient’s record. This meant the provider had no oversight of the practice of each doctor. If a patient presented post-operatively with an issue, doctors on duty may not have access to the patient’s communications with other staff because they did not consistently upload messages to the system. We asked the provider about this, and they sent us a standard operating procedure (SOP) for communication between doctors and patients. This did not reflect practices in reality.

A safeguarding policy was in place, but a lack of version control meant it was difficult to identify the current safeguarding lead. For example, 2 different versions of the policy were on display in the clinic, and each named a different member of staff for safeguarding lead.

We spoke with the 2 people named as safeguarding leads and they said each would be able to make a referral and support staff to keep patients safe from harm. However, general knowledge of safeguarding was limited amongst staff, and they could not identify any scenarios in which a referral might be needed.

We asked doctors how they would respond to a patient who claimed they were experiencing concerns or unexpected side-effects of treatment post-operatively and communicate this using the messaging app. A doctor told us they used a ‘territorial’ approach to patient care, and they would actively avoid asking the patient to return to the clinic if they were not on duty. They also said they would avoid telling patients to seek urgent care in an NHS service since the clinic operated on a for-profit basis and they would prefer to provide care that was chargeable. This highlighted a lack of mechanisms in place to prevent patients being placed at the risk of harm due to a focus on financial income instead of care.

Staff did not involve patients in the management of risks during treatment. Another organisation took each patient’s medical history although patients told us this consisted simply of a tick-box exercise and no discussion about risks. In most cases doctors had no knowledge of a patient’s medical history until they arrived at the clinic for treatment. Doctors based treatment decisions on a brief pre-operative discussion. Where patients expressed concerns or anxieties, doctors offered medicine for this but made it clear any attempt to delay or cancel treatment would result in the forfeit of the patient’s deposit or payment. Such a focus on financial income prioritised profit over patient wellbeing and safety.

We saw technicians give patients basic safety information during treatment. For example, they told patients not to lock the door when they used the bathroom in case they fainted and could not be helped. However, information was inconsistent, and staff did not act on other risks, such as patients wearing scrubs to move around the clinic without changing them for the clinical space.

Staff provided brief information to patients regarding aftercare, such as how much time they should have away from work, which activities they should avoid, and how to clean and care for the surgical site. Where staff carried out a follow-up phone call with patients, they recorded checks on whether patients had adhered to post-operative advice, including avoiding alcohol and smoking.

The provider had carried out some improvements in the environment, including repairs to damaged ceilings. However, there was evidence of ongoing poor maintenance and a lack of preventative practices. For example, in some areas, joints between the ceiling and wall had begun to detach, with gaps in between. Floor joints in some areas were also damaged. Such damage presented a risk to infection control because they could not be cleaned and also reflected a lack of maintenance by the provider.

The service was partly compliant with the Control of Substances Hazardous to Health (COSHH) Regulations. Staff stored chemicals in a locked cupboard and kept information sheets about their safe and correct use. However, some products in the cupboard were unlabelled. Staff could not tell us what was in them and said a technician took the lead in this area but was not at work on the day. This presented a risk because staff could not respond appropriately if there was a spillage of the product or if it came into contact with skin. The provider had implemented a daily COSHH checklist to improve standards of practice. However, staff did not use the checklist consistently and effectively. For example, the checklist named an infection control supervisor as the named sign off for the process. However, the managing director told us this individual was not a supervisor and the information on the form was inaccurate. They said assurance was provided by mandatory doctor sign-off but in the previous 3 months, a doctor had not signed off any daily checks.

Management of the kitchen shared between patients and staff did not facilitate good standards of safety. We found meat products stored in unrefrigerated cupboard with no open or use by date. The products had a pungent odour that suggested the food was unsafe for consumption. While the food belonged to a member of staff and so posed little risk to patients, it reflected poor standards of environmental management and awareness in the clinic.

Doctors and technicians were responsible for clinical care and treatment. Staff completed a range of mandatory training, including infection control and safeguarding level 2. Training was delivered online using a self-study format and the provider did not monitor understanding or competencies. The practices of concern we observed reflected a lack of training and competencies, including poor standards of hygiene and cleanliness in the environment and poor medicines management.

The provider told patients care was provided by “surgeons” and doctors called themselves surgeons. ‘Surgeon’ is a protected title under the Medical Act 1983 and can only be used by qualified surgeons. While all 3 doctors were registered with the General Medical Council, none were qualified surgeons. In 1 case a doctor who called themselves a surgeon was the equivalent of a foundation year 2 doctor, or junior doctor. This doctor carried out surgical procedures without formal training or supervision. They said they had completed a series of observations of treatment and felt this was sufficient evidence of competency. The provider was unable to provide evidence of appraisals, supervision, or peer review. This placed patients at risk of harm because they were treated by underqualified staff who misrepresented professional titles.

Technicians carried out the majority of procedures and we saw doctors had limited involvement. Technicians underwent very basic initial training and induction, which consisted of a single day of observations and a tick list to note they had understood the information. We could not establish how the provider gained assurance of competencies because there was no assessment of care standards or practice. In addition, some technicians we spoke with had limited English language skills. There was no evidence the provider had assurance training for these individuals had been effective.

The service had not acted on extensive, ongoing safety issues relating to infection prevention and control (IPC) that we highlighted during previous inspections. For example, the waiting area and office were visibly dirty. There was no evidence of what cleaning had been done in these areas since a checklist completed in June 2024. We saw service users undergoing treatment used the waiting area to take breaks between treatment whilst in surgical scrubs.

Staff moved between surgical spaces and the office whilst in surgical scrubs. There was no change of protective clothing, use of antibacterial hand gel, or other preventative methods. These practices presented a risk of surgical site infection which can lead to sepsis.

Staff did not safely manage products designed to reduce IPC risks. Antibacterial hand gel in situ next to a handwashing sink had expired in December 2023. This meant the manufacturer could not guarantee it was effective or retained its antibacterial properties. We highlighted this to staff during our onsite assessment on 24 September 2024. However, the gel remained in use when we returned on 5 November 2024. This presented a risk of infection to patients because staff did not have assurance their hand hygiene practices were effective.

Staff used skin sanitiser spray during treatment to reduce the risk of infection or contamination. The product expired 12 months from the first day it was opened. Staff did not label the containers when they were first used. This meant they did not have assurance the product was effective. We told the provider about this area for improvement during our inspection on 1 February 2024, but they had not acted.

Staff did not use sterile field during surgery. Combined with the poor IPC control elsewhere in the clinic, there was a risk of surgical site infections (SSIs). SSIs can lead to sepsis if not properly identified and treated.

The service did not have safe standards of medicines management in place. Staff were not trained to safely manage, prepare, and administer medicines and doctors demonstrated little knowledge of medicines management. For example, 1 doctor did not understand the term ‘medicines management’ and said they had not undertaken any training in the safe use of medicines. We saw it was customary practice for doctors to prescribe medicines before a patient arrived to speed up the start of treatment. This meant they had not assessed or consented the patient prior to preparing medicines. In addition, 1 doctor told us it was common practice for them to delegate the preparation of medicines to technicians. Technicians did not have specialist training, and this practice presented a risk of harm to patients because their medicines had been prepared by unqualified staff without appropriate supervision.

We observed staff conducting surgical procedures using plastic pots of liquid medicine that were not properly labelled, and injected into patients’ surgical sites. There was no documentation of the name of the date of preparation, quantity, volume or dosage of medicine or the diluent in each pot, no record of who had made up the pots, no record of verification of the preparation by a second person and no record that the pots had been sterilised. Staff said they did not record this information and so they were unable to provide it.

The provider did not have a procedure for staff to follow for preparing the medicines into pots using an aseptic no touch technique. Staff did not record the times of administration; how much was administered or who had administered the medicine. This procedure was not adequate for the safe management and use of medicines. There was a risk that service users could receive too much medicine and experience serious, life-threatening side effects. For example, too much adrenaline can result in tachycardia.